Transcript
Gianluca Bini: All right, so tonight it's Tasha's topic.
Annatasha: Whoop whoop!
Gianluca Bini: What you got? What you got?
Annatasha: I know. Bailey, hope you took an A.T.
Ryan Bailey: Oh God.
Annatasha: diarrhea medication for this topic because I feel like you're gonna blow some part of a sphincter out, but...
Ryan Bailey: Or the hot dogs will cause that one of the two.
Annatasha: I actually had sausage for dinner myself, Bailey. We barbecued a bratwurst tonight.
Ryan Bailey: Hell yeah.
Gianluca Bini: OK.
Ryan Bailey: What do you put on your
Annatasha: And I hit it up with some mustard that I have to buy only in Vienna and then bring all the way back from Austria just to eat it here. So, yeah.
Ryan Bailey: Just
Annatasha: We also barbecued like mixed veggies, so like peppers and mushrooms and onions and stuff.
Ryan Bailey: No one cares about any of that garbage. What'd you put?
Annatasha: Oh, we also had a side of steak.
Annatasha: We had a little meat with a little meat and then we threw some vegetables in it.
Ryan Bailey: I just like what goes on the brat. Just mustard, bratwurst, bun.
Annatasha: Pure.
Ryan Bailey: No kraut, no onion, no...
Annatasha: That's it.
Ryan Bailey: Wow, all right.
Annatasha: I'm not German, Bailey. I'm Austrian.
Ryan Bailey: A real carrot, a real no cheese.
Annatasha: Oh, okay. First of all, if an Austrian saw cheese on a wiener, they would die. And secondly, sauerkraut on the hot dog is a little bit more German than it is Austrian. So the Viennese, usually they just eat their various types of sausages on a small paper plate.
Ryan Bailey: Interesting.
Gianluca Bini: Hello.
Annatasha: And it comes little bit of grated horseradish and a thing of mustard. And then you get a side piece of bread and that's it.
Ryan Bailey: It's a dream. All right, well, now we got all the hot dog talk out of the way. Now we get to the real meat of the issue.
Annatasha: That is the issue. I'm just kidding. I'm turning this into the full-time hot dog podcast.
Ryan Bailey: The random hot dog podcast.
Annatasha: I know. And also a big shout out to, we recently received our first fan mail.
Ryan Bailey: Oh, yeah.
Gianluca Bini: Yeah. Yeah.
Annatasha: Yeah. Where your wallpaper was highlighted, Bailey, which I thought was really funny.
Ryan Bailey: My wife's choice.
Ryan Bailey: She's only.
Annatasha: dare they? But yeah, okay, so my topic tonight, it's little more broad, although it definitely has direct ramifications within our tiny realm of veterinary anesthesia.
Annatasha: Tonight we are going to discuss, if Bailey survives this, evidence-based medicine.
Ryan Bailey: Oh, God.
Annatasha: Oh, God, even Beanie was like, So evidence-based medicine for the listeners who may not be terribly familiar with this, but it's essentially what you're trying to do is you're trying to get like high quality, mostly like perspective studies, blinded, randomized, controlled, blah, blah, blah. and they've been peer reviewed by a series of other experts, and they've gone through the rigmarole of publication.
Annatasha: And you're supposed to use the evidence that we find in that literature to drive clinical decision making. One of the limitations that we frequently encounter in veterinary medicine is that our study populations or our study groups within these papers are insanely low, right? Like there are more than a handful of papers out there that are published with four to six, you know, cats in a group. And, you know, it's the one paper on this topic and we're all supposed to, you know, make these big extrapolations thereof.
Annatasha: I sort of have this Bartell theory of veterinary literature in general, which is There's six different levels of what's considered to be worthwhile in terms of knowledge, right? And evidence-based meant to be the top of the pyramid and at the bottom of the pyramid is basically experiential, right? So it's what you do day to day.
Annatasha: But personally, I very much struggle with making these decisions off of A, like one paper, right, that's never been validated or further studied or anything like that. Two, with these incredibly small numbers because the statistical power of the study is non-existent. Like human statisticians must just laugh themselves asleep at night when they see these veterinary papers.
Annatasha: And so you get one paper with like four cats in it, and then you look at somebody who's maybe had like a 20 to 30 year career and they've probably done something related to this topic like 20,000 times, actual number.
Annatasha: And I struggle with the fact that this stupid paper about four cats is supposed to have more merit and more worth the 20,000 cases that this person has had in terms of clinical experience and how they've developed their intuition.
Annatasha: Anyway, I just didn't know, like, in terms of evidence-based medicine, like, how much do you allow this to drive what you do day to day? The other problem that we often face is that we don't have streamlined guidelines, or if we do their waffly, like maybe we should use capnography, you know, or there's just a total absence of,
Gianluca Bini: No, no, no, no, fuck that. You need to use the capnography
Annatasha: I know we, there's one thing we all advocate, even though Bailey loves the job, we all advocate that you should use capnography period. Others, there's a lot of other things that we get.
Gianluca Bini: right, it's a minimum basic fucking monitoring out of the question, right?
Annatasha: Yeah.
Annatasha: Oh, yeah.
Gianluca Bini: Anyway.
Annatasha: To our fan mail, listen to who's not being calm and rational right now. But anyway. Well, yeah. Evidence-based medicine and veterinary anesthesia.
Annatasha: Thoughts? Contemplations? Considerations?
Gianluca Bini: Well, so I think we need to bring up a couple of studies just to give an example, right?
Annatasha: How do you guys use it?
Gianluca Bini: So there is a study that says that cats are more likely to die if they're intubated.
Annatasha: I know that study.
Ryan Bailey: Wow.
Gianluca Bini: Well, I mean, we all do, right? Like, you know, who hasn't read that? But like, you know,
Annatasha: The two things that kill cats are fluids and intubating.
Gianluca Bini: absolutely, yes.
Annatasha: Yeah, right, sure.
Gianluca Bini: So box them all down.
Ryan Bailey: Oh, God.
Gianluca Bini: And never give any fluids to a cat, period. Now, I mean, problem is that, you know, a lot of the studies in vet med do not have enough sample size to actually demonstrate what they want to demonstrate, right? And, you know,
Gianluca Bini: To give you an example, right, like when I was, after I published my very first paper a first author, I was invited, you know, probably few months later a year later to review another paper, right, from the same journal.
Gianluca Bini: And when I pointed out that, you know, these guys did not have enough sample size or were not, and that should be, you know, as a first time reviewer trying to like, you know, do my due diligence and be very good at it and whatnot, you know, that the paper should be rejected. And the response from the editor was, well, we're not at the point where we can reject the paper because they don't have enough animals in the study because otherwise we would have to reject them all.
Gianluca Bini: And so that kind of summarizes a little bit the kind of body of evidence that we have in veterinary medicine, right? And so think, you know, studies out there, it's really important that we do studies, right? But also we need to take them with a grain of salt sometimes because some of them are what they are, especially, you know, when they point out something that's totally...
Gianluca Bini: counterintuitive. I think that, you know, we need to do multiple studies to prove the same thing. And that's the thing they were really terrible at. So in humans, there is plenty of studies that repeat the same study over and over to prove that what they found on the first one was actually true. Good luck in veterinary medicine to get a paper published after
Gianluca Bini: that finding was already published in another paper. There is this thing, apparently, and I don't know who's the Heliots that thought that that was a good idea, that once one finding is published out there, any other study that found the same thing, it's garbage.
Gianluca Bini: And so you're never going to see those papers published, right? And nobody does that kind of research anymore because, again,
Annatasha: It's like, we've come to the conclusion. And so we closed like the door on it.
Gianluca Bini: Yeah, that is it, right?
Annatasha: Right. It's everything we need to know now about, yeah, well, like we are done with isoflurane and dogs and we're done with isoflurane and cats.
Gianluca Bini: Like any other study that proves that that's real.
Ryan Bailey: Yeah.
Annatasha: So let's go do something else. Right. And it's just like, you know, and I agree with you too. Like I also find there's this weird phenomenon where we latch onto these weird random papers because they have like maybe an unexpected result or, like a controversial result and we're like limpets.
Annatasha: And it becomes like the de facto, you know, thought process. And my classic example for this is the Doppler blood pressure is reading mean in a cat, right?
Annatasha: It's reading the mean pressure in a cat. says paper from number of years ago that has never been resubstantiated significantly that had a poor sample size or whatever. And I have to go around debunking this mean, you know, pressured bullshit about Dopplers and cats because God forbid that is the systolic.
Gianluca Bini: Yeah.
Annatasha: But, you know, just, I don't know what it is about veterinary literature and publication and evidence-based, but question, have you ever bumped up against anesthesiologist who literally, like, they sort of operate in a way that almost like if it's published, it's like written in stone and it doesn't, Like there's no critical thinking or analysis of the quality of the paper.
Gianluca Bini: Yeah.
Annatasha: And so it doesn't matter whether it's rational or reasonable or it's been substantiated. They follow these published standards. Like, you know, they will be crucified if they don't.
Annatasha: And it's just like, oh, like,
Gianluca Bini: Like half of the veterinary literature of theirs, vomit, right?
Gianluca Bini: And
Annatasha: I can't wait for this week's fan mail.
Gianluca Bini: it's true, right? Isn't it true though? Like half of those studies, the orders of the studies are done institutions that need to publish because,
Annatasha: I'm not arguing. I mean, this is why I brought this topic.
Gianluca Bini: Somebody has to get tenured or somebody needs to fucking finish their residency, right?
Ryan Bailey: Yeah.
Gianluca Bini: So the residency papers account for probably half of three quarters of what's on VAA at the moment, right?
Annatasha: mean, I'll tell you this, review for VAA and I review for a couple other journals, including a few human ones. And it's interesting because, you know, it's interesting because it's almost like our community is so under-researched and under-published that sometimes papers are eking through just because the journal needs to self-sustain, right?
Annatasha: Like they'll take like a paper that would otherwise be, you know, you were to try to get it through nature or science as an example,
Gianluca Bini: Yeah. Yeah. Yeah.
Ryan Bailey: Yeah.
Annatasha: I know, right?
Annatasha: Like it wouldn't, it wouldn't, it wouldn't, it would be rejected at the first like proposal, right? Like, because it's just, they're so ludicrous, but we face this issue where there's not enough submissions.
Annatasha: And so, you know, you end up as a reviewer really having to like, trying squeeze water from a stone with these people, trying to get it to the point where it's decent, just so that there's content, which is suboptimal.
Gianluca Bini: It's sad. It's really sad. And then when somebody proposes to repeat a study from somebody else, they get trashed, right?
Annatasha: Letters.
Gianluca Bini: When actually it would have been a good study, right? Like just to prove, okay, did these guys did something legit or not, right? Let's double check, right?
Gianluca Bini: The whole purpose of writing your materials and methods on a fucking paper so that somebody can replicate it. If you don't give access to anybody to fucking replicate the paper, then it's stupid.
Ryan Bailey: Right. Yeah.
Gianluca Bini: Why do we even write it? You know what I mean? That's where half of the shit is.
Annatasha: You know, that's a good point because I hate the materials and methods section and I always have.
Ryan Bailey: Really?
Annatasha: Oh God.
Ryan Bailey: Oh, that's like a great.
Annatasha: Like I have hated it, I think since grade four science fair, right?
Ryan Bailey: Yeah. Wow.
Annatasha: Like it's just so technical and boring.
Ryan Bailey: Yeah. But it gives you like all the information like how it was set up.
Annatasha: I'm
Ryan Bailey: Was it like a lot of times you can.
Annatasha: not saying it's not valid. I'm just saying I personally do not enjoy it.
Ryan Bailey: Yeah.
Annatasha: And I think Beanie has a great point that what is,
Ryan Bailey: Oh, I always like, I'm like glue to that. The intro section is like some fluff. And then get the materials and methods and that's like the real meat of it. You know, the bratwurst, if you will.
Annatasha: because that's where you're going to critically analyze whether or not the study was biased or blinded or whether it has merit or...
Annatasha: Yeah.
Ryan Bailey: The troubles are here in the methods. Like, I'm going to do, like, the red, like, there's bigger, like, here's the big problem. All of this now after is, like, we can't, like, we have big problems.
Annatasha: I mean, I've actually received a few papers that have, you know, I've been asked to review sort of in final stages of publication almost as like an informal capacity. And it's gotten that far where there are major errors, not only in terms of the methodology, but even in like straightforward definitions related to anesthesia terms. Like,
Ryan Bailey: Right.
Annatasha: I remember in one paper, right, like the authors didn't understand what Mac stood for it and what it implied. And I was like, you can't, you can't publish this. Like, I was like, it's erroneous to say this. I was like, it's flat out a misunderstanding of what the concept implies.
Annatasha: And they were just like, well, that's not what we think. And I was like, well, then, then I'm not going to approve this for publication, you know, like, it's wild to me, and I agree with Beanie, that the quality is highly variable.
Annatasha: And in most instances, if this was human literature, be rejected. Okay, so Bailey then, on a scale of like, so zero 10, right?
Ryan Bailey: Okay.
Annatasha: So zero is you do whatever you want, you don't care what the papers say.
Gianluca Bini: Thank you.
Annatasha: 10 is you follow them in the way that it's like, and then five is like, you know, when it works for me, like, it's almost like moral relativism. When it works for me, I follow the paper and when it doesn't, I ignore it. Where are you in this scale?
Ryan Bailey: I mean, feel like I've been quiet relatively because I am probably the one who leans most heavily on the literature of this group. And I rely on it a lot because my mind, like it's, it's what supports the claims that we make.
Ryan Bailey: that go beyond our clinical experience. And I think it's important to recognize the bias that we bring to the table when we make a clinical choice.
Gianluca Bini: Thank you.
Ryan Bailey: We make a clinical choice, it goes well, there's confirmation bias, right? We make a clinical choice that we think is gonna go poorly, There's confirmation bias there as well. The bad choice we made, we knew was going to go bad, and it went bad, and therefore it is a bad choice. There's bias there. And so the idea to me, least in the aspirational my thoughts on research, are like it is to help remove some of those biases that are inherent in human nature.
Ryan Bailey: Like, so I rely pretty heavily on it. I don't, I wouldn't say I'm dogmatic about it where like, if they say something that challenges my worldview, I accept it without question.
Ryan Bailey: do accept things from the literature that question my opinions. or yeah, that question, my beliefs and, you know, either use that as a springboard to do more research on the topic, to continue to challenge my belief and practice and, and decide what's going to be best for my patients.
Ryan Bailey: And then I expand out too, you know, like, I think it's, I don't think we have to just use the veterinary literature as like, you know, what defines our practice, but we can use it to help,
Ryan Bailey: explore more options that maybe come from a, a larger patient population, like what we're seeing on the human side. I don't know if I can give you a number, it's probably like eight or maybe even a nine.
Annatasha: Here's a question for you, Bailey, then.
Annatasha: So in human medicine, I'll give you an example specifically.
Ryan Bailey: Yeah.
Annatasha: So back in the 80s, right, and then the 90s, they published a series of, like, major, major papers on, like, fluids under anesthesia, right?
Ryan Bailey: Yeah.
Ryan Bailey: Sure.
Annatasha: And, like, they were basically just drowning people to death for 20 years.
Ryan Bailey: Absolutely. Right.
Annatasha: And then, you know, in the early it started to shift, right?
Gianluca Bini: Thank
Annatasha: So that it's basically like goal-directed therapy, goal-directed therapy.
Ryan Bailey: Right here. Sure?
Annatasha: And now they're looking at basically like, you know, wet to dry, what's going to make you die. And, you know, dry anesthesia is now a thing. Now what's interesting and how it relates to our topic conversation tonight is that those papers out of the eighties were decent papers.
Ryan Bailey: Sure?
Annatasha: And they had big numbers, right?
Ryan Bailey: Sure?
Annatasha: Like they had strong statistical power. They were validated in the sense that they were repeatable. And then what happened is after 15 to 20 years of this,
Annatasha: the papers were basically became a wash because the clinical experience was driving the fact that these were the wrong decisions, even though the papers were valid.
Annatasha: And I think that's something also need to be careful about too, is just because you have good numbers and good statistics. I mean, there isn't actually a book that is called how to lie with statistics, right?
Ryan Bailey: Right. Sure.
Annatasha: And if you know what you're doing enough with statistics, you can tell any story you want and you can make it look credible.
Ryan Bailey: Yeah.
Ryan Bailey: Sure.
Annatasha: But I'm, you know, I have a concern with following the literature at face value because this happens, right? Because you can publish and get a meaningful result and it doesn't align clinically with what's going on.
Ryan Bailey: But clinically, how do you know?
Annatasha: Right.
Ryan Bailey: Like, guess like, okay, so fine. They told them to flood the patients and then now we're on dry patients. And then you say like statistically, the paper showed that like these were the benefits and they had objective outcomes that they measured and then statistically analyzed, et cetera, et cetera.
Ryan Bailey: But you're now saying clinically these patients are doing better even though we're ignoring the literature, but better by what?
Gianluca Bini: Thank you.
Ryan Bailey: Like how are they doing better?
Annatasha: Well, we're not ignoring the literature.
Ryan Bailey: And then-
Annatasha: We're ignoring the earlier literature for newer literature that actually shows the outcomes related to morbidity and mortality and like the list of adversities, right?
Ryan Bailey: Sure, sure, sure.
Annatasha: So for example, like just as an example would be woundy hysterics.
Ryan Bailey: But at one point you said that clinically we're doing something in spite of what the literature is saying. That's where, like, where is this definition coming from?
Ryan Bailey: And like, as a scientist, isn't our job to like take ourselves and our opinions out of it a little bit and like bring some objective quality to the decisions making?
Annatasha: Well, see, Kaylee, that's probably where you and I differ, right? Because that's where I know that, quote, what we call clinical experiential knowledge is meant to be the lowest form.
Ryan Bailey: Yeah.
Ryan Bailey: Right.
Annatasha: But at the same time, too, I would rather be anesthetized by somebody who has done it 60,000 times than by somebody who's done it six times, but they know the literature inside out and they're following it.
Annatasha: And that's my preference, right?
Ryan Bailey: Right.
Annatasha: Because there's no way that the literature carries the capacity to be able to troubleshoot all the things that happen simultaneously.
Gianluca Bini: Oh, 100%.
Annatasha: The other thing that I also like take beef with in the veterinary literature too, is that like, let's say for example, we're looking at, regurgitation under anesthesia, right?
Ryan Bailey: Right. Okay.
Annatasha: We take six healthy beagles who don't have gut disease or any form of obstruction or trauma.
Gianluca Bini: Thank you.
Annatasha: They have no other issues. They never have heart murmurs. They never have skin disease. They're never on medication. And then we draw these conclusions that say like X about Meropitin or B about metoclopramide or C about famotidine, right?
Annatasha: And then everyone's like, well, this is what you should do. And I'm like, well, you see, I've probably done thousands of foreign bodies. And I'm going to tell you that that's not what you should do. Because these six perfectly healthy beagles who were pre-medded with isoflurane and maintained on isoflurane and recovered without any other analgesia, and they have no comorbidities have no pre-medication and they're perfectly stable.
Ryan Bailey: Right.
Annatasha: And I'm like, I really struggle to transcribe that context into what's happening in front of me in a patient who is totally destabilized with multiple comorbidities.
Ryan Bailey: Right.
Annatasha: And that doesn't exist in their literature.
Ryan Bailey: But can't we walk into gum?
Gianluca Bini: Yeah.
Annatasha: It doesn't exist in our literature, right?
Ryan Bailey: Or can't we walk into gum? Like, can we use the research that we're seeing, use that to help us inform our clinical decisions, use our clinical intuition and the clinical, like all the guidelines of what we've done clinically to help take that research in, decide what's good, decide what's maybe not worth pursuing, then make a on that.
Annatasha: Well, to your point then, Bailey, that's your whole point is that aren't we trying to remove subjectivity as scientists? Well, then there is some degree of subjectivity in terms of the individual then interpreting which papers are good and which papers are bad.
Ryan Bailey: Sure, but that's inherent.
Gianluca Bini: Yeah.
Ryan Bailey: Like, that's an inherent issue of, like, reading papers is, like, you can read a paper. The paper can be good and have a clear outcome, and you can take totally different message from the way the paper was written, and you can use that paper to either confirm or deny the bias you have when you go into reading that paper.
Annatasha: I also just want to be clear.
Ryan Bailey: Sure.
Annatasha: I don't take the literature and just like light it on fire and run around naked going boop, boop, boop with like pickles coming out of my ears, right? Like, I mean, read it, I review it, I participate in reviews, I published.
Annatasha: It's not my passion.
Ryan Bailey: I
Annatasha: I'm aware of what's going on in the updated research and also within like the relevant factions, but I am not the person who follows it to the letter. And that's, you know, like, I think it has its place.
Annatasha: So I agree with you. Yeah, I think You know, the literature, it's a great place to start discussions about, you know, clinical things and what have you. Clinical things, that was very technical.
Annatasha: Clinical things, guys.
Ryan Bailey: guess so
Annatasha: But at the same time, too, I just, I hate when people tell me, they say some dumb shit and they go, well, it was in a paper, you know?
Ryan Bailey: Well, I hate when people are like, you know what worked for years? Fucking this and that. And I'm like, you know what else worked for fucking years? Ether. And people made a lot of good clinical decisions when they use fucking ether.
Ryan Bailey: And then we did a bunch of research. You're like, hey, you know what? Maybe we should stop fucking using ether. But like those people have been doing it for a long time and they probably have really good clinical decision making with fucking ether.
Gianluca Bini: That's true.
Gianluca Bini: The other...
Ryan Bailey: So no, I don't want to be anesthetized by the person who's not up to date on the literature, but has done 20,000 cases because who knows what the fuck they're fucking doing.
Annatasha: I mean, if they're really good with ether and they're like catastrophic with desflurine, I'd probably like, if it was push comes to shove, I'd be like, fuck, let's rock with the ether.
Ryan Bailey: Yeah, no way.
Gianluca Bini: But besides this, other point is that sometimes the literature is just
Ryan Bailey: Okay.
Gianluca Bini: made up, right? Like technically, right?
Ryan Bailey: Sure. And that's big issue.
Gianluca Bini: Like if you look at all the literature, the body of literature that we had on like starches from the human literature, right? Like, you know, all you know, synthetic colloids, right?
Annatasha: Oh yeah.
Gianluca Bini: Like they made it seem like it was this amazing And then, you know, how many like dozens of papers got retracted once somebody that repeated the same fucking studies,
Gianluca Bini: figured out that was all BS, right? Which because we don't repeat those studies in that mad, we'll never find out.
Ryan Bailey: Yeah.
Gianluca Bini: Like if somebody put fucking random numbers in a table and made it look good, God the fuck knows, right?
Ryan Bailey: But people are still using it.
Annatasha: this is interesting. like this conversation because I'm learning about you guys, which is what hill do you want to die on? Beanie's is that the quality of literature is poor.
Annatasha: Bailey's is he wants to mitigate issues associated with subjectivity. And mine is I'm trying to get people to think critically, which is very interesting that the same topic can elicit these different reactions.
Annatasha: I mean, to your point, Beanie too,
Ryan Bailey: Yes.
Annatasha: You know, there's papers, for example, like vitamin C cures colds. And like, how many times has it been published that it does not? And this week I have this massive mucus cold problem and everyone's like, did you take your vitamin C?
Annatasha: And I'm like, oh, please fuck off. And then the same thing with like vaccines cause autism. I mean, that has caused cultural damage at like...
Gianluca Bini: Tylenol, right?
Annatasha: Right.
Gianluca Bini: Tylenol causes autism if you take it during pregnancy, right?
Annatasha: Right.
Gianluca Bini: It says the guy with it.
Ryan Bailey: But now, Taiwan, all the rage in our nations.
Annatasha: And it's like one bad paper, you know, one bad paper can affect people for generations too.
Ryan Bailey: Yeah.
Annatasha: So like I said, yeah, it's a good point, Beanie.
Gianluca Bini: Oh, yeah.
Annatasha: It's a good point. They sometimes just make this shit up and get it published. And if there is no repeatability, then how do you know?
Ryan Bailey: But like, but look at Colloet's album.
Gianluca Bini: Yeah.
Gianluca Bini: I mean, publish or perish, right? Like there is literally crap load of people that they have to publish.
Annatasha: Yeah, reduce.
Ryan Bailey: Yeah.
Gianluca Bini: They have to, like regardless of whether they have a good idea, regardless of whether their study made sense or not, regardless of, there is a push to create content that,
Annatasha: Or they lose their jobs.
Gianluca Bini: whether it's good or not.
Annatasha: think that's a huge problem with the residency projects too, right? Because you can get like well into your project.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Annatasha: But, you know, that's the thing. Like, you can be halfway through or, like, three quarters way through a project and your project is shit.
Annatasha: And, you know, people are going to turn themselves inside and out because you don't simply have the time anymore to do another project. And it has to go to publication.
Gianluca Bini: Yeah.
Annatasha: And whether you publish it in, like... you know, the Journal of Sub-Pacific Medicine, you know, or whatever, it doesn't matter. And, you know, I think, as usual, like the whole system in and of itself is problematic and contributes to the worsening of the problem. But I don't know, it's interesting how, like, Bailey, how do you mitigate it then? So just like, give me an example, right? So like, let's say there's a paper that says,
Annatasha: the analgesic dose of buprenorphine in a cat is at least 0.02 mg per kg, right?
Ryan Bailey: Sure.
Annatasha: And then this particular paper, you know, looked at four to six healthy lab cats with no comorbidities and there was no...
Ryan Bailey: Yeah.
Annatasha: Classic, right? Classic, classic, classic, classic.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: So then you walk away from that and say... this is the, I keep turning my hand just to like gesticulate and keeps thinking I'm giving you guys thumbs up, which I am not.
Gianluca Bini: I didn't want to say anything. I was like, if somebody's watching this, you know.
Annatasha: I know someone's teasing you.
Ryan Bailey: Bartels? Bartels, six cats.
Annatasha: This is like, this is like my thumb. This is like, I should be, I think it was Italian in a former life, right?
Ryan Bailey: I don't have it anymore.
Annatasha: Being like, can't keep my thumb still. But anyway, how do you then choose to go forward? and say, yes, I'm going to use that as my analgesic cutoff?
Ryan Bailey: Yeah.
Annatasha: Or how would you work within that? Like, talk me through this example based on you being a little bit more conservative when it comes to evidence-based medicine than maybe beanie and iron.
Ryan Bailey: Once you say, think it's more the opposite. You tend to be more conservative towards evidence-based medicine and rely more on your clinical approach, whereas I tend to be more like...
Annatasha: Sorry, I meant conservative in the sense that I'm conservative, you're conservative in the sense that you like to follow it really closely.
Ryan Bailey: Oh, I don't know if I would say that.
Gianluca Bini: religiously.
Ryan Bailey: I like to use it to either to inform the decisions I make and try and, you know, take things away from it that I think are going to help improve the patient care that I provide.
Ryan Bailey: Yeah, for sure. So like in your example, if I read a paper that did say buprenorphine was like, okay, and not bad, I would approach it as like, all right, this is a tool in my toolkit.
Annatasha: Yep.
Ryan Bailey: Maybe there will be a time to break it out, but maybe it's not today. But now, let's say, for instance, we have a patient who's getting what I would call a mild to moderately painful procedure where maybe we could get good local regional on board and I could feel confident that whether or not the buprenorphine had good effect...
Ryan Bailey: And so I'm also going to use some clinical knowledge here in that like cats sometimes can get a little bit better sedation quality with buprenorphine as compared to other pure mu agonists. So like maybe in those situations, I might use the buprenorphine to get the better quality sedation from the drug in this mild to moderately painful procedure and see how the patient does under anesthesia in my care? Am I wishing I had more options during this procedure? Am I seeing more? I mean, it's a cat, so like the sympathetic activation is like a whole different discussion and kind of outside the
Ryan Bailey: the topic here but that might be how i approach like that specific example because that that is an example that i have dealt with clinically all the time of like you get the cat who has ureteral obstruction he's been on buprenorphine all day long for multiple days and oh now by the way he needs a cystotomy because we just diagnosed him with a stone that we missed you know earlier in the in the week and so now he needs to go to surgery but he's been on he's been doped up on buprenorphine for like days on end So like our PMU agonists are probably not going to work as well. And so that might be another case where if I read this paper, I say, hmm, you know what?
Ryan Bailey: I can do this and I cannot, you know, beat up the other clinicians saying like, you should have looked at this, you should have done this, you should have done that, whatever. And feel confident that like, maybe I'm not doing a disservice to my patient and think like that this is not an adequate solution.
Ryan Bailey: drug to give them. So, you know, using opportunistic cases where like it's already going to be kind of in line with the treatment that we're doing would be approach that I would take to the specific example you're giving.
Annatasha: Wow, Bailey, that was like, you missed your calling as a politician or as a Miss Universe candidate. Okay, no, I was just curious, like, like how you choose to mitigate that.
Ryan Bailey: I mean, I can tell you how papers have...
Annatasha: Like when you when you did that, so in this specific example, so buprenorphine, analgesic thresholds, CATS.
Ryan Bailey: Yeah. Yeah.
Annatasha: would you then take pause and think, well, you know, it's only six cats and they're pretty healthy and they weren't actually like, I mean, there's a big difference between shattered pelvis and like a toe pinch, in my opinion.
Ryan Bailey: Yeah. Yes.
Ryan Bailey: Absolutely.
Annatasha: Yeah.
Ryan Bailey: But conversely, conversely, there a, there is a big difference though, between a toe pinch and a shattered pelvis, because that toe pinch is not going to get a local regional technique that shattered pelvis.
Ryan Bailey: Maybe it is.
Annatasha: Okay.
Ryan Bailey: Disappoint.
Annatasha: But yeah, I just, I don't know, like, know, like, you know, cause I would be like, okay, well that shitty paper with, you know, four healthy cats who had nothing going on and blah, blah, blah, blah.
Ryan Bailey: Disappoint.
Annatasha: You know, this was the analgesic threshold cut up. Well, okay.
Ryan Bailey: Sure.
Annatasha: you know, but how many times have I seen cats do well non-point at one and how many times have I seen cats do 0.03 or do I actually really want to use a full immune agonist type thing or do I not need any of that can I switch over to for example butorphanol which in IMO is a great sedative.
Ryan Bailey: Yeah. Sure.
Ryan Bailey: Right.
Annatasha: And then, for example, use my local regional neuro axial blah, blah, blah.
Ryan Bailey: Sure.
Ryan Bailey: Yeah.
Annatasha: But I don't know, like, do you ever take, like, do you take that moment's pause to sort of think whether or not is this paper piece of shit?
Ryan Bailey: Oh, all the time. Like when I read a paper, I like review the method.
Annatasha: I mean, you've talked me through some of the papers that you've been trying to review to get my opinion too. And you're like, I need to reject this Bartel. And I'm like, 100% you do. And you're like, but I can't really reject it.
Ryan Bailey: Yeah.
Annatasha: So now it's like you and I are like scrambling behind the scenes trying to help these people like make their paper worthwhile for like, you know, what's the alfaxilone dose and the Argentinian skunk or whatever.
Ryan Bailey: Sure.
Annatasha: But, yeah, like I know, I'm just curious.
Ryan Bailey: I mean...
Annatasha: Because a lot of times, like people quote me papers, and I'm like, what paper is that?
Ryan Bailey: And so,
Annatasha: And I'll be like, yeah, that paper is garbage. And this is why.
Ryan Bailey: sure. I mean, like every paper, like when I read a paper and like, you know, it depends on the week, the month, the year, how much I'm up to date on delivery.
Annatasha: Yeah.
Ryan Bailey: I can't say I'm super up to date as of right now. Like, I don't know the last, I can't say the last paper can, that I read off the top of my head. So like, that's on me, you know, I should be reading more. But like, sometimes you read a paper, like,
Ryan Bailey: There's a great paper that I read about the effects of opioids and sympathetic toe or it was about the effects of drugs, sedating cats and MAC reduction.
Ryan Bailey: it was combining like a bunch of oral sedatives as well as opioids to see like the MAC reduction they got in these cats. But there was a granule in that paper about the sympathetic activation cats, which
Annatasha: Which is your favorite anesthesia topic.
Annatasha: Like nobody gets more excited about sympathetic tone in cats than Ryan Bailey is.
Ryan Bailey: Oh, I know. And you know what? I can say went into that paper and that confirmed a clinical intuition that I had and probably confirmed bias as well. So like I probably went in with the bias of like cats do this under anesthesia. This confirms it. I was right. Blah, blah, blah. They had citations, you know, to read about that. So like.
Ryan Bailey: yeah, like, I'm not, I'm not saying I'm not prone to bias, for sure. But like, we can take different things out of the papers as well that may not be associated with like, the materials and methods, you know, so like, that's
Annatasha: Yeah. I mean, I usually just use the papers to substantiate my own opinions.
Ryan Bailey: Yeah, for sure. think that's so much of what we do. And I think it's also important to like,
Annatasha: I'm kidding, by the way, but I do think that that is an easy thing to lapse into. And I think a lot of people manipulate paper outcomes to do that, right? They're doing it in the wrong way, right?
Annatasha: They're like, they've been doing this clinically or they were taught this, right? And then they go and find the papers that enforce this or enhance this.
Ryan Bailey: Right.
Annatasha: Now, Beanie, have you ever bumped into somebody... This is one of the things where I'm just like... I just like little birds tweet in circles around my head when this happens.
Annatasha: But there are few things in our body of literature where it has been studied over generations and generations, but maybe over like 10 to 15 years.
Annatasha: And different people, different schools, but sort of the concept is the same.
Gianluca Bini: Sure.
Annatasha: And I've seen this happen where the outcome has been substantiated in a repeatable fashion. And then you get this one random standalone paper out of the group. So let's say there's 22 papers on this one topic and one paper's kind of wishy-washy.
Annatasha: And then you bump into these people whose practice is like they hang their hat on the wishy-washy paper, right? So like one of my biggest pet peeves is like this single dose of pre-anesthetic metaclopramide, right?
Annatasha: Like stop, just stop it, right?
Ryan Bailey: Sir?
Annatasha: And I don't know how many papers we have to put out that say that that a total waste of time in terms of like trying to mitigate
Gianluca Bini: Yeah.
Annatasha: And it still goes on. Like there are still actual veterinary schools. They are training this as part of a standardized protocol.
Gianluca Bini: Oh, I know.
Annatasha: And I'm just like, why are we still doing, like how many papers need to come out, you know, before we stop doing this? And then I'm just, I don't get
Gianluca Bini: You know, so, and Part of this, think it's also like that people really wanna hang to something that, regurgitation is a great example, right? There is no drug that has ever been demonstrated that actually works for regurgitation. It can't because it's a fucking passive process, right? If you think about it, it makes sense that nothing would actually work.
Gianluca Bini: And then somebody wants to try to, you know, you know, make themselves feel better try and they have to find something, do something so that they can feel better that they did something about it. Right. And, and, and, you know, when somebody has, you know, we, I'm not going to lie to you. We have clients that do it.
Gianluca Bini: We do tell them that it doesn't work. You still want to do it. I don't care. Let's do it. Like, you know, it makes you feel better, it. No big deal. Right.
Gianluca Bini: it's usually those areas that there is no actual real solution to it.
Annatasha: And
Gianluca Bini: you know, and, But then funny enough, going off a tangent on this, I
Gianluca Bini: think of all the clinics that we onboard, think that probably half of them, before using us, they didn't have a way to suction their patients.
Annatasha: Mm-hmm.
Gianluca Bini: which actually the only thing that if you actually want to do something about regurgitation, you should be doing.
Ryan Bailey: Yeah.
Gianluca Bini: Suction before extubation. Just remove it or have a way to fix it if regurgitation does occur. But then they may give the serenia to every single patient. They give the onanzitrone. Some people even give metacrobamide or whatnot.
Gianluca Bini: It's funny, but...
Annatasha: Interesting. So you think it's because it's like an emotional bandaid, Bailey.
Gianluca Bini: Oh, yeah, absolutely.
Annatasha: And I'm not disagreeing with you or discrediting you.
Gianluca Bini: It's perfect.
Annatasha: I do think that there is one of those things that's like, you don't know what to do or, or there is no specific, you know, therapeutic that isn't going to mitigate something, but you feel like, you know, that there's a risk that you have to do something.
Annatasha: And yeah, I get it.
Gianluca Bini: How many clinics?
Annatasha: get it.
Gianluca Bini: How many clinics, Ryan, have you seen? that use olfaxolone for every single patient, even though there is zero evidence that olfaxolone is any better than propofol, or that they strongly prefer olfaxolone over propofol,
Ryan Bailey: that only use Elfaxlon? Oh, I don't know. Oh, yeah. There's...
Annatasha: Or they strongly prefer alfaxilon in cats over dogs because alfaxilon really better in cats.
Ryan Bailey: Hey, that's me.
Gianluca Bini: or if anything,
Ryan Bailey: And you know what that's based on? You know what that's based on, Bartell? That's based on my clinical experience.
Annatasha: Yeah, I know.
Ryan Bailey: That's based on me.
Ryan Bailey: That's based on my hand. That's not based on literature. That's based on the drugs in my hand and what I see and me relying on my own clinical knowledge or whatever.
Ryan Bailey: So, like,
Annatasha: With you, I trust because you're smart and you're educated and you're qualified. But there's that whole thing about alfaxalone being better in cats. And that's not a Bailey thing. That's like a total urban legend thing that goes around.
Annatasha: Like I'll have people be like, I'm not a alfaxalone because that's a cat.
Ryan Bailey: I'm always out there fucking talking.
Annatasha: And I'm like, what are we talking about? Like, did I miss a paper?
Ryan Bailey: Hey, you know, it's probably because I'm out there fucking talking up, being like, out back, slaying cats, baby.
Annatasha: Oh,
Ryan Bailey: And it gets disgusting.
Gianluca Bini: This is like the...
Annatasha: a love-hate relationship over here, gentlemen.
Gianluca Bini: What's this new...
Annatasha: It's a love-hate.
Ryan Bailey: I love it.
Gianluca Bini: Did
Ryan Bailey: I use in my own personal cat when he got all his fucking teeth ripped out. It's great. It was great.
Gianluca Bini: you... Sure. Good for you, Rania.
Ryan Bailey: It was awesome. Beautiful.
Gianluca Bini: Anyway, there is no heavy land.
Annatasha: Why don't you go get your Doppler, Bailey, and comfort yourself? Okay.
Gianluca Bini: There is no evidence about a vaccine.
Ryan Bailey: There.
Gianluca Bini: Anyway, did you hear this new story about small dogs don't get lepto?
Ryan Bailey: No. I feel
Gianluca Bini: Right? So the AVMA had to put out a thing about it, right? There was like, you know, small dogs can't get lepto. Fucking vaccinate them, right?
Gianluca Bini: Like, they had to out...
Ryan Bailey: like they're like the prime suspects.
Gianluca Bini: Huh? Huh?
Annatasha: I wish I had the courage to start this kind of rumor. You know what, like six months before I retire, I'm just gonna like drop a bomb, like something absolutely ridiculous. And I'll give you guys the inside track, but we're gonna see whether it goes viral or not, but yeah.
Ryan Bailey: Wow.
Annatasha: Little dogs can't get lepto. That's hilarious. I love up here in Canada, it's a land of like thaw and snow and thaw and snow.
Gianluca Bini: Yeah, there is a...
Annatasha: So we have like this constant contaminated water table and actually lepto goes up in the winter for us. And I'm just like, everything can get lepto. Everything can get lepto.
Gianluca Bini: Yeah, no shit. But yeah, they may have to put out a post on their social, like trying to like, you know, this is fake. Maybe they should put out a post about alfaxalan and Brebofowl.
Ryan Bailey: I haven't, haven't got it brought enough. I gotta keep, I gotta keep pushing it. You know, I gotta keep fucking saying it. But like, so, so I guess is, is the, the like most pro literature voice on this discussion. Like,
Annatasha: That is not true, Bailey. That is not true. just a little bit more realistic about the quality of the literature.
Gianluca Bini: Thank you.
Ryan Bailey: Sure. not saying that the literature is not bad and there are not issues with it. And I don't read every paper be like, well, I got change my practice now because this fucking one paper came out and said, got to do this or that. Or as some people have pointed out, there are papers that
Annatasha: Has a paper ever done that to you? Have you ever read paper where you were just like, holy shit, I have been wrong for years and I need to do something different? Have you ever had your socks knocked off by a veterinary paper?
Ryan Bailey: by a single paper?
Annatasha: No.
Ryan Bailey: Gosh, I don't, well, I will say there, it's not paper, but there was a poster at AVA. I mean, I'm not gonna say posters are like not bad either, but like at AVA that was like,
Ryan Bailey: showing a model cats who were hypotensive responded faster to norepi than to dopamine. And that knocked my socks off.
Annatasha: Okay, Beanie?
Ryan Bailey: Totally, totally changed my approach.
Gianluca Bini: No. Have I tried something because I found, you know, there is a paper out there? Yeah, I did. Right. But then, you know, mix the evidence or the literature, because don't want to call it evidence, with the clinical practice. I have to say that, you know, I found...
Gianluca Bini: way more interesting things to have my clinical judgment and practice in human literature than in veterinary literature.
Ryan Bailey: Oh, for sure.
Gianluca Bini: Like there is a lot of stuff that people have no fucking clue about in veterinary medicine. Like even anesthesiologists, like there's people that like I remember when I was diving deeper into my brain research and stuff like that, people had never heard the word neurovascular coupling. They didn't know what the fuck it meant.
Gianluca Bini: And even people that have been doing this for 20 years, and there's stuff out there on it for the last 30. The problem that we have in Batman oftentimes is that people don't read human literature.
Gianluca Bini: Nobody, people read Lamb and Jones, they do not read Miller.
Ryan Bailey: Yeah.
Gianluca Bini: That's the problem. We are so focused on, you know how many people I heard that when I cite those papers about
Gianluca Bini: risk of AKI after I put the engine and whatnot, those are human papers. And they're like, yeah, but those are not dogs' kidneys. was like, are you fucking kidding me?
Gianluca Bini: Like, that's totally hiding behind the figure, right? Like, the kidneys are the fucking same, right?
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Maybe there is going to be a little variation on maybe the number is not exactly the same, right? But in reality... probably they work the same way. But we have this bad attitude on reading Vat med stuff and ignoring where the shitload of evidence actually is, which is on the human side.
Ryan Bailey: That paper changed the way practiced, absolutely.
Gianluca Bini: Oh, yeah.
Annatasha: I'm more like, I go like down that rabbit hole, right?
Ryan Bailey: Thank you.
Annatasha: So like, I'll hear something and I'll be like, huh. And then like, where's Bailey has this thing with cats and sympathetic tone and opioids all that kind of stuff. My rabbit hole for sure is dexmedetomedy, right?
Annatasha: And a few years ago, I started reading about dexmedetomedy being used in septic ventilated patients, you know, and various mortality outcomes associated with that. And so then I've been down the rabbit hole for years now about when and where you can use alpha-2 agonists clinically and blah, blah, And this keeps churning out too, right? You know, like the more ECC conferences you go to, the more they're like, you know what, dexmedetomedy you could totally use in the ICU all the time. And I'm like, don't So, you know, what I do is like, if I find something that's interesting, I start to pick away at it.
Annatasha: Now, I'm not going to like hear that and the next day rock up to like some unstable septic patient and be like, hey guys, guess what we're going to do today.
Ryan Bailey: Right.
Annatasha: But I am going to talk to other people who I would consider to be clinical experts, right? So Bailey, did you see the email that came from Hancavara this week about Xenalfa?
Gianluca Bini: Yeah, absolutely.
Annatasha: Right. So I always read his responses, right? Because he is like leading publisher in Alpha 2s, right? In veterinary medicine. It's the Finland group, right? So I'll be like, okay, well, I know you see and like personally and I'm like, I trust him when it comes to like, I would query that maybe more, that two more people in our community have more knowledge about Alpha 2s than he does if that.
Ryan Bailey: Yeah. Right. Yeah. Yeah.
Annatasha: And I save like his little emails and like this little crazy dexamethatomidine file keep like a chipmunk before the winter.
Gianluca Bini: Okay.
Annatasha: You know, and then I start building this case for it. And then I go and then start to become more of a clinical cowboy once I've talked to the people, once I've heard like what their outcomes are like. So I don't have these thunderclap moments in the sense that it's like read the paper and change practice.
Annatasha: But, you know.
Ryan Bailey: Oh yeah.
Annatasha: I'll see these shifts or like these, like you said, like these tiny notes sort of pop up here and there. And then that is what triggers me to then go off over here and then start like mining exists currently or like where people are at what people are talking about at conferences. And then that's how I end up doing these different things.
Ryan Bailey: Yeah. And like the Norapi thing is like, you know, people, John Luca, for example, have been talking up the utility of norepi and I've been like norepi, vasoconstrictor, da da da, but there's that like nice paper in research beagles. I mean, again, this is research, but it's like focused on cardiac output stuff. So like, I think more cardiac output and less SVR.
Ryan Bailey: And so it like, it started to build in that, like that paper is, is, you know, like probably 2017 or something like that. And like maybe 2022, I don't know.
Ryan Bailey: And then, you know, I hear people are using it.
Gianluca Bini: 2021 and 2023. Yeah. Yeah.
Ryan Bailey: as like a first line therapy. And then we have evidence that like maybe works a little faster. And given the time spent in hypotension is an important thing. Like I put it all together and you know, it's the exact same way.
Annatasha: So to wrap up, gentlemen, would you say that in...
Gianluca Bini: But this stuff was, sorry, Tascha, this stuff in human medicine was out 15 years ago.
Annatasha: Sure.
Gianluca Bini: We're not, you know, there is like, you know, Kristen was saying that when they were on the floor, they don't even have dopamine. Like when we were still using fucking dopamine around, they didn't even have it.
Ryan Bailey: Yeah. Yeah. Yeah.
Gianluca Bini: Human cardiovascular issues, right? Like they didn't have it, right? they use Norebi. Like they were 15 years ahead, but the only way you get, you advance dopamine.
Gianluca Bini: rapidly is to read the human stuff. We need to quit the shit of like, oh, that's for humans. It does not apply. fucking does. You don't need to wait 15 years for somebody to repeat.
Annatasha: to be ridiculous, grade 20.
Annatasha: But okay, so question then. So sort of having a general idea of where everyone kind of falls in the evidence-based spectrum and like where we find utility where we find problems. But would you say overall that in the last, like in the duration of your careers, like from the start of training till now, have you,
Annatasha: And I'm hoping the answer is going be yes. Have you changed or modified your practice as you've gained experience and as the literature has changed so that what you were doing now versus 10 years ago, you could actually like notice there's a big differential there?
Annatasha: Yes, no, maybe so?
Gianluca Bini: You mean like, sorry, so you mean like.
Annatasha: So for example, right, like, you know, I used to be way more like aggressive with fluid therapy than I currently am, right?
Gianluca Bini: Hmm.
Gianluca Bini: All
Ryan Bailey: Mm-hmm.
Annatasha: And that is because have stayed like with my finger on the pulse of fluid therapy. Like if there's a talk about it at a conference and like I just came from a conference and I went to the fluid talk and I learned absolutely nothing new and that's totally fine.
Gianluca Bini: right.
Annatasha: But at least I know where we are in terms of fluid therapy and like what the actual pulse of the situation is. And that's why do that. So, you know, how I, you know, would have treated hypovolemia or hypotension 15 years ago is really different to how I treat now.
Annatasha: how I utilize opioids is different. How I practice max sparing is different. My comfort level, obviously with alpha twos and my crazy chipmunk brain is different.
Annatasha: So, you know, if you had been my RVT this entire time, and I've now worked with some RVTs for, you know, 10 or 12 years consecutively, they can tell that how much I have changed.
Annatasha: And I've actually ended up on the flip side of the coin on certain topics, not because I'm indecisive or I'm capricious, but just because it's actually the evidence, both my own and what's published, that's driving me to be better, I hope.
Ryan Bailey: Yeah. I mean,
Annatasha: Do you guys like, is everything that you do is the same thing that you did when you were interns or do you do things differently?
Gianluca Bini: No, absolutely not. No, no, no. Stuff has changed and you need to open-minded and change with the times and with what comes out. And I think, again, as Ryan was saying, you need to have multiple bodies of evidence that say that, you know,
Gianluca Bini: Probably we should do something different and then you change. And then, you know, yes, you need to try it in the clinical setting, do right. Like it's something that, you know, even though you have papers that tell you that, you know, had the starch worked amazingly.
Gianluca Bini: If when you go clinically, half of the patient you give it to end up in a KI, then, you know, maybe you ask yourself couple of questions, right. So, you
Ryan Bailey: Yeah.
Annatasha: I've been giving all my patients Meropitin for years and everybody still regurgitates.
Ryan Bailey: Oh my God.
Gianluca Bini: Yeah, no shit, right?
Annatasha: No shit.
Ryan Bailey: Who the guys? I mean, I'm like, next year will be 10 years out of residency.
Gianluca Bini: Yeah, yeah.
Ryan Bailey: So like, I can tell you, there's a bunch of stuff that has changed. And like, I'm sure if any of the technicians who I used to work with are listening to this podcast and are like, why did you do this or that? Like, you don't do that anymore. You did this back then. Why don't you do that now? Like fluids is another one.
Ryan Bailey: 10 years ago, everything just hose them down, you know, just like blast.
Annatasha: Yeah. As fast as we can go, right?
Ryan Bailey: Yeah, get shit in there.
Annatasha: Like,
Gianluca Bini: Yeah.
Ryan Bailey: And now like,
Annatasha: and now it's like, let's all simmer down with fluids.
Ryan Bailey: Yeah, like unless they're coming in hypovolemic and they weren't corrected before they were in my hands, they're going straight to a processor most likely because like there's not a lot of evidence for that to work.
Ryan Bailey: There is the whole delay in treatment of hypotension. And if you're dicking around with that fluid bolus for 10, 20 minutes, hoping to eat some effect out in a patient who's probably not going to be a responder like you're doing your patient a disservice so like to all those technicians who i said why aren't you giving you a fluid bowl before you're starting the presser i'm sorry i've grown i've learned science has changed we're all learning like yeah like when i was a student you know like even going back 20 years now everything was still getting like flat 10 mils per kg
Annatasha: remember when it was 10 to 20, right?
Annatasha: And it was 10 if you were normal and it was 20 if you were maybe like a little hyposis. My vet school rates were 10 to 20 mils per kg per hour for sure. And that includes cats, which is like, makes me very uncomfortable to say out loud.
Ryan Bailey: Yeah, that makes me so anxious.
Gianluca Bini: That's crazy.
Annatasha: Yeah.
Gianluca Bini: That's crazy.
Annatasha: Yeah. No, but
Gianluca Bini: Did you give a shot of Lasix in recovery to everybody? I'll tell you about it.
Ryan Bailey: No, that was part the pre-mat. That was to help the Rieger and Shell Luke.
Annatasha: Listen, I'll tell you this. I'll tell you this. When I was in vet school, furosemide got batted around a hell of a lot more. And I can't even remember the last time I gave a dose of Lasix to a clinical patient.
Ryan Bailey: Oh my gosh, yeah.
Annatasha: Yeah.
Gianluca Bini: Wow,
Ryan Bailey: Yeah.
Gianluca Bini: this was a good talk.
Annatasha: Well, guys, that was pretty cool.
Ryan Bailey: Yeah?
Gianluca Bini: Good talk, good talk. All right, you guys have a good night.
Annatasha: Peace out, everybody.
Ryan Bailey: Bye.
Gianluca Bini: Bye.
