Latest / 20-Minute Health Talk / Nerve blocks: Fighting opioid addiction with safer pain management

Transcript

Nerve blocks: Fighting opioid addiction with safer pain management · 20-Minute Health Talk

• 0:02
  Dr. Marino: What's so beautiful about the nerve block
• 0:05
  is that, God forbid, if you fracture your hip, you're going to come in
• 0:08
  and people are going to perform a procedure that takes seconds and is
• 0:14
  going to give you significant pain relief without the adverse effects
• 0:17
  of morphine-like drugs.
• 0:19
  This will be standard of care across every Northwell facility.
• 0:30
  Host: Welcome to 20-Minute Health Talk.
• 0:32
  I'm your host Rob Hoell. The overuse of pain medications and narcotics
• 0:37
  like opioids in health care over
• 0:39
  the last two decades has had devastating effects.
• 0:42
  Our guests today are leading the way in expanding the use of nerve
• 0:45
  blocks.
• 0:46
  The use of this long-lasting regional anesthetic has revolutionized
• 0:50
  the field of anesthesia and is part of an important and necessary
• 0:54
  shift in the conversation about how we manage pain
• 0:58
  joining us in the studio is
• 1:00
  Dr. Joseph Marino.
• 1:01
  He is Northwell's senior, vice president for anesthesia who is not
• 1:04
  only championing
• 1:05
  the use of nerve blocks in the surgical setting.
• 1:07
  Now expanding its use to other services, including emergency
• 1:11
  departments; a game changing move that has immediate and potentially
• 1:15
  life-saving results.
• 1:19
  Here to share their experience and joining us virtually in implementing
• 1:22
  this novel approach in an emergency department setting are:
• 1:25
  Dr. Joshua, Greenstein, assistant medical director, the department of
• 1:29
  emergency medicine at Staten Island.
• 1:31
  Dr. Maria Tama, co-director for the division of emergency, ultrasound and
• 1:35
  Dr. Simone Rudnin, co-director division of emergency ultrasound.
• 1:40
  So, we'll get started with a question for you.
• 1:42
  Dr. Marino. Tell us what exactly is a nerve block?
• 1:45
  Dr. Marino: So a nerve block is nothing more than the placement
• 1:49
  of Novocaine or local anesthetic around the nerve.
• 1:53
  visa-vie a needle tip. Under the guidance of an ultrasound probe
• 1:59
  we're able to visualize the needle tip and also visualize the
• 2:05
  novocaine or local anesthetic.
• 2:07
  Bathe the surrounding nerve.
• 2:10
  Host: So, basically, what it's doing, it's like almost big being at the
• 2:12
  dentist.
• 2:13
  It's numbing the area, so you're not feeling pain, but you're not
• 2:16
  feeling High?
• 2:17
  Correct
• 2:19
  Host: That's awesome.
• 2:20
  So you're saying that nerve blocks have revolutionized the field of
• 2:23
  anesthesiology in the last two decades.
• 2:25
  Why?
• 2:26
  Dr. Marino: So I just want to give the visual to the patients and two people out
• 2:31
  there.
• 2:32
  We used to put people to sleep and the only mechanism that we had to
• 2:36
  treat their post-operative pain was intravenous morphine-like drugs
• 2:42
  or narcotics.
• 2:43
  So typically, you would find a patient in the recovery room
• 2:47
  holding an emesis basin
• 2:49
  nauseous and potentially vomiting because of the side effects
• 2:54
  of that opioid and also very drowsy and very sedate.
• 3:00
  In certain cases, if there was too much morphine or too much opioid given
• 3:06
  there would be some respiratory rate or breathing decrease issues.
• 3:12
  So, opioids, and I'm talking not too far ago
• 3:17
  I'm talking probably 15 years ago, were the mainstay of post-operative
• 3:23
  pain therapy. Now because of the advent of the nerve block, and the
• 3:28
  ability for us
• 3:30
  to anesthetize a certain part of the body that had surgery performed
• 3:36
  on it
• 3:37
  virtually eliminates the need for these post-operative opioids.
• 3:42
  Host: Dr. Greenstein the team at Staten Island University.
• 3:44
  Hospital began using femoral nerve blocks for patients into the
• 3:48
  emergency department in 2021.
• 3:49
  Tell us about how this got started started.
• 3:52
  Dr. Greenstein: It started becoming described in the literature in the last decade, but it
• 3:55
  really wasn't standard care.
• 3:57
  I myself graduatedin 2015.
• 4:00
  Never did a single one of these procedures who during my residency and so we
• 4:03
  didn't really have the staff that was really trained to do it.
• 4:06
  Even though it was something we thought we thought we'd be able to do.
• 4:09
  We put a lot of needles
• 4:10
  next targets.
• 4:10
  We use ultrasound in many different procedure itself.
• 4:13
  So Dr. Marino, the real visionary along with power chair at the time.
• 4:16
  Dr. Birol, who's now, the associate medical director came together
• 4:19
  and we said, how can we make this a reality for our patients?
• 4:22
  How can we train our staff? Help
• 4:23
  Provide some education. And furthermore it was a little complicated because
• 4:26
  a lot of these patients were doing this for patients with hip fractures
• 4:30
  So they're being admitted to other services.
• 4:32
  Other surgeons are taking care of the patients.
• 4:34
  They're gonna have to deal with the procedure that we do, and they're
• 4:36
  going to manage it.
• 4:37
  And so it's kind of like we're handing off or procedure and they're
• 4:39
  going to then be left with the patient and self.
• 4:41
  And so, we brought all the players involved, we brought
• 4:43
  orthopaedics, we brought
• 4:44
  Trauma, anesthesia, kind of explained what we're going to do.
• 4:48
  We got brought in from all the major players, and we were able to
• 4:50
  accomplish it.
• 4:51
  And we're currently, we're aiming to get 100% by September of this
• 4:55
  year.
• 4:55
  We're currently at 70% of our emergency medicine, physicians, are all
• 4:58
  trained
• 4:59
  how to do this and
• 5:00
  credentialed.
• 5:00
  That's really really revolutionized
• 5:02
  how many are getting it
• 5:03
  Because instead of being one in a few that know how to do it
• 5:06
  70% are doing it.
• 5:07
  So, when you have this patients, it's not like, oh, I don't know how
• 5:09
  to do it.
• 5:10
  It's when can we do it?
• 5:13
  Host: Dr. Greenestein just talked a little bit about training
• 5:15
  emergency room physicians in the use of femoral nerve blocks.
• 5:18
  Dr. Rudnin
• 5:19
  Can you tell us a little bit more about that process?
• 5:22
  Dr. Rudnin: Sure. So the ultrasound division in the ER is ensuring that all of our Ed
• 5:29
  providers
• 5:29
  are receiving training to perform these procedures. Our residents get
• 5:37
  every several months, a procedure lab where they get to practice it.
• 5:41
  Our attendings also.
• 5:41
  We do faculty development for that.
• 5:44
  So they have simulators where they can actually practice these
• 5:47
  procedures and they ultimately get credentialed and are very excited
• 5:52
  to go ahead and continue and providing these procedures to actual
• 5:56
  patients.
• 5:57
  Dr. Tama: And we also
• 6:00
  review a lot of these cases.
• 6:03
  And so a lot of the residents and attendings are kind of still
• 6:06
  reaching out to us.
• 6:07
  Like, oh, we did this nerve block, can you take a look?
• 6:10
  So we're still kind of, you know, making sure everyone's following the
• 6:13
  rules and doing it appropriately.
• 6:16
  Host: It's awesome to hear about that enthusiasm Dr. Tama
• 6:19
  right now, emergency departments at Northwell
• 6:21
  are starting with femoral block, but there are many types of
• 6:24
  nerve blocks. Are there plans expanding training to emergency
• 6:28
  physicians in uses for others?
• 6:30
  Dr. Marino: So I love the question and just like the Staten Island team and I were
• 6:35
  envisioning bringing this powerful tool to treat hip fractures
• 6:42
  vis-à-vis, the femoral block and that can can essentially eliminate
• 6:47
  pain leg knee
• 6:52
  foot, if we have to. We already have visions of expanding the use of
• 6:56
  ultrasound-guided nerve blocks for
• 7:00
  Upper arm problems.
• 7:02
  So somebody comes in with a shoulder dislocation or a
• 7:05
  laceration to the arm, shoulder or hand
• 7:09
  God willing
• 7:10
  If we continue on this path of innovation, we're going to be able to
• 7:16
  in service our emergency medicine physicians, in partnership and
• 7:20
  collaboration with the anesthesiologist, to do these upper arm or
• 7:25
  upper extremity nerve blocks and provide a reduction in pain.
• 7:30
  A reduction in need for opioids and significant patient satisfaction.
• 7:35
  Host: So where exactly are the nerves that get the nerve blocks in the human
• 7:39
  body?
• 7:40
  Dr. Marino: Yeah.
• 7:40
  So, you know, I'm going to give you a little bit of an anatomy lesson
• 7:44
  here.
• 7:44
  So the brachial plexus or the upper extremity nerve bundle is just
• 7:51
  above the shoulder and we could place novocaine around that brachial,
• 7:56
  plexus to essentially numb the shoulder entire arm
• 8:00
  and hand. The lumbar plexus is where the femoral nerve is located in
• 8:04
  the groin.
• 8:05
  And then the abdomen has a variety of different areas that we could
• 8:10
  inject novocaine in under ultrasound guidance, to significantly
• 8:14
  reduce some of those more provocative surgical operations of the
• 8:18
  abdomen, like a hernia operation or a C-section.
• 8:24
  Host: It's great
• 8:25
  Dr. Tama what types of patients are using are using nerve blocks for?
• 8:30
  Dr. Tama: So, the majority of patients are ones with hip fractures.
• 8:35
  Sometimes, we'll get femur fractures as well.
• 8:37
  You also can use it for patients that have like really bad laceration or
• 8:43
  patients that have a significant burn to the thigh
• 8:47
  We're kind of on the lookout for that. But those are other potential
• 8:50
  uses for this nerve block.
• 8:53
  Host: Yeah.
• 8:53
  I mean, I would imagine it hip fractures and extremely painful and
• 8:58
  difficult to deal with.
• 8:58
  So Dr. Marino
• 8:59
  How does
• 9:00
  the nerve block compared to the standard approach in this situation and
• 9:04
  what has been the reaction from the patients who received the nerve
• 9:07
  block?
• 9:08
  Dr. Marino: Yeah.
• 9:08
  So excellent question and the reaction has been, you know, needless to
• 9:16
  say, high satisfaction scores.
• 9:19
  So, you know, just think about it.
• 9:21
  Somebody is going to church.
• 9:23
  They fall on the concrete and they don't know if they have a fractured
• 9:28
  hip, but it's really
• 9:30
  uncomfortable.
• 9:30
  And by the time they get into the ambulance and bounce around on the
• 9:35
  gurney, get taken to the hospital. Bounce Around even more.
• 9:39
  That is a very provocative experience for the patient.
• 9:42
  And again in the past all we did in all we had were IV morphine like
• 9:47
  injections for these patients.
• 9:49
  Now it worked it would take a little bit of the edge of the pain away.
• 9:53
  But if you moved that patient, the pain would still be there.
• 9:58
  And what's so beautiful
• 10:00
  about the nerve block is that you can move these patients.
• 10:05
  And the movement will not provoke that serious pain that you see with
• 10:11
  the with the IV narcotic injection.
• 10:13
  So, not only does it eliminate the need for narcotic, or I should say,
• 10:18
  significantly reduce - its opioid sparing - but the movement of the
• 10:24
  patient is appreciated with significant less provocation.
• 10:28
  Host: And when you talk about collaboration, you can only see this spreading
• 10:31
  and the Innovation growing, you know, not only in Northwell but
• 10:34
  in other places.
• 10:35
  Dr. Marino: Is correct hundred percent?
• 10:37
  Yeah, it's only a matter of time.
• 10:38
  I mean now we piloted this at Staten Island in their Brilliance and
• 10:43
  success demonstrated that it works and it's safe.
• 10:47
  We're rolling it out at South Shore [University Hospital] and before you know, what Northern
• 10:51
  Westchester [Hospital], Phelps [Hospital], [LIJ] Forest Hills, they're all going to be a part of it.
• 10:55
  And then before, you know it this will be standard of care across
• 10:59
  every Northwell facility.
• 11:01
  God forbid.
• 11:01
  If you fracture your hip you're going to come in and people are going
• 11:05
  perform a procedure that takes seconds and is going to give you significant
• 11:10
  pain relief without the adverse effects of morphine like drugs
• 11:14
  Host: Dr. Tama.
• 11:15
  What do you say to a patient?
• 11:16
  Obviously, a patient's going to come in and excruciating pain and they
• 11:18
  might be demanding, you know, some sort of pain medication.
• 11:21
  What do you say to them?
• 11:21
  And how do you can convince them that this is the right move?
• 11:26
  Dr. Tama: So it does take some finesse definitely, because it is something new
• 11:30
  that a lot of patients or their families are not familiar with.
• 11:34
  We tell them kind of what to expect.
• 11:37
  And then we tell them that later on
• 11:39
  they won't be able to move their legs and kind of the expectations of
• 11:42
  what they should feel after the block is done and when it's done
• 11:45
  correctly. And everyone is like signing the consent form, like right
• 11:49
  then and there like a sure, sign me up.
• 11:51
  No problem.
• 11:52
  It definitely kind of
• 11:54
  starts their treatment from the beginning
• 11:57
  they walk into the emergency department.
• 12:00
  and helps them kind of move along through
• 12:02
  the hospital stay quicker.
• 12:04
  Host: So, Dr. Rudnin
• 12:05
  does learning something like this, make you a better
• 12:08
  physician?
• 12:10
  Dr. Rudnin: So learning a technique like a nerve block, as long as we were
• 12:14
  familiar with the anatomy hitting that nerve kind of came as second
• 12:18
  nature
• 12:18
  once we were comfortable with the anatomy. When it comes to making you
• 12:23
  a better physician
• 12:24
  Absolutely.
• 12:25
  You're able to do a procedure that spares a patient significant pain
• 12:30
  without providing them, you know, the potential effects of opioids.
• 12:36
  Dr. Tama: Yeah, and the definitely the patients feel that also
• 12:40
  We've had a few cases where we've had patients request, you know, they
• 12:44
  didn't, they did not get their surgery within 24 hours because of
• 12:48
  other Hospital complications and they have actually called and
• 12:52
  requested to have the emergency department come and do another nerve
• 12:56
  block.
• 12:57
  And so they definitely feel the benefits of it as well.
• 13:01
  Host: Dr. Greenstein how satisfying is it to be leading this effort and to be
• 13:05
  helping to, to get this message out and to be training others?
• 13:08
  Dr. Greenstein: Yeah.
• 13:09
  I mean, it's absolutely amazing.
• 13:10
  That what's really amazing is when the patient's family finds in the
• 13:13
  hallway, the next day they tell you about how, like their mother,
• 13:16
  their grandmother got a good night's sleep or how they didn't
• 13:19
  take his another dose of pain medication till the surgery.
• 13:22
  That's really get the ultimate satisfaction.
• 13:25
  So, it's really great thing, and it's gone really
• 13:28
  Well.
• 13:28
  We've had no issues.
• 13:31
  Using the ultrasound has really made it straightforward and simple
• 13:33
  so it's really awesome.
• 13:42
  Host: We sort during Covid, such an increase in opioid use in opioid
• 13:46
  overdoses.
• 13:47
  While still necessary.
• 13:48
  In some cases.
• 13:49
  These dangerous narcotics can lead to addiction. About three to four
• 13:53
  percent of patients undergoing
• 13:54
  elective surgery who have never taken an opioid develop a dependency.
• 13:58
  The addiction rate is higher for some types of procedures, and we
• 14:01
  know it's also associated with longer hospital stays and a higher
• 14:04
  rate of readmission. Can nerve blocks help stem that tide.
• 14:09
  Dr. Marino: Oh, it's always
• 14:12
  Back to, you know, the concept of treating pain.
• 14:14
  So procedurists in general, that would perform a surgical procedure,
• 14:19
  would typically give a patient, you know, a couple of week or a month
• 14:23
  supply of opioids.
• 14:25
  We no longer do that.
• 14:26
  We Now understand that giving a patient the appropriate dose of a pain
• 14:32
  medication.
• 14:33
  After a surgical procedure 3 to 5 days-worth; getting a nerve block,
• 14:39
  which is going to essentially
• 14:41
  significantly reduce the amount of pain in that very provocative first
• 14:46
  post-operative day and then allow the pain to the patient to
• 14:50
  transition to their pain medication for a three to four day
• 14:55
  period is exactly how the medical community is looking to.
• 15:00
  address and define success in reducing opioid dependency in surgical
• 15:04
  population.
• 15:05
  Host: Have you seen any data yet showing that how this is reducing
• 15:09
  addiction?
• 15:10
  Dr. Marino: So that's what the Statin Staten Island team and I are planning on
• 15:15
  doing this collecting data.
• 15:17
  So we have years of data of not doing a femoral nerve block and seeing
• 15:22
  how much morphine like medication patients with a hip fracture
• 15:26
  typically have received, and now, we're going to compare
• 15:30
  this new cohort of patients that have received the femoral nerve
• 15:34
  block and we're going to look at variables like how long it took them
• 15:38
  to go to surgery?
• 15:39
  What their Hospital length of stay is.
• 15:42
  And without question what their pain scores and morphine consumption
• 15:46
  was. And I think it's going to be easy to show that the morphine
• 15:50
  consumption and the pain scores are significantly lower leading to
• 15:55
  higher patient satisfaction scores.
• 15:57
  Definitely, and Dr. Marino I'd like to add, I think also
• 16:00
  So the patient outcome is going to be not only are they going to have lower
• 16:02
  morphine, but their outcome; they'll be ambulatory more quickly
• 16:06
  after surgery.
• 16:06
  I think the all those things that you want, you want the person that
• 16:09
  fell and has a fracture to be the same person before the surgery as
• 16:13
  they are after the surgery.
• 16:14
  This is going to help a lot.
• 16:16
  Host: We've been talking about using one type of nerve block in emergency
• 16:19
  departments, but
• 16:20
  Dr. Marino
• 16:20
  How commonly do nerve blocks
• 16:21
  get used in the surgical setting and at Northwell
• 16:24
  what is the ratio of patients getting nerve blocks compared to
• 16:26
  those other methods of pain management?
• 16:29
  Dr. Marino: I would say it's the overwhelming majority of patients who were having
• 16:33
  some sort of a provocative Orthopedic procedure.
• 16:36
  So total knee replacement, total hip replacement, total shoulder
• 16:40
  replacement, standard of care is to get what we call a regional nerve
• 16:45
  block.
• 16:46
  In addition to some sort of either general anesthetic or sedation.
• 16:51
  So that when the patient does wake up from the surgical procedure,
• 16:57
  their body part is totally numb.
• 17:00
  Host: And what about when when, when it wears off the 18 to 24 hours is up
• 17:04
  then just the pain come back?
• 17:06
  Dr. Marino: So we teach the patient that as they're getting that numb and tingling
• 17:10
  feeling starting to come back because, you know, when the numbness is
• 17:14
  starting to wear off, they should start their oral pain medication
• 17:19
  regimen.
• 17:21
  Host: Ok. And what is that mostly is that mostly like ibuprofen?
• 17:23
  Dr. Marino: it's a, it's usually, a combination of Ibuprofen and Tylenol and a
• 17:27
  very, very light narcotic.
• 17:30
  Host: Are there any side effects?
• 17:32
  I know like sometimes with opioids, you could you get nauseous, you
• 17:35
  could vomit, you could have itching.
• 17:37
  Is there any side effects with with a nerve block
• 17:39
  Before when we were doing the Poke and hope approach
• 17:42
  We would put our finger on the femoral artery because the femoral
• 17:46
  nerve lies right next to it.
• 17:48
  And we would place the needle tip right next to the nerve.
• 17:52
  And again, we would poke through the skin and hope that the local
• 17:56
  anesthetic or novocaine was bathing
• 18:00
  The periphery of that nerve.
• 18:01
  Well, sometimes the needle tip would enter into a blood vessel and
• 18:07
  that's not where that local anesthetic should go.
• 18:10
  If that was the case, the patient may be afflicted with something called
• 18:16
  local anesthetic before when we were
• 18:19
  Where when the body when the blood vessels absorb quickly the local
• 18:24
  anesthetic that is not a good place to be. Patients can get very
• 18:28
  dizzy.
• 18:29
  They could get numbness
• 18:30
  around their lips; and in severe cases, it could lead to a seizure.
• 18:35
  So the ultrasound has virtually eliminated that concept that Prospect
• 18:40
  and that's why we're all as practitioners feel like we have power in
• 18:45
  our hands.
• 18:46
  Host: So this is all exciting stuff, you know and here on 20-Minute Health Talk
• 18:49
  We always like to end on a positive note.
• 18:51
  So I like to ask each one of you, what gives you hope what gives you
• 18:55
  optimism going forward and I'll start with you.
• 18:58
  Dr. Rudnin.
• 19:00
  Dr. Rudnin: So, what gives us hope at least for me is the fact that patients their
• 19:05
  overall satisfaction is going to be increased.
• 19:08
  They're going to be having a significant reduction of their pain
• 19:12
  without having the detrimental side effects of opioids
• 19:16
  Host: Dr. Tama, what gives you hope but gives you optimism.
• 19:21
  Dr. Tama: This collaboration that we have with anesthesia
• 19:26
  gives us hope.
• 19:28
  I think that
• 19:29
  as physicians we want to encourage each other to continue to do better
• 19:33
  and this kind of multidisciplinary team work
• 19:37
  really gives me hope that there's so much more that us as emergency
• 19:40
  department
• 19:40
  doctors can do for our patients and even started from the beginning
• 19:44
  because we are the entryway to the hospital.
• 19:47
  So I definitely think that this opens the door for so much more work.
• 19:51
  That could be done for them.
• 19:53
  Host: Has there been any
• 19:55
  pushback from Physicians?
• 19:58
  Because sometimes,
• 19:59
  People don't want to do different things.
• 20:00
  They're kind of set in their ways.
• 20:04
  Dr. Greenstein: Yes, I would say that.
• 20:05
  That was probably one of my biggest concerns was teaching, you know,
• 20:09
  new trick to some people that have their set ways and how they
• 20:11
  managed their practice and manage other things.
• 20:13
  And once somebody learned how to do it and do just that one of them
• 20:17
  and saw the impact on the patient's, they want to do it, like they
• 20:20
  wanted to become in their practice.
• 20:22
  So we've been able to just want to none like people do one of them
• 20:25
  like, oh, I need to do it for every single one of patients.
• 20:28
  So it's really been amazing.
• 20:28
  And that's really the hope for me is that we bought into this, this
• 20:32
  culture of nerve blocks
• 20:33
  is that the sky's the limit
• 20:35
  We're a burn center here.
• 20:36
  We have so many terrible burns of the extremities, imagine we can provide
• 20:39
  them with an anesthetic right to that to the nerve, give them 18 hours
• 20:43
  of pain control instead of pain medicine after pain medicine and pain medicine,
• 20:47
  and the outcomes could be great.
• 20:49
  Host: Dr. Greenestein I loved how you answered both of those questions right
• 20:52
  there.
• 20:52
  Dr. Marino, what gives you hope?
• 20:54
  What gives you optimism going forward?
• 20:56
  Dr. Marino: So, I'm the old guy of the group and you look at these three.
• 21:00
  brilliant young physicians to my right. You know, sometimes I come off
• 21:06
  as The Nutty Professor.
• 21:06
  Hey guys, I got this idea.
• 21:09
  I think it's going to work.
• 21:10
  I think it's going to have an impact on patients and you really don't
• 21:13
  know what the feedback or the buy-in is going to be.
• 21:17
  But my hope really lies and I'm really echoing what
• 21:21
  Maria said before, which is it all comes down to Innovation.
• 21:26
  So if you change your thought process and you have
• 21:30
  Courage to ask a question and then you have these young spirited,
• 21:34
  brilliant minds
• 21:36
  that look at you and have enough trust in you.
• 21:38
  And to say, okay.
• 21:42
  Let's try this.
• 21:43
  Let's make sure if we're going to do it
• 21:45
  Let's do it right.
• 21:46
  But let's try this.
• 21:47
  And just because of our partnership.
• 21:51
  We're already able to impact people on a real visceral level, and my
• 21:56
  hope lies in that.
• 21:57
  As long as we continue to come up with the idea.
• 22:00
  Continue to have the courage to ask the question.
• 22:03
  Always try and overcome the hurdle, find the yes.
• 22:06
  And together you could see that there are differences in generation
• 22:10
  because of the age gap. But because of these brilliant minds, my hope
• 22:15
  lies in them.
• 22:18
  Host: Thank you all so much for joining us here on 20-Minute Health Talk.
• 22:20
  It was a great conversation.
• 22:22
  Thank you.
• 22:23
  Dr. Marino.
• 22:23
  Dr. Greenstein.
• 22:24
  Dr. Tama and Dr. Rudnin.
• 22:27
  And thank you.
• 22:27
  The Listener for tuning in.
• 22:29
  I'm Rob Hoell
• 22:29
  Have a great day and stay safe.