Podcasts about ekg

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.

https://www.dbllawyers.com/ 800.747.9354 In a fast-evolving technological era, artificial intelligence is transforming industries—and the legal field is no exception. On a recent episode of The Attorney Post, intellectual property attorney Thomas Dunlap of Dunlap Bennett & Ludwig joined the discussion to break down the legal complexities of AI, patent law, and the future of IP protection in a digital-first world. Thomas Dunlap leads a national law firm with nearly 80 attorneys and offices in Washington D.C., New York, Seattle, Chicago, and Delaware. His practice is rooted in intellectual property litigation, with a strong emphasis on patent portfolios held by inventors and universities. Dunlap represents patent holders in enforcement actions, often backed by litigation funders—a model that's becoming increasingly necessary as litigation costs continue to rise. Although Dunlap's background is in traditional IP law, he's become deeply involved in AI law due to the growing number of legal grey areas surrounding artificial intelligence. The lack of specific U.S. legislation governing AI, particularly in IP, is creating both opportunity and uncertainty for attorneys and innovators alike. A central issue Dunlap addresses is the legal identity of AI in the context of inventorship. As of now, the U.S. Patent and Trademark Office (USPTO) has clarified that while AI can assist in the invention process, only human beings can be listed as inventors. Consequently, AI-generated inventions are considered public domain unless a human makes the inventive leap. This has profound implications for businesses investing in AI-driven R&D. While countries like South Africa and Saudi Arabia have granted patents to AI systems, the U.S. remains firm in its human-inventor requirement—raising questions about international IP protection, ownership, and enforceability. The High Cost of Defending Innovation Beyond AI, Dunlap highlighted systemic flaws in the U.S. patent system. Small inventors, despite contributing to over 60% of innovation, are often outmatched by large tech companies. Patent litigation can easily cost $4–8 million, making it financially impossible for independent innovators to protect their ideas without support from litigation funders. Dunlap pointed to a high-profile case involving a small company's EKG monitoring technology being used in Apple Watches, underscoring how large corporations can leverage legal and financial muscle to challenge or invalidate legitimate patents. This is part of what he calls the “invalidated” era, where inventors face an uphill battle in enforcing their rights. AI's Disruptive Power in Legal Practice While AI poses legal dilemmas, it's also reshaping the way lawyers work. According to Dunlap, tools that previously required five associates over a week can now be accomplished by three associates in just five days, thanks to AI-enhanced e-discovery systems. But he warns that overreliance on AI for document review still carries risks—missed keywords or misinterpreted nuance can drastically affect outcomes. Moreover, Dunlap noted that courts may begin to limit AI training on copyrighted materials, potentially restricting the development of AI tools. If copyright constraints tighten, AI systems might only be able to train on pre-1950s content, greatly reducing their value and utility across industries. Thomas Dunlap's insights make it clear that the legal system is at a crossroads. The collision of AI and intellectual property is forcing courts, lawyers, and lawmakers to rethink longstanding definitions of creativity, authorship, and ownership. As AI continues to revolutionize industries, those at the forefront of IP law—like Dunlap—will be pivotal in shaping the future of innovation. Sponsors: RankWith.NewsThe Attorney PostNational ERCAndropology

En tredjedel av säsongen har spelats och enligt Lukas Syberyjski har det sett ut som ett hälsosamt EKG. Vi går igenom de höga topparna och de djupa dalarna, diskuterar formationsval, laguttagningar, läktarstöd och mycket mer.

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...

EM and IM physicians don't get a great insight into each other's careers in medical school or in residencyDo hospitalists like doing consults as opposed to just taking admission requests?Sean says, yes, because it gives us an opportunity to solve problems together. They want to be consulted as much as possible Admissions would be greatly decreased if there was more robust outpatient follow up ability but various factors make this difficult Sometimes a slight delay in coordinating with the hospitalist or social work etc can save an admission and therefore free up ER beds down the line Not every conversation with the IM physician must be an admission requestWhen they are consulted, the expectation is that they put in a consultation note and see the patientLooking at an admission as trying to “sell” something is the wrong way to look at it. If you have a clear story and objective data, you should be able to articulate why they need admission most of the timeWhat does the day look like for a hospitalist?Admissions for our team are very easy early in the morning but rapidly ramp up during the afternoonThe admitting physician handles ER admissions, outside transfer direct admissions and ICU transfers to floor bedsSean goes into some detail about the workflow and what his day looks likeWhat are the difficult admissions to handle?We talk about one of the most difficult admissions we commonly see: An elderly patient with weakness, unable to walk but no acute findingsWe talk through possible solutions to better care for these difficult casesSupport 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 episode, Lyell K. Jones Jr, MD, FAAN, speaks with Valérie Biousse, MD, who served as the guest editor of the Continuum® April 2025 Epilepsy issue. They provide a preview of the issue, which publishes on April 3, 2025.   Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota.  Dr. Biousse is a professor in the departments of neurology and ophthalmology, as well as the Reunette Harris Chair of Ophthalmic Research, at Emory University in Atlanta, Georgia.  Additional Resources Read the issue: Neuro-ophthalmology Subscribe to Continuum®: shop.lww.com/Continuum More about the American Academy of Neurology: aan.com  Social Media  facebook.com/continuumcme  @ContinuumAAN  Host: @LyellJ  Guest: @vbiouss  Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about subscribing to the journal, listening to verbatim recordings of the articles, and exclusive access to interviews not featured on the podcast. Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr Valerie Biousse, who recently served as Continuum's guest editor for our latest issue on neuro-ophthalmology. Dr Biousse is a professor in the departments of neurology and ophthalmology at Emory University in Atlanta, Georgia where she's also the Renette Harris Chair of Ophthalmic Research. Dr Biousse, welcome and thank you for joining us today. Why don't you introduce yourself to our listeners? Dr Biousse: In addition to what you just mentioned, I would like to highlight that I have a French accent because I was born and raised and went to medical school in France in Saint Pete Pierre, where I trained as a neurologist. And I even practiced as a stroke neurologist and a headache specialist in the big university in Paris before I decided to move to the US to pursue my passion, which was really neuro-ophthalmology. And at the time, it was impossible to get a license in the US, so I had to repeat a residency and became an ophthalmologist. And this is what led me where I am today. Dr Jones: We're fortunate that you did that. I'm glad you did all that extra work because your contributions to the field have obviously been magnificent, especially this issue, which I think is an incredibly important topic for neurologists. This is why we include it in the rotation of Continuum topics. We all know the saying that the eyes are the windows to the soul, but for neurologists they are also the windows to the brain. The only part of the CNS that's visible to us is the optic disc. I think in spite of that, I think neurologists, our readers and our listeners would acknowledge the importance of the ophthalmic exam and respect the importance of that aspect of the neurologic exam. It's an area that feels challenging to us, and many of us, even with lots of years of experience, don't always feel very comfortable with this. So, it's a really important topic and I'm glad you have edited this. And let's start off with, you know, as you've reviewed all these articles from, really, the pinnacle experts in their specific topics in neuro-ophthalmology, as you were editing this issue, Dr Biousse, what would you say is the one biggest, most important practice-changing message about neuro-ophthalmology you would want to convey to our listeners? Dr Biousse: I think its technology, advances in technology. Without any doubt. The ophthalmology world cannot evaluate a patient anymore without access to fundus photography, optical coherence tomography (OCT) of the back of the eye, not just the optic nerve, but the retina. These advantages in technology have completely changed the way we practice ophthalmology. The same applies to neuro-ophthalmology. And these techniques can really help neurologists do a basic eye exam. Dr Jones: So, let's get right into that. And I'm glad you started with that because I still feel, even though I've done it thousands of times, I still feel a little fumbly and awkward when I'm trying to examine and fundus through an undilated pupil, right? And so, this is I think where technology has helped us quantitate with, as you mentioned, OCT, but I think from an accessibility perspective, I think nonmydriatic fundus photography is a very interesting tool for neurologists and non-neurologists.  Tell us how, how does that work and how could neurologists implement that in their practice? Dr Biousse: It's a very important tool that of course neurology should be able to use every day. You can take fundus photographs of the back of the eye without dilating the pupil. The quality of the photographs is usually very good. You only have access to what we call the posterior pole of the eye, so the optic nerves and the macula and the vascular arcade. You don't see the periphery of the retina, but in neuro-ophthalmology or neurology you don't need access to the periphery of the retina, so it doesn't matter. What is remarkable nowadays is that we have access to very highly performing fundus cameras which can take pictures through very, very small pupils or in patients of all ages. You can use it on a two-year-old in a pediatric clinic. You can use it on a much older person who may have a cataract or other eye problems. And what's really new and what this issue highlights is that it's not just that we can take pictures of the back of the eye, we can also perform OCT at the same time using the same camera. So, that's really a complete game changer for neurologists. Dr Jones: And that's extremely helpful. If I'm in a neurology clinic and I would like to use this technology, how would I access that? Do I need special equipment? Can I use my smartphone and an app? How would that work in terms of getting the image but also getting an interpretation of it? Dr Biousse: It all depends on what your ultimate goal is. The fundus cameras, they are like regular cameras or like any technology that would allow you to get brain imaging. The more sophisticated, the better the quality of the image, the more expensive they are. You know, that's the difference between a three-tesla MRI and a head CT. You buy a camera that's more expensive, you're going to have access to much easier cameras and to much higher resolution of images, and therefore you're going to be much happier with the results. So, I always tell people be very careful not to get a tool that is not going to give you the quality of images you need or you may make mistakes. You basically have two big sorts of cameras. You have what we call the tabletop cameras, which is a little more bulky camera, a little more expensive camera that's sitting on the table. The table can be on wheels, so you can move the table to the patient or you can move the patient to the table. That's very convenient in a neurology clinic where most patients are outpatient. It works in the emergency department. It's more difficult at bedside in the hospital. Or you can have a handheld camera, which can be sophisticated, a device that just uses a handheld camera or, as you mentioned, a small camera that you place on your smartphone, or even better, a camera that you can attach to some of the marketed direct ophthalmoscopes. In all situations, you need to be able to transfer those images to your electronic medical records so that you can use them. You can do that with all tabletop cameras, most handheld cameras; you cannot do it with your smartphone. So that gives you an idea of what you can use. So yes, you can have a direct ophthalmoscope with a little camera mounted. This is very inexpensive. It is very useful at bedside for the neurologists who do- who see patients every day, or the resident on call. But if you really want to have a reliable tool in clinic, I always recommend that people buy a tabletop camera that's connected to the electronic medical record. Dr Jones: You know, the photos always make it so much more approachable and accessible than the keyhole view that I get with my direct ophthalmoscope in clinic. And obviously the technology and the tools are part of the story, but also, it's access to the expertise. Right? There are not many neuro-ophthalmologists in the world, and getting access to the experts is a challenge, I think, everywhere, everywhere in the world really. When you think about how technology can expand that---and here I'm getting at AI, which I hesitate to bring up because it feels like we talk about AI a lot---are there tools that you think are here now or will be coming soon that will help clinicians, including neurologists, interpret fundus photography or other neuro-ophthalmologic findings, maybe eye movements, to make that interpretation piece a little more accessible? Dr Biousse: Absolutely. It's going to happen. It's not there yet. OK? I always tell people, AI is very important and it's a big part of our future without any doubt. But to use AI you need pictures. To get pictures, you need a camera. And so I tell people, first you start with the camera, you implement the camera, you incorporate the camera in your electronic medical record. Because if you do that, then the pictures become accessible to everyone, including the ophthalmologist who's maybe offsite and can review the pictures and provide an official interpretation of the pictures to help you. You can also transfer those pictures using secure mode of transfers and not your smartphone text application, which you really don't want to use to transfer medical information. And that's why I insist on the fact that those pictures should definitely appear in the patient's medical record. Otherwise you're going to break HIPAA laws, and that's an issue that comes up quite often. Once you have the pictures in the electronic medical record and once you have the pictures in the camera, you can do three things. You can look at them yourself. And many of my neurology colleagues are very competent at declaring that an optic nerve is normal or an optic nerve is swollen or an optic nerve is pale. And very often that's all we need. You can say, oh, I don't know about that one, and page the ophthalmologist on call, give the patient 's medical record number, have them look at the pictures, provide an interpretation, and that's where you have your answer. And this can be done in real time, live, when you're at bedside, no problem. Or you can use AI as what I call “Diagnostic A.” I always compare it as, imagine if you had a little robot neuro-ophthalmologist in your pocket that you could use at any time by just taking a picture, clicking submit on the AI app. The app will tell you never, it's normal or it's papilledema or it's pale. The app will tell you, the probability of this optic disk of being normal is 99% or the probability that this is papilledema. And when I say papilledema, I mean papilledema from rest intracranial pressure that's incredible as opposed to optic disc edema from an optic neuritis or from an ischemic optic neuropathy. And the app will tell you, the probability that this is papilledema is eighty six percent. The probability that it's normal is zero. The probability that it's another cause of disc edema is whatever. And so, depending on your probability and your brain and your own eyes, because you know how to interpret most fundus photographs, you really can make an immediate diagnosis. So that is not available for clinical use yet because the difficulty with the eye, as you know, is to have it have a deep learning algorithm cleared by the FDA. And that's a real challenge. But many research projects have shown that it can be done. It is very reliable, it works. And we know that such tools can either be either incorporated inside the camera that you use---in which case it's the camera that gives you the answer, which I don't think is the ideal situation because you have one algorithm per camera---or you have the algorithm on the Cloud and your camera immediately transfers in a secure fashion the images to the Cloud and you get your answer that way directly in your electronic medical record. We know it can be done because it happens every day for diabetic retinopathy. Dr Jones: Got it. And so, it'll expand, and obviously there has to be a period of developing trust in it, right? Once it's been validated and it becomes something that people use. And I get the sense that this isn't going to replace the expertise of the people that use these tools or people in neuro-ophthalmology clinics. It really will just augment. Is that a fair statement? Dr Biousse: Absolutely. Similar to what you get when you do an EKG. The EKG machine gives you a tentative interpretation, correct? And when the report is “it's normal,” you really can trust it, it's normal. But when it says it's not normal, this is when you look at it and you ask for a cardiology consultation. That's usually what happens. And so, I really envision such AI tools as, “it's normal,” in which case you don't need a consultation. You don't need to get an ophthalmology consultation to be sure that there is no papilledema in a patient with headache, in a patient with possible cerebrospinal fluid shunt malfunction. You don't need it because if the AI tool tells you it's normal, it's normal. When it's not normal, you still need the expertise of the ophthalmologist or the neuro-ophthalmology. The same applies to the diagnosis of eye movement. So that's a little more difficult to implement because, as you know, to have an AI algorithm, you need to have trained the algorithm with many examples. We have many examples of pathology of the back of the eyes, because that's what we do. We take pictures every day and there are databases of pictures, there are banks of pictures. But how many examples do we have of abnormal line movement in myasthenia, of videos or downbeat nystagmus? You know, even if we pulled all our collections together, we would come up with what, two hundred examples of downbeat nystagmus around the world? That's not enough to train an AI system, and that's why most of the research on eye movement right now is devoted to creating algorithm that mimic abnormal eye movements so that we can make them and then train algorithm which job will be to diagnose the abnormal eye movement. There's an extra difficult step, it's actually quite interesting. But it's going to happen. You would be able to have the patient look at the camera on the computer and get a report about “it's normal” or “the saccades, whatever, are not normal. It's most likely an internucleosomal neuralgia” or “it is downbeat nystagmus.” And that's not, again, science fiction. There are very good groups right now working on this. Dr Jones: That's really fascinating, and that- you anticipated my next question, which is, I think neurologists understand the importance of the ocular motor exam from a localizing perspective, but it's also complex and challenging. And I think that's certainly an area of potential growth. And you make a good point that we need some data to train the models. And until we have these tools, Dr Biousse, that will sort of democratize and provide access through technology to diagnosis and, you know, ultimately management of neuro-ophthalmology disorders, we know that there are gaps in the care of these patients right now in the modern day. In your own practice, in your own work at Emory, what do you see as the biggest gap in practice in caring for these patients?  Dr Biousse: I think there is a lack of confidence amongst many neurologists regarding their ability to perform a basic eye exam and provide a reliable report of their finding. And the same applies to most ophthalmologists. And that's very interesting because we have, often, a large cohort of patients who are in between the two specialties and are getting a little bit lost. The ophthalmologist doesn't know what to do. The neurologist usually knows what to do, but he's not completely sure that it's the right thing to do. And that's where the neuro-ophthalmologist comes in. And when you have a neuro-ophthalmologist right there, it's fantastic, okay? We bridge the two specialties, and we often just translate what the ophthalmologist said to the neurologist or what the neurologist said to the ophthalmologist and suddenly everything becomes clear. But unfortunately, there are not enough neuro-ophthalmologists. There is a definite patient access issue even when there is a neuro-ophthalmologist because not only is there a coverage heterogeneity in the country and in the world, but then everybody is too busy to be able to see a patient right away. And so, this gap impairs the quality of patient care. And this is why despite all this technology, despite the future, despite AI, we teach ophthalmologists and neurologists how to do a neuro-op examination, how to use it for localization, how to use it to increase the value and the power of a good neurologic examination so that nothing is missed. And I'm taking a very simple example. Neurologists see patients with headaches all the time. The vast majority of those headaches are benign headaches. 90% of headache patients are either migraine or tension headache or analgesic abuse headaches, but they are not secondary headache that are life threatening or neurologically threatening. If the patient has papilledema, it's a huge retina that really should prompt immediate workup, immediate prevention of vision loss with the help of the ophthalmologist. And unfortunately, that's often delayed because the patients with headaches do not see eye doctors. They see their primary care providers who does not examine the back of the eye, and then they reach neurology sometimes too late. And when the neurologist is comfortable with the ophthalmoscope, then the papilledema is identified. But when the neurologist is not comfortable with the ophthalmoscope, then the patient is either misdiagnosed or sent to an eye care provider who makes the diagnosis. But there is always a delay in care. You know, most patients end up with a correct diagnosis because people know what to do. But the problem is the delay in appropriate care in those patients. And that's where technology is a complete life-changing experience. And, you know, I want to highlight that I am not blaming neurologists for not looking at the back of the eye with a direct ophthalmoscope without pharmacologic dilation of the pupil. It is not possible to do that reliably. The first thing I learned when I transitioned from a neurologist to an ophthalmologist is that no eye care provider ever attempts to look at the back of the eyes without dilating the pupils because it's too hard. Why do we ask neurologists to do it? It's really unfair, correct? And then the ophthalmoscope is such an archaic tool that gives only a very small portion of the back of the eye and is extraordinarily difficult to use. It's really not fair. And so, until we give the appropriate tools to neurologists, I don't think we should complain about neurologists not being reliable when they look at the back of the eye. It's a major issue.  Dr Jones: I appreciate you giving us some absolution there. I don't think we would ask neurologists to check reflexes but then not give them a reflex hammer, right? So maybe that's the analogy to not dilating the pupil. So, for you and your practice, in our closing minutes here, Dr Biousse, what's the most rewarding thing for you in neuro-ophthalmology? What do you find most rewarding in the care of these patients?  Dr Biousse: Well, I think the most rewarding is the specialty itself. I'm a neurologist at heart. This is where my heart belongs. What's great about those neuro-ophthalmology patients is that it is completely unpredictable. They are unpredictable. They can have anything. I am super specialized because I'm a neuro-ophthalmologist, but I am a general neurologist and I see everything in neurology. So my clinic days are fascinating. I never know what's going to happen. So that's, I think, the most rewarding part of my job as an neuro-ophthalmologist. I'm having fun every day because it's never the same, I never know what's going to happen. But at the same time, we are so useful to those patients. When you use the neuro-ophthalmologic examination, you really can provide exquisite localization of the disease. You're better than the best of the MRIs. And when you know the localization, your differential diagnosis is always right, always correct, and you can really help patients. And then I want to highlight one point that we made sure was covered in this issue of Continuum, which is the symptomatic treatment of patients who have visual disturbances from neurologic disorders. You know, a patient with chronic diplopia is really disabled. A patient with decreased vision cannot function. And being able to treat the diplopia and provide the low vision resources to those patients who do not see well is extremely important for the quality of life of our patients with neurologic disorders. When you don't walk well, if you don't see well, you fall. When you're cognitively impaired, if you don't see well, you are very cognitively impaired. It makes everything worse. When you see double, you cannot function. When you have a homonymous anopia, you should not drive. And so, there is a lot of work in the field of rehabilitation that can greatly enhance the quality of life of those patients. And that really covers the entire field of neurology and is very, very important. Dr Jones: Clearly important work, and very exciting. And your enthusiasm is contagious, Dr Biousse. I can see how much you enjoy this work. And it comes through, I think, in this interview, but I think it also comes through in the articles and the experts that you have. And I'd like to thank you again for joining us today for a great discussion of neuro-ophthalmology. I learned a lot, and hopefully our listeners did too.  Dr Biousse: Thank you very much. I really hope you enjoyed this issue. Dr Jones: Again, we've been speaking with Dr Valerie Biousse, guest editor of Continuum's most recent issue on neuro-ophthalmology. Please check it out, and thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

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

New panel with Adam and Sean. Emergency and IM medicine physicians There is a study from 2023 called Battles to Burnout. Studying the role of inter-physician conflict in burnout. Primarily the conflict between emergency physicians and internal medicine physicians. A better relationship leads to less burnoutSean moved from primary care to hospitalist medicine when COVID was at its peakAdam, EM physician, returns to the showSean enjoys solving problems and that is what drew him to IM and hospitalist medicine, he did a 3-year residencyHe brings up an important distinction of our mindsets in patient care. In the ED we are looking more to find the problem, but he looks to solve the problem in the hospitalIn some ways, in the ED, we are a glorified triage. But more importantly, we are expected to be the second best in every specialty - the second best cardiologist, second best GI etcWe do still do a lot of problem solving in the ED as well, but we usually do have the skill of a lower cognitive switching cost, we can move between tasks quicklyWe to have to take efficiency into considerationSean talks about the superpower of IM being storytelling – one of his struggles is finding the best story to explain to everyone involved what is going on with the patient – sometimes the ED does not give the best storyWe need to help start the right story to help the IM physician on the back end to set them up for successOur limitations using a text platform to communicate does make it hard to read the intent behind questionsWith admission requests, Sean likes to hear what we think is going on. Not just a bunch of data points but rather the start of that storySean also likes to hear the chief complaint first, similar to what I like from our EMS crewsA 5- or 6-line paragraph max is sufficient, they start to worry when the paragraph gets longer that we either don't know what's going on or so much is going on its going to be a difficult caseAs APP's we don't get a ton of training in admission request story telling so it's an art we have to developAn admission request is a great time to slow down and really think about all the detailsBeing an ER APP can be a difficult position when working as a team with a physician. We tend to adapt to the physician we are working with. We share tasks and sometimes don't get all the same details on a given patientPatient hand-offs are a big source of information loss and errors. We can tend to turn patient stories into a game of telephone in the ED before the story even gets to the hospitalistSupport 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 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

Send us a textSixteen-year-old Musu Sangu faced a devastating diagnosis in Sierra Leone—a life-threatening heart condition requiring specialized surgery unavailable anywhere in her country. With her heart functioning at just 20% capacity and given only a 40% chance of survival, Musu's future looked grim. But what followed was an extraordinary demonstration of global compassion that would save her life.The journey began at Mercy Hospital in Sierra Leone, where Dr. Aruna Stevens identified Musu's condition using a newly acquired EKG machine. Through the Child Reintegration Center's family strengthening program, Musu already had access to medical care and a dedicated case manager who advocated tirelessly for her. When it became clear that she needed surgery unavailable in Sierra Leone, an incredible network of support mobilized across three continents.Gary and Mary Ann Gilkyson, who had met Musu during a mission trip, rallied their church in South Carolina to raise funds. The Sick Pickin Foundation connected her with surgical care in India. Staff members at multiple organizations coordinated passports, visas, medical clearance, and financial support. After a grueling journey from Freetown through multiple countries, Musu arrived in New Delhi where surgeons performed her high-risk aortic valve replacement.Against tremendous odds, Musu made a remarkable recovery. Within a month, she returned home to her family in Sierra Leone. Today, she's back in school, even playing Mary in the CRC Christmas play, while her mother builds stability through a microfinance program.This powerful story reminds us that when compassion knows no borders, extraordinary things happen. People who had never met Musu—and many who never will—worked together to give her a future. Consider joining this village of support through the Emergency Medical Health Fund, established to help more children like Musu access life-saving care when local resources aren't enough. Your contribution could be part of the next miracle.Maternal Health impacts child and family wellbeing, and is an indicator of societal wellbeing as well. If you want to support this work, please give to the HCW Maternal Health Mission - Maternal Health Matters!Support the showHelpingchildrenworldwide.org

The Original Southern Remedy is hosted by Dr. Jimmy Stewart, professor of internal medicine and pediatrics at UMMC. If you have a question for Dr, Jimmy, email it to remedy@mpbonline.org. In this episode, Dr. Jimmy answers a number of questions about cholesterol, and questions about fatty liver disease and EKG readings. Hosted on Acast. See acast.com/privacy for more information.

A difficult aspect of the job is the poor understanding of the public of what we do in EMS, and the poor understanding that our non-EMS friends and family have of what we doThose of us in EMS can understand each other better, we have seen the same tragedy and struggled with the same difficulties that are so hard to articulateWhat does retirement look like from a career paramedic in EMS?Casey struggles with this, it's hard to think about not caring for patients anymore. The closer he gets to retirement, the more it looks a little less clear what that looks like exactlyEddie isn't planning retirement soon so he can help provide for his kids. He does have retirement investments and fire benefitsAdvice for newbies in EMS:If you are seeing warning signs of burnout, get counseling immediately. Don't write it off or try to ignore it as normalEddie would not have tried to fight the warning signs of PTSD, he would have sought help much soonerHe did struggle with suicidal thoughts for a period of time – counseling was the solution. Sleep deprivation was a major factor in these thoughts for himHe had a breaking point where he felt ready to end his life – a counselor called him back at 2am and got him in quickly to talk and this helped him significantly. And he now feels the best he has mentally – it doesn't control him anymoreCasey talks about how few make paramedicine a career, it's a tough job and it has changed over his career, he recommends finding the fun. Learn new things. Self-reflection goes a long wayRecognize when you need to switch to a different place, organization or company as a paramedicCasey: “I feel bad, because I don't feel bad”We all feel different and respond differently to the things we see - you don't choose the things that affect youDon't be afraid to say something to your coworkers if you see something wrong, even though it's hard and confrontational – this helped me significantly when a partner called me out early in my EMT careerWe've lost people in EMS through the years, this is devastating. We share life with our partners and get to know them really wellWhen Eddie was feeling similar thoughts of suicide to our coworkers that committed suicide, it was a huge eye opener for him to see the grief of their lossBad calls can haunt you; we have all seen it in others and ourselvesSupport 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.

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

I tell those EMT's that want to go to PA school or further education to just skip paramedic school. Go to paramedic school if you want to be a paramedic“I'm not doing it for the pay, I'm doing it because I love it.”Being a paramedic puts you in a unique position to save someone's life in the span of 5 minutesEddie took calls personally. He gave every call his everythingSometimes the patients survive despite all the odds being against them and some die despite all the odds being in their favorWe have to remember to respect the patients that may not have earned it because it speaks more about who we are than who they areWe will always have patients that treat us poorly, but it is more about rising above and detachingWe have the privilege of taking care of people on their worst daysEddie talks about how EMS caused him to mature quickly You will always have to deal with Karens in emergency medicine, you must rise above their bad behaviorPatients deserve our professionalism and respect even when they may not have earned itEddie talks about the difference between being in the field as a paramedic and in the EDEddie talks about how important it is to treat your patient as a human and not be a robot but be a human yourselfWe need to build rapport and trust with our patient in order for them to accept our plan of careOften the concern is different than the chief complaintWe talk about how certain tasks become second nature and allow you to converse with patients simultaneously Humor can really help improve your patients' care if you can read the room accuratelyYou don't have to be an extrovert to be successful in EMSWe talk about how, working in emergency medicine, it can really take all the social energy you haveSupport 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.

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

N Engl J Med 2001;344:1879-1887Background: Acute coronary syndrome is broadly categorized into unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). In unstable angina, there is no rise in cardiac biomarkers, although some challenge this clinical entity in the current era of high sensitivity troponins. In NSTEMI, there is elevation of cardiac biomarkers but no ST segment elevation on the electrocardiogram. In STEMI, there is an ST segment elevation on the electrocardiogram as well as a rise in cardiac biomarkers.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.In patients with STEMI, percutaneous coronary intervention (PCI) significantly improves outcomes. However, its role in acute coronary syndrome without ST-segment elevation is less clear for several reasons. Patients with NSTEMI tend to be older and have more comorbidities, increasing procedural risks. This also means that they have competing risks for mortality, potentially reducing the benefit of PCI. Another key challenge is that NSTEMI patients frequently have multivessel disease, making it more difficult to identify the culprit lesion; since there is usually only partial occlusion of the culprit coronary artery. In contrast, there is usually complete occlusion of a coronary artery in STEMI and ST-segment elevation on the electrocardiogram helps localize the infarcted area, making it relatively easy to identify the culprit artery.The findings from previous randomized trials of revascularization in unstable angina and NSTEMI, have been inconsistent. The TACTICS–Thrombolysis in Myocardial Infarction 18 trial sought to compare early invasive vs conservative strategy in patients with unstable angina or NSTEMI.Patients: Eligible patients had angina within 24 hours that was: >20 minutes in duration, accelerating angina, or recurrent episodes at rest or with minimal effort. Patients also had to have one of the following: ST-segment depression of at least 0.05 mV, transient ( 2.5 mg/dL.Baseline characteristics: The trial randomized 2,220 patients – 1,114 randomized to early invasive strategy and 1,106 randomized to conservative strategy.The average age of patients was 62 years and 66% were men. Approximately 28% had diabetes and 39% had prior myocardial infarction.Troponin T levels were elevated (>0.01 ng/ml) in 54% of the patients.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo early invasive vs conservative strategy.Patients received aspirin 325 mg daily, intravenous unfractionated heparin (5000U bolus, followed by an infusion at 1000U/ hour for 48 hours), and intravenous tirofiban (0.4 μg/kg/minute for 30 minutes followed by an infusion of 0.1 μg/kg/minute for 48 hours or until revascularization with tirofiban administered for at least 12 hours after PCI).Patients in the early invasive arm underwent coronary angiogram between 4 and 48 hours after randomization and underwent PCI as appropriate. Patients in the conservative arm were treated medically. If stable, they underwent an exercise-tolerance test before discharged (83% of these tests were with nuclear perfusion or echocardiography imaging). Patients in the conservative arm underwent coronary angiography with PCI if they had angina at rest associated with ischemic EKG changes or elevation in cardiac biomarkers, had clinical instability or had ischemia on their stress test.Endpoints: The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome, at six months.The estimated sample size to provide 80% power was 1,720 patients. This assumed that 22% of the patients in the conservative arm would experience the primary outcome and that the early invasive strategy would result in 25% relative risk reduction in the primary outcome. The sample size was later increased to 2,220 patients.Results: In the early invasive strategy, 97% of the patients underwent coronary angiogram after a medium of 22 hours after randomization, and 60% underwent PCI or CABG. In the conservative arm, 51% underwent coronary angiogram and 36% underwent revascularization during the index hospitalization.The primary composite endpoint was lower with the early invasive strategy (15.9% vs 19.4%, odds ratio: 0.78, 95% CI: 0.62 - 0.97; p= 0.025). The Kaplan-Meier curves started to separate at approximately one week. This benefit was driven by lower myocardial infarction and lower rehospitalization for an acute coronary syndrome with the early invasive strategy; (4.8% vs 6.9%) and (11.0% vs 13.7%), respectively. There was no difference in all-cause death (3.3% vs 3.5%).There were 3 important subgroup interactions. First is based on ST changes where patients with ST changes at presentation had all the benefit with an early invasive strategy (16.4% vs 26.3% [for patients with ST changes] and 15.6% vs 15.3% [for patients without ST changes]). Second is based on Troponin T levels where patients with troponin T> 0.1 ng/mL had significantly more benefit with an early invasive strategy (16.4% vs 24.5% and 15.1% vs 16.6%). The third is based on TIMI score where patients with higher TIMI score had more benefit with an early invasive approach. For a high TIMI score of 5-7, the event rate was 19.5% with early invasive vs 30.6% with conservative approach. Patients with TIMI score of 0-2 had no benefit with an early invasive strategy (12.8% with early invasive vs 11.8% with conservative strategy).Note to readers: TIMI score is a risk stratification tool used to predict 14-day adverse outcomes in patients with unstable angina or NSTEMI. The score ranges from 0 to 7 with higher scores indicating worse prognosis.Conclusion: In patients with unstable angina or NSTEMI, an early invasive strategy reduced the composite endpoint of death from any cause, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome at six months with a number needed to treat of approximately 29 patients.The subgroup analysis of this trial is particularly important and biologically plausible, as the presence of ST changes and level of cardiac biomarkers elevation indicate more significant myocardial ischemia or necrosis. Patients without ST changes comprised 62% of the study participants, while those with negative cardiac biomarkers made up 59%, and the study results should not be generalized to these subgroups.Another key consideration is the lack of detailed criteria for what was deemed ‘appropriate' revascularization. Only 60% of patients in the early invasive strategy group underwent revascularization, underscoring that not all patients with unstable angina or NSTEMI benefit from coronary angiography and that further risk stratification is necessary.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

Host Richie Tevlin talks with Alyston Upshaw, owner of Concrete Blues Brewing Co. Originally from Orlando, Al brought his passion for food and beer to Philly in 2012. With experience at Tired Hands, Carbon Copy, and Meetinghouse, he's now on a mission to make Pub ale a staple in the craft beer scene.   Concrete Blues Brewing: https://www.concrete-blues.com/ @concreteblues_ _______________________________________ EPISODE NOTES: Mentioned Breweries Carbon Copy Brewing - Epi 2 - Philadelphia, PA Tired Hands - Ardmore, PA Meetinghouse - Philadelphia, PA Wishful Thinking Brewing - Epi 24 - Bethlehem, PA Wild Fern Brewing - Frenchtown, NJ Bonn Place Brewing - Bethlehem, PA  Forest & Main Brewing - Epi 17 - Ambler, PA Yards Brewing Co - Epi 36 - Philadelphia, PA Two Locals Brewing - Epi 27 - Philadelphia, PA Human Robot - Epi 10 & 15 - Philadelphia, PA Suarez Family Brewery - Hudson, NY Timothy Taylor Brewery - United Kingdom Fuller's Brewery - United Kingdom Space Cadet Brewery - Epi 22 - Philadelphia, PA Mentioned People Kyle Wolak & Brendon Boudwin - Epi 2 - Owners of Carbon Copy Colin McFadden - Owner of Meetinghouse Andrew Rubenstein - Brewer at Sacred Vice Brewing Tom Kehoe - Epi 36 - Founder of Yards Brewing Dan Suarez - Owner of Suarez Family Brewery Dan Endicott - Epi 17 - Co-Owner of Forest & Main Brewing Rich Wagner - Philadelphia Beer Historian & Author Mentioned Businesses Philly Beer Week - Epi 14 - Yearly Beer Celebration Steal this Beer - Beer Podcast Marigold Kitchen - Philly Restaurant - Closed in 2019 A Mano - Philly Italian Restaurant  Helm - Philly New American Restaurant  St. Oners - Philly Beer Bar Local 44 - Philly Bottle Shop _______________________________________ What We Drank? Alyston's Ordinary Bitter Session Ale | 3.5% | EKG & Cascade Concrete Blues Brewing _______________________________________ STAY CONNECTED: Instagram: ⁠⁠@brewedat⁠⁠ / ⁠⁠@thebrewedatpodcast⁠⁠ Tik Tok: ⁠⁠@brewedat ⁠⁠/ ⁠⁠@thebrewedatpodcast⁠⁠ YouTube: ⁠⁠@brewedat⁠⁠ / ⁠⁠@thebrewedatpodcast⁠ LinkedIn: ⁠BrewedAt Website: ⁠⁠www.brewedat.com

Lesley Logan sits down with Sam Mandel, co-founder of Ketamine Clinics Los Angeles, to discuss the transformative potential of ketamine therapy for mental health. They debunk common misconceptions, explore its impact on PTSD, anxiety, and depression, and highlight how it empowers individuals to reshape their personal narratives.If you have any questions about this episode or want to get some of the resources we mentioned, head over to LesleyLogan.co/podcast. If you have any comments or questions about the Be It pod shoot us a message at beit@lesleylogan.co. And as always, if you're enjoying the show please share it with someone who you think would enjoy it as well. It is your continued support that will help us continue to help others. Thank you so much! Never miss another show by subscribing at LesleyLogan.co/subscribe.In this episode you will learn about:What ketamine therapy is and how it differs from traditional treatments.How ketamine enhances neuroplasticity and helps reframe traumaThe science behind ketamine's impact on depression, anxiety, and PTSD.The difference between medical ketamine use and recreational misuse.What to expect during a ketamine therapy session.How ketamine therapy can help individuals reconnect with themselves and regain motivation.Episode References/Links:Ketamine Clinics LA Website - https://Ketamineclinics.comInstagram - https://www.instagram.com/ketamineclinicslaFacebook - https://www.facebook.com/KetamineClinicsLASam Mandel Instagram - https://www.instagram.com/thesammandelGuest Bio:Co-founder & CEO of Ketamine Clinics Los Angeles (KCLA), Sam Mandel, is a tour-de-force of compassion and innovation in mental health care. From volunteering at a teen-to-teen suicide prevention hotline at twelve to pioneering one of the world's foremost Ketamine Infusion Therapy clinics in 2014 alongside his father, Dr. Steven L. Mandel, Sam has channeled his lifelong passion for healthcare advocacy into transforming lives for the better. Sam was featured in Entrepreneur's list of Top 10 Inspiring Healthcare Entrepreneurs to Watch in 2023 and acknowledged by MSN as an Entrepreneur Leading the Business Frontier in 2024. Numerous media outlets have interviewed Sam for his expertise in Ketamine Infusion Therapy, and he is a frequent speaker at medical conferences and events. Under his leadership, KCLA has provided over 30,000 infusions to over 6,000 patients with an 83% treatment success rate, establishing the field's gold standard treatment protocols and patient satisfaction. If you enjoyed this episode, make sure and give us a five star rating and leave us a review on iTunes, Podcast Addict, Podchaser or Castbox.DEALS! DEALS! DEALS! DEALS!Check out all our Preferred Vendors & Special Deals from Clair Sparrow, Sensate, Lyfefuel BeeKeeper's Naturals, Sauna Space, HigherDose, AG1 and ToeSoxBe in the know with all the workshops at OPCBe It Till You See It Podcast SurveyBe a part of Lesley's Pilates MentorshipFREE Ditching Busy Webinar Resources:Watch the Be It Till You See It podcast on YouTube!Lesley Logan websiteBe It Till You See It PodcastOnline Pilates Classes by Lesley LoganOnline Pilates Classes by Lesley Logan on YouTubeProfitable Pilates Follow Us on Social Media:InstagramThe Be It Till You See It Podcast YouTube channelFacebookLinkedInThe OPC YouTube Channel Episode Transcript:Sam Mandel 0:00  When you look at trauma, for example, ketamine is extremely helpful for depression and anxiety, but also for PTSD and a lot of people have some trauma that is at the root of one of those issues, and ketamine helps people to recraft the story around that trauma. Lesley Logan 0:16  Welcome to the Be It Till You See It podcast where we talk about taking messy action, knowing that perfect is boring. I'm Lesley Logan, Pilates instructor and fitness business coach. I've trained thousands of people around the world and the number one thing I see stopping people from achieving anything is self-doubt. My friends, action brings clarity and it's the antidote to fear. Each week, my guest will bring bold, executable, intrinsic and targeted steps that you can use to put yourself first and Be It Till You See It. It's a practice, not a perfect. Let's get started.Lesley Logan 0:59  Okay, Be It babe. This is going to be a different kind of episode, but in the best way. I have Sam Mandel, who is a founder of Ketamine Clinics in LA and I was really intrigued by what I know about ketamine from my friends' holistic doctors. And when he came up as someone I could interview, I was like, oh, we need to do this, because there is a lot of misinformation about ketamine and what ketamine can be used for, and I'm on a mission to help you be it till you see it. And I really want you to understand all the different ways that you can have support in feeling more like yourself and not letting things get in your way. And so that is why we're going to talk about ketamine today. And if you think you know what it is, I strongly encourage you to just stay and listen, because I thought I knew and I learned so much. And then on top of all of that, I really enjoy Sam's story of how he started these clinics and what he and his dad did. And so there's just a lot of beautiful information in this episode, and I can't wait for you to hear it. So here is Sam Mandel. Lesley Logan 2:00  All right, Be It babe. I am really excited. I can tell you for a fact, we've never talked about this on the Be It Pod. And only is it quite timely, I think it's actually extremely imperative that we have this discussion so we have Sam Mandel here on the show. We're gonna talk about ketamine and all things about it, ketamine therapy. Sam, can you tell everyone who you are and probably why you rock at ketamine therapy?Sam Mandel 2:25  Yes, yeah. Thank you so much for having me, Lesley. So, I am Sam Mandel. I'm the co-founder and CEO of Ketamine Clinics Los Angeles. We're one of the first ketamine clinics in the country, established in 2014 and we specialize in IV infusions of ketamine for mental health, but we also offer several other innovative therapeutics for mental health. Lesley Logan 2:45  I love that mental health is something more people are talking about, and there's like more awareness around it, but also that there can be clinics that are working on different ways of helping, supporting mental health, including these infusions. For people who have heard about ketamine, and maybe not the positive ways, can we kind of, can we just dive in and ease their nerves about what we're talking about here?Sam Mandel 3:07  Let's do it. Some of your listeners are definitely like, ketamine what? And there's five different people saying that it's five different things, and all of them are correct. So that's one of the interesting things about ketamine. It is, first and foremost, an FDA-approved anesthetic for humans. It was FDA-approved in 1970. This is an old medicine. It's also commonly used in veterinary medicine. So a lot of people know of it as a horse tranquilizer or a cat tranquilizer. In some circles, it's more commonly known as that than as a drug for humans. But there's a lot of medications that we use for humans, that we also use in veterinary medicine. And it's also a drug of abuse, or something that people use recreationally or self-medicate with, depending on how you want to look at it, known as Special K. Same drug. It's used as an analgesic, as a pain reliever, in emergency room departments and crisis situations, trauma situations, when someone's in a terrible accident, they're in pain, they need sedation, or someone goes in and they need their shoulder reset, they commonly will use ketamine for conscious sedation. So it is a ubiquitous drug. It has a lot of different uses and applications, and one of its most recent, or probably its most recent, addition to that list of its identities, if you will, is as a mental health treatment. And in the last 25 years, there's been a growing body of clinical research proving ketamine to really be among the fastest, if not the fastest-acting, safest, most effective depression treatments available today.Lesley Logan 4:36  I mean, it's kind of amazing that it can be all these different things, also not, right? Like there's so many things, I feel like there's a lot of untapped medicines out there that we're already using, and we don't realize it could be done for other things. Can we talk about how it helps? Because I'll say my family's understanding of mental health treatment is when you sit on a couch and you talk to a therapist and you go weekly if you're depressed, you can take a pill that will kind of help with some hormonal imbalances. But that's not what this is. Sam Mandel 5:01  Yes, that is not what this is. And by the way, talk therapy is great. I go to therapy every week, you know, even when I'm in a good place and I don't necessarily feel like I have a lot to talk about, it's like going to the gym. I just go. I show up every week no matter what. And I think that's really good and healthy, especially if you have a therapist who you think cares about you and is invested in you, and you can just talk about, you know, life. And I'll tell you, sometimes when I go and I don't have anything bothering me or an agenda is when I do the most important work in those sessions, sometimes, so you just never know. But talk therapy is great, but it can only go so far. The conscious mind really gets in the way. Finding someone who cares is difficult the right credentialed person is expensive. A lot of the best people typically don't take insurance. It's not true for all of them. There's wonderful people out there who do, but a lot of the really good ones don't, and so it's a tough thing, but it has its limitations, like with anything. Ketamine and other psychedelic medicines, because ketamine, for all intended purposes, really is a psychedelic, and it's really the only legally available psychedelic in the United States, has the ability to really dissolve these barriers that get in our way. It helps people to get out of their own way and with exponential growth in ways that really are not possible and haven't been seen in any other treatment or modality. And the way it does that is really two primary mechanisms of action. The first is the neuro chemical effects and what's going on in the brain and how ketamine is impacting the brain and our neurochemistry in ways that really nothing else does. And the other is the experiential component, psychologically, what is going on during the experience or the trip that people have when they're receiving this medicine. And both of those are profound and really create lasting impact. On the neuro-chemical level, there's a neurotransmitter called glutamate. It's the most abundant neurotransmitter in the brain. It's present in 85% of the brain. All the other neurotransmitters combined comprise only 15% but for some reason, we've been disproportionately focused on them with mental health treatment. Those are the common ones you know of. Serotonin, dopamine, norepinephrine, you know, the most common class of antidepressant medications are SSRIs. Those are selective serotonin reuptake inhibitors, and those are targeting serotonin. They're a tool. They help some people. They really don't help a lot of people, too, and the people they do help, they really cause a lot of negative side effects and weight gain, sexual dysfunction, dried mouth, blurred vision, even increased suicidality, and the list goes on and on, really terrible side effects that are really debilitating for a lot of people. Even when those side effects are not as debilitating, the quality of relief is typically not very good. So people will say, oh, well, I definitely am not as depressed, but I don't feel happy either. I'm just kind of existing. They have the spectrum of life and of the human experience narrowed, so the lows are not as low, but they're not really thriving either. Not a nice place to be. Is it better than being in bed all day? Absolutely. But that's not the goal. That's not my goal for my life. That's not my goal for other people's lives and for the patients who come to our clinic. We want people to really thrive. Ketamine has the ability to help people to truly thrive. It restores compassion for self and others. It is enhanced energy and motivation for most people. It's a genuine reconnection of self. One of the things that happens with this, with the glutamatergic system and other processes that are occurring in the brain with IV infusions of ketamine, is it causes and promotes neurogenesis, enhanced neuroplasticity, actual new pathways, new connections forming in the brain. This helps people to form new habits, new patterns, new ways of thinking and being that can be very, very positive by disrupting a lot of the automatic responses and reactions we have in our day to day life that get so deeply enmeshed in us that they become a part of our personality, and ketamine can kind of push the reset button on that so that we have the opportunity to consciously choose who we want to be and how we want to be, and helps us call into question the things that we've accepted as just that's the way that I am, or that's the way that it is, and that's not the case most of the time. You look at trauma, for example, ketamine is extremely helpful for depression and anxiety, but also for PTSD, and a lot of people have some trauma that is at the root of one of those issues, and ketamine helps people to recraft the story around that trauma. So what happened is fixed and can never change. The past is the past, but our stories about it can change at any given moment, who we are and who we were and the other people and our role in it, and their role in it, and what happened and what didn't happen, and ketamine provides this kind of objective clarity on that that can be extremely healing and transformational for people.Lesley Logan 9:50  Yeah, this is fascinating. What I've known about ketamine, and I have friends who, I have a holistic doctor friend who offers it as a treatment, and I've heard of these amazing effects that can happen, but I never understood on the brain level, like what's going on and why it's different than the antidepressants that people are on, and how it could, so if someone comes in, first of all, what are some of the reasons why they're coming in for treatment, and then what is the, what are the expectations? Are they coming in one time for an IV infusion? Is this a weekly thing? And how long can the effects last? Can it be forever? Do they have to keep coming back? Can I get the lowdown on that? Sam Mandel 10:25  Yeah, you're asking all the right questions. So what treatment looks like is typically a series of six infusions over two to three weeks after that process I just explained where people are cleared for treatment. They come in, we have them fill out some paperwork, do a brief physical exam, and they come back to a private room. We help them to become comfortable in a recliner with noise canceling headphones, a sleep mask, unlimited selection of relaxing music, pillows, blankets, and we start an IV, and then we infuse the ketamine for 50 to 55 minutes. And it's a slow, gradual, steady state of infusion. People are conscious and awake the entire time. There's a level of dissociation where we don't want them to go so far that they don't know what's happening, but we want them to go into it far enough that they can kind of have a little bit of that quieting of the noise and chatter in their minds, and get a little bit of that clarity that I was describing earlier, and this separation really from themselves in a healthy way to take a look at things that can be really therapeutic, and doing that inner work. We monitor them the whole time. We use hospital-grade monitoring equipment. So that's like pulse, oxygen, EKG, blood pressure, continuous monitoring. I mean, it's a very safe medicine when it's used responsibly in a clinical setting like Ketamine Clinics Los Angeles. We still do all the proper monitoring just to make sure that people are comfortable and safe. And yeah, it's, that's pretty much the, you know, summary of the experience.Lesley Logan 11:53  Yeah, no. Thank you for sharing that, because I think, I don't think anyone's ever explained that, and I'm trying to think about people listening. It's like, well, what does it look like, you know, because let's just talk about what, we have heard about ketamine in the news lately, and it will continue to be in the news as people are going on trial, like when we hear Matthew Perry pass away from not the best use of ketamine, I think people are like, well, then how do you, what does it look like? Am I doing this myself? And I love that you have a wonderful protocol that allows people to be safe and use it in the best way that gets them the best results. But can we talk about the dark sides of ketamine, and what are some signs that people might not be in the safest situations using ketamine?Sam Mandel 12:30  Yeah, well, I'll definitely answer that with your reference to Matthew Perry, which is obviously a really sad situation. He was taken advantage of by people he trusted. He was a addict. He had a really, he's really struggled with addiction. He was very public about that, and not with ketamine specifically, but with really any substance that he could get his hands on. And was in a lot of pain, obviously, and it's a terrible situation. I think it's really important that people understand, though, that that has nothing to do with ketamine therapy. And the media created a lot of confusion for people saying that he had had ketamine therapy a few weeks ago and but that wasn't really a part, a factor in his death. But by the way, he had that and, you know, saying that he died from the acute effects of ketamine, that's just it was really, really distorted. He took more than 10 times the dose of ketamine that we give in the clinic by himself, in combination with buprenorphine, which is essentially an opioid, and Lorazepam, a benzodiazepine, which is another sedative. So he's combined three powerful sedatives, one of them in really absurd doses, by himself in a hot tub. And of course, what happens? He becomes incapacitated and he drowns. This is not, this is such a departure from what we do when we use ketamine in a therapeutic context. There's no correlation, but the way that it's been reported on, and what the average person hears is, oh, ketamine is a bad, dangerous drug, and that's it. That's the takeaway, and that's really a sad thing for people to to get from it. What they should get is that addiction is a serious illness. What they should get is taking lots of sedatives in combination is dangerous. Taking drugs unsupervised, alone in a hot tub is dangerous. These are the takeaways. There was even medical doctors involved in supplying it to him, but they were part of an illicit, underground, illegal drug ring. You know, this is not like mental health care, you know?Lesley Logan 14:25  I know. It's so sad because, well, first of all, the whole situation is sad. It's sad that someone was taken advantage of. It's sad that someone died from combining too many things, but also because they had doctors doing it, like all of that is sad, and, but, really, what I find, and one of the reasons I wanted to talk with you is, so this podcast is called Be It Till You See It, and one of the things that I am always on a search for is like, what can keep us from being it until we see it, what's holding us back in our life, or what can help us more? And the facts of what ketamine therapy that you do that is supervised, and you have pre-screened people to make sure that this is the right therapy for them, the benefits can actually change people's lives, like you said at the beginning, to choose what they want, and that allows them to step into the person that they want to be, like to me, this can be an amazing option for people who they know what they want, but they are just stuck, and they've got other things going on that with their mental health that the talk therapy hasn't helped with, or antidepressants haven't helped with. And so I really wanted to, like, clear the air and go, this can be an option for the right person.Sam Mandel 15:30  Absolutely and I'm really grateful for the opportunity to speak with you and for you creating a platform to have conversations like this, because people deserve to know the truth. And you know, you talk about talk therapy. I mean, a number of patients have literally said that was like 20 years of therapy in an hour. I mean, it really is that exponentially transformational. And it's not instead of therapy, but in addition to, right? When you can do a treatment like this and then work through the material and the learnings that come up for you with someone who understands mental health, who you trust, that's where a lot of even more growth can happen, and you can implement those learnings into your day to day life in the weeks to come. That process is usually referred to as integration, and it can look a lot of different ways, but then you have your experience. How do you integrate it into your life and actually make lasting change? Ketamine really does produce transformation for most people. In the almost 11 years that we've been doing this, we have done over 30,000 infusions. We have an 83% success rate, and we're typically not seeing people who are just wanting to have growth because they're stuck. We're seeing people who have treatment resistant depression, complex PTSD, severe anxiety, suicidality. I mean, there are definitely more moderate cases, but we see a lot of people have really just they've tried a lot, and some of them tried everything, and they haven't benefited. And this really works for them, because it works on under a completely different mechanism of action than the conventional treatments like antidepressant pills or even ECT or talk therapy, or really anything else out there. Lesley Logan 17:04  Yeah, when I think about PTSD, we obviously a lot of things about vets. People have been in the military, but there are people with PTSD who have had other traumas. It doesn't have to be that you've been to war. You could have been in a bad car accident, you could have been assaulted. Can you kind of explain and maybe it's redundant, but just how does ketamine help with PTSD, and then what does someone's life look like? What with one, do you have a case that a person who you can talk about, like, who had PTSD and like, what their life was like after the ketamine treatment? Sam Mandel 17:29  I'm glad you bring that up, because while a lot of us do think of military and war, there's actually many more cases of PTSD among the civilian population in the examples that you mentioned with violence, assault, accidents, etc. So it's super common, unfortunately. I believe there's around 16 million Americans suffering from PTSD who are at least diagnosed. There's many more, I'm sure, who are undiagnosed. And ketamine really does help with the neurochemistry in the brain and helping to rewire the brain, and it also really helps with the perception that we have of ourselves, of the event. People who have trauma are able to go back and revisit the trauma without being as emotionally triggered by it. And so sometimes, when I've talked about this with you know, friends, they say, yeah, you can revisit your trauma and work through it, and it's so great. And they're like, whoa, whoa, whoa. Why would I want to revisit my trauma? What are you talking about? I'm going to go and spend time and money to go there? No, thank you. I spent time and money avoiding my trauma, not going to visit it. But it isn't like that. You know? There's this ability to work through it without having the kind of pain of going there that is so often keeping people from addressing it head on in talk therapy and in life. We avoid, naturally, what's painful, but it isn't painful for most people in this context, they're able to have this detachment that is healthy in this way, to revisit it and to understand who we are, who we were, what our role was, what It was and etc, and to get clarity on that. And it can be really healing. It can really provide closure for a lot of people. And just with the whole cascade of different chemicals going on in the brain, it gives people generally a better mood and more positive outlook and demeanor, and enhanced feelings of compassion towards oneself and towards others and energy and motivation and just all around wellness, it's an elevator in that way which can just be really motivating for people to be able to do the things that most of us know we need to do and just struggle with in terms of our lifestyle, like fitness and eating healthy and sleeping well and talk therapy and having healthy relationships with people, getting outdoors and getting some sun and some fresh air, doing things we enjoy, all that stuff is absolutely critical for longevity, and for someone who's really severely depressed or anxious or dealing with real trauma, they can also feel like it's almost impossible to do a lot of those things. Lesley Logan 20:00  Yeah, yeah. You know, it's really interesting. If you're not someone who has PTSD, or you haven't had, like, severe depression, it can be hard to understand that it becomes all encompassing, you know? But if you think about it, like, when you've had an injury, you've been sick for a few days and you can't leave the bed, that's the the domino effect of what happens to your strength, and then what happens to your ability to, like, feel like you can reach out and that you can connect with people because you've been sick for a week. It's an easy way to see like, oh, if that's my life all the time, you know, it's not easy to go outside, and it doesn't feel easy to connect with people. And so it becomes part of their whole life. And so it's really cool to hear that with ketamine treatments over a couple of weeks that they could have a new lease on life and enjoy it. And I love that you brought up longevity, because I think we forget that how we treat our bodies now is what dictates how long will you get to have them? Hopefully, there won't be anything that stops us from living the life that we're supposed to but if you don't see like a lease on life there, what longevity do you have, you know, so it must be really amazing to get to do what you do every day. You really help so many people.Sam Mandel 21:01  I love it. It's the most gratifying thing ever, you know. When I tell people a lot of my job, the reality of what I do on a day to day basis, I have to do a lot of things I don't like to do, I don't want to do. I'm the CEO of my company. I get the worst, toughest problems that no one else can deal with. I get the fires to put out, the problems, the issues that got escalated to me, and all the weight and pressure and responsibility of it, and there's a lot of stuff, this is not fun, frankly, but I do it because of the, for the patients and for my team, and the work that we're doing, the impact that we're having. It's hugely motivating and gratifying. And when I see patient who I pass in the hallway in the clinic, and they just, can I just give you a hug, or I just want to say thank you so much, or we get a new Yelp review, and someone goes through and lists, you know, half my team by name and how amazing each one of them is, and how life-changing this has been for them. That's what gets me up in the morning, and that's what helps me to keep going every day. I just love it. The transformations are very abundant. And, you know, like I said, 83% it's not magic. It doesn't work for every person every time. It's not perfect, but it is a really incredible treatment.Lesley Logan 22:04  Yeah, yeah, I do understand that. I mean, my husband and I run our own businesses, and sometimes you can forget what you do while you're doing it, because you're doing all the fires, yeah? But then you do get stopped by someone who's been helped by it, or their life has changed, and you're like, oh, that's why I do this. Obviously, you know, it's been a journey to get to do this. Can you take us back how you figured out how to create a space where people could have ketamine therapy? You know, you are the first in the country. So, like, there wasn't really a model to go off of. So I feel like there's a be it till you see it story in there.Sam Mandel 22:36  Oh yeah. Started with me building the website with GoDaddy website builder, drag and drop modules, not knowing a lick of code, never built a website or anything of the sort, not even the most tech savvy guy, and literally just dragging and dropping and, you know, doing research on articles and clinical research, and conferring with my father, who I co-founded the practice with. He's a physician, and I'm talking about, what do you think about this? I'm just trying to make sense of it all in a way that I could understand it well enough to then be able to put it into layman's terms and explain it to other people. What is this? How does it work? And just putting it together, and then going to Radio Shack and getting a motorLesley Logan 23:17  That's how long ago this is because I don't even think they're around anymore.Sam Mandel 23:20  They're not, They went bankrupt. Lesley Logan 23:22  Was it the Radio Shack on Santa Monica Boulevard underneath the yoga place? Because that was my favorite. Sam Mandel 23:27  It was the Radio Shack in Marina Del Rey by the CVS and little strip mall off of Max Stella or something. Anyways, I got a Motorola flip phone prepaid, and I said to my father, you ready to launch the site? We're going to make it live. And made it live, and started taking calls on this cell phone. We were renting space in another doctor's office that was literally this closet. No kidding, they used it as a utility closet before we rented it, and once we moved out and got our own space. They went back to just keeping boxes in there. That's how tiny this room was, no kidding, and it was just really a trip. We had a operating room, recovery area, recovery room for an OR right outside of that little closet that we were in, which, by the way, we were sitting at literally just two folding chairs, a folding table with two laptops, and that was it, no kidding. And we use this recovery area to see patients. And we saw our first few patients, and their transformations were so incredible. We went, this is just too special. We have to do whatever it takes to do more of this. And my father was working as an anesthesiologist. He also has a master's degree in psychology. He was chief of anesthesia in this plastic surgery suite where we were. And so it started out with, well, he's already there, doing anesthesia for the surgery. Maybe we see a couple patients here or there, see how it goes. And next thing we knew, we just started getting busier and busier. The word got out. This was such a radical thing that a lot of people were very incredulous, very suspicious. A lot of people were very critical, but we were like, it doesn't matter. I mean, this is just too special. And it got to the point where my father had to choose between doing our cases or doing ketamine infusions for patients. And I, I remember that quite vividly, where I said, it's really gotta pick. We can't continue to do both. And it was a big risk, you know, it was a really big risk. So I have a lot of respect, you know, for him, for that and that we both just said, let's be all in on this. And, you know, we bootstrapped it. We put everything on credit cards. We had no investors, no financing, no loans, nothing. It's just a little bit of cash, credit cards. And really, just brick by brick, built it up, and now we have 15 employees, 5000 square feet, a really beautiful purpose-built office. I still have, well after the falling table, I had a custom desk built because of maximizing every inch of that space. So I had, there was a little nook between two pillars in that room, under a window, where they made this skinny little desk that was probably literally eight inches wide by three and a half feet long or something. Just stick it in this little nook so I could sit at a proper desk, and I still have that here in our suite now, and so that's kind of fun, but, yeah, it's just truly been an incredible journey.Lesley Logan 26:12  I thank you for taking this back, because we do have a lot of people who are entrepreneurs, and I think that they need to hear that like even a ketamine clinic, the first of its kind, starts in a utility closet. You know, people don't realize, because if you, one, you have to know if people want the thing. You knew it was great. You knew it could be amazing. But you have to get people to buy in, and especially on something that long ago, where people might not know all the amazing things that it can do. And even today, now, even with a beautiful space that can attract people in and make them feel super safe, doing something that changes lives, but also going up against where misconceptions, misinterpretations, and also the people who are misusing it can affect the majority getting the help that they need. I love hearing the stories of how things come to be. And also that is pretty amazing that your dad was like, yeah, I'm gonna quit my safe job. There's always gonna be surgeries, you know. So that's so, so, so cool, and it's really amazing. Is there anything about ketamine therapy that I haven't asked you, that you want to make sure people know? Is there anything else that we can help people understand why this would be something they might need to use, or might use so that they can have the life they want to have?Sam Mandel 27:19  Yeah, I do want to mention, you know, I was talking about how, you know, Matthew Perry was misusing it, and how different that situation is from what we do. And ketamine is still something that people do use recreationally or abuse or misuse. It's not as common, I think, as sometimes it's portrayed, but it definitely can happen, but it's also not in the same category as most other substances, because ketamine is not addictive in the way that most others are. And what I mean by that is you don't develop a physical dependence on it if, for example, like nicotine or opioids or alcohol or benzodiazepines, all you can get to the point where you actually need it to not feel sick. I mean, you have physical symptoms of feeling like nausea, headaches, wanting to throw up. Even with benzos, you can actually, if you abruptly stop taking high doses, you can literally have seizures and die. And you know, you can have symptoms from abrupt cessation of alcohol if you're a heavy alcoholic. That doesn't happen with ketamine. So some people can use it in the way that they're using it as a means to escape, but that's not really that different as far as the psychological dependence in the way that someone can use ice cream or chocolate or, you know, sour candies or sex or any of these other video games as a means of escape or avoiding or to self-soothe. So I think it's important that people understand that. It also has a very, very high therapeutic index. There's actually no known lethal dose of ketamine, so you can obviously be in a bad, unsafe environment, where, if you take a bunch and get into a car, that's not a not such a great outcome for you, or in a jacuzzi, but the medicine itself is unlikely to hurt you on its own. Most of the issues are people in bad situations, or they're combining it with other drugs. Virtually, almost all of the fatalities that are related to ketamine were one of those two, either in combination with other drugs and or in a situation like behind the wheel of a car. So I just want people to know that it's not to say that there aren't people who have an issue with misusing ketamine, because there are, but it really is distinct from most other substances that people are misusing or abusing.Lesley Logan 29:20  Thank you for saying that, because I do think, as a child of the night, you know, I grew up in the 80s, so it's, like, always just say no to drugs. Sam Mandel 29:25  The cocaine epidemic. Lesley Logan 29:28  Yeah, so I know they really that didn't really help them, did it? But, like, they thought it would. But I, like, grew up, so it's really funny when I have friends who, like, talk about doing some sort, some psychedelics, or do I have this innate like, I don't, I don't know, I don't know if I could do that. I'm afraid to try. I'm like, I'll be addicted on the first dose. Sam Mandel 29:45  Right, right, right. Lesley Logan 29:47  This is my fear, which is why I drink, right? That's what people do. And so they said no to drugs, but then they drink. But I really appreciate because it's nice to know that if I were to do a ketamine therapy, I'm not going to be dependent on coming to ketamine therapy every single week or I'll be using it at home, like, it's nice to know that it's a non-addictive thing that people can use to get the benefits. And I think that can make a lot of people feel more comfortable, you know. Sam Mandel 30:08  Yeah, because people are afraid of that, they think, God, well, if I go and do this, even if it's in a therapeutic way, am I going to become a ketamine addict? You know? I'm going to go and then be looking to score some on the street the next day. It's really a sad perception that some people might have due to the media or for whatever reason or they know somebody who misuse ketamine or the DARE program, like you said, or the 80s. A lot of baloney. Lesley Logan 30:28  Oh, and by the way, the DARE program was a lot of baloney. I just heard a whole podcast about it, and I was like, ah. So, but it, but it does put in people's minds, and also good for good reason. Like, I don't want people going out there doing other drugs we do know our addictive and like, hoping that they are fine out there the first time, but I am on this mission of helping people figure out how to get out of their own way and live their best life, and sometimes our own way are things that are really outside of our control, the PTSD, the depressions, the mental health, the suicide like I think it's important that people have access to forms of therapy out there that they may not know about or they may have misconceptions. Because we do know that the media does like to click bait things into headlines that get people to look at them, but don't actually give all the information. So I'm just so grateful that you were here to just really explain all this and the benefits of it.Sam Mandel 31:22  Absolutely, yeah, no, I appreciate the opportunity. Yeah, there are drugs that you can do once or twice and develop a real serious problem with pretty fast, methamphetamine, probably not one that you need to ever try. You know, if you're curious about trying drugs, I'd say take that one off the list. Heroin, probably not a good idea. Pretty easy to die, pretty easy to get addicted to that one, right? Opioids, crack, cocaine. These are some that maybe you don't need to, you don't need to check out, but maybe there's some others that if you really want to with the right mindset in the right context, if you're going to be safe or responsible, maybe you'd be okay with. And by the way, I'm not advocating for you to go do illicit drugs illegally either. But there are some that you can have, even in a controlled environment, such as ours, where you don't need to be afraid of them. I'll tell you what are the most dangerous, though, is the prescription legitimate drugs. As a matter of fact, prescriptions are more commonly abused than any of the other illicit drugs. You look at your stimulants like Adderall, your benzodiazepines, like Xanax, opioids, I mean, these are drugs that are a lot of people are really hooked on and that are killing a lot of people, especially the opioids, but because they're from big pharma, they're not all that bad. I mean, people are finally starting to scrutinize the opioids, but the others are still kind of under the radar, and they're really widely abused, but the focus is on the big, bad, illegal ones. Lesley Logan 32:39  I know of a client who's a social worker, and she used to work in a hospital, and we're talking about pain meds, and she's like Lesley, I watched a 14 year old kid come in super healthy, just had a broken arm. They had to have surgery, but within the three days they were there, they were extra tapping the pain meds. And she's like, we create addicts with these pharmaceutical drugs quickly, but we don't think of it like that, because they had a prescription written. And so it's important for us to educate ourselves, to be informed and to be able to advocate for ourselves or advocate for others when we have this information we can. So, thank you so much. I'm not gonna let you go. We actually are gonna take a brief break, and then we're gonna find out Be It Action Items from you. Lesley Logan 33:19  All right, Sam, where can people find you, follow you, connect with you. If they want to know more about ketamine therapies, if they want to come to your clinics, how can they connect with you best?Sam Mandel 33:28  Yeah, so ketamineclinics.com. That's K-E-T-A-M-I-N-E-C-L-I-N-I-C-S dot com. Lots of great information on there. People are more than welcome to call us, 310-270-0625. Consultations are free. We're always happy to chat see how we can help you. We do offer other treatments we really didn't talk about today, TMS, General Psychiatry, medication management, we take 12 of the biggest insurance networks in California, including Medicare, so there's a lot more that we can cover with you. Whether or not ketamine is the right fit if you are dealing with a mental health condition, I would encourage you to call and see if there's anything we can do to help. And we're on social it's ketamineclinicsLA on all socials and my personal is theSamMandel on all socials. And just really happy to connect with people and hear their stories, answer questions and help in any way that we can. Lesley Logan 34:23  I love it. Thank you. And that's also so cool, because we mentioned, like, it can be really hard to find a therapist these days because they don't always take insurance. So to hear that you do. It's really nice. Okay, we always ask people bold, executable, intrinsic or targeted steps they can take to be it till they see it. What do you have for us?Sam Mandel 34:41  Oh, I wasn't ready for that one. I would say action. Take action. Just do it. Take Nike slogan. I mean, honestly, planning and strategizing is important, and thinking things through and figuring out who you are. What you want, what you like, what you don't like, putting together a plan matters. But I think most of us, or almost all of us, spend too much time on that, and there's just too many unknowns and too many things that you really can't solve for until you're in it and doing it, and it's too easy to let perfectionism keep us from taking the steps that we need to take to get done what we want, become, who we want to be, and who what our potential is. And I personally struggle with this too. So I say that from, you know, my own experience, and I really strive, and I want to encourage other people to really strive, to just get out there and do it, and you're going to make mistakes, and that's okay, but it's really the only way to succeed in life. You have to be on the fields, on the court, in it, and behind the scenes, thinking, planning, strategizing is only going to get you so far.Lesley Logan 35:58  Yeah, yeah. Oh, thank you for that. And also, I can tell you, practice what you just preached, because it's true. You started with a utility closet and some folding chairs and a Motorola phone, I mean. But also, you're correct. People do spend too much time in the planning, or they're waiting for it to be perfect, or they're waiting for the perfect decoration, and then they have the perfect branding and all the things. And if you guys had done that, you wouldn't have been able to help the thousands of people that you have today. So thank you so much, Sam for being here, for educating us, for informing us. Lesley Logan 36:29  And, you guys, how are you gonna use these tips in your life? Please share this episode with a friend as you hear conversations come up about the misuse of ketamine, and now you know you could share this with them to educate them, and also, if you have friends and family or yourself who needs this, please contact Sam and his team, because there's help out there for you. Until next time, Be It Till You See It.Lesley Logan 36:50  That's all I got for this episode of the Be It Till You See It Podcast. One thing that would help both myself and future listeners is for you to rate the show and leave a review and follow or subscribe for free wherever you listen to your podcast. Also, make sure to introduce yourself over at the Be It Pod on Instagram. I would love to know more about you. Share this episode with whoever you think needs to hear it. Help us and others Be It Till You See It. Have an awesome day. Be It Till You See It is a production of The Bloom Podcast Network. If you want to leave us a message or a question that we might read on another episode, you can text us at +1-310-905-5534 or send a DM on Instagram @BeItPod.Brad Crowell 37:33  It's written, filmed, and recorded by your host, Lesley Logan, and me, Brad Crowell.Lesley Logan 37:38  It is transcribed, produced and edited by the epic team at Disenyo.co.Brad Crowell 37:42  Our theme music is by Ali at Apex Production Music and our branding by designer and artist, Gianfranco Cioffi.Lesley Logan 37:49  Special thanks to Melissa Solomon for creating our visuals. Brad Crowell 37:53  Also to Angelina Herico for adding all of our content to our website. And finally to Meridith Root for keeping us all on point and on time.Support this podcast at — https://redcircle.com/be-it-till-you-see-it/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

And the F WORD is Fearlessly Facing Our Futures and our future health. Dr. Jayne Morgan, a cardiologist, joins host, Amy Schmidt to explore the link between hormones and heart health in women at midlife and beyond. They discuss heart disease, the leading cause of death among women, and emphasize the need for greater awareness. Dr. Morgan shares her journey into menopause and women's health, discussing the most important thing that women can do today to advocate for their health. They also address three things that women can incorporate into their lives to put heart health as a priority as we age. TakeawaysDr. Jayne Morgan transitioned from cardiology to menopause education during the COVID-19 pandemic.Heart disease is the number one killer of women, and the risk increases during perimenopause and menopause.The symptoms of heart disease in women can be different from those in men, and it is important to recognize and address them.Cholesterol, statins, and testosterone play a role in heart health, and further research is needed to understand their impact on women.If there is one thing we can do today is to ask our physicians for a baseline EKG.Follow Dr. Jayne Morgan hereOrder my book now hereLink to my website hereListen to the podcast here#heartdisease #menopausetreatment #menopause #hearthealth #hormonetherapy

In this episode, we explore the safe use and monitoring of lamotrigine, focusing on cardiac risks and when EKG monitoring is necessary. Did you know that reducing lamotrigine dose doesn't actually mitigate cardiac risks but could increase the risk of psychiatric destabilization? Faculty: Scott Beach, M.D. Host: Richard Seeber, M.D. Learn more about our memberships here Earn 0.5 CME: Lamotrigine: From Current Indications to Cardiac Side Effects Strategies for Safe Usage and Proper Monitoring of Lamotrigine

CardioNerds Cardiac Amyloidosis Series Chair Dr. Rick Ferraro and Episode Lead Dr. Anna Radakrishnan discuss the biology of transthyretin amyloid cardiomyopathy (ATTR-CM ) with Dr. Daniel Judge.  Notes were drafted by Dr. Anna Radakrishnan. The audio was engineered by student Dr. Julia Marques.  This episode provides a comprehensive overview of transthyretin (ATTR) cardiac amyloidosis, a complex and rapidly evolving disease process. The discussion covers the key red flags for cardiac amyloidosis, the diagnostic pathway, and the implications of hereditary versus wild-type ATTR. Importantly, the episode delves into the current and emerging therapies for ATTR, including stabilizers, gene silencers, and promising treatments like CRISPR-Cas9 and antibody-based approaches. Dr. Judge shares his insights and excitement about the rapidly advancing field, highlighting the need for early diagnosis and the potential to improve long-term outcomes for patients with this condition.  Enjoy this Circulation Paths to Discovery article to learn more about the CardioNerds mission and journey.  US Cardiology Review is now the official journal of CardioNerds! Submit your manuscripts here.  CardioNerds Cardiac Amyloid PageCardioNerds Episode Page Pearls: - Biology of Transthyretin amyloid cardiomyopathy Maintain a high index of suspicion! Look for subtle (yet telling) signs like ventricular hypertrophy, discordant EKG findings, bilateral carpal tunnel syndrome, and spontaneous biceps tendon rupture.  Utilize the right diagnostic tests. Endomyocardial biopsy remains the gold standard, but non-invasive tools like PYP scan with SPECT imaging and genetic testing are essential for accurate diagnosis.  Differentiating hereditary from wild-type ATTR is critical, as genetic forms may have a more aggressive course and familial implications.  Early diagnosis and intervention significantly improve prognosis, making vigilance in screening and prompt treatment initiation essential.  The future is now! Cutting-edge therapies are transforming the treatment landscape, including TTR stabilizers, gene silencers, and emerging technologies like CRISPR-Cas9 and antibody-based treatments.  Notes - Biology of Transthyretin amyloid cardiomyopathy What is transthyretin amyloid (aTTR) and how is it derived?  Transthyretin (TTR) is a transport protein primarily synthesized by the liver, responsible for carrying thyroid hormones (thyroxine) and retinol (vitamin A) in the blood. It circulates as a tetramer, composed of four identical monomers, which is essential for its stability and function.  In transthyretin amyloid (ATTR) amyloidosis, the TTR protein becomes unstable, leading to its dissociation into monomers. These monomers misfold and aggregate into insoluble amyloid fibrils, which deposit extracellularly in tissues such as the heart, nerves, and gastrointestinal tract. This progressive amyloid deposition leads to organ dysfunction, including restrictive cardiomyopathy and neuropathy.  There are two main forms of ATTR amyloidosis: hereditary (variant) and wild-type (senile) ATTR.  Hereditary ATTR (ATTRv) is caused by mutations in the TTR gene. These mutations destabilize the TTR tetramer, making it more prone to dissociation. This increases misfolding and amyloid fibril formation, resulting in systemic amyloid deposition.   Wild-type ATTR (ATTRwt) occurs without genetic mutations and is primarily age-related. Over time, even normal TTR tetramers can become unstable, leading to gradual misfolding and amyloid deposition, particularly in the heart. ATTRwt is a common but often underdiagnosed cause of heart failure with preserved ejection fraction (HFpEF) in elderly individuals.  How does aTTR lead to deleterious effects in the heart and other organ systems?    Transthyretin amyloidosis leads to organ dysfunction through the deposition of misfolded TTR protein as amyloid fib...

Get instant access to 8 subscriber-only episodes: https://realestateteamos.com/subscribeFounder and team leader George Laughton is focused on top-line revenue growth. COO Billy Hobbs is focused on expense management and operational efficiency.   Both have an eye on net operating income, but neither is cuffed to the numbers or focused on making a specific margin at all costs.   Ultimately, they're working to build a durable business - one that's healthy enough to adapt to and endure changes in market conditions, technologies, regulations, and anything else they face as a real estate team.George and Billy were our first two guests in our Inside The Laughton Team series, in which we met and learned from eight different leaders in their 200-agent, 25-staff, and 5-office organization in Phoenix, Arizona.They're back on the show and together in this episode to share ideas on profitability, trust, consumer experience, video messages, transaction coordination, the infinite game, and “the EKG of the business.”Watch or listen for insights into:- Recognizing the need for and value of trust, intuition, and patience within the team- Getting a snapshot of the team today (agent count, staff size, year-over-year growth)- Running the organization on a modified version of EOS (and why they modified it) and how they prioritize problems and opportunities- Elevating consumer experience through video communication- Creating the most consistent and efficient agents possible- Improving CRM, transaction management, and business intelligence over the past 7 years and through 10x agent count - and having one place to access everything from the macro level down to micro details- Creating a durable, profitable business that shields your people through different seasons and different markets- Watching out for the “it's only”s that eat into profit- Evaluating the ROI of lead sources and keeping an eye on originating source on every conversion- Judging the effects of the NAR settlement as a net positive so farAt the end, learn about Apple update insights, too-effective Instagram ads, and empty health hacks.The Laughton Team - https://www.instagram.com/laughtonteam/- https://www.instagram.com/georgelaughton/- https://www.instagram.com/billyhobbsjr/Inside The Laughton Team Series- https://www.youtube.com/playlist?list=PLCJiXNo93cVr9Oc0ptse5z6Vaq5l0T1kAReal Estate Team OS:- https://www.realestateteamos.com- https://linktr.ee/realestateteamos- https://www.instagram.com/realestateteamos/ Get instant access to 8 subscriber-only episodes: https://realestateteamos.com/subscribe