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Take aways: Learn about Hilary and Steve's journey to enhance care for people with aphasia. Learn about communication access as a health equity issue. Identify systematic gaps and the disconnect between training and real world needs of people with aphasia. Learn about the development of the MedConcerns app. Get sneaky! Learn how the MedConcerns app can serve four functions simultaneously: 1) meeting the needs of someone with aphasia 2) serving as a tool that providers can use to communicate with people with aphasia 3) providing education to providers who learn about aphasia as they use the app 4) bringing SLPs and other providers together to meet the needs of people with aphasia   Welcome to the Aphasia Access Conversations Podcast. I'm Jerry Hoepner. I'm a professor at the University of Wisconsin – Eau Claire and co-facilitator of the Chippewa Valley Aphasia Camp, Blugold Brain Injury Group, Mayo Brain Injury Group, Young Person's Brain Injury Group, and Thursday Night Poets.  I'm also a member of the Aphasia Access Podcast Working Group. Aphasia Access strives to provide members with information, inspiration, and ideas that support their aphasia care through a variety of educational materials and resources. I'm today's host for an episode that will feature Hilary Sample and Dr. Steven Richman to discuss their app, MedConcerns. We're really excited to share this with you, so I'll jump into introducing them.   Hilary G. Sample, MA, CCC-SLP Hilary is a speech-language pathologist, educator, and co-creator of MedConcerns, a communication support app that helps people with aphasia express medical concerns and participate more fully in their care. The app was born out of her work in inpatient rehabilitation, where she saw firsthand how often individuals with communication challenges struggled to share urgent medical needs. Recognizing that most providers lacked the tools to support these conversations, she partnered with physician Dr. Steven Richman to create a practical, accessible solution. Hilary also serves as an adjunct instructor at Cleveland State University.   Steven Leeds Richman, MD Dr. Steven Richman is a hospitalist physician and co-creator of MedConcerns, a communication support app that helps people with aphasia express medical concerns and participate more fully in their care. With nearly two decades of experience in inpatient rehabilitation, he saw how often communication barriers prevented patients from being heard. In partnership with speech-language pathologist Hilary Sample, he helped translate core medical assessments into an accessible tool that supports clearer, more effective provider-patient communication.     Transcript: (Please note that this conversation has been auto-transcribed. While we do our best to review the text for accuracy, there may be some minor errors. Thanks for your understanding.)   Jerry Hoepner: Well, Hello, Hillary and Steve. Really happy to have you on this aphasia access conversations podcast. With me, I'm really looking forward to this conversation. It's maybe a year or 2 in the making, because I think this was at the previous Aphasia Access Leadership Summit in North Carolina. That we initially had some discussions about this work. And then life happens right? So really glad to be having this conversation today. Hilary Sample: And we're really glad to be here.   Jerry Hoepner: Absolutely. Maybe I'll start out just asking a little bit about your background, Hillary, in terms of how you connected with the life participation approach and aphasia access and how that relates to your personal story.   Hilary Sample: Sure, so I haven't been in the field long. I graduated in 2019 and began my career immediately in inpatient rehab. I have to remember. It's talk slow day, and I'm going to make sure that I apply that as I speak, both for me and for listeners. So I began on the stroke unit, primarily in an inpatient rehab setting, and I've worked there for the majority of my career. I came in as many, probably in our field do, trained and educated in more of an impairment based approach but quickly when you work with people, and they let you know who they are and what they need. The people that I worked with on the stroke unit, the people with aphasia let me know that they needed more of a life participation approach. You know I learned how vital it was to support communication and to help him, you know, help them access their lives, because most of the time I entered the room. They had something they wanted to communicate, and they had been waiting for someone who had those skills to support communication in order to get that message across. So it wasn't about drills it was about. It was about helping them to communicate with the world, so that I spent more and more time just trying to develop my own skills so that I could be that professional for them and that support. And then that took me. You know that it just became my passion, and I have a lot of room to improve still today, but it's definitely where my interest lies and at the same time I noticed that in general in our hospital there was a lack of communication supports used, and so I thought that in investing in my own education and training, I could help others as well. And so I started doing some program development to that end as well with training and education for healthcare staff.   Jerry Hoepner: I just love the fact. And actually, our listeners will love the fact that it was patients who connected with you, people with aphasia, who connected with you and encouraged you to move towards the life participation approach, and how you learn together and how that's become your passion. That's just a really great outcome when people can advocate for themselves in that way. That's fantastic.     Hilary Sample: Yeah, it really meant a lot to me to be able to receive that guidance and know that, you know there's an interest in helping them to let you know what they want from therapy, and that was there. But a lot of times the selections were impairment based, and then we. But there was something wrong, and we needed to uncover that. And that was, you know, that was the push I needed to be able to better support them.   Jerry Hoepner: Yeah, that's really great, Steve. I'm interested in your story, too. And also how you came to connect with Hillary.   Steve: I started as a trained as a family physician, had a regular outpatient office for a number of years, and then transitioned into inpatient rehab. That's where I really started to meet some people with aphasia. For the 1st time. Hilary and I have talked a few times about my training and education about aphasia before we met each other, and it was really minimal in Med school. They had lectures about stroke and brain injury, and some of the adverse effects you might get from that. And they, I'm sure, mentioned aphasia. But I really don't recall any details, and if they did teach us more, it would just nothing that I grasped at the time. So I would walk into these patient rooms, and what I would normally do for my trainings. I would ask people all these open, ended questions to start with, and then try to narrow down, to figure out what their problems are, and with people with aphasia, especially when they have minimal or no language skills. They couldn't. I was not successful at getting useful information out, and I remember walking out of those patient rooms and just being frustrated with myself that I'm not able to help these people, and the way I can help everyone else, because if I don't know what's going on. you know. How can I? It was really challenging and I really didn't know where to go. I talked to a few other doctors, and there didn't seem to be much in the way of good information about how to move forward. Eventually I met Hillary, and we would have these interesting episodes where I would talk or try to talk with the patients and get minimal, useful information. And Hillary would come back and say, they're having this problem and this concern. And with this medicine change. And how do you do that? How and that kind of started our us on the pathway that we've taken that recognition from my end that there's a lot that can be done. And the yeah.   Jerry Hoepner: Yeah, I love that story, and it's a really good reminder to all of us that sometimes we forget about those conversations, the conversations with physicians, with other providers who might not know as much about aphasia. I'll just tell a really quick story. My wife used to work in intensive care, and of course she had been around me for years, and they would have someone with aphasia, and her colleagues would be like, how do you even communicate with them, and she would be coming up like you, said Steve, with all of this information about the patient, and they're like, where are you getting this information. The person doesn't talk.   Hilary Sample: Yes.   Jerry Hoepner: And that just emphasizes why it's so important for us to have those conversations, so that our all of our colleagues are giving the best care that they can possibly provide.   Hilary Sample: That's a great story. That was very much like almost verbatim of some of the conversations that we initially had like, where is this coming from? They don't talk, or you know they don't have. Maybe they don't have something to say, and that's the assumptions that we make when somebody doesn't use verbal communication. You know, we quickly think that maybe there's not something beneath it, you know. I have a story as well. So what led to a little bit more toward where we are today. sitting in those rooms with people with aphasia and apraxia and people with difficulty communicating. There's 1 that stuck out so much. She was very upset, and that it was. And I we had just really developed a very nice relationship, a very supportive relationship she kind of. She would let me have it if she was upset about something. We had really honest conversations and it and it was earlier on to where I was stretching my skills in in using communication supports, and she really helped me grow. But I remember being in her room one day, and she had something to share. And this is a moment that repeated itself frequently, that the thing that needed to be shared was medical in nature, you know, in inpatient rehab. That's a frequent. That's a frequent situation that you run into. And we sat there for maybe 15 min, maybe more. And we're working on getting this out. We're narrowing it down. We're getting clarity. We're not quite there yet, as I said, I'm still new, and but the physician walks in and we pause. You know I'm always welcoming physicians into the into therapy, because I really see that we have a role there. But and talk slow. Hilary, the physician, asked an open-ended question like Steve was talking about asking those open-ended questions as they're trained to do, and it was a question that the person with aphasia didn't have the vocabulary available to answer, and before I would jump in, that person shrugged her shoulders and shook her head that she didn't have anything to share with them, and I was like, but we had just been talking. You know, there's definitely something, and I think I just sat there a little bit stunned and just observing more. And you know the physician finished their assessment mostly outside of verbal communication, and left the room, and then I spoke to her, and we. We tracked down what the rest of her concern was, and clarified it, and then I found the physician who was not Dr. Richman, and I shared all the things that they had told me that she had told me, and I remember her saying I was just in there. She didn't have anything wrong. and I and I was, you know, I told her, like the communication supports that I used, and you know we got that. We moved forward with the conversation. But there were a few things that stuck out to me in that, and one was the way that the physician was communicating wasn't using. They weren't using supports. For whatever reason, I didn't have that knowledge yet. We dove into the literature to learn more later on. The second thing was that the person with aphasia seemed to give up on the provider, knowing that since supports weren't being used. It wasn't going to be a successful communication attempt. So why even bother, and that definitely fits her personality. She's like I give up on you. And the 3rd thing was that the education about that somebody has something to share the education about. Aphasia was lacking, so you know that the person's still in there. They still have their intellect, their identity, their opinions, beliefs. But they didn't have the ability to communicate that piece seemed to be missing on the part of the provider, because they were saying they didn't have anything to share. So, it was like, I said that situation happened repeatedly, and very much. Sounds just like yours, but it hit me how much there was to do. And so, hearing, you know Steve's experiences that are on the other side of that. Such a caring, the one thing that led me to want to speak to Steve is that he's a very compassionate caring physician, so it's not a lack of care and compassion. But what else was going on what led to this, and we started learning that together. It was really interesting for me to learn how Hillary's 1st assumption is. Why aren't these physicians using communicative supports or other things that we were never taught about? The assumption that the docs know all this, and there's plenty we don't know. Unfortunately, there's, you know there's so much out there.   Steve Richman: The other thing Hillary touched on that was so true in my experience, is here. I'm meeting people that had a significant event, a traumatic brain injury, a bad stroke. And we're so used to judging people's intelligence through their speech. And they're not speaking. And it's so easy to start thinking there's just not much going on up there, and I didn't have the education or information or training to know for a long time. That wasn't the case until my dad had a stroke with aphasia. And so yeah, there's still plenty going on there just hard to get it out. And even as a medical provider, I really wasn't fully aware of that. And it took personal experience and learning from Hillary to really get that. it's still there just need to find out how to help them get it out.   Jerry Hoepner: Yeah, I think that's a rather common story, especially for people with aphasia. But even for people without aphasia, that sense that the doctor is coming in, and things have to happen. And I know I'm sitting here with Steve, who is very compassionate and wants to ensure that communication. But I think there's a little bit of fear like, oh, I can't get it out in this context, and just bringing awareness to that, and also tools. So, tools in education. So those physicians can do the work that they need to do and get that knowledge that they may have never been exposed to, and probably in many cases have never had that training to communicate with someone so like you, said Steve. How are you supposed to know when they didn't train us in this? And I guess that brings us back around to that idea that that's part of the role of the speech language pathologist and also kind of a vacancy in tools. Right? We're. We're just missing some of the tools to make that happen consistently across facilities and across people. So, I'm really interested in hearing a little bit about the tools you've created, and kind of the story leading up to that if you if you don't mind sharing.   Hilary Sample: Absolutely. 1st I'll share. There's a quote, and I'm not going to remember who said it. Unfortunately, I'll come up with it later, and I'll make sure to share with you. But that healthcare is the medium by or I'm sorry. Communication is the medium by which healthcare is provided, or something to that extent. We need communication in order to ensure equal access to health care. And like you said that gap, it's really big, and it's a systemic issue. So, leading up to us, coming together, we had those experiences on both of our ends. I realized that I wasn't a physician. I already knew this, but I also I was trying to provide communication support to enable them to communicate something on a topic that I'm not trained in. In order to really give what it's due right? I don't know what questions that Steve is going to ask next, you know I tried, but I and I tried to listen, but I didn't always have, you know. Of course, I don't have that training, so know your limits right. But I did. The general overarching method that I was using was we'd have concerns to choose from, including the question mark that enabled them to tell. Tell me that you're way off, or you didn't guess it, or it's not on here. And then narrow choices that I try to come up with, and we'd move on like that. And anytime somebody appeared to have a medical concern. There's those general topics that you would try to see if it's 1 of these things. One of these concerns, and then those would generally take you to a series of sub questions, and so on, and so forth. So, I recognize that this was repeatable. I also, at the same time as I shared, was recognizing that communication supports weren't being used. And that doesn't. That doesn't end with, you know, a physician that's also nurses nursing aides. That's therapists, including SLPs, and you know, so I'm doing a thing that can be repeated. Why not stop recreating it every time I enter the room and make it into something that I can bring with me a prepared material that I can bring with me and ideally share it with others. So, I again, knowing my limitations, know what I have to bring to that equation. But I knew that I needed to partner with someone that cared just as much but had the medical knowledge to inform that tool. So at 1st it was a print little framework that I brought, and what happened is, I came up to Steve, and I let him know what I was thinking, and he was open and willing to work together on this, and Hillary showed me these pictures that were kind of showing some general medical concerns, and brought up the whole concept and we initially were going for this pamphlet booklet idea, you know. If you have this concern, you go to this page to follow it up with further questions, and then you go to this other page to finalize the subs. We realized there was a lot of pages turning involved to make that work, and we eventually turned it into an app where you could take your concern, and we start with a general Hello! How are you? You know? Kind of what's the overall mood in the room today. And then what medical concerns do you have? And then from those concerns, appropriate sub questions and sub questions and timeframes, and the stuff that you would want to know medically, to help figure out the problem. And then go ahead. I'm sorry.   Jerry Hoepner: Oh, oh, sorry! No, that's terrific. I appreciate that that process and kind of talking through the process because it's so hard to develop something like this that really provides as much access as is possible. And I think that's really key, because there's so many different permutations. But the more that you get into those the more complex it gets. So, making it easy to access, I think, is part of that key right?   Hilary Sample: One thing that I'm sorry. Did you want to say? Yeah, I'll say, okay, 1. 1 part of it. Yes, the accessibility issue. Every provider has a tablet or a phone on them, and many of our patients and their families also do so. It made it clear that it's something that could be easier to use if that's the method somebody would like to use, but also having a moment where my mind is going blank. This is gonna be one of those where we added a little bit. This is what you call a mother moment.   Jerry Hoepner: Okay.   Steve Richman: The one thing that was fascinating for me as we were developing this tool is I kept asking why? And Hillary kept explaining why, we're doing different parts of it. And at this point it seems much more obvious. But my biggest stumble at the beginning was, why are these Confirmation pages. Why do we have to keep checking, you know? Do they mean to say yes? Do they mean to go ahead? And that education about how people with language difficulties can't always use language to self-correct. We need to add that opportunity now makes so much sense. But I remember that was a stumbling block for me to acknowledge that and be good with that to realize. Oh, that's really important. The other thing that Hillary said a lot, and I think is so true is in developing this tool. We're kind of developing a tool that helps people that know nothing about communication supports like myself how to use them, because this tool is just communication supports. You know, I hear these repeatedly taught me about the importance of layering the clear pictures and words, and the verbal, and put that all the well, the verbalizing, the app is saying the word in our case, so that could all be shared and between all that layering hopefully, the idea gets across right and then giving time for responses.   Jerry Hoepner: It sounds like the tool itself. Kind of serves as an implicit training or education to those providers. Right?   Hilary Sample: And there's the idea that I was missing when I had a little bit of.  So yes, all of those strategies. They take training right? And it takes those conversations. And it takes practice and repetition. And there's amazing, amazing things happening in our field where people are actually undertaking that that transformation, transforming the system from above right.   Jerry Hoepner: Right.   Hilary Sample: But one thing that a big part of this work was trying to fill the gap immediately. I know you and I had previously talked about Dr. Megan Morris's article about health equity, and she talks a lot about people with communication disorders, including aphasia. And you know there's and she mentions that people cannot wait. The next person pretty much cannot wait for that work to be done, though that'll be amazing for the people that come down the line, the next person, what can we do for them? So we also need to be doing that. And that's where we thought we could jump in. And so I think the biggest you know. The most unique aspect of MedConcerns is that, or of the tool we created is that it kind of guides the clinician, the healthcare provider, through using communication supports. So you know, when I go in the room I offer broad options, and then I follow up with more narrow choices, always confirming, making sure I'm verifying the responses like Steve talked about, and or giving an opportunity to repair and go back and then that I summarize at the end, ensuring that what we have at the end still is valid, and what they meant to say. And so that's how the app flows, too. It enables the person to provide a very detailed, you know, detailed message about what's bothering them to a provider that has maybe no training in communication supports, but the app has them in there, so they can. It fills the gap for them.   Jerry Hoepner: Absolutely. It's kind of a sneaky way of getting that education in there which I really like, but also a feasible way. So, it's very pragmatic, very practical in terms of getting a tool in the hands of providers. It would be really interesting actually, to see how that changes their skill sets over time but yeah, but there's definitely room for that in the future. I think.   Hilary Sample: We could do a case study on Dr. Richman.   Steve Richman: whereas I used to walk out of those patient rooms that have communication difficulties with great frustration. My part frustration that I feel like I'm not doing my job. Well, now you walk out much more proudly, thinking, hey, I able to interact in a more effective way I can now do in visit what I could never accomplish before. Not always, but at least sometimes I'm getting somewhere, and that is so much better to know I'm actively able to help them participate, help people participate. I love writing my notes, you know. Communication difficulties due to blank. Many concerns app used to assist, and just like I write, you know, French interpreter used to assist kind of thing and it does assist. It's it makes it more effective for me and more effective for the person I'm working with. It's been really neat to watch you know, go from our initial conversations to seeing the other day we were having a conversation kind of prepping for this discussion with you and he got a call that he needed to go see a patient and I'll let you tell the story. So we're prepping for this. A couple of days ago. I think it was this Friday, probably, or Thursday, anyways, was last week and I'm at my office of work and again knock on the door. Someone's having chest pain. I gotta go check that out. So I start to walk out of the room. Realize? Oh, that room! Someone was aphasia. I come back and grab my phone because I got that for my phone and go back to the room. And it's interesting people as with anything. People don't always want to use a device. And he's been this patient, sometimes happy to interact with the device, sometimes wanting to use what words he has. And so I could confirm with words. He's having chest pain. But he we weren't able to confirm. What's it feel like? When did it start? What makes it better. What makes it worse? But using the app, I can make some progress here to get the reassurance that this is really musculoskeletal pain, not cardiac chest pain. Yes, we did an EKG to double check, but having that reassurance that his story fits with something musculoskeletal and a normal EKG. Is so much better than just guessing they get an EKG, I mean, that's not fair. So, it would have been before I had this tool. It would have been sending them to the er so they can get Stat labs plus an EKG, because it's not safe just to guess in that kind of situation. So, for me, it's really saved some send outs. It's really stopped from sending people to the acute care hospital er for quick evaluations. If I if I know from the get go my patient has diplopia. They have a double vision, because that's part of what communicated. When we were talking about things with help from MedConcerns. Yeah, when I find out 4 days later, when their language is perhaps returning, they're expressing diplopia. It's not a new concern. It's not a new problem. I know it's been a problem since the stroke, whereas I know of other doctors who said, Yeah, this person had aphasia, and all of a sudden they have these bad headaches that they're able to tell me about. This sounds new. I got to send them for new, you know whereas I may have the information that they've been having those headaches. We could start dealing with those headaches from the day one instead of when they progress enough to be able to express that interesting.   Jerry Hoepner: Yeah, definitely sounds like, I'm getting the story of, you know the improvement in the communication between you and the client. How powerful that is, but also from an assessment standpoint. This gives you a lot more tools to be able to learn about that person just as you would with someone without aphasia. And I think that's so important right to just be able to level that playing field you get the information you need. I can imagine as well that it would have a big impact on medication, prescriptions, whatever use? But also, maybe even counseling and educating that patient in the moment. Can you speak to those pieces a little bit.   Steve Richman: You know, one of my favorite parts of the app, Hillary insisted on, and I'm so glad she did. It's an education piece. So many people walk into the hospital, into our inpatient rehab hospital where I now work, and they don't recall or don't understand their diagnosis, or what aphasia is, or what happened to them. And there's a well aphasia, friendly information piece which you should probably talk about. You designed it, but it's so useful people are as with any diagnosis that's not understood. And then explained, people get such a sense of relief and understanding like, okay, I got a better handle of this. Now it's really calming for people to understand more what's going on with them.   Hilary Sample: This is, I think you know, that counseling piece and education, that early education. That's some of the stuff that could bring tears to my eyes just talking about it, because it's; oh, and it might just now. So many people enter, and they may have gotten. They may have received education, but it may not have. They may have been given education, but it may not have been received because supports weren't used, or there's many reasons why, you know, even if it had been given, it wasn't something that was understood, but so many people that I worked with aphasia. That one of the 1st things that I would do is using supports. Tell them what's going on or give them. This is likely what you might be experiencing and see their response to that. And that's you know what aphasia is, how it can manifest. Why it happens, what happened to you, what tools might be useful? How many people with aphasia have reported feeling? And you might be feeling this way as well, and these things can help. And it's very simple, very, you know. There's so much more to add to that. But it's enough in that moment to make someone feel seen and you know, like a lot of my friends, or one of my friends and former colleagues, uses this, and she says that's her favorite page, too, because the people that she's working with are just like, yes, yes, that's it, that's it. And the point and point and point to what she's showing them on the app. It's a patient education page, and then they'll look at their, you know, family member, and be like this. This is what's going on this, you know, it's all of a sudden we're connecting on that piece of information that was vital for them to share. And it was. It was just a simple thing that I kept repeating doing. I was reinventing the wheel every time I entered the room, but it was. It stood out as one of the most important things I did. And so that's why Steve and I connected on it, and like it needed to be in the app. And there's more where that came from in the future planning. But we added to that A on that broad, you know, kind of that page that has all the different icons with various concerns, we added a feelings, concern emotions, and feelings so that someone could also communicate what's going on emotionally. We know that this is such a traumatic experience, both in the stroke itself, but also in the fact that you lost the thing that might help you to walk through it a little easier which is communicating about it and hearing education learning about it. But so those 2 tools combined have really meant a lot to me to be able to share with people, with aphasia and their families, and also another sneaky way to educate providers.   Jerry Hoepner: Yeah, absolutely.   Hilary Sample: Because that's the simple education that I found to be missing when we talked about training was missing, and this and that, but the like when Steve and I talked recently, we you know, I said, what did you really learn about aphasia? And you kind of said how speech issues? Right?   Steve Richman: The speech diagnoses that we see are kind of lumped in as general like the names and general disorders that you might see, but weren't really clearly communicated as far as the their differential diagnoses being trained as a generalist, we would learn about, you know, neurology unit stroke and traumatic brain injury. And somewhere in there would be throwing in these tumors, which are huge aphasia and apraxia and whatnot, and I don't think I recall any details about that from Med school. They probably taught more than I'm recalling, but it certainly wasn't as much as I wish it was.   Hilary Sample: and so that education can just be a simple way to bring us all together on the same page as they're showing this to the person that they're working with. It's also helping them to better understand the supports that are needed.   Jerry Hoepner: Sneaky part.   Steve Richman: Yeah, speaking of the sneaky part, I don't think I told Hilary this yet, but I'm sure we've all had the experience or seen the experience where a physician asked him, What does that feel like? And the person might not have the words even with the regular communication, without a communication disorder. and last week I was working with a patient that just was having terrible pain and just could not describe it. and using the icons of words on that he had a much better sense of. You know it's just this and not that, and those descriptors of pain have been really useful for people now without more with communication difficulties that I just started doing that last week. And it was really interesting.   Hilary Sample: You mentioned about how those interactions with physicians are can be. Well, it's not nothing about you guys.   Jerry Hoepner: It's the rest of the physicians.   Hilary Sample: No, it's the, you know. There's a time. It's the shift in how our whole system operates that it's, you know I go in and I'm like, I just need notes if I need to speak about something important to my physician, because, like, I know that one reason I connect so deeply with people with communication disorders is that my anxiety sometimes gets in the way of my ability to communicate like I want to, especially in, you know, those kind of situations. And so, you know, it can help in many ways just having something to point to. But we also saw that with people with hearing loss, which, of course, many of the people that we run into in many of the patients that we work with are going to have some sort of hearing loss. People that speak a little different, you know. Native language. You know English as a second language.   Jerry Hoepner: Absolutely.   Hilary Sample: There and then. Cognitive communication disorders, developmental disorders, anybody that might benefit with a little bit more support which might include you and me. You know it can help.   Jerry Hoepner: And I think you know the physician and other providers having the tools to do that education to use the multimodal supports, to get the message in and then to get responses back out again. I think it's really important. And then that process of verifying to just see if they're understanding it. Are you? Are you tracking with me? And to get that feedback of, I'm getting this because I think sometimes education happens so quickly or at a level that doesn't match, and they might not understand it. Or sometimes it's just a matter of timing. I know we joke about Tom Sather and I joke about this. We've had people come to our aphasia group before who traveled out to a place in the community and they're sitting next to you. And they say, what is this aphasia stuff everyone's talking about? And I'm like, you literally just passed a sign that said Aphasia group. Right? But it's so hard to ensure that the message does go in, and that they truly understand that until you get that Aha moment where you describe like, yes, that's me, that's it. And that's just so crucial.   Hilary Sample: yeah, it's 1 of the most important pieces, I think to name it doesn't for anything that anybody is dealing with that's heavy, you know, to have to have it named can really provide relief just because that unknown, you know, at least at least you can have one thing that you know. I know what it is, and then I can learn more about it. Once I know what it is, I can learn more about it, and I can have some sort of acceptance, and I can start that grieving process around it, too, a little bit better. But when it goes unnamed, and the other part of it is if you don't tell me that, you know like that, you can see and understand what I might be experiencing, I might not think that you know what it is either, and I might not feel seen. So just the fact that we're both on board that we know I have this thing. I think it can take a lot of the weight off. At least, that's what I've seen when it's been presented.   Jerry Hoepner: No or care, right?   Hilary Sample: Yeah. Yes. Exactly.   Jerry Hoepner: Yep, and that's a good a good chance to segue into we I know we picked on Steve a little bit as a physician but the system really kind of constrains the amount of time that people have to spend with someone, and they have to be efficient. I'll go back to that sneaky idea. This seems like a sneaky way to help change the system from within. Can you talk about that a little bit like how it might move care forward by.   Hilary Sample: Showing what's possible. Yeah, I'm sorry, sure. In part time. Constraints, unfortunately, are very real, and without the knowledge of training how to communicate or support communication. It's challenging for us to move us physicians to move forward, but with something like our app or other useful tools in a short amount of time you could make some progress. And then, if you could document, this is worthwhile time worthwhile that I'm accomplishing something with my patient. I'm helping to understand what their issues are, and helping to explain what we want to do. That all of a sudden makes the time worthwhile, although time is a real constraint. I think, is general. Doctors are happy to spend extra time. If it's worthwhile that's helping our patient. That's the whole reason we go into this is help our people. We help the people we're working with, you know. No one wants to go in there and spend time. That's not helping anybody. But if you could justify the time, because I'm making progress. I'm really helping them great go for it. It's worth doing, and the part about efficiency. So there's so many ways that this focus on. And it's not even efficiency, because efficiency sounds like some success was achieved, you know. But this, this we only have this amount of time. One of the one of the things that's kind of interesting to me is that it an assumption? I've seen a lot, or I've heard a lot is that using communication supports takes time. More time and I have watched plenty, an encounter where the physician is trying, and it takes forever. I've experienced my own encounters as I was growing and deepening my own skills, and where it took me forever. And that's because we're trying. We care, but we don't have something prepared. So when you have a prepared material, it not only helps you to effectively and successfully you know, meet that communication need and find out what is actually bothering the person that you're working with. But it enables you to move at a pace that you wouldn't be able to otherwise, you know. So if Steve and I have this kind of running joke that I'll let you tell it because you have fun telling it.   Steve Richman: With the MedConcerns app. I could do in a little while what I can never do before, and with the med concerns App Hillary could do in 5 min. What used to take a session? It's really.   Jerry Hoepner: Yeah.   Hilary Sample: Makes huge impacts in what we could accomplish, so less of a joke and more of just.   Jerry Hoepner: Yes, but having the right tools really is sounds like that's what makes the difference. And then that gives you time and tools to dedicate to these conversations that are so important as a person who's really passionate about counseling. One of the things we were always taught is spending time now saves time later, and this seems very much like one of those kind of tools.   Hilary Sample: Yeah. Well, we had one of the 1st times that we brought the prototype to a friend of ours who has aphasia. And it kind of speaks to the exactly what you just said. Spending time now saves time later, or saves money. Saves, you know, all the other things right is our friend Bob, and he doesn't mind us using his name. But I'll let you tell this story a little bit, because you know more from the doctor. Bob was no longer a patient of ours, but we had spent time with him and his wife, and they were happy to maintain the relationship, and we showed him that after he had this experience but he was describing experience to us, he was having hip pain. He had a prior stroke hemiplegic and having pain in that hemiplegic side. So the assumption, medically, is, he probably has neuropathy. He probably has, you know, pain related to the stroke, and they were treating with some gabapentin which makes sense. But he kept having pain severe. 10 out of 10. Pain severe. Yeah. And just. We went back day after day, and not on the 3rd day back at the er they did an X-ray, and found he had a hip fracture and look at our app. He was like pointing all over to the things that show the descriptors that show not neuropathic pain, but again, musculoskeletal pain and that ability to, you know, without words we could point to where it hurts. But then, describing that pain is a makes a huge difference. And he knew he very clearly. Once he saw those pictures he like emphatically, yes, yes, yes, like this is this, we could have, you know, if we could have just found out this stuff, we wouldn't have had to go back to the er 3 times and go through all that wrong treatment and this severe amount of pain that really took him backwards in his recovery to physically being able to walk. And things like that, you know, it's just finding out. Getting more clarity at the beginning saves from those kind of experiences from the pain of those experiences. But also, you know, we talked about earlier. If you have to sort of make an assumption, and you have to make sure that you're thinking worst case scenario. So in other situations where you send out with a chest pain and things like that, there's a lot that's lost for the person with aphasia because they might have to start their whole rehab journey over. They have to incur the costs of that experience. And you know they might come back with, you know, having to start completely over, maybe even new therapists like it's. And then just the emotional side of that. So, it not only saves time, but it. It saves money. It saves emotional. Yeah, the emotional consequences, too.   Jerry Hoepner: Yeah. Therapeutic Alliance trust all of those different things. Yeah, sure. Yeah. I mean, I just think that alone is such an important reason to put this tool in the hands of people that can use it. We've been kind of talking around, or a little bit indirectly, about the med concerns app. But can you talk a little bit about what you created, and how it's different than what's out there.   Hilary Sample: Yeah, may I dive in, please? Okay, so we yeah, we indirectly kind of talked about it. But I'll speak about it just very specifically. So it starts with an introduction, just like a physician would enter the room and introduce themselves. This is a multimodal introduction. There's the audio. You can use emojis. What have you then, the General? How are you? Just as Steve would ask, how I'm doing this is, how are you with the multimodal supports and then it gets to kind of the main part of our app, which is, it starts with broad concerns. Some of those concerns, pain, breathing issues, bowel bladder illness. Something happened that I need to report like a fall or something else and the list continues. But you start with those broad concerns, and then every selection takes you to a confirmation screen where you either, you know, say, yes, that's what I was meaning to say, or you go back and revise your selection. It follows with narrow choices under that umbrella concern, the location type of pain, description, severity, exacerbating factors. If you've hit that concern so narrow choices to really get a full description of the problem, and including, like, I said, timing and onset. And then we end with a summary screen that shows every selection that was made and you can go to a Yes, no board to make sure that that is again verified for accuracy. So, it's a really a framework guiding the user, the therapist healthcare provider person with aphasia caregiver whomever through a supported approach to evaluating medical concerns. So generally, that's the way it functions. And then there are some extras. Did you want me to go into those? A little bit too sure.   Jerry Hoepner: Sure. Yeah, that would be great.   Hilary Sample: Right? So 1 1. It's not an extra, but one part of it that's very important to us as we just talked about our friend Bob, is that pain? Assessment is, is very in depth, and includes a scale description, locations, the triggers, the timing, the onset, so that we can get the correct pathway to receiving intervention. This app does not diagnose it just, it helps support the verbal expression or the expression. Excuse me of what's wrong. So, it has that general aphasia, friendly design the keywords, simple icons that lack anything distracting, clear visuals simple, a simple layout. It also has the audio that goes with the icon, and then adjustable settings, and these include, if you know, people have different visual and sensory needs for icons per screen, so the Max would be 6 icons on a screen, although, as you scroll down where there's more and more 6 icons per screen. But you can go down to one and just have it. Be kind of a yes, no thing. If that's what you need for various reasons, you can hide specific icons. So, if you're in a setting where you don't see trachs and pegs. You can hide those so that irrelevant options don't complicate the screen. There's a needs board. So we see a lot of communication boards put on people's tray tables in in the healthcare setting, and those are often they often go unused because a lot of times they're too complex, or they're not trained, or they, for whatever reason, there's a million reasons why they're not used. But this one has as many options as we could possibly think might need to be on there which any of those options can be hidden if they need to be. If they're not, if they're irrelevant to the user language it's in. You can choose between English and Spanish as it is right now, with more to come as we as we move along, and then gender options for the audio. What voice you'd like to hear? That's more representative. And the body image for the pain to indicate pain location. There's some interactive tools that we like to use with people outside of that framework. There's the whiteboard for typing drawing. You can use emojis. You can grab any of the icons that are within the app. So, if you know we if it's not there and you want to detail more, you can use the whiteboard again. That needs board the Yes, no board. And then there's also a topic board for quick messages. We wanted to support people in guiding conversations with their health care providers. So, I want to talk to Steve about how am I going to return to being a parent? Once I get home, what's work life going to be. I want to ask him about the financial side of things. I want to ask him about therapy. I want to report to him that I'm having trouble with communication. I want to talk on a certain topic. There's a topic board where you select it. It'll verify the response. It has a confirmation page, but from there the physician will start to do their magic with whatever that topic is. And then, of course, there's those summary screens that I already detailed, but those have been very useful for both, making sure at the end of the day we verify those responses but then, also that we have something that's easy to kind of screenshot. Come back to show the physician. So show the nurse as like a clear message that gets conveyed versus trying to translate it to a verbal message at the end from us, and maybe missing something so straightforward, simple to address very complex needs, because we know that people with aphasia would benefit from simple supports, but not they don't need to stay on simple topics. They have very complex ideas and information to share. So we wanted to support that. That's what it is in a nutshell that took a nutshell. I love that. It's on my phone, or it could be on your.   Jerry Hoepner: Oh, yeah.   Hilary Sample: Or on your or on your apple computer. If you wanted that, it's on the app store. But I love this on my phone. So, I just pull in my pockets and use it. Or if you happen to have an another device that works also.   Jerry Hoepner: Sure.   Hilary Sample: We're in the. We're in the process of having it available in different ways. There's a fully developed android app as well. But we're very much learners when it comes to the business side of things. And so there's a process for us in that, and so any. Any guidance from anybody is always welcome. But we have an android that's developed. And then we're working on the web based app so that we could have enterprise bulk users for enterprise, licensing so that that can be downloaded straight from the web. So that's all. Our vision, really, from the onset was like you said, shifting the culture in the system like if there's a tool that from the top, they're saying, everybody has this on their device and on the device that they bring in a patient's room, and there's training on how to use it, and that we would provide. And it wouldn't need to be much, just simple training on how to use it. And then you see that they are. They get that little bit more education. And then it's a consistent. We know. We expect that it'll be used. The culture can shift from within. And that's really the vision. How we've started is more direct to consumer putting it on the app store. But that's more representative of our learning process when it comes to app development than it is what our overall vision was, I want to say that equally as important to getting this into systems is having it be on a person's device when they go to a person with aphasia's device when they go to an appointment. I always, when we've been asked like, Who is this? For we generally just kind of say, anybody that that is willing to bring it to the appointment, so that communication supports are used, and maybe that'll be the SLP. Maybe it's the caregiver. Maybe it's care partner or communication partner, maybe a person with aphasia. Maybe it's the healthcare staff. So, whoever is ready to start implementing an easier solution. That's for you.   Jerry Hoepner: Yeah, absolutely. And that brings up a really interesting kind of topic, like, what is the learning curve or uptake kind of time for those different users for a provider on one hand, for a person with aphasia. On the other hand, what's a typical turnaround time.   Hilary Sample: We've tried to make it really intuitive, and I think well, I'm biased. I think it is   Hilary Sample: I for a provider. I think it's very easy to show them the flow and it, and it becomes very quickly apparent. Oh, it's an introduction. This is putting my name here. What my position is next is a how are you that's already walk in the room, anyways. And that's that. What are your concerns? Okay, that that all. Okay. I got that I think with time and familiarity you could use the tool in different ways. You don't have to go through the set up there you could jump to whatever page you want from a dropdown menu, and I find that at times helpful. But that's you. Don't have to start there. You just start with following the flow, and it's set up right there for you. The, as we all know people with the page I have as all of us have different kind of levels, that some people, they, they see it, they get it, they take the app, and they just start punching away because they're the age where they're comfortable with electronic devices. And they understand the concept. And it takes 5 seconds for them to get the concept and they'll find what they want. Some of our older patients. It's not as quick. But that's okay. My experience with it's been funny to show to use it with people with aphasia versus in another communication disorders, and using it with or showing it to people in the field or in healthcare in general, or you're just your average person most of the time that I showed this to a person with aphasia or who needed communication supports. It's been pretty quick, even if they didn't use technology that much, because it is it is using. It's the same as what we do on with pen and paper. It's just as long as we can show them at the onset that we're asking you to point or show me right. And so once we do that and kind of show that we want you to select your answer, and some people need more support to do that than others. Then we can move forward pretty easily. So people with aphasia a lot of times seem to be waiting for communication supports to arrive, and then you show them it, and they're like, Oh, thanks, you know, here we go. This is what's going on. Of course, that's there are varying levels of severity that would change that. But that's been my experience with people with aphasia. When I show people that do not have aphasia. I see some overthinking, because you know. So I have to kind of tell people like, just them you want them to point and hand it over, you know, because when I've seen people try to move through it, they're overthinking their what do you want me to do? I'm used to doing a lot with an app, I'm used to, you know, and the app moves you. You don't move it. So the real training is in stepping back and allowing the communication supports to do what you're thinking. I need you to do right. Step back and just let the person use the communication supports to tell you their message. And you, you provide those supports like we tend to provide more training on how to help somebody initiate that pointing or maybe problem solving the field of responses or field of icons that's on the page, or, you know, troubleshooting a little bit. But the training more is to kind of have a more hands off. Approach versus you know, trying to move the app forward since the apps focus, really, on describing what's going on with somebody and not trying to diagnose once someone gathers. Oh, I'm just trying to get out what I'm experiencing, it becomes very intuitive. Yeah, that's the issue. And this is, yeah, that's how describes it more. And yeah, this is about when it started that   Jerry Hoepner: That makes sense. And it's in line with what we know about learning use of other technologies, too, right? Usually that implicit kind of learning by doing kind of helps more than here's the 722, you know, pieces of instruction. So yeah, that kind of makes sense.   Hilary Sample: Simple training. I just to throw in one more thought I you know a little bit of training on what communication supports are, and then you show them. And it really, the app shows you how to use communication supports. And so it, you know instead of having to train on that you can just use the app to show them, and then and then they sort of start to have that awareness on how to use it and know how to move forward from there. Generally, there's some training that needs to be to be had on just where things are maybe like the dropdown menu, or you know what's possible with the app, like changes, changes, and settings and the adjustments that we talked about earlier but usually it's a little bit of a tool that I use to train people how to use communication support. So, it's sort of like the training is embedded. So we're doing both at the same time. You're getting to know the app, and you're learning more about how to support communication in general.   Jerry Hoepner: I think that's a really great takeaway in terms of kind of that double value. Right? So get the value to the person with aphasia from the standpoint of multimodal communication and self-advocacy and agency, those kinds of things, and then the value to the providers, which is, you learn how to do it right by doing it.   Hilary Sample: Which is great. Yeah.   Jerry Hoepner: Really like that.   Hilary Sample: Some of the most meaningful experiences I've had are with nurses like, you know, some of those incredible nurses that, like they see the person with aphasia. They know they know what to say, they want to. They know that the person knows what they want to say, but has difficulty saying it. We have one person I won't mention her name, but she's just incredible, and you know the go to nurse that you always want to be in the room she pretty much was like, give me this as soon as we told her about it, and I did, you know, and she goes. She's like, see, you know she uses it as a tool to help her other nurses to know what's possible for these. She's such an advocate but if it can be used like that to show what's possible like to show, to reveal the competency, and to let other nurses know, and other physicians, and so on, to help them to truly see the people that they're working with. It's like that's my favorite part. But the it's not only like a relief for her to be able to have a tool, but it's exciting, because she cares so much, and that like Oh, I'll take that all day long. That's wonderful.   Jerry Hoepner: Absolutely well, it's been really fun having a conversation with you, and I've learned a lot more than I knew already about the app. Are there any other things that we want to share with our listeners before we close down this fun conversation.   Hilary Sample: I think maybe our hope is to find people that are ready to help kind of reach that vision of a culture shift from this perspective from this angle. Anybody that's willing to kind of have that conversation with us and see how we can support that. That's what we're looking for just to see some system change and to see what we can do to do that together, to collaborate. So if anybody is interested in in discussing how we might do that, that's a big goal of ours, too, is just to find partners in in aphasia advocacy from this angle.   Jerry Hoepner: That's great!   Hilary Sample: Perfect. I totally agree. We're very grateful for this conversation, too. Thank you so much, Jerry.   Jerry Hoepner: Grateful to have the conversation with both of you and just appreciate the dialogue. Can't wait to connect with you in future conferences and so forth. So, thank you both very much.   Hilary Sample: Thank you.   Jerry Hoepner: On behalf of Aphasia Access, thank you for listening to this episode of the Aphasia Access Conversations Podcast. For more information on Aphasia Access and to access our growing library of materials go to www.aphasiaaccess.org. If you have an idea for a future podcast series or topic, email us at info@aphasiaaccess.org. Thanks again for your ongoing support of Aphasia Access.

Creator of the philosophy The Art of Bending TimeYou can find her work at Michelleniemeyer.com, LinkedIn and can text CLARITY to 33777 to get supportMichelle talks about a turning point in her life where she ended up in the ER and how this changed her perspective on health and nutrition after she was later diagnosed with PBCIs burnout in our control?Michelle says that the things that cause burnout are not in our control, but you can impact how you respond and how you look at the worldShe recommends focusing on the things that you enjoy in your day, meditating on themMichelle talks about some of the struggles she had as a lawyer and how it was difficult to not see the benefit of her work for 8 months to a year sometimesLearn to be in the moment, if you are thinking about the future all the time you will suffer anxiety and if you are thinking about the past, you will be depressedSetting goals is important, you need to be working towards something in life and figure out an action plan to accomplish themMake sure they are goals that YOU want, as opposed to something that someone else wants for youDelegate certain tasks, ask for help, don't always micromanageStep back and allow others to learn and growMichelle talks about how shifting from running all the time to enjoying walks outside improved her health and prevented injuryShe talks about the importance of getting enough sleep and movementNutrition can be medicineMichelle talks about a big case she was working on and how some dedicated, focused time, away from distractions, with adequate rest and movement, helped her throughTake care of yourself before you take care of patients To get focused work done, you need to set up your environment correctly and remove distractionsOne distraction can make you lose precious focus one a given taskMultitasking is a mythBurnout happens when people don't feel any meaning in what they're doingSometimes switching jobs or careers will not solve burnout, but establishing some good habits can recreate the fulfillment in your current job againYou don't see the light when you stay doing the same stuffSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Get ready to demystify the 2025 Tax Bill.Hosts Tait Duryea and Ryan Gibson sit down with Nathan Sosa, tax strategist at Hall CPA, to uncover what this sweeping legislation really means for pilots and high-income earners. From the return of 100% bonus depreciation to new deductions for auto loans and overtime, Nathan breaks down exactly who benefits and how. Whether you're building passive income or just want to keep more of what you earn, this is required listening.Nathan Sosa is a Certified Public Accountant (CPA) with Hall CPA, a firm specializing in real estate tax strategy. As a seasoned tax strategist, Nathan works closely with high-income professionals and investors to navigate complex tax codes and optimize financial outcomes. With expertise in Opportunity Zones, real estate syndications, and tax planning, Nathan empowers clients with proactive strategies to minimize tax liabilities and build wealth.Show notes:(0:00) Intro(02:29) The one test every pilot over 40 should do(05:25) Treat your medical like a checkride(07:09) Primary care vs. AME: What's the risk?(12:33) EKG tip that can save your exam(16:01) Why most AMEs can't coach you(19:43) ADHD, mental health, and new FAA standards(25:07) Screening tests to do by age group(31:02) MedExpress simulator and application tips(35:06) How to access your past FAA medicals(49:00) OutroConnect with Nathan Sosa:Book a Discovery Call with Nathan Sosa: https://bit.ly/HallCPA —If you're interested in participating, the latest institutional-quality self-storage portfolio is available for investment now at: https://turbinecap.investnext.com/portal/offerings/8449/houston-storage/— You've found the number one resource for financial education for aviators! Please consider leaving a rating and sharing this podcast with your colleagues in the aviation community, as it can serve as a valuable resource for all those involved in the industry.Remember to subscribe for more insights at PassiveIncomePilots.com! https://passiveincomepilots.com/ Join our growing community on Facebook: https://www.facebook.com/groups/passivepilotsCheck us out on Instagram @PassiveIncomePilots: https://www.instagram.com/passiveincomepilots/Follow us on X @IncomePilots: https://twitter.com/IncomePilotsGet our updates on LinkedIn: https://www.linkedin.com/company/passive-income-pilots/Do you have questions or want to discuss this episode? Contact us at ask@passiveincomepilots.com See you on the next one!*Legal Disclaimer*The content of this podcast is provided solely for educational and informational purposes. The views and opinions expressed are those of the hosts, Tait Duryea and Ryan Gibson, and do not reflect those of any organization they are associated with, including Turbine Capital or Spartan Investment Group. The opinions of our guests are their own and should not be construed as financial advice. This podcast does not offer tax, legal, or investment advice. Listeners are advised to consult with their own legal or financial counsel and to conduct their own due diligence before making any financial decisions.

Chytré hodinky, hlavní reprezentanti „nositelné elektroniky“ neboli wearables, nám mohou přivolat pomoc při pádu nebo autonehodě, pomohou s detekcí arytmií nebo upozorní na fyzické vyčerpání. Dokáží naplánovat trénink téměř libovolného sportu, monitorují spánek a upozorní na podezření z onemocnění spánkovou apnoe. Téměř všechny chytré hodinky dnes měří tepovou frekvenci, saturaci krve kyslíkem a počet kroků. Nejznámější značky se pokoušejí EKG v hodinkách stále zdokonalovat a přidat k němu i tonometr, bez nutnosti nasazení manžety. A to jsme nezmínili řadu dalších funkcí malých sourozenců mobilních telefonů, které jsou vidět pomalu na každém druhém zápěstí. Snaha o nastolení nebo udržení zdravého životního stylu s pomocí chytrých hodinek se ovšem někdy změní v závislost na měření základních vitálních funkcí a vyhodnocování nejrůznějších aktivit. Samotná data mohou také začít vyvolávat úzkost a další nechtěné stavy. Zvláště tehdy, když jsou naměřené údaje vyhodnocované a vnímané chybně. I proto je dobré vědět, zda si chytré hodinky vůbec nasadit na zápěstí a pokud ano, tak jaké a proč. A jak s nimi pracovat, aby nám skutečně pomáhaly. Právě o tom budeme v Zátiší hovořit s Ioannisem Papadopoulosem, který je redaktorem serveru mobilenet.cz a jednou z hlavních tváří stejnojmenného YT kanálu.

CardioNerds (Dr. Claire Cambron and Dr. Rawan Amir) join Dr. Ayan Purkayastha, Dr. David Song, and Dr. Justin Wang from NewYork-Presbyterian Queens for an afternoon of hot pot in downtown Flushing. They discuss a case of congenital heart disease presenting in adulthood. Expert commentary is provided by Dr. Su Yuan, and audio editing for this episode was performed by CardioNerds Intern, Julia Marques Fernandes. A 53-year-old woman with a past medical history of hypertension visiting from Guyana presented with 2 days of chest pain. EKG showed dominant R wave in V1 with precordial T wave inversions. Troponin levels were normal, however she was started on therapeutic heparin with plan for left heart catheterization. Her chest X-ray revealed dextrocardia and echocardiogram was suspicious for the systemic ventricle being the morphologic right ventricle with reduced systolic function and the pulmonic ventricle being the morphologic left ventricle. Patient underwent coronary CT angiography which confirmed diagnosis of congenitally corrected transposition of the great arteries (CCTGA) as well as minimal non-obstructive coronary artery disease. Her chest pain spontaneously improved and catheterization was deferred. Patient opted to follow with a congenital specialist back in her home country upon discharge.   US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls- A Case of Congenital Heart Disease Presenting in Adulthood Congenitally Corrected Transposition of the Great Arteries (CCTGA) is a rare and unique structural heart disease which presents as an isolated combination of atrioventricular and ventriculoarterial discordance resulting in physiologically corrected blood flow.   CCTGA occurs due to L looping of the embryologic heart tube. As a result, the morphologic right ventricle outflows into the systemic circulation, and the morphologic left ventricle outflows into the pulmonary circulation.   CCTGA is frequently associated with ventricular septal defects, pulmonic stenosis, tricuspid valve abnormalities and dextrocardia.   CCTGA is often asymptomatic in childhood and can present later in adulthood with symptoms of morphologic right ventricular failure, tricuspid regurgitation, or cardiac arrhythmias.   Systemic atrioventricular valve (SAVV) intervention can be a valuable option for treating right ventricular failure and degeneration of the morphologic tricuspid valve.  notes- A Case of Congenital Heart Disease Presenting in Adulthood Notes were drafted by Ayan Purkayastha.  What is the pathogenesis of Congenitally Corrected Transposition of the Great Arteries?   Occurs due to disorders in the development of the primary cardiac tube   Bulboventricular part of the primary heart forms a left-sided loop instead of right-sided loop, leading to the normally located atria being connected to morphologically incompatible ventricles   This is accompanied by abnormal torsion of the aortopulmonary septum (transposition of the great vessels)   As a result, there is ‘physiologic correction' of blood flow. Non-oxygenated blood flows into the right atrium and through the mitral valve into the morphologic left ventricle, which pumps blood into the pulmonary artery. Oxygenated blood from the pulmonary veins flows into the left atrium and through the tricuspid valve to the morphologic right ventricle, which pumps blood to the aorta. Compared with standard anatomy, the flow of blood is appropriate, but it is going through the incorrect ventricle on both sides.  Frequent conditions associated with CCTGA include VSD, pulmonic stenosis and dextrocardia  

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Es wird heiß draußen – und bei uns im Podcast nicht minder: Während andere bei 30 Grad lieber am See chillen, haben wir uns im Studio eingeschlossen und zurückgeblickt. Auf einen Monat voller persönlicher Erkenntnisse, logistischen Überraschungen und kleinen emotionalen Ausrastern – natürlich mit einem Augenzwinkern. Tobias erzählt, wie er durch ein unerwartetes Gespräch plötzlich ins Handeln kam. Und Andreas? Der muss sich mit imaginären Zaunlöchern herumschlagen.

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Dr. Emma Jones is a hospice and palliative care physician, also worked as a pediatric oncologist and pediatrician. She's been in the field for over 10 years and is active in helping healthcare professionals with burnout in the modern medical system. She is the author of The Phoenix Blueprint, Emerging Stronger from the Blaze of Healthcarehttps://www.emmajonesmd.comBoundaries are important to set up in your work. Proper emotional boundaries with your patients are important to maintain your separation from another personYou can see another person's emotions, recognize them and understand that they are not your emotions True empathy does not improve your ability to provide patient careRecognize when you do take on another person's burden so you can do the work to set it downWe have to always remember to be patient centered. When you express empathy or share a personal experience with someone it should be serving a clinical purpose. It should never be done to help you process somethingIs the patient benefiting from you relating to their experience?Would you be better off to discuss your experience with a therapist or family member?Spending more time to reassure and answer patient questions will save time in the long run and allows you to fully address the chief concern over the chief complaintRapport is developed not with time but can be done instantly by simply being a human beingUnconditional positive regard is viewing the patient or coworker or whoever you are interacting with in a positive lightThis allows you to interact better with the patients you see, viewing the problem as the enemy and not each otherPositive attitudes, smiling and friendly behavior can be culturally discouraged in medicine and this needs to change, of course some situations call for a reserved attitude, but many do notGiving away happiness and positivity does not take something away from you, it actually gives you more joyWe talk about mentoring and teaching the next generation of medical professionalsAdvocacy for policy change is one of the last chapters of the book because you really have to overcome burnout in order to have the energy and motivation to take those stepsYou must restore yourself to help make changes to the systemWe talk about the pit fall of perfectionism. Perfectionism is different than excellence Perfectionism is a habit that does not servePerfectionism is when you try to bring things from the circle of concern into your circle of control - it doesn't workSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

RE-RELEASE This was first published in 2023 but it's so good we are running it back! Buckle up, PGY-1's! Intern year is starting whether you're ready or not. Don't fret, BTK has your back to make sure you dominate the first year of residency. Today, we're hitting the wards and tackling some of the scary clinical scenarios you will see as an intern. Hosts: Shanaz Hossain, Nina Clark Tips for new interns: THINGS TO REMEMBER ·       BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn't help anybody. ·       See the patient. Getting a bunch of pages? Worried about someone? Confused as to what's going on? Go see the patient and chat with the bedside team. ·       Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients. ·       Load the boat. You've heard this one from us all week! Loop senior level residents in early. HYPOTENSION ·       Differential: measurement error, patient's baseline, and don't miss – SHOCK.            - Etiologies of shock: hemorrhagic, hypovolemic, ·       On the phone: full set of vitals, accurate I/Os, ·       On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day ·       In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is ·       Get more info: labs, consider imaging, work up specific types of shock based on clinical concern. ·       Initial management: depends on etiology of hypotension; don't forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care HYPOXEMIA ·       Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload ·       On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement ·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection ·       In the room: ABCDs, pulmonary and cardiac exam, volume status exam ·       Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest ·       Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology ·       ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/ ALTERED MENTAL STATUS ·       Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium ·       On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies ·       In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient's mental status is adequate for airway protection! ·       Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke. ·       Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes. OLIGURIA ·       Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction ·       On the phone: clarify functional foley or bladder scan results, full set of vitals ·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection ·       In the room: ABCDs, confirm functioning foley catheter ·       Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US ·       Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don't overload them -- look for other etiologies! TACHYCARDIA ·       Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE ·       On the phone: full set of vitals, acuity of change in heart rate, updated I/Os ·       On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os ·       In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection ·       Get more info: basic labs, EKG, consider CXR, troponins ·       Initial management: depends heavily on etiology Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Former Georgia Lieutenant Governor, former Republican, Geoff Duncan, appeared on the Atlanta Journal Constitution's "Politically Georgia" podcast earlier this week to hawk his centrist overtures (again) to Democrats, only this time, he's hinted at receiving calls from 'folks across the state' (sure, dude) to run for governor - as a Democrat. "I've heard the rumor," he said. Sorry, if he has, he's the first.When asked, he said “I'm certainly not going to run as a Republican," then groused about how difficult it is to run as a third party candidate in this country. Duncan would like the Democratic Party to abandon a lot of its core principles for the sake of winning, and I'm here to reject his thought process. Instead, Republicans like Duncan should show some spine and go win back their party from the nuts they once benefitted from being shovel-fed so much disinformation. Instead, what Democrats should do is listen to Reverend Senator Raphael Warnock's floor speech Sunday and follow his lead. His impassioned plea for his Senate colleagues to reject the budget measure they eventually passed with a tie-breaking Vice Presidential vote. "In a real sense, the question tonight is, who are we? Not who we tell ourselves we are, but who are we really? What and who do we care about? What kind of nation are we? What kind of people do we want to be? Who matters and who doesn't? What do we think is dispensable?In no place is the answer to that question clearer than in a nation's budget. I submit that a budget is not just a fiscal document, a budget is a moral document. Show me your budget, and I'll show you who you think matters and who doesn't.If this awful budget were an EKG, it would suggest that our nation has a heart problem and is in need of moral certainty."His 20-minute oratory was a work of art, and the exact type of tone Democrats need to take, going forward.

As will be the routine in 2025, the Extra Monday Episodes are dedicated to interpreting EKG rhythms. This month, the crew discusses, bradycardias, tachycardias and wide and narrow rhythms.

Dr. Emma Jones is a hospice and palliative care physician, also worked as a pediatric oncologist and pediatrician. She's been in the field for over 10 years and is active in helping healthcare professionals with burnout in the modern medical system. She is the author of The Phoenix Blueprint, Emerging Stronger from the Blaze of Healthcarehttps://www.emmajonesmd.comSometimes you need to realize you may be part of someone else's plan and get onto your own planDr. Jones talks about the difficulties with working with pediatrics but also the amazing resiliency of kids and their parentsWe are told that medicine is a calling and a privilege, and we should sacrifice everything in service of the patient – this is an unrealistic expectation We talk about burnout and moral injuryBurnout a helpful term because it's something we can all feel and understand and use to seek helpMoral distress or injury is something that occurs regularly - when there is discordance between what you want to do and what you are able to do - whereas burnout is more at the end of a line of moral injuriesBurnout triad: emotional exhaustion, cynicism, lack of fulfillmentIf we can get the frontline healthcare workers out of burnout and the day-to-day strife, we can help them be part of the solutions to the problems we faceDr. Jones talks about the philosophy of yoga and how it can help us flourishSleep is vital to healing from burnout. It allows the brain to clean itself; you are smarter after getting adequate sleepA lot of us are not even giving ourselves the opportunity to get enough sleepLack of sleep makes it difficult to put things in their proper context and map solutionsWe talk about core values and the importance of knowing what yours are and how they correspond to your actionsEmma shows the actions she takes to correspond with her core valuesJoy and humor are a huge part of our humanity Questioning your thoughts is key. All thoughts are lies. We recreate memories. Our memories are fallible and tend to degenerate the more we recall an eventLearn to let go of thoughts that do not serve you. Choose the ones that are helpful. You get to control them. You cannot believe every thought that comes into your headSteven Covey describes 3 types of circles in our lives in The Seven Habits of Highly Effective People. You have the circle of control you have direct control over but the circle of influence and circle of concern you have less control over. The point is to recognize what is worth focusing on and what is not worth your focus. For examplSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Was passiert, wenn man einem echten EKG-Nerd ein Mikrofon vor die Nase hält? Genau: eine der lehrreichsten (und unterhaltsamsten) Folgen von Retterview!

What could cost you your flying career? Not being prepared for your medical. Hosts Tait Duryea and Ryan Gibson welcome back Dan Monlux of Wingman Med to discuss how pilots can protect their FAA medical certificates. Dan breaks down what happens during a medical exam, the importance of primary care, and why early detection matters. This is a must-listen for pilots over 40 and anyone serious about staying in the skies.Dan Monlux is a retired Navy F-18 pilot and dual-trained physician in family and aerospace medicine. As co-founder of Wingman Med, he now helps pilots navigate complex FAA medical certification issues. With thousands of pilots successfully guided through the process, Dan combines flight experience and deep regulatory insight to keep aviators flying safely and confidently.Show notes:(0:00) Intro(03:29) The one test every pilot over 40 should do(06:25) Treat your medical like a checkride(08:09) Primary care vs. AME: What's the risk?(13:33) EKG tip that can save your exam(17:01) Why most AMEs can't coach you(20:43) ADHD, mental health, and new FAA standards(26:07) Screening tests to do by age group(32:02) MedExpress simulator and application tips(36:06) How to access your past FAA medicals(50:00) Outro

Bryan Jepson MD and CFP, author of The Physician's Path to True Wealth: 12 steps to gaining control over your money and your time – you can find it on Amazon and at this website for free Bryan Jepson MD, CFP® | physician financeDisclaimers:This is not specific financial advice, this is general education. Talk with your own advisor or schedule with Bryan to get specific advice The easiest, most straightforward way to start creating assets is to invest in your 401kDebt to fund a liability is bad debt, it takes money out of your pocketDebt that leads to more money in your pocket is good debt, but this requires wisdom in choosing your degree and education pathThere are a couple of methodologies to pay off debt, the snowball method vs the avalanche method. Snowball goes smallest debt to largest. Avalanche goes from highest interest to lowest interest. Use the one that will actually work for YOU and will make you be consistentThe 4% rule: generally, when you can live off 4% of your investments per year, you have enough for retirementSo, if you need 100K to live off in retirement, you need 2.5 million in investmentsWhy does everyone need a will? If you have kids, it allows you to designate a guardian should you die. It also allows you to allocate where your assets goWhat is the importance of giving away money?Giving can be looked at through a couple different lenes. When you give, you are blessed in return. Or maybe you can view it as good karmaBryan talks about how relationships are an important aspect of life and giving allows for meaningful relationships with something you value. Donate money but also your timeWhen you are rich, you don't have the cushion to give. When you are wealthy, you have the ability to give to othersFinance is simple but not easy because you need discipline. You don't have to get far into the weeds to be successfulBryans book has the foundation you need to understand financeBryan talks about the difference between a financial advisor and a certified financial planner Bryan gives his opinion on whole life insurance vs term insuranceSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Tracy and Holly share experiences of having their hearts monitored using EKG technology. They also talk about whether or not Albert Bierstadt had any natural talent. See omnystudio.com/listener for privacy information.

Not Today... Jenn and Eddie are joined in studio by the wonder dog Kevin. Are dogs evolving before our eyes? Wanna see a dead body Jenn didn't. Keida met Colton and it was.... something.  Eddie got some fancy clothes for his upcoming cruise. Jenn has some heart issues and spent the night in the hospital. What's a BBL? Plus, Florida Man Friday!

John Kosar walks through the Asbury 6, an “EKG for the market.” Four of their metrics are negative, while only two are positive, and he explains what the model is telling him about market direction. “Follow the signal rather than the noise,” he emphasizes. “If the market can't start to move higher again over the next week or so, we could be in for a surprisingly sharp move down.” However, he thinks the April lows will hold.======== Schwab Network ========Empowering every investor and trader, every market day. Subscribe to the Market Minute newsletter - https://schwabnetwork.com/subscribeDownload the iOS app - https://apps.apple.com/us/app/schwab-network/id1460719185Download the Amazon Fire Tv App - https://www.amazon.com/TD-Ameritrade-Network/dp/B07KRD76C7Watch on Sling - https://watch.sling.com/1/asset/191928615bd8d47686f94682aefaa007/watchWatch on Vizio - https://www.vizio.com/en/watchfreeplus-exploreWatch on DistroTV - https://www.distro.tv/live/schwab-network/Follow us on X – https://twitter.com/schwabnetworkFollow us on Facebook – https://www.facebook.com/schwabnetworkFollow us on LinkedIn - https://www.linkedin.com/company/schwab-network/ About Schwab Network - https://schwabnetwork.com/about

Lee Morris is Vice President of Underwriting, Life & Annuity Brokerage who rejoined the Gallagher Life & Executive Benefits consulting team in January of 2023.Lee Morris has been in the insurance industry specializing in technical underwriting risk management for over 33 years. She is known for her astute ability to merge the technical attributes of underwriting with the art of modern-day medical advancements and interpretation while protecting the interests of all stakeholders. Lee's strong experience with the top one percent of the wealth management firms and the ultra-affluent market demonstrates her ability to address the needs of clients requiring an enhanced “boutique” encounter.Certified in EKG interpretation and a dynamic presenter, Lee's past experience of 17 years at the carrier include being Assistant Chief leading one of the top premium distributions in the high-net-worth arena. She is one of very few in the brokerage market who achieved a prior insurance carrier underwriting single signature authority of $20M dollars.Lee holds a Cum Laude Bachelor of Science Degree in Accounting from Grambling St. University, Grambling, LA. She enjoys her free time volunteering with the K-12 school she is the co-founder of, hunting, shopping and is the mother to one son, Evan who is a Senior Pre-Med student at Morehouse College in Atlanta, Ga.Learn more: http://www.ajg.com/Take advantage of the Gallagher Underwriting expertise platform that can move your life insurance consideration from a “success story” to reciprocal “successful solutions”Financial Professionals should ensure they continue to follow the current policies and procedures of their broker dealer and/or registered investment adviser and the insurance carriers they represent on the use of any advertising, third-party materials, sales processes and/or social media/internet use. This marketing presentation in no way supersedes the requirements of a financial professional's license requirements or the policies and procedures of your broker dealer or registered investment advisory firm.This content is for informational and educational purposes, and is not designed, or intended, to be applicable to any person's individual circumstances. It should not be considered as investment advice, nor does it constitute a recommendation that anyone engages in (or refrains from) a particular course of action.Influential Entrepreneurs with Mike Saundershttps://businessinnovatorsradio.com/influential-entrepreneurs-with-mike-saunders/Source: https://businessinnovatorsradio.com/interview-with-lee-morris-vice-president-of-underwriting-of-life-annuity-brokerage-with-gallagher-inc

Lee Morris is Vice President of Underwriting, Life & Annuity Brokerage who rejoined the Gallagher Life & Executive Benefits consulting team in January of 2023.Lee Morris has been in the insurance industry specializing in technical underwriting risk management for over 33 years. She is known for her astute ability to merge the technical attributes of underwriting with the art of modern-day medical advancements and interpretation while protecting the interests of all stakeholders. Lee's strong experience with the top one percent of the wealth management firms and the ultra-affluent market demonstrates her ability to address the needs of clients requiring an enhanced “boutique” encounter.Certified in EKG interpretation and a dynamic presenter, Lee's past experience of 17 years at the carrier include being Assistant Chief leading one of the top premium distributions in the high-net-worth arena. She is one of very few in the brokerage market who achieved a prior insurance carrier underwriting single signature authority of $20M dollars.Lee holds a Cum Laude Bachelor of Science Degree in Accounting from Grambling St. University, Grambling, LA. She enjoys her free time volunteering with the K-12 school she is the co-founder of, hunting, shopping and is the mother to one son, Evan who is a Senior Pre-Med student at Morehouse College in Atlanta, Ga.Learn more: http://www.ajg.com/Take advantage of the Gallagher Underwriting expertise platform that can move your life insurance consideration from a “success story” to reciprocal “successful solutions”Financial Professionals should ensure they continue to follow the current policies and procedures of their broker dealer and/or registered investment adviser and the insurance carriers they represent on the use of any advertising, third-party materials, sales processes and/or social media/internet use. This marketing presentation in no way supersedes the requirements of a financial professional's license requirements or the policies and procedures of your broker dealer or registered investment advisory firm.This content is for informational and educational purposes, and is not designed, or intended, to be applicable to any person's individual circumstances. It should not be considered as investment advice, nor does it constitute a recommendation that anyone engages in (or refrains from) a particular course of action.Influential Entrepreneurs with Mike Saundershttps://businessinnovatorsradio.com/influential-entrepreneurs-with-mike-saunders/Source: https://businessinnovatorsradio.com/interview-with-lee-morris-vice-president-of-underwriting-of-life-annuity-brokerage-with-gallagher-inc

Bryan Jepson MD and CFP, author of The Physician's Path to True Wealth: 12 steps to gaining control over your money and your time – you can find it on Amazon and at this website for free Bryan Jepson MD, CFP® | physician financeDisclaimers:This is not specific financial advice, this is general education. Talk with your own advisor or schedule with Bryan to get specific advice The earlier you can get financially literate and work on a plan the betterBryan is an emergency medicine physician, along his journey in medicine he also spent 5 years working in Autism before coming back to EM full timeThe covid pandemic and a feeling of stagnation and desire to keep learning prompted Bryan to pursue a master's degree in finance Bryan finds familiarity in his role as a physician to his role as a financial planner. You listen to the client and come up with a plan that fits their needsBryan talks about the difference between riches and wealth; discretionary income is the income above your mandatory expenses – and what you do with that extra income is how you become wealthy or richRiches are the material things you may spend that money on, car, house, toysWealth is the money you could spend but instead save or invest insteadThe goal is to create assets so that your income is no longer needed. Buying back your timeWhen you have true wealth, you can make decisions with your timeWorking towards being financially independent prevents burnoutChoosing to work vs working because you have to is easier, and makes you a better providerKey attributes to develop to be financially successful: Be patient – assets grow slowly. Be consistent in investing. It is boring. Be honest with what you know and what you don't know so you can spend some time educating yourself. Courage, because it does take some risk taking to invest instead of just savingIf you keep all your money in cash, you are guaranteed to lose purchasing powerThe longer your time frame the better the stock market will perform for youCreating discretionary income is difficult at lower incomes levels. But I do still believe you can retire from EMS. One way that I was able to save and invest as a paramedic was working overtimeHaving higher incomes does speed things along but it is not the cure for financial problems because we all have a tendency to spend what we make – fundamentally it's the same problemWe talk about the vehicles we drive and how we have utilized them to save more moneyBut spend money on Support the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

We need to remember that paramedic and EMT's are solely focused on emergency medicine vs RN's or even PA's who are trained in general medicine then learn how to do EM later onLearning sick vs not sick is a skill that develops with time, it's not always easyGestalt can be an important factor in your assessment but don't trust it all the time, it can lead you astrayA negative work-up does not always mean there isn't something dangerous going onRecognizing your biases will help protect you from making a mistake or overlooking somethingAdvice for the newbies:Have humility when you are new, be willing to be taughtNever stop learningBe proud when you do perform wellDon't trust your gestalt when you are new. Take every patient seriouslyKeep a journalBe honest, do what you document and document what you do, admit your mistakes quicklyTaking ownership over mistakes helps you learn and gives you more respect than passing the buckThe call you are going to is the call you are supposed to go to. That is where you are meant to go. No patient is a waste of time. That patient deserves your undivided attention Too many people hear the other exciting calls dropping nearby and they become distracted from what they are currently doingPeople are put in your path for a reasonAlex talks about a night he ran 3 GSW's and had to use good coping skills to recoverSometimes the lower acuity patients can rejuvenate youRunning only high acuity will burn you out too, take some joy in the less stressful callsAppreciate the highs and lowsSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Die Welt blickt gebannt auf das Scheidungsdrama zwischen Donald Trump und Elon Musk. Die LGBTQ-Community trotzt der politischen Einschüchterung. Und: Heute ist Tag der Organspende. Das ist die Lage am Samstagmorgen. Die Artikel zum Nachlesen: Mehr Hintergründe hier: Der ultimative LoyalitätstestDie ganze Geschichte hier: Wie Trump die größte LGBTQ-Party sabotiertDie ganze Geschichte hier: »Was findest du besser, Ultraschall oder EKG?« +++ Alle Infos zu unseren Werbepartnern finden Sie hier. Die SPIEGEL-Gruppe ist nicht für den Inhalt dieser Seite verantwortlich. +++ Den SPIEGEL-WhatsApp-Kanal finden Sie hier. Alle SPIEGEL Podcasts finden Sie hier. Mehr Hintergründe zum Thema erhalten Sie mit SPIEGEL+. Entdecken Sie die digitale Welt des SPIEGEL, unter spiegel.de/abonnieren finden Sie das passende Angebot. Informationen zu unserer Datenschutzerklärung.

How do we have long careers and avoid burnout?Micah talks about burnout and how we have the advantage in emergency medicine that we can leave work at work and step backHave time off and don't work overtime every time an opportunity arises, don't only discuss work with your spouse, have other interests that you can engage inEmergency medicine is a fun job to identify with because we get to save lives, but you should not make it your whole personalityFind an identity outside of work, you may not have work at some point and life changesAudrianna talks about taking care of yourself. As we spend so much time being empathetic for others, we can lose that empathy for family or even ourselvesWe talk about the lower acuity patients we care for and infrastructure to take care of their complaint quickly from the ED, patients have poor access to primary care, and we can be that solutionWe can't use low acuity calls as something that burns us out or allows us to get frustrated, it will always be part of the job and we should view it as us being the solutionWe can be educators, we are trained to recognize emergencies, the layperson shouldn't be expected to know thisWe have the privilege of taking care of everyone regardless of complaint, ability to pay, social statusBurnout begets burnoutTake the time off when you need it, overtime takes more from you than it may be worthCertain seasons of life may necessitate working more but you have to understand the cost benefitJust making it through COVID is a victory, it burned a lot of providers out, even those with experienceWe recount some of our COVID war storiesSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Episode 192: ADHD Treatment.  Jordan Redden (MSIV) explains the treatment of ADHD. Dr. Bustamante adds input about pharmacologic and non-pharmacologic treatments. Dr. Arreaza shares the how stimulants were discovered as the treatment for ADHD. Written by Jordan Redden, MSIV, Ross University School of Medicine. Comments and edits by Isabelo Bustamante, MD, and Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.ADHD is a chronic neurodevelopmental condition characterized by inattention, impulsivity, and/or hyperactivity. While it's often diagnosed in childhood, symptoms can persist well in adulthood. The treatment for ADHD is multifaceted. It often includes medication, behavioral therapy, environmental modifications, and sometimes educational interventions which are especially effective in younger patients. Ongoing evaluation is needed during treatment. Treatment needs adjustments over time.Starting with medications: Stimulants are the most well-studied and effective pharmacologic treatment for ADHD. These include methylphenidate-based medications such as Ritalin, Concerta, and Focalin, and amphetamine-based options, like Adderall, Vyvanse, and Dexedrine. Discovery of stimulants for ADHD> Dr. Charles Bradley discovered stimulants as the treatment for ADHD around 1937. ADHD did not have a name at that time, but it was known that some children had behavioral problems related to poor attention and inability to control their impulses, but they were still intelligent. Dr. Bradley was a psychiatrist who was working in the Bradley Hospital (Rhode Island), he was studying these children and, as part of his experiments, they developed severe headaches. He gave “Benzedrine” (a decongestant) to his pediatric patients to treat severe headaches, and he discovered that Benzedrine improved academic performance and interest in school and improved disruptive behavior in some children.How do stimulants work.Stimulants work primarily by increasing dopamine and norepinephrine levels in the brain, which helps improve focus, attention span, and impulse control. They typically show a rapid onset of action and can lead to noticeable improvements within the first few days of use. Dosing is individualized and should start low with gradual titration. Side effects can include reduced appetite, insomnia, headaches, increased heart rate, and emotional lability.Types of stimulants. Stimulants come as short acting and long acting. They can come as a tablet, liquid, patch, or orally disintegrating tablet. After the discovery of Benzedrine as a possible treatment for ADHD, more research was done over the years, and Ritalin became the first FDA-approved medication for ADHD (1955). The list of medications may seem overwhelming, but there are only two types of stimulants used to treat ADHD: methylphenidate and amphetamine. Long-acting stimulant medications are often preferred for their consistent symptom control and lower potential for misuse. Vyvanse (lis-dexa-mfetamine) is a widely used long-acting amphetamine-based option. As a prodrug, it remains inactive until metabolized in the body, which results in a smoother onset and offset of action and may reduce the risk of abuse. This extended duration of effect can help patients maintain focus and regulate impulses throughout the day without the peaks and crashes sometimes seen with shorter-acting formulations. Of note, Vyvanse is also approved for Binge Eating Disorder. Many of these medications are Schedule II controlled substances, so to prescribe them you need a DEA license. Other long-acting options include Concerta, an extended-release methylphenidate, as well as extended-release versions of Adderall and Focalin. These are especially helpful for school-aged children who benefit from once-daily dosing, and for adults who need sustained attention during work or academic activities. The choice between short- and long-acting stimulants depends on individual response, side effect tolerance, and daily routine.For patients who cannot tolerate stimulants, or for those with contraindications such as a history of substance misuse or certain cardiac conditions, non-stimulant medications are an alternative. One of the most used is atomoxetine, which inhibits the presynaptic norepinephrine transporter (NET). This leads to increased levels of norepinephrine (and to a lesser extent dopamine). Guanfacine or clonidine are alpha-2A adrenergic receptor agonists that lead to reduced sympathetic outflow and enhanced prefrontal cortical function, improving attention and impulse control. These alpha agonists are particularly useful in younger children with significant hyperactivity or sleep disturbances.Non-pharmacologic treatments.Behavioral therapy before age 6 is the first choice, after that, medications are more effective than BH only, and as adults again you use CBT.Medication is often just one part of a broader treatment plan. Behavioral therapy, especially in children, plays a critical role. Parent-training programs, positive reinforcement systems, and structured routines can significantly improve functioning. And for adolescents and adults, cognitive-behavioral therapy (CBT) is particularly helpful. CBT can address issues like procrastination, time management, emotional regulation, and self-esteem which are areas that medication doesn't always touch.Using medications for ADHD can be faced with resistance by parents, and even children. There is stigma and misconceptions about mental health, there may be concerns about side effects, fear of addiction, negative past experiences, and some parents prefer to treat ADHD the “natural” way without medications or only with supplements. All those concerns are valid. Starting a medication for ADHD is the first line of treatment in children who are 6 years and older, but it requires a shared decision with parents and patients. Cardiac side effects are possible with stimulants. EKG may be needed before starting stimulants, but it is not required. Get a personal and family cardiac history, including a solid ROS. Benefits include control of current condition and treating comorbid conditions.The presentation of ADHD changes as the person goes through different stages of life. For example, you may have severe hyperactivity in your school years, but that hyperactivity improves during adolescence and impulsivity worsens. It varies among sexes too. Women tend to present as inattentive, and men tend to be more hyperactive. ADHD is often underdiagnosed in adults, yet it can significantly impact job performance, relationships, and mental health. In adults, we often use long-acting stimulants to minimize the potential for misuse. And psychotherapy, particularly CBT or executive functioning coaching, can be life-changing when combined with pharmacologic treatment. There are several populations where treatment must be tailored carefully such as pregnant patients, individuals with co-occurring anxiety or depression, and those with a history of substance use. For example, atomoxetine may be preferred in patients with a history of substance misuse. And in children with coexisting oppositional defiant disorder, combined behavioral and pharmacologic therapy is usually more effective than either approach alone.Comorbid conditions.Depression and anxiety can be comorbid, and they can also mimic ADHD. Consult your DSM-5 to clarify what you are treating, ADHD vs depression/anxiety.Treatment goes beyond the clinic. For school-aged children, we often work closely with schools to implement 504 plans or Individualized Education Programs (IEPs) that provide classroom accommodations. Adults may also benefit from workplace strategies like structured schedules, noise-reducing headphones, or even coaching support. Ongoing monitoring is absolutely essential. We assess side effects of medication, adherence, and symptom control. ***In children, we also monitor growth and sleep patterns. We often use validated rating scales, like the Vanderbilt questionnaire for children 6–12 (collect answers from two settings) or Conners questionnaires (collect from clinician, parents and teachers), to track progress. And shared decision-making with patients and families is key throughout the treatment process.To summarize, ADHD is a chronic but manageable condition. Effective treatment usually involves a combination of medication and behavioral interventions, tailored to the individual's needs. And early diagnosis and treatment can significantly improve quality of life academically, socially, and emotionally.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022. CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). Understanding ADHD. Accessed May 2025. https://chadd.org National Institute for Health and Care Excellence (NICE). Attention Deficit Hyperactivity Disorder: Diagnosis and Management. NICE guideline [NG87]. Updated March 2018. Accessed May 2025. https://www.nice.org.uk/guidance/ng87 Pliszka SR; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894–921. doi:10.1097/chi.0b013e318054e724 Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528 Texas Children's Hospital. ADHD Provider Toolkit. Baylor College of Medicine. Accessed May 2025. https://www.bcm.edu Wolraich ML, Hagan JF Jr, Allan C, et al. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate. Published 2024. Accessed May 2025.https://www.uptodate.comThe History of ADHD and Its Treatments, https://www.additudemag.com/history-of-adhd/Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Apple filed a patent for a wearable loop-shaped electronic device that can be worn on the wrist, around the neck, or attached to everyday items, enabling features such as blood pressure monitoring, skin moisture tracking, EKG readings, haptic feedback, voice input, and positional sensing. The device may serve as a visual marker in augmented and virtual reality systems and supports wireless charging. The patent indicates potential integration with Apple's broader ecosystem and suggests new applications for artificial intelligence and smart device connectivity.Learn more on this news by visiting us at: https://greyjournal.net/news/ Hosted on Acast. See acast.com/privacy for more information.

How do we handle the sensitive hand-off reports from EMS to the ED?Different aspects, like potentially violent family members, unsafe scenes, are often a critical details that need to be conveyed to the ED but don't have to be announced to everyone in the hand-off report in front of the patientMicah works as a field and ER paramedic. He talks about this situation and how it's going for him. He enjoys the number of resources he has access to in the EDBeing able to see the whole workup and outcome of the patient is a big benefit as well, working in the EDI love it when the EMS crews come back and follow up on their patients, it's a big way to help them improve and learnWe talk about interpersonal conflict on scenesCasey tries to be as friendly as he can and learn everyone's namesIt's easy for all of us to allow our egos to get too out of hand, but we need to treat everyone how we would want to be treatedI talk about some issues I've had with the fire department in the past – sometimes it is all about how you are doing something as opposed to what you are doing in your interactions with other agenciesAt the end of the day, the patient can be affected when we have confrontational scenes so we should always be seeking to avoid thisAlex talks about working 48 hours with his fire crew and responding on scenes with the same crew and how this differs from private ambulance responding with other agencies he may not know very wellCasey talks about how, years ago, the EMS crews had more time to stop by the fire stations and become more familiar with the fire crewsCasey talks about the power of edifying others in our fieldAudrianna talks about a fire crew going above and beyond in the ED as wellWe talk about small things we can all do to go above and beyond our regular tasks, helping families navigate the ED, getting a blanket for someone, cleaning a roomLittle things like this also help you feel better about your job too; they help you remember why you got into medicine in the first placeIt does require you to look beyond yourself to see those opportunitiesSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

Episode 2648: Vinnie Tortorich talks with Robert Soulliere about learning to just breathe for performance, mindfulness, your nervous system, and more.  https://vinnietortorich.com/2025/05/just-breathe-with-robert-soulliere-episode-2648 PLEASE SUPPORT OUR SPONSORS YOU CAN WATCH ALL THE PODCAST EPISODES ON YOUTUBE -  Just Breathe Robert helps people learn how to breathe properly for performance and health. (3:00) Breathing correctly can improve your nervous system, mental clarity, and even your eyesight. (8:00) Doing Zone 2 cardio while breathing through your nose can improve your health. (11:30) The longer you can stay in an aerobic state, the less lactic acid builds up. (20:00) The goal is to keep your breathing calm regardless of the intensity of the exercise. (23:00) Breathing can help regulate your emotions and your nervous system response. (35:00) You can get the effects of Viagra or nitrous oxide by breathing through your nose; proper breathing increases NAD, which is a vasodilator. (41:00) Breathing through the mouth is similar to rusting (causing oxidation) because it allows free radicals to remain in your system. (43:00) Robert enjoys using measuring devices such as continuous glucose monitors (CGMs) that track numbers over time. He uses a device that measures HRV by using an EKG patch attached to your chest. Robert has training events to help optimize performance and mindfulness. You can find out more about Robert and his training programs at breatheryourpower.com. More News If you are interested in the NSNG® VIP group, closed for registration, but you can get on the wait list - Don't forget to check out Serena Scott Thomas on Days of Our Lives on the Peacock channel.  “Dirty Keto” is available on Amazon! You can purchase or rent it . Make sure you watch, rate, and review it! Eat Happy Italian, Anna's next cookbook, is available!  You can go to  You can order it from .  Anna's recipes are in her cookbooks, website, and Substack–they will spice up your day!  Don't forget you can invest in Anna's Eat Happy Kitchen through StartEngine.  Details are at Eat Happy Kitchen.  There's a new NSNG® Foods promo code you can use! The promo code ONLY works on the NSNG® Foods website, NOT on Amazon. https://nsngfoods.com/   PURCHASE  DIRTY KETO (2024) The documentary launched in August 2024! Order it TODAY! This is Vinnie's fourth documentary in just over five years. Visit my new Documentaries HQ to find my films everywhere:  Then, please share my fact-based, health-focused documentary series with your friends and family. Additionally, the more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! PURCHASE BEYOND IMPOSSIBLE (2022) Visit my new Documentaries HQ to find my films everywhere:  REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere:  FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: 

New panel with Audrianna (RN), Alex (paramedic), Casey (paramedic) and Micah (paramedic)What do the ER nurses like to get in the hand-off report from EMS?Audrianna likes to hear clear, concise reports. How ambulatory was the patient on scene? Casey recalls from years ago how the ER nurses didn't understand enough about what EMS did, that always made giving reports more difficult and how that has improved over the yearsI always try and give new EMT's the freedom to struggle through giving reports so they can practice and improve without cutting them off or making them feel rushedGiving report is a difficult aspect of the job, especially when it's a critical trauma patient and you are giving report to a room full of peopleIt's easy to get in a rush to move the patient over, but we need to give EMS the time to give report - It's a big part of our day that allows us to build the team rapport between EMS and the EDAlex talks about the perspective going from a busy private ambulance to a slower county system We talk about differences in nurse workload vs paramedic in the fieldSometimes EMS doesn't fully understand some of the nuances of how and what we use their IV's for in the EDAudrianna talks about how ER nurses are trying to maximize their time while getting report from EMSED charting is a lot more complicated than the fieldI talk about how seeing ambulances when they arrive should be the highest priority for a providerMicah talks about the limits of our ability to obtain accurate information in the field many timesSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

As we are having these necessary conversations on how to be prepared for unexpected medical events or natural disasters, I saw a friend of mine Sarah Hart Unger had one of her own. I asked her to come on the podcast so we could talk about what happened, how she handled it, what she learned from it, and how she may improve her preparedness. I'm Healthy Sarah shared how she was so excited to get back into running marathons. There she was in Miami in about mile 11 of her half marathon when all the sudden she heard her body say something wasn't right. She bunked (marathon runner speak for running out of steam) and she was surprised and disappointed, why was this happening? Her friend took her to the medical tent and they told her all was well. She was so confused because she was a runner and she considered herself a very healthy person. Five steps into leaving the tent something told her no, and to go back. Moments later she was on her way to the hospital. She was pleading with them to just let her get to the hospital to be put under so they could shock her heart there, not that moment in the ambulance! Sarah has been diagnosed with a rare condition called Arrhythmic Cardio Myopathy. What Systems were in place?  Thankfully Sarah was near where her in-laws live so they could support Sarah during her hospital stay and gave comfort to her daughters that someone was there comforting their mom. Sarah appreciated the medical team that took care of her, she felt heard, that they were honest with her, and was thankful for the way they cared for her. She wrote questions down because sometimes there wasn't anyone to ask if it was like 2am. And she had realistic expectations of how long it may take to get a diagnosis.  She got images in hand for additional specialists she wanted to see for second opinions. She advises to always ask for the images and reports. I feel like digital records help us to be productive and physical records help us to look, analyze, and see patterns. We're all under this false pretense that our records are digital. And they may be, but, do you want your doctor visit to consist of tracking results down or do you want it to be focused on the course of action for treatment? Remember the mini medical binder is available for free right now. If you even show up with that you are ahead of other people. You can just start putting the medical papers in a pile and bring them. Sarah is a Pediatric Endocrinologist and says that she'd rather have people show up with results and reports messy than not at all.  How to better prepare?  Sarah wishes she had her old labs and EKG's for comparison sake. I remember being able to show my doctor my cholesterol history and I avoided being put on medicine. I showed that for years my normal is in the “yellow” zone. Sarah also wishes she would have headed the advice to get another EKG years ago but life got busy and she forgot. Sarah stressed that we have to take care of ourselves just like we do our children. She accredits their amazing nanny for being able to step in and fill in the gaps. However, because they always plan their week out and share it with the nanny, they nanny knew how to fill out the schedule for the family. Sarah suggested a family member maybe come observe a couple days at your house to see the day to day unfold and be aware of what they may need to do in your absence. It's ok if the ship sinks a little like if someone has to miss soccer, that's ok. Sarah warned “Don't ever assume ‘I'm healthy, nothing can happen to me.” EPISODE RESOURCES: Mini Medical Binder Sunday Basket® Sign Up for the Organize 365® Newsletter Did you enjoy this episode? Please leave a rating and review in your favorite podcast app. Share this episode with a friend and be sure to tag Organize 365® when you share on social media.

Some ambulance crews may not have the best understanding of how a fire crew is going to run a call, with everyone assigned specific roles – often the fire department will be allowing a new crew member to lead the callI always struggled with arriving first on scene on the ambulance because that role is more work and more pressure What does fire like from the ambulance crews when they arrive first?First on scene should be allowed to lead the call and ask for help where needed, second on scene should not be pushing their way in and trying to take over the callSometimes the providers that take over lack experience or are not yet comfortable enough with their own skills to allow someone else to leadIf you have another provider on scene constantly trying to interrupt, give them something to do - often this applies to a disruptive family memberDoes the ambulance paramedic have to attend in the back if the fire paramedic rides in?As a previous ambulance paramedic, I viewed the ambulance as my space, meaning I always appreciated it when the fire paramedic had the respect to treat it as such, asking to ride into the hospital as opposed to telling me they were riding in. As a general rule, if the fire paramedic believes they need to ride in due to acuity, the ambulance paramedic should also attendKash, as a medical director, gives his opinion on this situationI really appreciated it when the fire crews respected our ambulance because the front is truly our officeEMT's can ride in too on low acuity where more hands, not ALS treatment, is neededI've talked before that a paradigm shift is needed for the paramedics at times, where they are more likely to have to attend more calls then their EMT partners -  easy for me to say from outside the field now – but transporting the patient is almost always the safest, lowest liability option, we shouldn't be trying to get out of transports just because it's less workAlways treat the patient like they are a family memberWe are looking for proof that the patient is not sick, as opposed to assuming they are not sick from the outset, our approach is different in emergency medicineWe have, historically, reversed hypoglycemia or opiate OD, and the patient has refused when maybe transport to the hospital is warranted despite the fact that we have temporarily fixed a major problemSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

How does a personal passion project turn into a groundbreaking neurotech startup? In this episode, we sit down with Dr. Ildar Rakhmatulin to explore his remarkable journey from academia to entrepreneurship — and how a global chip shortage sparked the creation of Pi-EEG, a Raspberry Pi-based BCI device that's transforming neuroscience education. Discover how Ildar's open-source innovation makes brain-computer interfaces more accessible, engaging both the research community and curious learners. We dive into the evolution of his work, from the RMBCI project to the Pi-EEG platform, and explore its exciting integration with tools like ChatGPT and P300 gaming applications. In this episode, you'll learn about: The evolution from RMBCI to the Pi-EEG device The power of open-source collaboration in neurotech How Pi-EEG connects with ChatGPT and brain-signal-based gaming The educational impact on neuroscience and signal processing Join us for an inspiring conversation on turning persistence and creativity into cutting-edge innovation in the world of brain-computer interfaces. Chapters: 00:00:02 - Launching Personal Projects in Neurotech 00:05:12 - Development of the Pyg Device 00:09:31 - Benefits of Open Source Collaboration 00:13:55 - Challenges in EEG Device Development 00:17:16 - Motivation Behind Passion Projects 00:20:00 - Introducing the Latest PiEG Device 00:25:49 - Measuring Multiple Biological Signals 00:29:02 - Introduction to EEG Signal Processing 00:31:06 - Understanding EEG and Signal Processing 00:38:52 - Finding Passion in Neurotechnology Careers 00:43:50 - Balancing Work and Passion Projects 00:47:49 - Real-World Problems and Neurotechnology Trends 00:50:43 - Careers in Neurotechnology 00:59:38 - Advancing Your Neurocareer About the Podcast Guest: Dr. Ildar Rakhmatulin is a scientist, engineer, and entrepreneur based in the United Kingdom, working at the intersection of neuroscience, biosignal processing, and brain-computer interface (BCI) innovation. He is the founder of PiEEG, an open-source, low-cost BCI platform built on Raspberry Pi, designed to democratize access to neurotechnology for students, researchers, and developers around the world. With a Ph.D. in hardware and software engineering, Dr. Rakhmatulin specializes in real-time biodata acquisition, including EEG, PPG, and EKG, and applies machine learning and deep learning algorithms to brain signal classification. His engineering work bridges research and accessibility—helping transform neuroscience education and experimentation through affordable, modular tools.

How do we have successful, long careers in EMS?John recommends living away from where you work, doing unrelated activities outside of work so your life doesn't revolve around work thingsTaking care of someone you know is an odd position to be in, it can mess with your ability to be objectiveJason says we need to have an awareness of how we are feeling and how those around us are feeling, therapy is always a great option, get outsideThose of us in EMS/fire do deal with a level of PTSDTerry talks about this in his own life, when he broke down and started crying without an obvious reasonPTSD is not a lack of desire to cope nor is it a sign of weaknessKash talks about burnout vs moral injuryBurnout tends to blame the individual vs moral injury blames the system we work inI don't disagree that the systems we work in are imperfect and moral injury exists, but I still like the term burnout because, no one is coming to save us, the responsibility is on the individual to overcomeBurnout can slowly occur to the degree that you don't even realize right away what is happeningIs burnout inevitable?Kash says that moral injury is inevitable in some form or another - the important thing is to recognize it and deciding what to do about it, take actionAcute vs chronic burnout requires different solutions as wellKash recounts the Covid effects on EMSTerry talks about the ability to acknowledge your struggles and continue to move on and live your life, in spite of themI asked Jason about his decision to stay a fire paramedic instead of promoting up the chain, he didn't want to promote just for the money, he would rather have passion for it. He is still very passionate about practicing medicine as a paramedic and enjoys his career as it isHow do we get along on scene when responding with multiple agencies, fire vs private ambulanceJason talks about how beneficial it has been to see both sides, you can have more compassion for the other side when you see their strugglesHave the right attitude approaching a scene, work to get along with others as best you can despite the strong personalities we all tend to haveSometimes a short conversation goes a long way. Having ambulance crews stop by the fire station for some food or short hang-out can also dramatically improve your relationshipWe tend to assign ill-intent when we don't know someone, vs good intent when we do know themIt is difficult to fully understand each other's roles, when you aren't doing that job on a daily basis, trauma bonding calls can be helpful when you get into thSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

This week on the Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson tackle a metabolic monster that every EMS provider needs to master: diabetic ketoacidosis (DKA). They kick off with a common (but critical) 911 scenario: a 19-year-old with a history of Type 1 diabetes, confusion, vomiting and a blood sugar of 500. Sound familiar? Kelly dives into the physiology of DKA, explaining how glucose can be sky-high while cells starve, triggering fat breakdown and ketone production that spirals into life-threatening acidosis. The hosts hit the must-know pathophysiology, signs and symptoms (hello, Kussmaul breathing!), and what providers often miss — like dehydration, vomiting and abdominal pain. They break down how to spot DKA with capnography and EKG changes, especially when hyperkalemia mimics a STEMI. From EMS management tips (don't shut down those fast respirations!) to fluid resuscitation caveats, this is a crash course in saving DKA patients before they crash. Whether you're running calls or managing chronic patients, this episode arms you with the clinical know-how and common-sense insight to handle DKA with confidence. Memorable quotes  “We're starting to see more increasing calls for type one diabetes, insulin-dependent type two diabetes ... and we need to be able to understand what we're doing. — Chris Cebollero “One of the big clues in the scenario is the vomiting. Lots of DKA patients will have vomiting and abdominal pain.” — Kelly Grayson “A lot of times, these hyperkalemia patients and these acidotic patients are going to be handled just fine by correcting their fluid deficits and correcting their glucose with an insulin drip. Just getting their glucose back down to normal level is going to manage the lion's share of the hyperkalemia.” — Kelly Grayson Enjoying the show? Email theshow@ems1.com to suggest episode ideas or to pitch someone as a guest!

Our system has made access to EMS trained medical directors much easier, which is a huge benefit to the crewsThe EMS fellowship for MD's tends to attract those that are interested in helping EMS because they are passionate about it and not in it for the moneyWe are always trying to give EMS the amount of time they deserve when giving reports from the ER sideKash talks about his technique in getting a good report from EMS on the higher acuity sideEvery provider has slightly different preferences on how much information they like to get from EMS, Kash talks about his ideal EMS reportI really like the crews to lead with the chief complaint so I can understand how pertinent the rest of the report isWe talked about the previous culture on contacting medical control and how this has changed over timeWhat does retirement from EMS/fire look like?Terry's retirement came suddenly after an injury, which made it difficult as he wasn't expecting itTerry still remembers the calls he has run around town, the intersections, he says the bad memories have tended to get better over time. He recommends finding something else to do in retirement, keeping busy. Don't get stuck in the past recounting call after call. It can be difficult to give up the comradery you have at the fire departmentWe talk about the terrible question “What is the worst thing you've ever seen?” that we frequently getIt forces us to recount those horrific callsThe person asking the question is not mentally prepared to hear the answerI talk about the difference dealing with tragedy in the ER vs the fieldSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

The JournalFeed podcast for the week of April 21-25, 2025.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Wednesday Spoon Feed:This preplanned subgroup analysis of the TOMAHAWK Trial of patients with ROSC after OHCA found no EKG findings (excluding STEMI) that predicted the presence of coronary artery lesions.Thursday Spoon Feed:In this substudy of the Canadian TIA Score cohort, researchers found score utilization with subsequent MRI imaging could improve the outcome of patients suffering from TIA or stroke, particularly in the medium-risk category, scoring between 4-8 points.

Is this EKG even for the right patient? A wild call with everything from pediatric to... significant OLMC considerations causes the guys to call in some backup... this time in the form of Dr. Michael Lauria! Can the team find some useful lessons with a little help? Listen and find out!

The Rich Dickman Show Episode 297 - Tornado Drill Position with hosts Rem, Cody, Ray, and Randy Opening Banter Recap: The episode begins with the hosts returning, with Rem noting that they are "back at it". Rem explains that he finally figured out a camera or account issue from a couple of years ago, realizing his wife had created a new account that bypassed security, making the old one look like a fresh reinstall. He wiped the new account, reverted to the old one, and his stuff, including old backgrounds from about two years ago, reappeared. This brought back some "blast from the past" backgrounds. They confirm the episode number is 297, correcting Randy who thought it was 296. Randy is asked to create a Brady Bunch screen using illustrations or real photos, including one of Ray. Ray mentions he can text a picture he took in front of a gas pump where the average price was $5.90 a gallon, which prompts comments on high gas prices (Rem filled up for $2.79 and was annoyed, Ray was around $2.93) and the general expense of things where Ray is located. Ray then mentions his recent weight loss. Randy asks what Ray's weight was last week, and Ray gives a number (396.8). Cody and Ray guess Ray's current weight before Ray reveals it is 393.4. Cody wins the guess. Ray clarifies he started at 436 pounds, tracking it in the show notes, indicating a loss of 21.8 pounds just on the show. This prompts praise from the others, calling it "good" and "a month's worth of work". Ray mentions building a fence so his dogs can go out without needing to be walked. They briefly discuss protecting wells from zombies like in The Walking Dead. Ohio is described as "weird" and Ray's backyard video is mentioned as everything imagined for Ohio – flat, surprisingly lacking trees initially, although Ray clarifies he has trees, and his side yard is 65 feet long by 25 feet wide with a zipline. Cody mentions his acre is half dead grass, ants, and dirt. Ray notes that living on a hill sucks. Rem talks about growing up on three acres and how fun it was as a kid, not needing to be manicured. Rem mentions dealing with his "little one" digging holes and making mud for monster trucks in his yard and getting annoyed by ants. Cody mentions chilling post-Easter with leftovers and discount candy, referring to the period as the "holy refraction". There's discussion about the Pope dying, mentioning it happened on 4/20 or 4/21, his age (88), and nationality (Argentina). They list the last four Popes they've lived through: John Paul I, John Paul II, Benedict, and Pope Francis. Ray questions why anyone not Catholic would care who the Pope is. Rem argues everyone should care who the "Holy Father" is. They discuss Catholic practices like infallibility, celibacy, and the public recognition of the Pope compared to leaders of other religions. Cody recounts being asked to be godparents for his brother-in-law's child and being told they had to be married in a Catholic church, highlighting what he sees as Catholicism focusing on the "wrong things" and being too "ceremonial" rather than practical. Rem agrees it's all ceremony. Despite critiques of the ceremony, they acknowledge that if Catholics believe Christ died and was resurrected, they can still get to heaven, and that religion in general, like the Ten Commandments, provides a good way of living. The "best atheist on the show" (Rem) states that the lack of religion in society is a big problem because people need it. They critique the commandment "Shall not take the Lord's name in vain," arguing the Constitution supersedes the Ten Commandments. They discuss Cody's religious background in Alabama, describing it as "white people Baptist type stuff". Cody mentions being baptized "like 30 times" by different denominations. He ranks his top three baptism experiences: Nazarene (clinical) is number three, Episcopalian (female officiant) is number two, and Baptist (party, dunked in a creek, held under) is number one. They discuss sourdough starter and Ray's wife's breast milk used for practical purposes like treating pink eye. Ray describes his first experience with a bidet in a fancy restaurant restroom, being scared by the air dry function. They argue about the necessity of bidets vs. manual cleaning in the shower. Rem's Steve's Lava Chicken t-shirt design being rejected by Amazon merch is mentioned. They mention starting a band called Bubblegut and the Poops. The podcast is noted for surpassing the episode count of wrestling shows Dynamite and Nitro. We did the following segments: Thinking with your Dickman This segment features the hosts answering listener questions. Question 1 (from Joanna, treated as John/Joe): "Do I poop too much? I use the restroom an average of three times a day. My boyfriend says a woman shall need to poop once per day, but I'm not convinced. Is there any science to back up this claim? Are there any methods or devices you would recommend to measure my poop volume?". Cody, who has IBS and is a "two time a day type of pooper," validates that pooping multiple times a day is possible. Ray notes his toilet time is typically at least 30 minutes. They recommend getting a bidet for cleanliness, especially with frequent use, but caution against high water pressure to avoid hemorrhoids. They also recommend a seat cushion (like a donut) for long drives. Question 2 (from James, a recently retired actor): "I am a recently retired actor looking for things to do. I am famously starred in a long time running television show... I would like to find some activities that would allow some privacy... suggest some in Denvers.". Cody suggests mini golf and bumper boats as fun activities that might be less conducive to mobs. Rem suggests creating a profile on Fet Life and attending meetups, arguing that people in that lifestyle community are likely to keep secrets to protect themselves. Ray jokingly suggests starting an island. Question 3 (anonymous): "I hate chunky spaghetti sauce. Can you please tell me the best red sauce for pasta that isn't lumpy? Preferably, this advice would come from a true Italian.". Ray, claiming to be the most Italian, suggests Tutori tomato sauce, particularly the canned version, describing it as just sauce, not lumpy. He notes that while it's good as is for the "American people," you can spice it up with garlic, onions, and oregano. Rem talks about making sauce from scratch but acknowledges it's hard to beat store-bought like Prego or Ragu. Cody shares a story of making meatballs and sauce for multiple families using Target brand sauce and pasta, adding baked Italian spicy sausage and basil, and being asked for his "recipe" later. They joke that Americans are easy to please with Italian food. Question 4 (from John): "I want to play hookie from school for a day and need a legitimate excuse. Do you have any ways of getting out of school, but in a way that I can't get caught?". Suggestions include hacking the school's mainframe and changing attendance, getting a contagious illness like mono or pink eye (noting pink eye isn't that bad and a remote doctor's note is easy to get now). An interesting suggestion from Cody is to use microwave beeps to fake an EKG sound during a call. Another suggestion is to get surgery, like for a lazy eye, which could provide extended time off. Cody Reads Copy about Verilife Dispensary in Hillsboro, OH: Cody reads a descriptive piece about a dispensary called Verilife in Hillsboro, Ohio, located between cornfields and Dairy Queens. The copy highlights the "chill energy" and "tactical command" of an employee named Emily, who handles a chaos-inducing attempted robbery ("Tiger King's backup dancer" trying to "jack the stash") by leading the staff in a defensive maneuver before calmly ringing up the customer. The copy concludes that at Verilife, you get "weed," a "story," a "community," and "Emily," and encourages listeners to visit and mention Randy. Dick of the Week: Four nominees are presented for the "Dick of the Week" title. Nominee 1: A 31-year-old woman arrested in Floren Park, New Jersey on April 6, 2025, for DUI and refusing a breath test after driving the wrong way on a turnpike and other roads during a rainstorm. Dash cam footage showed erratic driving, running safety zones and a red light. She showed signs of intoxication, failed field sobriety tests, and had a concealed alcoholic beverage. She faces multiple charges including DUI refusal, reckless driving, careless driving, and lane violations. Nominee 2: A 47-year-old former Hillsboro County, Florida Sheriff's Office deputy and current county schools employee, Brandon Scott Parker, charged after a road rage incident on April 6, 2025, where he allegedly threw a bottle at a driver who honked at him, causing injury (contusion and abrasion). He was charged with the felony of throwing a deadly missile into an occupied conveyance. Nominee 3: A motorcyclist with a passenger involved in a road rage incident in El Cajon, California on April 7, 2025, who fired a gun at a truck. The truck driver was unharmed but found a bullet hole. The suspects fled on the motorcycle, which was found to be stolen, and were later found hiding in a drainage tunnel. Nominee 4: A 24-year-old man from Wisconsin who stole a bag of food from the kitchen of a McDonald's in Elmhurst, Illinois on April 7, 2025, and resisted arrest. Voting results in a tie between the Wrongway DUI driver (Nominee 1), supported by Randy and Rem for violating fundamental societal rules, and the Road rage bottle thrower (Nominee 2), with Cody voting against it specifically because the person was a former cop. Given the tie and the mention of Hillsboro in two different stories (Ohio and Florida), they declare the "Dick of the Week" is the "simulation". Dickman Dilemma: Three hypothetical dilemmas are discussed. Dilemma 1 (from Senson): Choose between having sex with a woman you find ugly once a week for $5,000 a week, or having the hottest woman you can think of peg you for $6,000 a week. Cody chooses the $5,000 option, reasoning he can turn the lights off and find enjoyment. Ray and Rem both choose the $6,000 option, seemingly unbothered by the act of pegging and appreciating the extra money. Dilemma 2: Hire a zombie chef who cooks Michelin star meals, but there's a 0.5% chance he eats your brains for each dish. Do you hire him?. Cody and Rem immediately decline, citing the disgusting nature of zombies and the unacceptable risk of death for a meal, regardless of quality. Ray compares the odds to other risky activities, noting he wouldn't risk his life for a meal but might for a large sum of money, and discusses the illusion of control people feel in everyday risks like driving. Dilemma 3: You get 2 million for a tattoo that forces you to blurt out the truth 10 minutes daily. Do you ink it?. The discussion centers on whether the 10 minutes are predictable and if the person can control what truths are revealed. Rem and Cody both agree they would take the tattoo for $2 million, particularly if the truth-telling was controllable or if it was like the movie Liar Liar, or simply because they believe in honesty and feel they don't have secrets bad enough to lose $2 million over. They consider doing it after retiring or getting divorced to minimize potential negative consequences. What Would Jesus Draw - Jesus at Wrestlemania 41 - Winner Ray: The hosts generate AI images based on the theme "Jesus Christ at Wrestlemania 41 in Las Vegas". Randy's prompt: Jesus Christ of Nazareth fighting the old Undertaker in a Hell in a Cell match on top of the cage. Cody's prompt: Jesus Christ of Nazareth powerbomb Mussolini through the Spanish broadcast desk. Rem's prompt: Jesus Christ of Nazareth hosting Wrestlemania 41 in Las Vegas, yelling at a hostile crowd of internet nerds telling them they're ruining the show with a dialogue bubble saying "You're ruining wrestling for everybody". Ray's prompt: Jesus Christ of Nazareth at Wrestlemania being submitted by Bret Hart's sharpshooter. Ray clarifies the spelling of Hart and that sharpshooter is a submission hold. During judging, Ray's prompt generated an image of Jesus Christ versus Bret Hart (spelled correctly by the AI), showing Jesus in agony, in robes, with the crown of thorns, being put into a submission hold (though not an exact sharpshooter). This image was seen as capturing the spirit and specific details of the prompt very well. Cody's image showed Jesus powerbombing someone who looked like "young Mussolini". Randy's image showed Jesus fighting someone resembling the Undertaker but missing key prompt elements like being on top of the cage. Rem's image showed Jesus yelling at nerds with bad hands and text issues. Ray's image of Jesus vs. Bret Hart was chosen as the winner, with Ray crediting the use of ChatGPT. The episode concludes with hosts mentioning making the Jesus art available on their website, whatwouldjesusdraw.com, plugging their social media and projects, and thanking their listeners.

New panel: Fire officer/paramedic John, fire paramedic Jason, retired fire paramedic Terry and EMS medical director KashHow to determine capacity and how this differs from competency This becomes critical when doing refusals – when the patient decides not to be transported – a very high liability part of EMSThis is different than AAOX4Capacity is very situational and specific, competency is determined by a judgeWe determine capacity:They must communicate a clear choice, an understanding of their current situation, understanding the risks and benefits of refusing or accepting careSuicidal thoughts mean the patient does not have the capacity to makes decisions for that particular aspect of their careBack when I first started in EMS, we would routinely force a suicidal patient to go to the hospital. The current culture puts EMS crew safety as a higher priority. Meaning, if we don't have the support of law enforcement, we are not going to force patients against their will to get a mental health evaluationWe talk about our relationship and reliance on our mental health evaluatorsDocumenting these difficult cases involving suicidality and capacity can be toughOne of the current challenges is assuring cooperation between EMS and PD to help safely transport a patient with suicidality but that is also a potential danger to providersInvolving medical control is critical in these difficult situations, especially with technological changes decreasing the difficultyWhen in doubt, just make the consult EMS trained physicians improve our ability to do our jobs as more and more emergency medicine physicians get this training, it can only benefit usSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

In this sermon, Ed Young, uses his heart surgery story to highlight how Jesus' journey—up from Heaven, down to Earth, lifted up on the cross, down in the grave and up through the resurrection—mirrors the spiritual rhythm God invites us to follow, challenging us to sync our hearts with His divine "EKG."

The difficult admissions are the generally weak, unable to walk with no acute findings. They typically do not uncover any acute findings while in the hospitalIn the ED, we can probably do a better job of involving some of our resources like social work to really give the patient and their family a better understanding of what admission will and won't accomplish for themPart of the America culture does put us in unique situations as the elderly often do not live with their children anymore. Family live far apart and often cannot help each other when in needNo one blames the patient for the situation they are in, but we want to find the best solution to serve themIM deals with the limitations of insurance much more than we do in the EDUltimately, each hospital group needs to establish a culture. What would you want done for your Grandma?A little more work now on these difficult cases in the ED can have the downstream benefit of keeping admission beds open for your next shiftDementia patients with progression of their disease process can be tricky to disposition as wellWe don't do the best job in our society of talking about the normal aging process and how to preserve our patient's dignity and sense of self in that processWe are scared to death of deathWhat is the difference between Observation admission and Inpatient admission? The care is the same regardless of the admission typeAn observation admission is best thought of as a problem that could likely be handled in the outpatient setting if the patient had unfettered access to follow up to PCP and specialistsIn-patient implies that they need resources only found in the hospitalIn-patient vs obs can change over time, if nothing new is found, these statuses can changeSean recommends the book Same As Ever by Morgan Housel He talks about the changes in medicine being so gradual that they don't make headlines, but they are dramatic over time none the lessSupport the showFull show notes can be found here: Episodes - Practical EMS - Content for EMTs, PAs, ParamedicsMost efficient online EKG course here: Practical EKG Interpretation - Practical EMS earn 4 CME and learn the fundamentals through advanced EKG interpretation in under 4 hours. If you want to work on your nutrition, increase your energy, improve your physical and mental health, I highly recommend 1st Phorm. Check them out here so they know I sent you. 1st Phorm | The Foundation of High Performance Nutrition Everything you hear today from myself and my guests is opinion only and doesn't represent any organizations or companies that any of us are affiliated with. The stories you hear have been modified to protect patient privacy and any resemblance to real individuals is coincidental. This is for educational and entertainment purposes only and should not be taken as medical advice nor used to diagnose any medical or healthcare conditions.

The Dow Jones looks like an EKG chart. The world economy feels like the Cuban Missile Crisis. And the sycophantic administration's policy is more volatile than the Denver Nuggets' front office. But to Stephanie Ruhle — the former banker turned host of MSNBC's The 11th Hour, receiving frantic calls from investors and C-suite execs — the real problem underneath America's tariff turbulence is more fundamental: trust that was gained in droplets is now lost in buckets. Who's suffering the consequences of the art of the deal while Trump and his cronies profiteer from golf tournaments? Probably you. Plus: the dark heart of a Twitter warrior, Stephen A. Smith's tariff strategy...and a basement taco joint with A-Rod and J-Lo. Learn more about your ad choices. Visit podcastchoices.com/adchoices

The Dow Jones looks like an EKG chart. The world economy feels like the Cuban Missile Crisis. And the sycophantic administration's policy is more volatile than the Denver Nuggets' front office. But to Stephanie Ruhle — the former banker turned host of MSNBC's The 11th Hour, receiving frantic calls from investors and C-suite execs — the real problem underneath America's tariff turbulence is more fundamental: trust that was gained in droplets is now lost in buckets. Who's suffering the consequences of the art of the deal while Trump and his cronies profiteer from golf tournaments? Probably you. Plus: the dark heart of a Twitter warrior, Stephen A. Smith's tariff strategy...and a basement taco joint with A-Rod and J-Lo. Learn more about your ad choices. Visit podcastchoices.com/adchoices

CardioNerds (Drs. Daniel Ambinder and Eunice Dugan) join Dr. Namrita Ashokprabhu, Dr. Yulith Roca Alvarez, and Dr. Mehmet Yildiz from The Christ Hospital. Expert commentary by Dr. Odayme Quesada. Audio editing by CardioNerds intern, Christiana Dangas. This episode highlights the pivotal role of cardiac MRI and functional testing in uncovering coronary vasospasm as an underlying cause of MINOCA. Cardiac MRI is crucial in evaluating myocardial infarction with nonobstructive coronary arteries (MINOCA) and diagnosing myocarditis, but findings must be interpreted within clinical context. A 58-year-old man with hypertension, hyperlipidemia, diabetes, a family history of cardiovascular disease, and smoking history presented with sudden chest pain, non-ST-elevation on EKG, and elevated troponin I (0.64 µg/L). Cardiac angiography revealed nonobstructive coronary disease, including a 40% stenosis in the LAD, consistent with MINOCA. Eight weeks later, another event (troponin I 1.18 µg/L) led to cardiac MRI findings suggesting myocarditis. Further history revealed episodic chest pain and coronary vasospasm, confirmed by coronary functional angiography showing severe vasoconstriction, resolved with nitroglycerin. Management included calcium channel blockers and long-acting nitrates, reducing symptoms. Coronary vasospasm is a frequent MINOCA cause and can mimic myocarditis on CMRI. Invasive coronary functional testing, including acetylcholine provocation testing, is indicated in suspicious cases.  US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Notes - Coronary Vasospasm What are the potential underlying causes of MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries)?  Plaque Rupture: Plaque disruption, which includes plaque rupture, erosion, and calcified nodules, occurs as lipids accumulate in coronary arteries, leading to inflammation, necrosis, fibrosis, and calcification. Plaque rupture exposes the plaque to the lumen, causing thrombosis and thromboembolism, while plaque erosion results from thrombus formation without rupture and is more common in women and smokers. Intravascular imaging, such as IVUS and OCT, can detect plaque rupture and erosion, with studies showing plaque disruption as a frequent cause of MINOCA, particularly in women, though the true prevalence may be underestimated due to limited imaging coverage.  Coronary Vasospasm: Coronary vasospasm is characterized by nitrate-responsive chest pain, transient ischemic EKG changes, and >90% vasoconstriction during provocative testing with acetylcholine or ergonovine, due to hyper-reactivity in vascular smooth muscle. It is a common cause of MINOCA, with approximately half of MINOCA patients testing positive in provocative tests, and Asians are at a significantly higher risk than Whites. Smoking is a known risk factor for vasospasm. In contrast, traditional risk factors like sex, hypertension, and diabetes do not increase the risk, and vasospasm is associated with a 2.5–13% long-term risk of major adverse cardiovascular events (MACE).  Spontaneous Coronary Artery Dissection: Spontaneous coronary artery dissection (SCAD) involves the formation of a false lumen in epicardial coronary arteries without atherosclerosis, caused by either an inside-out tear or outside-in intramural hemorrhage. SCAD is classified into four types based on angiographic features, with coronary angiography being the primary diagnostic tool. However, in uncertain cases, advanced imaging like IVUS or OCT may be used cautiously. While the true prevalence is unclear due to missed diagnoses, SCAD is more common in women and is considered a cause of MINOCA when i...

N Engl J Med 2005;353:1095-1104Background: Prior trials on revascularization in patients with acute coronary syndromes without ST-segment elevation have yielded mixed results. While FRISC II and TACTICS-TIMI 18 demonstrated a significant reduction in myocardial infarction, this benefit was not observed in RITA 3. None of these trials showed a significant reduction in mortality. Further research is needed to guide treatment strategies in this population, particularly after the introduction of early use of clopidogrel and intensive lipid-lowering therapy.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) trial sough to test the hypothesis that an early invasive strategy is superior to selective invasive strategy for patients with non-ST elevation myocardial infarction (NSTEMI).Patients: Eligible patients had to have all of the following: Worsening symptoms of ischemia or symptoms at rest with the last episode being 24 hours before randomization, elevated cardiac troponin T level (≥0.03 μg per liter); and either ischemic EKG changes (defined as ST-segment depression or transient ST-segment elevation exceeding 0.05 mV, or T-wave inversion of ≥0.2 mV in two contiguous leads) or a documented history of coronary artery disease.Patients were excluded if they were older than 80 years, had an indication for primary percutaneous coronary intervention or fibrinolytic therapy, hemodynamic instability or overt congestive heart failure, oral anticoagulant drugs use in the past 7 days, fibrinolytic treatment within the past 96 hours, percutaneous coronary intervention within the past 14 days, elevated bleeding risk, plus others.Baseline characteristics: The trial randomized 1,200 patients from 42 Dutch hospitals – 604 randomized to early invasive strategy and 596 randomized to selective invasive strategy.The average age of patients was 62 years and 74% were men. Approximately 39% had hypertension, 14% had diabetes, 35% had hyperlipidemia, 23% had prior myocardial infarction and 41% were current smokers.Approximately 48% of the patients had ST deviation equal to or greater than 0.1 mV.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo early invasive vs selective invasive strategy.Patients received 300 mg of aspirin at the time of randomization, followed by at least 75 mg daily indefinitely, and enoxaparin (1 mg/kg for a maximum of 80 mg) subcutaneously twice daily for at least 48 hours. The early use of clopidogrel (300 mg immediately, followed by 75 mg daily) in addition to aspirin was recommended to the investigators after the drug was approved for acute coronary syndrome in 2002. Intensive lipid-lowering therapy, preferably atorvastatin 80 mg daily or the equivalent was recommended as soon as possible after randomization. All interventional procedures during the index admission were performed with the use of abciximab.Patients assigned to the early invasive strategy were scheduled to undergo angiography within 24 - 48 hours after randomization. Patients assigned to the selective invasive strategy underwent coronary angiography if they had refractory angina despite optimal medical therapy, hemodynamic or rhythm instability, or significant ischemia on pre-discharge exercise test.In both groups, percutaneous coronary intervention (PCI) was performed when appropriate, without providing more details in the manuscript.The level of creatine kinase MB was measured at 6-hour intervals during the first day, after each new clinical episode of ischemia, and after each percutaneous revascularization procedure.Endpoints: The primary endpoint was a composite of all-cause death, myocardial infarction, or rehospitalization for angina at 1-year.The estimated sample size to provide 80% power to detect 25% relative risk difference between the two treatment groups at 5% alpha was 1,200 patients. This assumed that 21% of the patients in the early invasive arm would experience the primary outcome.Results: During the index admission, 98% of the patients in the early invasive strategy arm underwent coronary angiogram compared to 53% in the selective invasive arm. At 1-year, 79% of the patients in the early invasive strategy arm underwent revascularization compared to 54% in the selective invasive arm.The primary outcome was not significantly different between both treatment groups (22.7% with early invasive vs 21.2% with selective invasive, RR: 1.07; 95% CI: 0.87 - 1.33; p= 0.33). All-cause death was the same in both groups (2.5%). Myocardial infarction was significantly higher with the early invasive strategy (15.0% vs. 10.0%, RR: 1.50, 95% CI: 1.10 – 2.04; p= 0.005), while rehospitalization for angina was lower with early invasive (7.4% vs. 10.9%, RR: 0.68, 95% CI: 0.47 – 0.98; p= 0.04). Most myocardial infarctions were revascularization related and these were significantly more frequent with early invasive (11.3% vs 5.4%). Spontaneous myocardial infarctions were 3.7% with early invasive and 4.6% with selective invasive and this was not statistically significant.Major bleeding, not related CABG, during the index admission was more frequent with the early invasive strategy (3.1% vs 1.7%).There were no significant subgroup interactions for the primary outcome, including based on ST deviation and troponin levels.Conclusion: In patients with NSTEMI, an early invasive strategy was not superior to selective invasive strategy in reducing the composite endpoint of all-cause death, myocardial infarction, or rehospitalization for angina at 1-year. An early invasive strategy was associated with more myocardial infarctions with a number needed to harm of 20 patients, which was secondary to revascularization related myocardial infarction. An early invasive strategy reduced rehospitalization for angina with a number needed to treat of approximately 29 patients.The ICTUS trial showed that revascularization can cause harm and highlighted how counting procedural myocardial infarctions can influence outcome estimates. While there is ongoing debate about the significance of periprocedural myocardial infarctions, evidence indicates an association with increased mortality. Whether periprocedural myocardial infarctions are 'less severe' than spontaneous myocardial infarctions remains controversial, as their impact varies based on infarct size and patient characteristics. This underscores the importance of including all-cause mortality or advanced systolic heart failure as endpoints in trials of revascularization.Patients in ICTUS received better background medical therapy compared to prior trials in this area. While this could be responsible for the divergent results compared to other prior trials. It also highlights the heterogeneity of NSTEMI patients and that an invasive strategy is not appropriate for all.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

This podcast is brought to you by Outcomes Rocket, your exclusive healthcare marketing agency. Learn how to accelerate your growth by going to outcomesrocket.com Textiles offer an unprecedented opportunity to bridge the gap between humans, AI, and healthcare by creating a seamless, continuous data stream for proactive prevention.  In this episode, Dr. Tony Chahine, CEO and founder of Myant, shares his mission to transform healthcare through textile computing. Inspired by his father's dementia, he developed sensor-embedded clothing that passively monitors vital signs like EKG, core body temperature, and breathing rate, transmitting real-time data to care teams for remote monitoring and more accurate diagnoses. Myant's initial focus is on cardiology clinics, offering an alternative to Holter monitors for patients with cardiovascular disease while also consolidating multiple health devices into a single wearable garment. Dr. Chahine envisions a future where AI models trained on this data can predict health events before they occur, emphasizing the need for perseverance and long-term vision in pioneering innovation. Tune in and learn how textiles are poised to revolutionize preventive healthcare! Resources:  Connect and follow Tony Chahine on LinkedIn. Learn more about Myant on their LinkedIn and website. Discover more about Myant's manufacturing division here. Fast Track Your Business Growth: Outcomes Rocket is a full-service marketing agency focused on helping healthcare organizations like yours maximize your impact and accelerate growth. Learn more at outcomesrocket.com

A Minnesota jail nurse is now facing second-degree manslaughter and felony criminal neglect charges nearly six years after an inmate under her care died—an incident that led to a $2.6 million settlement and inspired a new state law to prevent similar tragedies. According to the criminal complaint, 27-year-old Hardel Sherrell was booked into the Beltrami County Jail on August 24, 2018. Despite high blood pressure and a history of respiratory failure, his initial condition appeared stable. Three days later, Sherrell began experiencing chest pain and tingling in his left hand. He received an electrocardiogram (EKG) and painkillers, and he reported that he had stopped taking his blood pressure medication months earlier. Over the following days, Sherrell's health deteriorated further. He frequently fell out of his bunk and complained of numbness in his legs. On August 31, he was observed lying on a mat, unable to move; his mouth drooped, and his speech was slurred. A jail doctor suspected Guillain-Barré Syndrome, a rare autoimmune disorder. Hospital tests, however, led an emergency room physician to diagnose him with “malingering and weakness” before sending him back to the jail. When 37-year-old nurse Michelle Rose Skroch—then employed by MEnD Correctional Care, LLC—came on duty September 1, she was briefed about Sherrell's rapidly worsening condition. Prosecutors allege she simply stood at his cell door, refused to conduct any standard medical assessment, and told Sherrell he could walk if he wanted to. When he begged for help, she allegedly stated she “would not bargain with him.” Across two days, Skroch is accused of never taking Sherrell's vital signs, even as he struggled to eat, drink, or go to the bathroom unassisted. The complaint further states she told a jail doctor that Sherrell was improving, despite video footage apparently showing him taking rapid, shallow breaths. She purportedly told correctional officers he was “perfectly fine.” Around 4:46 p.m. on September 2, officers discovered Sherrell unresponsive; he was pronounced dead shortly thereafter. An autopsy showed he died from pneumonia and cerebral edema (brain swelling), with a separate pathologist concluding the cause of death was complications from Guillain-Barré Syndrome. A correctional health expert reviewing the case stated that Skroch failed to perform the “most basic nursing care,” labeling the lack of vital sign checks on a critically ill patient a “tremendous breach” of duty. Medical experts believe Sherrell likely would have survived had he received proper treatment. Sherrell's mother filed a lawsuit against the county and MEnD, resulting in a $2.6 million settlement. In response to the case, Minnesota lawmakers passed the “Hardel Sherrell Act,” granting the Department of Corrections greater oversight of county jails. Skroch, whose nursing license has been revoked, was arrested Friday and charged with second-degree manslaughter (culpable negligence) and two counts of felony criminal neglect. She is scheduled to appear in court on April 11. Want to listen to ALL of our podcasts AD-FREE? Subscribe through APPLE PODCASTS, and try it for three days free: https://tinyurl.com/ycw626tj Follow Our Other Cases: https://www.truecrimetodaypod.com The latest on The Downfall of Diddy, The Trial of Karen Read, The Murder Of Maddie Soto, Catching the Long Island Serial Killer, Awaiting Admission: BTK's Unconfessed Crimes, Delphi Murders: Inside the Crime, Chad & Lori Daybell, The Murder of Ana Walshe, Alex Murdaugh, Bryan Kohberger, Lucy Letby, Kouri Richins, Malevolent Mormon Mommys, The Menendez Brothers: Quest For Justice, The Murder of Stephen Smith, The Murder of Madeline Kingsbury, The Murder Of Sandra Birchmore, and much more! Listen at https://www.truecrimetodaypod.com

MN Jail Nurse Refuses To Treat Inmate, Who Dies… Finally Charged! A Minnesota jail nurse is now facing second-degree manslaughter and felony criminal neglect charges nearly six years after an inmate under her care died—an incident that led to a $2.6 million settlement and inspired a new state law to prevent similar tragedies. According to the criminal complaint, 27-year-old Hardel Sherrell was booked into the Beltrami County Jail on August 24, 2018. Despite high blood pressure and a history of respiratory failure, his initial condition appeared stable. Three days later, Sherrell began experiencing chest pain and tingling in his left hand. He received an electrocardiogram (EKG) and painkillers, and he reported that he had stopped taking his blood pressure medication months earlier. Over the following days, Sherrell's health deteriorated further. He frequently fell out of his bunk and complained of numbness in his legs. On August 31, he was observed lying on a mat, unable to move; his mouth drooped, and his speech was slurred. A jail doctor suspected Guillain-Barré Syndrome, a rare autoimmune disorder. Hospital tests, however, led an emergency room physician to diagnose him with “malingering and weakness” before sending him back to the jail. When 37-year-old nurse Michelle Rose Skroch—then employed by MEnD Correctional Care, LLC—came on duty September 1, she was briefed about Sherrell's rapidly worsening condition. Prosecutors allege she simply stood at his cell door, refused to conduct any standard medical assessment, and told Sherrell he could walk if he wanted to. When he begged for help, she allegedly stated she “would not bargain with him.” Across two days, Skroch is accused of never taking Sherrell's vital signs, even as he struggled to eat, drink, or go to the bathroom unassisted. The complaint further states she told a jail doctor that Sherrell was improving, despite video footage apparently showing him taking rapid, shallow breaths. She purportedly told correctional officers he was “perfectly fine.” Around 4:46 p.m. on September 2, officers discovered Sherrell unresponsive; he was pronounced dead shortly thereafter. An autopsy showed he died from pneumonia and cerebral edema (brain swelling), with a separate pathologist concluding the cause of death was complications from Guillain-Barré Syndrome. A correctional health expert reviewing the case stated that Skroch failed to perform the “most basic nursing care,” labeling the lack of vital sign checks on a critically ill patient a “tremendous breach” of duty. Medical experts believe Sherrell likely would have survived had he received proper treatment. Sherrell's mother filed a lawsuit against the county and MEnD, resulting in a $2.6 million settlement. In response to the case, Minnesota lawmakers passed the “Hardel Sherrell Act,” granting the Department of Corrections greater oversight of county jails. Skroch, whose nursing license has been revoked, was arrested Friday and charged with second-degree manslaughter (culpable negligence) and two counts of felony criminal neglect. She is scheduled to appear in court on April 11. Want to listen to ALL of our podcasts AD-FREE? Subscribe through APPLE PODCASTS, and try it for three days free: https://tinyurl.com/ycw626tj Follow Our Other Cases: https://www.truecrimetodaypod.com The latest on The Downfall of Diddy, The Trial of Karen Read, The Murder Of Maddie Soto, Catching the Long Island Serial Killer, Awaiting Admission: BTK's Unconfessed Crimes, Delphi Murders: Inside the Crime, Chad & Lori Daybell, The Murder of Ana Walshe, Alex Murdaugh, Bryan Kohberger, Lucy Letby, Kouri Richins, Malevolent Mormon Mommys, The Menendez Brothers: Quest For Justice, The Murder of Stephen Smith, The Murder of Madeline Kingsbury, The Murder Of Sandra Birchmore, and much more! Listen at https://www.truecrimetodaypod.com

Here's my new idea for an episode. Welcome to it. I want to talk about a major theme running through the last few episodes of Relentless Health Value. And this theme is, heads up, going to continue through a few upcoming shows as well. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. We have Matt McQuide coming up, talking about patient engagement, and Christine Hale, MD, MBA, talking about high-cost claimants. And we also have an encore coming up with Kenny Cole, MD, talking about a lot of things; but patient trust is one of them. But before I get to the main theme to ponder here, let me talk about what gets selected to talk about on Relentless Health Value. I will freely admit, how topics for shows get picked, it's not exactly a linear sort of affair. And furthermore, even if it were, I can't always get the stars to align to get a specific cluster of guests to all come on like one after the other. So, for sure, it might be less than obvious at times where my head is at—and sometimes, admittedly, I don't even know. This may sound incredibly scattershot (and it probably is), but in my defense, this whole healthcare thing, in case you didn't know, it's really complicated. Every time I get a chance to chat with an expert, I learn something new. I feel like it's almost impossible to sit in a vacuum and mastermind some kind of grand insight. Very, very fortunately, I don't need to sit in a cave and do all this heavy thinking all by myself. We got ourselves a tribe here of like-minded, really smart folks between the guests and you lot, all of you in the tribe of listeners who are here every week. Yeah, you rock! And I can always count on you to start teasing out the themes and the through lines and the really key actionable points. You email me. You write great posts and comments on LinkedIn and elsewhere. Even if I am a little bit behind the eight ball translating my instinct into an actual trend line, it doesn't slow this bus down. It's you who keeps it moving, which is why I can confidently say it's you all who are to blame for this new idea I came up with the other day after the podcast with Al Lewis (EP464) triggered so much amazing and really deep insight and dot connecting back and forth that hooked together the past six, I'm gonna say, or so shows. Let's just start at the beginning. Let's start with the topics that have been discussed in the past several episodes of the pod. Here I go. Emergency room visits are now costing about 6% of total plan sponsor spend on average. That was the holy crap moment from the episode with Al Lewis (EP464). Emergency room volume is up, and also prices are up. In that show with Al Lewis, I did quote John Lee, MD, who is an emergency room doctor, by the way. I quoted him because he told a story about a patient who came into the ER, winds up getting a big workup in his ER. Dr. Lee says he sees this situation a lot where the patient comes in, they've had something going on for a while, they've tried to make an appointment with their PCP or even urgent care, they could not get in. It's also really hard to coordinate and get all the blood work or the scans and have that all looked at that's needed for the workup to even happen. I've spoken with multiple ER doctors at this point, and they all say pretty much the same thing. They see the same scenario happen often enough, maybe even multiple times a day. Patient comes in with something that may or may not be emergent, and they are now in the ER because they've been worried about it for weeks or months. And the ER is like the only place where they can get to the bottom of what is going on with their body. And then the patient, you know, they spend the whole day in the ER getting what amounts to weeks' worth of outpatient workup accomplished and scans and imaging and labs. And there's no prior authing anything down. It's also incredibly expensive. Moving on from the Al Lewis show, earlier than that I had had on Rushika Fernandopulle, MD (EP460) and then also Scott Conard, MD (EP462). Both are PCPs, both talking about primary care and what makes good primary care and what makes bad primary care and how our current “healthcare marketplace,” as Dr. Conard puts it, incentivizes either no primary care and/or primary care where volume driven throughput is the name of the game—you know, like seeing 25 patients a day. These visits or episodes of care are often pretty transactional. If relationships are formed, it's because the doctor and/or the patient are rising above the system, not the other way around. And none of that is good for primary care doctors, nurses, or other clinicians. It's also not good for patients, and it's not good for plan sponsors or any of the ultimate purchasers here (taxpayers, patients themselves) because while all of this is going on, those patients getting no or not good primary care are somebody's next high-cost claimant. Okay, so those were the shows with Rushika Fernandopulle and Scott Conard. Then this past week was the show with Vivian Ho, PhD (EP466), who discusses the incentives that hospital leadership often has. And these incentives may actually sound great on paper, but IRL, they wind up actually jacking up prices and set up some weird incentives to increase the number of beds and the heads in them. There was also two shows, one of them with Betsy Seals (EP463) and then another one with Wendell Potter (EP384), about Medicare Advantage and what payers are up to. Alright, so let's dig in. What's the big theme? What's the big through line here? Let's take it from the top. Theme 1 is largely this (and Scott Conard actually said this flat out in his show): Primary care—good primary care, I mean—is an investment. Everything else is a cost. And those skyrocketing ER costs are pure evidence of this. Again, listen to that show with Al Lewis earlier (EP464) for a lot of details about this. But total plan costs … 6% are ER visits. Tim Denman from Premise Health wrote, “That is an insane number! Anything over 2% warrants concern.” But yeah, these days we have, on average across the country, 200 plan members out of 1000 every single year dipping into their local ER. That number, by the way, will rise and fall depending on the access and availability of primary care and/or good urgent cares. Here's from a Web site entitled ER Visit Statistics, Facts & Trends: “In the United States, emergency room visits often highlight gaps in healthcare accessibility. Many individuals turn to ERs for conditions that could have been managed through preventative or primary care. … This indicates that inadequate access to healthcare often leads to increased reliance on emergency departments. … “ED visits can entail significant costs, particularly when a considerable portion of these visits is classified as non-urgent. … [Non-urgent] visits—not requiring immediate medical intervention—often lead to unnecessary expenditures that could be better allocated in primary care settings.” And by the way, if you look at the total cost across the country of ER visits, it's billions and billions and billions of dollars. In 2017, ED visits (I don't have a stat right in front of me), but in 2017, ED visits were $76.3 billion in the United States. Alright, so, the Al Lewis show comes out, I see that, and then, like a bolt of lightning, François de Brantes, MBA, enters the chat. François de Brantes was on Relentless Health Value several years ago (EP220). I should have him come back on. But François de Brantes cemented with mortar the connectivity between runaway ER costs and the lack of primary care. He started out talking actually about a new study from the Milbank Memorial Fund. Only like 5% of our spend going to primary care is way lower than any other developed country in the world—all of whom, of course, have far higher life expectancies than us. So, yeah … they might be onto something. François de Brantes wrote (with some light editing), “Setting aside the impotence of policies, the real question we should ask ourselves is whether we're looking at the right numbers. The short answer is no, with all due respect to the researchers that crunched the numbers. That's probably because the lens they're using is incredibly narrow and misses everything else.” And he's talking now about, is that 5% primary care number actually accurate? François de Brantes continues, “Consider, for example, that in commercially insured plans, the total spend on … EDs is 6% or more.” And then he says, “Check out Stacey Richter's podcast on the subject, but 6% is essentially what researchers say is spent on, you know, ‘primary care.' Except … they don't count those costs, the ER costs. They don't count many other costs that are for primary care, meaning for the treatment of routine preventative and sick care, all the things that family practices used to manage but don't anymore. They don't count them because those services are rendered by clinicians other than those in primary care practice.” François concludes (and he wrote a great article) that if you add up all the dollars that are spent on things that amount to primary care but just didn't happen in a primary care office, it's conservatively around 17% of total dollars. So, yeah … it's not like anyone is saving money by not making sure that every plan member or patient across the country has a relationship with an actual primary care team—you know, a doctor or a nurse who they can get on the phone with who knows them. Listen to the show coming up with Matt McQuide. This theme will continue. But any plan not making sure that primary care happens in primary care offices is shelling out for the most expensive primary care money can buy, you know, because it's gonna happen either in the ER or elsewhere. Jeff Charles Goldsmith, PhD, put this really well. He wrote, “As others have said, [this surge in ER dollars is a] direct consequence of [a] worsening primary care shortage.” Then Dr. John Lee turned up. He, I had quoted on the Al Lewis show, but he wrote a great post on LinkedIn; and part of it was this: “Toward a systemic solution, [we gotta do some unsqueezing of the balloon]. Stacey and Al likened our system to a squeezed balloon, with pressure forcing patients into the [emergency room]. The true solution is to ‘unsqueeze' the system by improving access to care outside the [emergency room]. Addressing these upstream issues could prevent patients from ending up in the [emergency room]. … While the necessary changes are staring us in the face, unsqueezing the balloon is far more challenging than it sounds.” And speaking of ER docs weighing in, then we had Mick Connors, MD, who left a banger of a comment with a bunch of suggestions to untangle some of these challenges that are more challenging than they may sound at first glance that Dr. Lee mentions. And as I said, he's a 30-year pediatric emergency physician, so I'm inclined to take his suggestions seriously. You can find them on LinkedIn. But yeah, I can see why some communities are paying 40 bucks a month or something for patients without access to primary care to get it just like they pay fire departments or police departments. Here's a link to Primary Care for All Americans, who are trying to help local communities get their citizens primary care. And Dr. Conard talked about this a little bit in that episode (EP462). I can also see why plan sponsors have every incentive to change the incentives such that primary care teams can be all in on doing what they do. Dr. Fernandopulle (EP460) hits on this. This is truly vital, making sure that the incentives are right, because we can't forget, as Rob Andrews has said repeatedly, organizations do what you pay them to do. And unless a plan sponsor gets into the mix, it is super rare to encounter anybody paying anybody for amazing primary care in an actual primary care setting. At that point, Alex Sommers, MD, ABEM, DipABLM, arrived on the scene; and he wrote (again with light editing—sorry, I can't read), “This one is in my wheelhouse. There is a ton that could be done here. There just has to be strategy in any given market. It's a function of access, resources, and like-minded employers willing to invest in a direct relationship with providers. But not just any providers. Providers who are willing to solve a big X in this case. You certainly don't need a trauma team on standby to remove a splinter or take off a wart. A great advanced primary care relationship is one way, but another thing is just access to care off-hours with the resources to make a difference in a cost-plus model. You can't help everybody at once. But you can help a lot of people if there is a collaborative opportunity.” And then Dr. Alex Sommers continues. He says, “We already have EKG, most procedures and supplies, X-ray, ultrasounds, and MRI in our clinics. All that's missing is a CT scanner. It just takes a feasible critical mass to invest in a given geography for that type of alternative care model to alter the course here. Six percent of plan spend going to the ER. My goodness.” So, then we have Ann Lewandowski, who just gets to the heart of the matter and the rate critical for primary care to become the investment that it could be: trust. Ann Lewandowski says, “I 100% agree with all of this, basically. I think strong primary care that promotes trust before things get so bad people think they need to go to the emergency room is the way to go.” This whole human concept of trust is a gigantic requirement for clinical and probably financial success. We need primary care to be an investment, but for it to be an investment, there's got to be relationships and there has to be trust between patients and their care teams. Now, neither relationships nor trust are super measurable constructs, so it's really easy for some finance pro to do things in the name of efficiency or optimization that undermine the entire spirit of the endeavor without even realizing it. Then we have a lot of primary care that doesn't happen in primary care offices. It happens in care settings like the ER. So, let's tug this theme along to the shows that concern carriers, meaning the shows with Wendell Potter (EP384) on how shareholders influence carrier behavior and with Betsy Seals (EP463) on Medicare Advantage plans and what they're up to. Here's where the primary care/ER through line starts to connect to carriers. Here's a LinkedIn post by the indomitable Steve Schutzer, MD. Dr. Schutzer wrote about the Betsy Seals conversation, and he said, “Stacey, you made a comment during this fabulous episode with Betsy that I really believe should be amplified from North to South, coast to coast—something that unfortunately is not top of mind for many in this industry. And that was ‘focus on the value that accrues to the patient'—period, end of story. That is the north star of the [value-based care] movement, lest we forget. Financial outcome measures are important in the value equation, but the numerator must be about the patient. As always, grateful for your insights and ongoing leadership.” Oh, thank you so much. And same to you. Grateful for yours. Betsy Seals in that podcast, though, she reminded carrier listeners about this “think about the value accruing to the patient” in that episode. And in the Wendell Potter encore that came out right before the show with Betsy, yeah, what Wendell said kind of made me realize why Betsy felt it important to remind carriers to think about the value accruing to patients. Wall Street rewards profit maximization in the short term. It does not reward value accruing to the patient. However—and here's me agreeing with Dr. Steve Schutzer, because I think this is what underlies his comment—if what we're doing gets so far removed from what is of value to the patient, then yeah, we're getting so removed from the human beings we're allegedly serving, that smart people can make smart decisions in theoretical model world. But what's being done lacks a fundamental grounding in actual reality. And that's dangerous for plan members, but it's also pretty treacherous from a business and legal perspective, as I think we're seeing here. Okay, so back to our theme of broken primary care and accelerating ER costs. Are carriers getting in there and putting a stop to it? I mean, as aforementioned about 8 to 10 times, if you have a broken primary care system, you're gonna pay for primary care, alright. It's just gonna be in really expensive care settings. You gotta figure carriers are wise to this and they're the ones that are supposed to be keeping healthcare costs under control for all America. Well, relative to keeping ER costs under control, here's a link to a study Vivian Ho, PhD, sent from Health Affairs showing how much ER prices have gone up. ER prices are way higher than they used to be. So, you'd think that carriers would have a huge incentive to get members primary care and do lots and lots of things to ensure that not only would members have access to primary care, but it'd be amazing primary care with doctors and nurses that were trusted and relationships that would be built. It'd be salad days for value. Except … they're not doing a whole lot at any scale that I could find. We have Iora and ChenMed and a few others aside. These are advanced primary care groups that are deployed by carriers, and these organizations can do great things. But I also think they serve—and this came up in the Dr. Fernandopulle show (EP460)—they serve like 1% of overall patient populations. Dr. Fernandopulle talked about this in the context of why these advanced primary care disruptors may have great impact on individual patients but they have very little overall impact at a national scale. They're just not scaled, and they're not nationwide. But why not? I mean, why aren't carriers all over this stuff? Well, first of all—and again, kind of like back to the Wendell show (EP384) now—if we're thinking short term, as a carrier, like Wall Street encourages, you know, quarter by quarter, and if only the outlier, mission-driven folks (the knights) in any given carrier organization are checking what's going on actually with plans, members, and patients like Betsy advised, keep in mind it's a whole lot cheaper and it's easier to just deny care. And you can do that at scale if you get yourself an AI engine and press Go. Or you can come up with, I don't know, exciting new ways to maximize your risk adjustment and upcoding. There's an article that was written by Sergei Polevikov, ABD, MBA, MS, MA