Latest / Style Points / Going the Distance with Jordan Crouch

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Going the Distance with Jordan Crouch · Style Points

0:10
Hello anesthesia enthusiasts, and welcome to
0:11
season three of Style Points. I'm not sure what
0:15
that means, other than this being the third year
0:17
of me recording the podcast. However, I feel
0:20
that calling it a season lends the podcast a
0:22
certain sense of gravitas. I'm your host, John
0:25
Crow. Today, we're going to discuss long distance
0:28
running and its physiologic implications for
0:31
anesthesiology with CRNA Jordan Crouch. Before
0:34
I let him run away with things, though, I'm going
0:36
to hand it over to my co -host, Nate Moore, to
0:39
introduce this month's RSI, which of course stands
0:42
for Resident Selected Information. Thank you,
0:45
John. I get to introduce Dr. Wes Young, formerly
0:48
a PA working in a cardiac ICU before he went
0:50
to med school and joined us in anesthesia, making
0:52
him especially qualified to give his RSI on hemodynamic
0:55
management. We think his insights are so valuable
0:58
that the chair of our department, Dr. Stuart
1:00
Birch, is currently sitting stool in his spine
1:02
case so that Wes can be with us. Welcome, Wes.
1:06
Hello, my name is Wesley Young. I'm one of the
1:08
CA1s at the University of Cincinnati, and I'm
1:10
going to talk to you about pressors in the operating
1:12
room. There are hemodynamic effects and common
1:14
uses. But before diving into the drugs and their
1:17
mechanism of action, I think it's important to
1:19
review some cardiovascular physiology. Our oxygen
1:22
delivery system can be broken down into our macrocirculation,
1:24
which we often refer to as like blood pressure,
1:26
heart rate. cardiac output and SVR. But then
1:30
we also have the microcirculation, which represents
1:32
the flow required to deliver adequate amounts
1:34
of oxygen to a particular organ. And this is
1:36
what we really care about. Some organs are great
1:39
at auto -regulation, meaning that they can maintain
1:41
flow over a wide range of blood pressures, and
1:43
others struggle a little bit in the department,
1:45
kind of like the kidneys. But they all, to a
1:47
certain extent, have the ability to have their
1:48
arterioles vasodilate or vasoconstrict depending
1:51
on local meters, like PO2, potassium, lactic
1:54
acid, etc., in order to regulate the flow. So
1:56
from a big picture, our body creates a pressure
1:59
gradient using cardiac output and changes in
2:01
the resistance provided by arterioles to increase
2:03
or decrease flow to our organs, which means we
2:05
can quickly shift blood to our quadriceps when
2:07
running a marathon or our intestines when eating
2:09
a delicious burger. The problem is that in the
2:12
OR, we have departed from normal physiology and
2:14
thrown in drugs that cause venous and arterial
2:16
dilation. Patients bleed, they have inappropriate
2:19
inflammatory cascades, and we often switch them
2:22
from negative pressure to positive pressure ventilation.
2:25
One last thing. Hypotension is the primary reason
2:27
for using vasopressors, but we can't forget that
2:30
even though our blood pressure is the driving
2:32
factor for flow, it's generated through a cardiac
2:35
output and systemic vascular resistance, either
2:37
of which could be the problem. The primary receptors
2:40
that mediate an increase in blood pressure are
2:43
typically the alpha -1 adrenergic receptor. We
2:47
also have our V1 receptor, and then we also have
2:50
the beta -1 adrenergic receptor that increases
2:52
cardiac output and heart rates. The first vasopressin
2:55
that we oftentimes use in the operating room
2:56
is called norepinephrine. It's a potent agonist
2:58
of the alpha -1 adrenate receptor, and that causes
3:01
vasoconstriction. And then there's also some
3:03
modest beta -1 adrenate activity, which helps
3:05
maintain cardiac output and doesn't have much
3:07
effect on the heart rate. We typically give this
3:10
in bolus dosing of around 8 to 16 mics. Phenylephrine,
3:14
on the other hand, is a selective alpha -1 adrenergic
3:16
agonist. It particularly leads to arterial and
3:20
venous vasoconstruction and has very little effect
3:23
on cardiac output. We typically give both doses
3:27
of around 100 mics. Ephedrine acts a little bit
3:30
differently. It indirectly stimulates the release
3:34
of endogenous norepinephrine, and has some direct
3:37
effect by binding to alpha -1 and beta -1 receptors,
3:41
but that effect isn't as pronounced. You can
3:43
see an increase in heart rate and some cardiac
3:45
output, as well as your increase in vascular
3:47
tone. We can give it intravenously through bolus
3:50
dolcing around 5 to 10 milligrams, and then we
3:53
can also use it as an IM injection around 20.
3:58
25 milligrams. Epinephrine is a non -selective
4:01
adrenergic agonist. At low doses, it causes a
4:04
beta -1 effect, mostly by increasing heart rate
4:07
and contractility. And at higher doses, it leads
4:09
to alpha -1 vasoconstriction. We typically give
4:13
bolus doses around 10 mics. Dopamine is kind
4:16
of a dirty drug that we used to use back in the
4:18
day, but it causes so many tachyarrhythmias that
4:20
we've kind of fallen out of favor. Vasopressin,
4:23
on the other hand, is a non -catecholamine vasopressor.
4:27
that acts on the V1 receptor on vascular smooth
4:29
muscle, and that causes vasoconstriction that
4:32
way. We usually give it in one to two units at
4:37
a time. So as a general rule, norepinephrine
4:40
is the most balanced vasopressor that generates
4:42
a nice rise in blood pressure without sacrificing
4:44
too much on your cardiac output. It's usually
4:46
the first -line pressor for the majority of the
4:49
shock states, and you can rarely go wrong by
4:51
giving norepinephrine. Phenylephrine is a great
4:53
drug. We've been giving it for years in the operating
4:55
room. It's a good option for the majority of
4:57
our hypotension that's related to anesthesia.
4:59
You know, a lot of our drugs cause low SVR, maybe
5:02
decreased venous tone as well, and that can be
5:05
quickly counteracted by the phenylephrine. like
5:08
pure alpha -1 agonism. So we'll see a rise in
5:11
SVR that way. But then you also have some venous
5:14
vasoconstriction, which kind of increases venous
5:16
return. We have to be careful with phenylephrine,
5:18
though. It does have a reflexive bradycardia
5:21
that we can see pretty profoundly in the operating
5:24
room. The increase in SVR also can decrease cardiac
5:27
output. So it's something to be avoided in patients
5:30
who have heart failure or severe pulmonary hypertension.
5:34
Epinephrine we use in the operating room as well.
5:37
It increases more of your cardiac output as well
5:40
as SVR. And you'll notice a nice rise in your
5:44
heart rate when you use it in the operating room.
5:46
You should be careful by not giving it too much
5:48
because it does cause some tachyarrhythmias.
5:51
Vasopressin used to be a drug that we use in
5:53
our ACLS algorithm all the time. It's a useful
5:55
adjunct to increase vascular tone. And there
5:58
is a theoretical benefit that we can increase
6:01
SVR without really affecting your pulmonary vascular
6:04
resistance. And so sometimes we'll try and use
6:07
vasopressin more in patients who have severe
6:09
pulmonary hypertension as opposed to other pressors.
6:12
And then finally, we have ephedrine. And like
6:14
we said earlier, this is the one that mostly
6:16
relies on endogenous catecholamines. And it can
6:20
be given IM, which gives it kind of a longer
6:22
acting range. And it's useful in our OB population
6:26
who oftentimes have hypotension from either the
6:30
epidural causing the sympathectomy. and it will
6:33
slowly wear off as the epidural wears off as
6:35
well. It's simply not recommended in patients
6:38
who are critically ill because they likely have
6:40
depleted catecholamine stores and therefore wouldn't
6:43
have much effect on their blood pressure. I hope
6:45
this quick review on vasopressors was helpful
6:47
and hopefully next time in the operating room
6:49
you can choose the best drug for your patient.
6:57
My athletics started in football, then to a 5K,
7:01
then to Ironman. into endurance running. I feel
7:06
like 5k to Ironman is maybe a little bit of a
7:10
jump there. Yeah, it was a progressive process.
7:17
It's kind of like a draw the rest of the owl
7:19
situation. Okay, Jordan, thanks for joining us.
7:25
Yeah, thanks for having me. Absolutely. Jordan,
7:28
before we... get started I'd love it if you'd
7:30
tell our audience a little bit about yourself
7:32
and your training all that sort of thing I've
7:36
been a nurse anesthetist for five years I trained
7:40
at UC and my athletics background is I played
7:47
football for a while and after football really
7:51
wanted to stay in shape and keep exercising but
7:58
Wasn't really interested in going to the gym
7:59
anymore. And I think football kind of made weightlifting
8:05
feel like a job. And for whatever reason, I just
8:09
kind of got burnt out on that. And I think you
8:13
see that both ways. Some runners gravitate towards
8:15
weightlifting after, you know, after their collegiate
8:17
careers. But yeah, so I took up running and I
8:22
started off with a 5K and then gradually. Kept
8:27
growing my running volume to some longer endurance
8:31
and then eventually into Ironman distance What
8:37
what is Ironman distance Ironman distance? It's
8:41
like 140 like point six miles and it involves
8:46
a 2 .4 mile swim 112 mile bike ride and then
8:52
a marathon so It's an all day event and it's
8:57
a lot of endurance and I really like that. But
8:59
there's I think there's parts of Ironman that
9:04
you gravitate towards more like you really like
9:06
swimming or you really like biking or like running.
9:09
And I really fell in love with the running part
9:14
of it the most. So I tend to gravitate towards
9:16
that afterwards. One of the reasons why I wanted
9:21
to have you on the podcast is because I've heard
9:24
you. talk about your running experience before
9:26
and i found it super interesting um you have
9:30
run i think probably more distance than maybe
9:35
the rest of the department combined i would say
9:38
is there anyone else in the department that runs
9:41
anywhere close to as much as you that's a good
9:43
question i don't know i i have heard there might
9:45
be somebody who's Trying to do like all the marathons
9:49
and all the states or something or all the all
9:50
the big marathons I'm not sure but every now
9:53
and then people you know when they hear you run
9:54
though Though it like mentioned somebody else
9:56
that also runs and it's hard to keep them all
9:58
straight But yeah, it's a lot of it's a lot of
10:01
running. It's a lot of miles. So I think the
10:05
my weekly volume I try to keep around 50 to 70
10:09
miles a week at least and then you kind of go
10:12
up or down from there depending on You know races
10:14
or what you have going on Excellent. So how do
10:19
you fit in 50 to 70 miles per week? How does
10:22
that look in your life? Well, I'm very lucky
10:26
that I live close enough that I can run to work.
10:29
So, you know, that's about six miles there. See,
10:35
that's just right out for me, because if you
10:37
said the same for me, if I said I live six miles
10:40
from work, that would exclude me from running
10:42
from work. Yeah, yeah, yeah. I mean. So it actually
10:45
it's only so it's six miles total, but it's like
10:47
three here, three home. Yeah, that's a little
10:51
bit. It's not as much. Yeah. But I think that
10:54
that's easy because, you know, after work or
10:59
before work, if you want to add a little distance,
11:02
you know, it's very easy to just keep going and
11:05
get like the training plan done or whatever you
11:07
have for that day. And it's honestly, it's a
11:11
great stress relief after work to. you know,
11:15
be able to go outside and move around. You kind
11:19
of learn to value the nice weather, you know,
11:21
after you have some bad weather. So it works
11:24
out really well for me. I know not everybody
11:26
has that luxury, you know, if you live, you know,
11:28
10, 15 miles out, but finding a way to make it
11:32
work is key. Well, let me back up for a second.
11:36
I want to ask the same question that I like to
11:39
ask everybody. If you could invite anyone over
11:42
in the world for dinner, could be somebody from
11:44
the past or even from fiction, who would you
11:46
invite over? That's a good question. I think
11:52
right now, just on top of my mind, is this character
11:57
called, his name's Gary Cantrell, and he goes
12:00
by the alias Lazarus Lake. recently featured
12:08
in a book i'm reading it just came out uh it's
12:11
a really good book but the book's called the
12:13
endurance artist and um gary cantrell he's um
12:19
credited for creating a lot of the race formats
12:23
and endurance running and he's designed a lot
12:26
of the racing styles that we that we use in an
12:30
ultra running um including the backyard race
12:33
it's a Last man standing race where you will
12:38
run 4 .1 miles every hour on the hour until there's
12:50
one person left standing. So he has these really
12:53
unorthodox or unique racing designs. And he also
12:58
is the guy behind the Barkley marathons. And
13:01
the Barkley Marathons have a pretty famous documentary
13:05
about them that made it really popular. But just
13:08
to give you an idea, the race is so difficult,
13:12
like very few people have ever finished it. I
13:15
think it's been going, you know, I'm not really
13:17
sure on the exact year, but around the 1980s,
13:19
it's been going on like that long. And, you know,
13:23
there's only been a handful of people that's
13:25
ever successfully completed it. So he really
13:28
threads the needle on. making a race that's just
13:31
difficult that it's possible to do but like very
13:34
few people can actually do it and i i think it's
13:37
interesting the book actually made him even more
13:38
interesting to me because you learn a lot more
13:40
about him and now i have more questions or more
13:44
things i want to like ask him if i could so that's
13:47
who i'd pick to have dinner with if i could i
13:52
don't know That person would want to have dinner.
13:56
They'd want to maybe go on a jog with you. Yeah,
13:57
that's right, yeah. Okay, you have sort of a
14:03
unique perspective as both an ultramarathon runner,
14:07
really, and as a practitioner of anesthesiology.
14:12
Tell me about how those things intersect. How
14:15
does it influence how you think about endurance
14:18
and physiology when you're thinking about your
14:22
training as a CRNA? and how it applies to running
14:26
these enormous distances? I think the right amount
14:33
of training and knowledge about the body allows
14:35
people to go a lot farther than what they think
14:37
is possible. And I guess that kind of comes across
14:43
in anesthesia in the sense that the body is not
14:51
really a machine. A lot of people think that
14:54
You're going to wear your joints out. But the
14:57
thing with, you know, machines is that they can't
14:59
heal themselves or they can't really adapt, you
15:01
know. So, you know, if you need new car tires,
15:05
you just go buy new car tires. They don't really
15:07
heal themselves or they don't really adjust the
15:08
amount you're driving. So one of the things,
15:11
you know, from the health care background or
15:14
from anesthesia is that our bodies are way more
15:17
incredible than what we give them credit for.
15:22
They're unique to machines in the sense that,
15:24
you know, you can train and build up your physiology.
15:31
And with through like, you know, consistent training,
15:36
you can really allow yourself to go farther than
15:41
what you think is possible. That's really interesting.
15:45
I think that in anesthesia a lot, we see people
15:49
that. are what we would consider to be surprisingly
15:55
alive, who are kind of pushing the limits of
15:58
human physiology, less because they're healthy,
16:03
but more that they are dramatically unhealthy.
16:06
So we see people who are just clinging to life
16:09
with an extremely low ejection fraction, or maybe
16:12
an extremely high BMI, things like that. But
16:16
you're talking about pushing it the other direction,
16:19
where... You're so healthy that you can overcome
16:23
some of these other things. Is that sort of what
16:25
you were saying? Oh, yeah. Yeah, I think that,
16:28
you know, the biggest thing that I notice in
16:32
ultra running is it'll show you really quickly
16:35
is consistency. You know, being consistent is
16:38
what allows for those adaptive changes. And it's
16:43
evident just in a personal level, but also just
16:47
through a lot of the training plans you see.
16:49
One of the benefits, you know, honestly, going
16:52
back to the run commuting is some would argue
16:55
that doing a double exercise during the day,
16:59
like two runs a day instead of like one long
17:01
run, is that you're actually activating a lot
17:04
of those physiological responses. You're activating
17:07
those twice. So rather than just running once
17:10
and kind of turning everything off or on and
17:13
then showing it all back off again in terms of
17:15
your exercise, doing that more frequently. could
17:19
could be beneficial so I think the consistency
17:23
of if I work you know a 12 -hour shift I'm kind
17:27
of like running every 12 hours you know if I'm
17:29
running home and then running to work and then
17:31
adding some so it really becomes like interwoven
17:34
into your life and it becomes second nature almost
17:37
like climbing a flight of stairs or walking into
17:40
work so so a lot of people are really interested
17:45
in biofeedback and People like myself, I wear
17:49
my Apple Watch or you've got Oura rings or all
17:54
these sort of things that help you measure different
17:56
physiologic parameters. And that's sort of what
17:59
we do in anesthesia as well. Is that something
18:01
that you like to take a close look at when you're
18:05
doing your runs? Is your heart rate and heart
18:07
rate variability and all those sorts of parameters?
18:10
Yeah, I do. I'm actually, as we sit here, I have
18:13
two watches on. I'm just noticing you have two
18:16
watches. Yeah, that's kind of a leading question,
18:18
I think. But yeah, it's like, you know, I do
18:20
have two watches on. So I wear the Apple Watch
18:23
while I'm at work. It connects nicely too. the
18:27
iPhone and messages, but I like to wear the running
18:30
watch at the same time because it's tracking
18:33
my recovery and a lot of the other health metrics
18:37
that you get from wearing it for extended periods
18:39
of time, like when you sleep or while you're
18:42
moving or at rest throughout the day. So even
18:44
though I'm not exercising, it's still collecting
18:45
some data that gives me information on my recovery.
18:49
How do you track your recovery? That's really
18:51
interesting. Yeah, it's mostly like heart rate
18:54
variability is a common tool. And these things
18:57
fall in and out of favor all the time. But I
19:00
mostly like to do like the sleep score. And,
19:03
you know, I like to trend these things because
19:05
I think that, you know, like an anesthesia, trending
19:08
is always a little bit more evident than just
19:11
any single number by itself. So I kind of just
19:14
hop on the trends of heart rate variability,
19:19
looking at my resting heart rate. really tell,
19:22
like, for instance, yesterday, I ran, I ran 20
19:25
miles yesterday. And this morning, on my way
19:28
to work, as I ran in here for this podcast, my
19:32
heart rate was quite a bit higher. And that just
19:34
kind of shows that I had a big effort yesterday.
19:36
So you can kind of tell, you know, like, based
19:40
on how your heart rate responds from the previous
19:42
day, how how difficult that exercise was for
19:47
you. The issue with heart rate specifically is
19:50
that It's not as much as we love numbers and
19:53
anesthesia. It's not always the greatest insight
19:58
into your efforts. Why not? Well, I think it's
20:05
usually it can be very jumpy and it can be affected
20:08
by a lot of things. And again, in anesthesia,
20:11
that's one of the things we notice is that when
20:13
we like a number, you can realize that that number
20:15
can be affected by. you know, surgical stimulation.
20:18
It can be affected by epinephrine injection.
20:21
It can be affected by all kinds of different
20:23
things. So depending on what's happening, you
20:25
know, there's a number of explanations for it.
20:27
So a lot of people like to lean towards this
20:33
scale that they create called the rate of perceived
20:36
exertion. And it's a lot of times it's abbreviated
20:39
RPE. So using the rate of perceived exertion,
20:43
you kind of come up with a scale in your own
20:46
mind. And you give yourself a score, like how
20:49
difficult is this run for me right now? Is that
20:52
what pops up on my Apple Watch after I work out
20:55
and it says, how difficult do you think that
20:56
this was? Yeah, that's exactly it. Yeah, it's
20:59
kind of getting that in your mind. So it's able
21:02
to maybe help you plan your training from there.
21:06
So if that workout was really difficult, it might
21:08
suggest an easier exercise the next day. But
21:12
it's good to kind of be in tune with that a lot
21:16
of times. The biggest thing that I think happens
21:19
is as an ultra runner, if you're really good
21:23
and consistent in your training, the thing that
21:25
tends to throw a wrench in the works is when
21:28
you have to start tapering to go into a race
21:30
because that's when your consistency fluctuates
21:33
a lot. And by tapering, I mean you start to decrease
21:37
your weekly miles and you kind of rest yourself
21:41
leading up to a big event. That big event when
21:45
it starts and sometimes because of the rest you've
21:48
taken your heart rate is like all over the place
21:50
It'll shoot way up and you're not even running
21:53
that hard, but your heart rates really high It'll
21:57
also be very erratic. So if you stop it'll it'll
22:00
come way back down And then if you start again,
22:02
it'll shoot back up or if you start going up
22:04
hilly terrains so That's where the rate of perceived
22:10
exertion comes in because a lot of times you
22:12
won't feel like you're working very hard at all.
22:14
It's really just a physiological adjustment to
22:17
maybe drinking a ton of fluids, eating a huge
22:19
meal the day before, and also just taking that
22:22
week off. It's just your body's kind of getting
22:25
set back into what you're about to do. And it
22:27
could also just be race anxiety, you know. So
22:30
what is your resting heart rate? My resting heart
22:34
rate. So. When I'm at sleep, it's occasionally
22:38
dipped into the 30s, which people love to hear
22:40
about. You know, they like to think that, you
22:43
know, my heart's beating it like once every two
22:46
seconds. You know, I don't know. It's some people
22:48
that causes anxiety. But yeah, it's most of the
22:52
time it's in the 40s or 50s. You know, I would
22:58
say if you were to look at your resting heart
23:00
rate, like if you're like throughout the day,
23:02
if you're sitting, it trends more towards like
23:04
the mid to high 50s. So a lot of people, when
23:10
they see a heart rate of 50 on an anesthesia
23:12
monitor, start to feel a little bit anxious because
23:15
they think, oh no, the heart's slowing down and
23:18
I must give glycopyrrolate to speed the heart
23:20
rate back up. And what I will typically tell
23:24
the newer practitioners who might want to treat
23:28
a heart rate of 49 or 50 is I will point to my
23:31
heart rate trend on my watch and say, Well, my
23:35
heart rate was 48 last night while I was sleeping.
23:38
Please don't sneak into my house and give me
23:40
glycopyrrolate. I don't need that to keep me
23:42
alive. That's right, yeah. Yeah, they are asleep,
23:44
yeah. And a lot of times when we're noticing
23:47
that, it's, you know, in this phase between like
23:49
after we've put them to sleep and before the
23:51
surgery starts. They're truly just laying there,
23:53
right? Like they're not even having surgery yet.
23:55
Their rate of perceived exertion is very low.
23:57
Yeah, very, very low. It's like they're in the
24:00
deepest sleep they've ever been in technically,
24:01
you know. So, yeah. That is a very interesting
24:06
point. I try to remind myself of that too because
24:09
it's very different when you see things like
24:12
that. You cycle up blood pressure and you go,
24:14
okay, it's asymptomatic bradycardia. They're
24:16
totally fine. There's no reason to really be
24:20
that worried about this. So when you do endurance
24:25
training, it changes your heart rate and your
24:27
stroke volume, things like that. Can you talk
24:30
a little bit about that? Yeah. So what you'll
24:34
generally see as you start to exercise is, you
24:39
know, they always talk about this left ventricular
24:41
left ventricle dilation that you get and you
24:43
get like a slightly increased amount of muscle
24:45
on your left ventricle that will, you know, increase
24:49
your stroke volume to help you meet the demands
24:52
that your body's asking for. And I think, you
24:56
know, that's why the consistency is so important.
24:58
You have to activate these things very consistently
25:00
over a long period of time. To get all the adaptions
25:04
that you that you're looking for to to reach
25:07
your potential and. The heart rate for me with
25:13
consistency and, you know, it wasn't with like
25:15
very hard runs all the time or anything. You
25:19
know, extra crazy. It was really just getting
25:21
outside and moving consistently, consistently.
25:24
My heart rate started to trend down where I noticed,
25:28
you know, after a couple of weeks or months.
25:30
At the same. running pace my heart rate was much
25:34
much lower and much comfortable much more comfortable
25:36
um i think a lot of people start off running
25:39
too hard or too fast for themselves and uh i
25:44
learned early on that every training session
25:46
doesn't have to be like the hardest training
25:48
session you've ever done so i you know i definitely
25:51
started off as like uh they call it like you
25:54
know the the workout hero or the training hero
25:56
where you're like trying to like break records
25:57
in your training every day. And a lot of that's
26:00
just carry over from my football experience where,
26:03
you know, it might be motivational to do that
26:06
if you're like lifting weights and you're really
26:08
trying to, you know, throw heavy weight around
26:11
and things like that. But I think for running,
26:12
it's really just about like, like a consistency
26:15
that you can maintain and sustain and going too
26:19
hard every day is not sustainable. It's just,
26:22
it's going to lead to injury and, and, some you
26:25
know other complications and also burnout are
26:28
you shooting for a particular heart rate when
26:30
you're running yeah for me everybody has a little
26:34
bit different that you can calculate there's
26:35
ways to calculating your heart rate zones um
26:38
you know the oldest one that we hear about is
26:40
220 minus your age and uh you can kind of calculate
26:44
it from instead of the generic 220 you can kind
26:47
of calculate it from a maximum heart rate where
26:49
you give your hardest effort See how high your,
26:52
you know, heart rate will get and then kind of
26:54
calculate some heart rate zones from there. It
26:57
gets a little bit more complicated because with
26:59
your training, you can actually dilate out these
27:01
heart rate zones. Heart rate zones being like,
27:05
like zone one would be, you know, like you're
27:08
almost at rest or not really doing like very
27:11
difficult activity at all. And zone two would
27:14
be like a very comfortable. slightly elevated
27:18
heart rate so for me i think it's around like
27:21
120 to 140 but you can actually extend these
27:26
out so that they're they're wider to some extent
27:28
you know depending on how your training is focused
27:30
so you know track athletes might have a very
27:35
like wider upper range or a very like you know
27:39
steep upper range where they can go into like
27:41
very high heart rates because that's what they're
27:43
pushing a lot of the time so when you're Prepping
27:47
for a really long run, it strikes me as some
27:52
of the same prep that we would do for a really
27:54
long anesthetic. There's things that you have
27:56
to plan on in terms of hydration and sodium and
28:01
all those sorts of things. Can you talk a little
28:04
bit about the physiology of what it takes to
28:07
plan for a really long run and what you do to
28:09
prepare? Yeah, I think that is something that
28:14
is kind of... overlaps a lot with ultra running
28:18
is like the planning component um it's tough
28:21
because as a as the runner and you're the only
28:24
one that's being affected by your own decisions
28:26
so it's very easy just to to go out the door
28:29
without without doing the planning you need to
28:31
do um but you learn quickly that it's important
28:34
to take the second to think like do i need gloves
28:37
before i do this because you know cold hands
28:39
can really just kind of ruin the whole run if
28:42
your hands are cold the whole time uh but Yeah,
28:46
you know, there are a lot of things I basically
28:51
for myself personally, I'll take, you know, maybe
28:55
some electrolyte drink with me. If not, then
28:59
I kind of just rely on gas stations, which I
29:01
think is kind of fun. Like you just run to like
29:03
some unknown area that you haven't been to before,
29:06
haven't been to in a long time and pop into a
29:08
gas station, get a snack, get a drink, and then
29:11
you just kind of keep the run going. I usually
29:13
do that if I'm doing like 20 plus miles, I'll
29:15
do that around like mile 13. And I'll grab a
29:19
drink, grab some food, and then just go back
29:22
out and finish the next, you know, seven plus
29:23
miles. The nice thing about that as well is that
29:26
it kind of is a little bit of a stomach training.
29:29
And it's very similar to a race in which as I'm
29:34
running, I will, you know, stop and get all this
29:37
food and, you know, eat maybe like a snack and
29:41
then. drink a bunch of fluid and then uh start
29:44
running again and that's kind of very similar
29:47
to like a race where you might come up to an
29:50
aid station you're going to eat and drink a lot
29:52
and then you're going to start running again
29:53
and it kind of helps your body get used to that
29:56
feeling if you're running one of your big 100
30:00
mile races or something like that how much fluid
30:04
do you need to support yourself in that sort
30:08
of environment is it just purely based on thirst
30:10
or is there calculations that you have to do?
30:13
How does that work? Yeah, I kind of wish it was
30:15
purely based on thirst because there would be
30:17
a lot less calculation needed. But unfortunately,
30:20
I think when you're setting a goal, you know,
30:24
goal -based fluid replacement, you know, when
30:26
you're setting a goal to it, that's when it kind
30:28
of becomes dangerous because you can override
30:30
a lot of those mechanisms because, you know,
30:33
you've calculated that you do, in fact, need
30:35
a certain amount. And you're going to override
30:37
like I'm not going to wait till I'm thirsty.
30:40
It's an ultra running. It may be too late, you
30:42
know, to start eating when you're hungry. Like
30:44
it's very hard to to meet the demands. You know,
30:48
once once you're already getting like signals
30:50
really firing that, oh, you're thirsty, you need
30:53
water. And it's like it's hard to replenish and
30:56
keep it going for an extended period of time.
30:58
It might not be a bad option to drink to thirst
31:01
in a shorter event like a 5K or even the Camarathon.
31:04
But. I think a shorter event, like a marathon,
31:07
like a marathon, just because you on that. Yeah,
31:11
I think, I think because, you know, the consequences,
31:15
well, marathons can be long, you know, depending
31:18
on the speed and things like that. The consequences
31:20
don't play out over like. over the entire night
31:24
you know like a 24 -hour race if you make a mistake
31:27
you have to deal with the consequences until
31:30
like from 7 p .m to 7 a .m so it can be it can
31:34
be a long haul but you know back to the question
31:36
about the electrolyte goals and then the fluid
31:40
replacement so I tend to the best way to kind
31:44
of come up with a plan for fluid replacement
31:45
that I've come across is You weigh yourself before
31:51
an exercise without clothes or anything as a
31:54
variable. You go out into the heat and run for
31:57
about an hour and come back and weigh yourself
32:01
again. That will essentially, the only thing
32:05
that will be different there is that the amount
32:08
that you sweated is gone. So any kind of sweat
32:11
loss is out of the equation now. And you'll come
32:14
up with a weight difference. You'll convert that
32:16
to liters in terms of water. Um, and you'll,
32:19
your goal would be to replace 90 to 95 % of that.
32:22
So if you lost, you know, like two liters of
32:27
sweat in an hour and like a very hot condition,
32:30
um, that's kind of on the upper, upper end of
32:32
the sweat loss. But if you were to do that, you
32:34
would aim for, you know, like 1 .8 liters of
32:37
replacement. And then is that just water that
32:40
you're replacing? Yeah. So in this equation,
32:42
it's, it's, you kind of just figure out the water.
32:45
component so it'd be like 1 .8 liters and the
32:49
most important part of this is that the amount
32:52
of electrolytes you replace is a ratio so you
32:56
don't really want to like pick like an electrolyte
32:58
like and think i'm going to take 500 milligrams
33:02
of sodium every hour that's like not what you
33:04
want to do you always want to replace electrolytes
33:06
as a ratio to water because as your water intake
33:09
changes then your electrolyte intake will change
33:16
To give you an example, one of my races, I had
33:20
a very difficult time with electrolytes. My goal
33:23
was to kind of just drink this amount of water,
33:25
take this amount of electrolytes every hour.
33:28
What I ended up finding out was that I had severely
33:32
low sodium at one point because I had taken in
33:36
about three gallons of water and very, very little
33:39
electrolyte because the hourly intake electrolytes
33:43
I had calculated seemed okay. Until you add in
33:46
the three gallons of water. It was very imbalanced.
33:49
You know, it's very water heavy So I kind of
33:53
went through the cascade of every symptom of
33:56
low sodium that you could have, you know Let's
33:59
go over hyponatremia. Let's go back to internal
34:01
medicine days. Yeah. Yeah, so step by step, you
34:04
know, I I Didn't really notice the first couple
34:08
signs, you know It was hard it was eventually
34:13
became hard to to want to take in anything um
34:18
so i started having like like lack of thirst
34:21
and then kind of lethargic a little bit and i
34:25
felt like my performance was lacking like in
34:27
terms of like the run and i was having a hard
34:29
time like running um and that's one of the first
34:31
things you'll see with dehydration in a sense
34:33
is that you're having a difficulty like maintaining
34:36
the performance you were you were before But
34:41
eventually it got to the point that I was kind
34:43
of confused and a little bit delirious. But again,
34:45
you're running a race at the sun setting is starting
34:47
to get dark outside. So you're thinking like,
34:49
you know, it's just all part of the race. What
34:54
I ended up realizing as things progressed down
34:57
were that I began to lose fine motor function,
35:00
which is one of the very final signs of hyponatremia.
35:05
So, yeah. Talk about what that means. What did
35:10
you notice? Yeah. Again, this was all of these
35:15
things. I think at the time I wasn't the best
35:18
person to step back and analyze this at the time
35:21
because I was, in fact, the person who was being
35:23
affected by it. But I remember as the sun went
35:27
down, I felt like my hands were cold. And in
35:31
reality, it was just that they weren't working
35:33
because of hyponatremia. Because I think it was
35:37
like 78 degrees outside. I remember I was having
35:40
a hard time like turning my headlight on, things
35:44
like that. And I felt like I needed gloves, you
35:47
know, even though it was 78 degrees out. And
35:49
I just I couldn't put the pieces together. I
35:50
wasn't the best. At the time, I was the best
35:53
person to help myself. But thankfully, the crew
35:57
that I had, you know, in my last ounce of self
36:01
-preservation, they gave me a sodium tablet.
36:04
And even though I was being pretty uncooperative
36:06
at the time, I guess, I think they were able
36:10
to get me to take this sodium tablet. And I kind
36:15
of laid down for a second and eventually came
36:18
to and felt 100 times better just from like getting
36:21
sodium in my system. So, you know, you live and
36:24
you learn. And that's something like I didn't
36:27
always try to connect dots, you know, from my
36:30
anesthesia experience. But, you know, that. You
36:33
know, these ratios that we use in terms of fluid
36:35
replacement, like having a balanced crystalloid
36:37
solution, you know, in a sense, that's kind of
36:41
what you need to do for fluid replacement. Another
36:44
area this came up in is we did the analysis on
36:48
whole blood replacement, you know, rather than
36:50
reconstituting whole blood, you know, making
36:53
whole blood through multiple units of packed
36:56
reds and FFP and cryo and all these components.
37:01
we're trialing this whole blood, uh, and, and
37:04
traumas. And it's very similar to that. It's
37:05
like, it's much easier to do, um, like the, you
37:09
know, like the solution that's like a, you know,
37:12
electrolyte drink or electrolyte mix versus like,
37:14
I'm going to drink a bunch of water and then
37:16
I'm going to take a bunch of sodium and then
37:17
I'm going to drink a bunch more water. And then
37:19
I'm going to take a bunch of sodium. It's like,
37:21
you know, having a more stable, smooth, uh, hydration
37:24
plan is, is much, much easier to maintain and,
37:27
and, uh, easier to control. So some of the different
37:33
races that you've run or been adjacent to deal
37:36
with some pretty extreme temperatures too, right?
37:40
Can you talk a little bit about that? Yeah. So
37:43
I, you know, the crazy thing about, you know,
37:48
performing outside is temperature starts to affect
37:52
you. And this is from, you know, research, but
37:55
the heat. In particular, heat starts to affect
37:58
you as little as 45 degrees Fahrenheit. So if
38:02
it's over 45, you're dealing with heat. And even
38:06
though that's typically a cold temperature, that's
38:09
where it begins to affect your performance. So
38:12
heat training has become really popular lately.
38:17
It's shown to increase red blood cell mass and
38:21
kind of help you adapt to... oxygen carrying
38:26
capacity and and uh heat um during your exercise
38:30
or during your races so one of the races i was
38:34
a part of um was you know one of the hardest
38:38
ultra marathons in the world it's uh called the
38:41
bad water 135 um i was able to go out and crew
38:45
and pace uh my friend uh harvey lewis He was
38:49
doing it for the 14th time, which is absolutely
38:52
incredible to think. Somebody's done that race
38:55
14 times. He's very skilled and talented. We
39:04
went out there this past summer, and again, of
39:09
course, it's in Death Valley. The race is in
39:13
the summer, so they really leaned into the heat
39:15
component of this race. How hot is it there?
39:18
race is going on yeah so uh there's nobody ever
39:23
really confirms anything but there's rumors that
39:25
it's the 135 miles and it's the bad water 135
39:28
because it's been 135 degrees out there before
39:32
so there's like some kind of like link to that
39:36
um i think uh when we were out there it was a
39:41
it was a chilly year you know it was kind of
39:43
cool that year and it was like 120. You know,
39:48
it's not too hot, you know, just 120 degrees.
39:51
Did you wear a jacket? Yeah. Yeah, I wore a jacket
39:56
and I wore gloves also. No, the the the interesting
40:04
thing. So the the heat in Death Valley, a lot
40:09
of people were saying that like, oh, well, Death
40:11
Valley, it's a dry heat. I always before this
40:15
was leading up to the race and I kept thinking.
40:17
yeah it's dry heat but it's still feel the fuel
40:20
like temperature is still 125 you know like it's
40:22
still like if it's 125 degrees it's 125 degrees
40:25
that's something i can set my oven to yeah exactly
40:28
so yeah um it certainly was hot but i will i
40:33
can you know give a testament to the heat training
40:37
i think that the sauna really helped and again
40:41
it's it with sauna specifically the saw in a
40:46
training plan they actually had one from the
40:48
race you know it's the first race i've ever been
40:50
a part of that had requirements for crews and
40:52
pacers where they actually sent us a a guide
40:55
and kind of showed us the how to you know prepare
41:00
yourself for the heat out there as hard as the
41:04
race is they have a really good safety record
41:06
and they're really well organized and making
41:09
sure everybody is safe during the event and the
41:15
like just like ultra running the sauna plan is
41:18
mostly about consistency it's about exposing
41:21
yourself to heat very consistently so that you
41:23
get these adaptive changes and what you'll find
41:27
is that throughout these sauna sessions after
41:30
a week or so you tend to get way more comfortable
41:35
and you'll surpass thresholds where you would
41:38
previously feel like you really had to get out
41:40
of the sauna You'll kind of meet that mark and
41:42
be like, oh, I remember this part. You know,
41:44
I remember when that used to be very, very difficult.
41:46
And now I'm like, you know, zoned out completely.
41:50
I'm not even really focused on my effort in here
41:52
up until five minutes after that now. So what
41:59
happens with your GI system when you're on these
42:03
long runs? Do you find that you still need to
42:07
go to the bathroom the same amount or? How does
42:10
that work? Are you finding yourself hungry? What
42:12
do you eat? Yeah, you know, I'm lucky that I
42:16
don't I haven't really had any stomach problems.
42:19
So I guess I'm lucky in that sense. And I generally
42:24
I find it easiest in races to eat things that
42:28
are familiar to you. A lot of people, you know,
42:32
you could try these like the sports sugar supplements
42:37
like the. goo like the gels and things like that
42:39
these uh they have like sachets of um different
42:42
components of it's like maltodextrin powder with
42:45
water and some fructose um they're essentially
42:48
simple sugars that are easy easy to digest as
42:51
the thought and uh they work in you know a more
42:55
timely matter once you consume them they'll get
42:57
into your bloodstream quicker um but i you know
43:01
i find for these longer events one of the enjoyable
43:03
parts is coming up to an aid station with a like
43:06
wide variety of snacks. And you can kind of just
43:08
look at the layout and just find something that
43:11
looks good to you and eat it. And I think that
43:14
that for a lot of people starting out is a really
43:18
good way of going about nutrition because in
43:21
the end, the goal is just to keep eating and
43:24
not to be dependent on something that you're
43:27
like very tired of eating. And you can get palate
43:30
fatigue with some of those gels where. You just
43:33
can't stand to eat another one. And that's not
43:36
a situation you want to be in because ultimately
43:38
in these events, your body needs fuel. So just
43:41
finding fuel any way you can get it, you know,
43:44
whether it's something sweet or salty, just finding
43:47
something that sounds good to you at the moment
43:48
and keeping your palate moving. In a really long
43:53
race, I imagine you've been doing essentially
43:56
the same thing for a very long time. How do you
44:00
manage the mental fatigue and stress of being
44:03
in these extremely long events? Yeah, you know,
44:07
that's a really good question. I think that,
44:10
you know, with training, to be honest, the difficulty
44:15
and the time component, it actually just extends
44:19
everything out further. So in a sense, you're
44:21
chasing the dragon of that difficulty even further
44:24
every time. For instance, the last race I did,
44:29
I had one of the best, you know, trainings like
44:32
blocks going into it. I had really great training.
44:35
I had a lot of really great guidance from friends
44:38
and things. And I remember going into that race.
44:41
I actually didn't feel any difficulty until around
44:46
like mile 70. Like it felt very comfortable.
44:49
And I, you know, I just felt. You know, to be
44:55
honest, I didn't have any issues. Like the weather
44:57
was like relatively good. It was kind of hot
45:00
during the day, but I had done a lot of heat
45:03
training. So overall, you know, I felt very,
45:06
very good up through mile 70. And when it gets
45:09
difficult, I really just more appreciate it.
45:13
I find a way to appreciate it because you had
45:15
to run 70 miles for it to get difficult, you
45:18
know. And that's something you've worked really
45:20
hard to feel. I don't really dread it at all.
45:25
I think that like, you know, you find out how
45:28
deep your well is in a sense whenever you get
45:31
to that moment and you get some difficulty from
45:33
it. The component of like kind of like getting
45:39
stressed out during a race is a lot of times
45:43
if the weather changes, you know, if you're dealing
45:46
with things that you kind of didn't anticipate
45:49
during the race, like. You think the race is
45:51
going to be hard, but when it starts thunderstorming
45:54
and things get really muddy, there are ways to
45:59
deal with, you know, stress or like, you know,
46:04
some like negative mental aspects during a race.
46:08
One of the big things with that that I learned
46:11
from Harvey Lewis is to kind of reframe or just
46:17
really focus on what you can control. I think
46:21
that that, again, has a lot of overlap with anesthesia.
46:26
You know, if you get into a critical situation,
46:28
we have like protocols already in place. We have
46:30
a plan of how we're going to do it. And you really
46:32
just focus on that. You're not really focused
46:34
on, you know, something not going well. If all
46:37
else fails, do chest compressions. Exactly. Yeah,
46:40
there's always a plan B, C, and D. So that's...
46:46
that's really helpful in that sense is I really
46:48
just focused on what I can control. The one race
46:50
I did that had a lot of mud and, you know, as
46:53
a runner, that's one of the most dreaded things
46:56
because you do a lot of training and you do a
46:58
lot of running. And then if you get to a race
47:00
and you have to walk through mud for like eight
47:02
hours, it's like, it's like, you know, you start
47:06
to really think like, I didn't come out here
47:07
to walk through mud for eight hours, but I just
47:11
kind of. You know, you can reframe it and, you
47:14
know, think, well, you know, it's muddy for everybody
47:16
and it's everybody's wet and it's raining on
47:18
everybody. So it's not a problem that's unique
47:21
to you. And with the with the mud, you know,
47:27
if you just keep going, it's it gets better.
47:31
And that race in particular, it rained again
47:34
and there's like puddles that formed. And the
47:37
puddles actually helped you clean the mud off
47:39
of yourself a little bit. And it actually made
47:41
the mud less sticky. So as much as everybody
47:44
was frustrated about the additional rain, it
47:46
actually made the course better, you know, in
47:48
a sense. So, yeah, I just try to focus on what
47:52
I can control. And in that sense, like, am I
47:55
getting blisters because of this mud? Like, maybe
47:57
I need to do extra management with my feet or
48:00
my shoes to help manage it. Or maybe I need to,
48:04
you know. change, you know, clothes a little
48:08
bit more often or prepare, you know, try to wipe
48:10
some of the mud off your legs if you're starting
48:12
to get like, you know, friction or rubbing around
48:14
like your shorts and stuff like that. So what's
48:18
the next big race that you're planning to do?
48:22
So the plan right now, the very next one is going
48:26
to be in just about a month, I think. So in December,
48:32
there's a race called the Dreadmill. And it's
48:36
a treadmill race, so it's – I'm sure everybody's
48:40
done this, but – You're going to have to explain
48:44
what a treadmill race is. Yeah, so it's a race
48:48
that's 48 hours on a treadmill, and the goal
48:51
is just to go as far as you can. So it's pretty
48:59
easy. I'm pretty sure the Geneva Convention has
49:03
outlawed what you're talking about. Yeah, it
49:06
might be a war crime. You're right. Yeah. So,
49:12
yeah, the Dreadmill, I did it last year. It's
49:14
actually a really fun race because there's people
49:19
who you know that might not run or might not
49:23
run your pace. But they can come over and hang
49:26
out with you the whole time you're doing it,
49:27
you know, and you can be right next to them.
49:29
So it adds like a lot of layers. Like that's
49:31
the fun thing about these races is that there's
49:33
different formats and there's always like a different
49:36
layer that makes it a little bit more interesting
49:38
or a little bit more fun. While like, you know,
49:41
a lot of these races are very solo, you know,
49:45
the community around them is really good. So
49:48
almost every race I've made. two to three friends
49:51
that I talk to you regularly, you know, and like
49:53
the network has grown so much just because of
49:55
the community and I think people knowing like
49:58
the consistency and the training it takes you
50:00
kind of find solidarity in that and My one of
50:06
my first races I met you know a friend that I
50:10
now use their treadmill for this treadmill race
50:13
and We kind of do it together and it's it's been
50:15
a lot of fun so Do you have any rituals that
50:20
you will do before a race or after a race? Yeah,
50:23
I think the lead up to a race can be it's different
50:28
for everybody. But a lot of people mentioned
50:32
if they really taper their training, it's strange,
50:35
but you can kind of get a little bit irritable
50:37
from not running as much. It's just a strange
50:39
phenomena. I think it's like. Maybe you're not
50:42
getting the outlet or maybe you have like this
50:44
extra energy that's kind of given off an irritability
50:47
or, you know, it's really hard to describe. I
50:51
don't find that I'm like super irritable, but
50:54
I do feel like I have like some like energy that
50:58
I can't really do anything with going into a
51:01
race. So in addition to that, I also cut my caffeine.
51:07
So I've completely stopped caffeine the week
51:10
of a race. to kind of make myself more sensitive
51:13
to it. And basically going into a race that last
51:17
day or so of prep can be very, uh, like stressful
51:23
and frustrating, I guess, because you're doing
51:26
a lot of stuff for the race, but it's not running,
51:29
you know, and it can be a little hectic sometimes
51:32
where you kind of just want to be done with all
51:34
that background stuff and just start running
51:36
in the race. So I think the biggest thing that
51:40
I do is I, plan in that I'm going to have everything
51:44
done by a certain time and truly have like a
51:47
window of time where I do like nothing where
51:50
I can just relax and not have to do anything
51:53
else for the race. And just that way I'm able
51:55
to say everything is done. Like everything's
51:57
been checked and double checked and I have everything
52:00
I need. And most importantly, my ritual is try
52:04
to go to bed early. A lot of the races, either
52:07
the commute to the race or the race itself will
52:10
start early in the morning. And, you know, if
52:12
you're doing a race that's going to go for 24
52:16
hours or more, you know, sometimes 30 plus hours
52:19
or sometimes days, then you really want to start
52:23
that off with a good night of sleep, you know.
52:25
But I think that that as a ritual is giving me,
52:29
you know, I think success so far in terms of
52:32
feeling tired during a race. So lastly, what
52:37
style points or points of personal preference?
52:40
have helped you both in and out of the operating
52:44
room or both on and off of the race course? I
52:48
think being consistent in some kind of exercise
52:56
is super important. You know, I kind of talked
52:59
when I first did my introduction, I talked about
53:01
this circuitous path to ultra running. And, you
53:06
know, when I look back at that, I realized that
53:08
it's. really just like a legacy of just like
53:11
physical activity. Like, you know, that's kind
53:13
of what it's chalked up to. It's not really,
53:14
you know, it's just my personal story of just
53:17
being physically active. And it doesn't have
53:20
to be, you know, one specific thing. You can
53:23
always like change out of, you know, different
53:26
things that you're into at the time. But in the
53:28
end, it's all physical activity. And I think
53:31
that having some component of that, even if it
53:34
changes over the years, is super important to
53:36
your professional life. a great work -life balance
53:40
it's a great like stress reliever um it um yeah
53:46
it keeps you healthy you know like weight -bearing
53:47
exercise and just you know it helps you age better
53:50
and um you have a much better uh quality of life
53:59
for much longer that's really neat i appreciate
54:03
that and i have one last question for you do
54:07
you feel like you're running towards something
54:09
or away from something oh man that's a good question
54:12
it depends you know i yes you asked me a question
54:19
earlier about uh the competition during or about
54:22
the the last part of a race in the last 80 miles
54:25
or when you get to mile 80 of a race and uh you
54:28
know a big part of that is the competition at
54:31
that point you know in the beginning of 100 mile
54:32
race mile one for me personally i'm not super
54:35
concerned about the competition or really looking
54:37
at the competition, but around mile 80, it can
54:40
be a big motivator. And in those cases, you do
54:42
feel like you're both chasing somebody and you're
54:45
running away from somebody. So that's kind of
54:47
the fun of the race is that like, there's a lot
54:50
of camaraderie, like your competition will be
54:52
like offering you water, like offering you help,
54:54
um, at the same time as like you're racing them.
54:57
And it's, it's, you know, that's, that's all
55:00
part of like the, the fun culture of, of ultra
55:03
marathons. Jordan, thank you so much for joining
55:06
us. Yeah. Thanks for having me. Thanks for joining
55:12
us for yet another episode of the award -winning
55:14
style points podcast. What award you ask? That
55:18
would be the award for the best anesthesiology
55:21
themed long form interview style podcast at the
55:24
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55:26
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55:30
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55:42
.com. Well, we have reached the end of the marathon,
55:47
everyone. Take a deep breath. Open your eyes.
55:51
We're all done.