Transcript
Gianluca Bini: All right. I guess tonight it's my turn to ask the random question. So I think everybody's been talking about this. Do you have, you know, there is a huge hype about, you know, the new pre-med that the GV20,
Gianluca Bini: you know,
Annatasha: Bailey's reaction was pricey.
Gianluca Bini: Ryan doesn't even count, right? Like, he used to use his fucking ass promoting. So he...
Ryan Bailey: Exactly. Thank
Annatasha: wrong with A's promazine, Gianluca? It's great incentive.
Ryan Bailey: you so much, Tasha.
Gianluca Bini: Fucking...
Ryan Bailey: God.
Annatasha: It's underutilized in cats where it really smooths out the psycho for a few hours. Like, don't test A's promazine.
Ryan Bailey: Anti-emetic, long-lasting.
Gianluca Bini: What What is...
Annatasha: Just because a incentive. Just because something's from the end of the 20th century like Bailey and I are doesn't make it useless.
Ryan Bailey: Exactly.
Gianluca Bini: What's your guys' take on that? I don't think anybody knows really how that works. Why it have such a fast effect of action?
Ryan Bailey: Yeah.
Annatasha: Well, it's on an acupuncture meridian, right? So that's, it's in one of your meridians or your chi channels. In terms of the physiological effect, I mean, that area has low fat, low musculature and is vascularized well. So that could explain the uptake.
Annatasha: Yeah, but no,
Gianluca Bini: Do you use it?
Annatasha: no.
Gianluca Bini: Why? The next question is why?
Ryan Bailey: Okay, so is there evidence for it? Like, is there evidence that actually works faster or better?
Gianluca Bini: I've seen it work like this. Now, is the publish evidence?
Ryan Bailey: I'm not talking about anecdotal because anecdotal is crap and we know that.
Gianluca Bini: Okay.
Annatasha: I mean, there is paucity of literature.
Ryan Bailey: love that.
Annatasha: Okay.
Ryan Bailey: They were abstracts.
Gianluca Bini: So is that published or is it an abstract? Because if it's published in a state...
Ryan Bailey: think one of them might be. I'm actually in my reference finder right now to see if it did get published because...
Gianluca Bini: Wow.
Ryan Bailey: I remember it was all, but I mean, it will be published, right? Because, no, I guess the producers don't publish the abstracts do.
Gianluca Bini: Maybe. Maybe.
Ryan Bailey: These are posts.
Annatasha: Let's just go to Tasha's summary, which is despite the WCVA, there's still a paucity of literature, even in a veterinary paper context, which means it's a double paucity from normal people.
Annatasha: And there's still a lot of research and verification even clinical outcomes to evaluate. And of course, don't forget the whole phenomenon of human-based confirmation bias, which is I think it has faster uptake because I wanted to have faster uptake because it's the new and cool kit on the block.
Annatasha: And so, you know, I'm never the first person, like for the most part, I'm not the first person to do stuff. Like I like to sit back for a bit and see how things pan out. But I guess my point about this particular injection site is,
Annatasha: does it, you know, the core of it is, does it confer an advantage? And then in the face of this advantage what are the welfare implications to the patient? I mean, if I went to the dentist and you injected me square in the middle of my face, I don't know. I'm not sure. I mean, but like I said, I said this in a conference recently where I was lecturing. was like, I mean, I also get Botox, so I'm maybe not the right person to ask. But yeah, I really like just, I don't know, like injecting something in the middle of its head over putting it into the triceps the back musculature.
Annatasha: what is so special about it that I'm missing out on?
Gianluca Bini: Yeah, I think that's what people you know, I think that people are mistreating like faster for better.
Annatasha: True.
Gianluca Bini: Right?
Ryan Bailey: Yeah.
Gianluca Bini: Right? So like faster doesn't necessarily mean better. Right? Also like, you know, sticking a needle in a, you know, patient head may or may not be, you know, you may may not get bitten.
Annatasha: Brownie in her forehead with a needle, that's the last time you'll ever use that hand. So protection
Gianluca Bini: You know? So it depends on, you
Annatasha: is also, I'm sure, part of it, you know.
Ryan Bailey: that's that's where i come from is like it's a lot easier to approach a patient who is like in the patient population we're talking about who's going to be these like great gv20 things are probably not the most friendly patients not patients you want to go near the biting ends if you will so i like as possible.
Ryan Bailey: And in a patient who's fractious, like maybe they decide to jump as you go for their GV20 and you get them in the eye. That's probably not going to work so great for everyone involved.
Annatasha: That's like the most grandpa statement. And then you get them in the eye. Like you sound like your Christmas story.
Ryan Bailey: Like,
Annatasha: Like don't shit out your eye.
Ryan Bailey: Like, you know, like, I think it works just fine to, you know, inject the epaxiols or even the quadriceps, you know, if they tolerate that or whatever.
Annatasha: I have more concern about the back leg injection, which is supposed to be faster than the back because 98% of the time I watch people do that injection and almost guaranteed they are coming millimeters within the sciatic.
Ryan Bailey: I mean...
Annatasha: Every single time I watch this happen, I'm like, you're about to hit the sciatic and then they just inject anyway. And I'm like, okay.
Ryan Bailey: And it's like, am I struggling with a pack seal sedation? Absolutely not. Not in my practice.
Annatasha: Right.
Ryan Bailey: Like, works just fine.
Annatasha: Right.
Ryan Bailey: 90% of the time works every time.
Annatasha: Yeah, I like for me, like the back is a nice place because then you've got a really safe hold on restraint for the patient. It's a large area where you have to really make a concerted effort to goof that up and go somewhere where you shouldn't be. Yeah.
Annatasha: And, you know, I don't mind the back leg, but I go into the quadriceps.
Ryan Bailey: mean,
Gianluca Bini: Bye.
Annatasha: I don't go in through the hamstrings, which I see a lot of people do because they're like, I keep hearing people be like, I go through the back of the leg to avoid the sciatic. And I'm like, that's one of the actual approaches to the sciatic. So, yeah, I have no issue with the back.
Annatasha: And like I said, what does a shot into the face confer to me clinically or practically that you know, I should be changing practice. For me, it's too early in the situation to call.
Annatasha: And honestly, I don't have enough time on clinics anymore to be the person driving that like bulk of evidence.
Ryan Bailey: Yeah.
Annatasha: So
Ryan Bailey: I also think it's, to me, it's harmless as long as you can do it safely. think it's just another way to go about it. But at the same time, my big concern is, so is GV20, like, okay, so first of all, I'm going to say, like, I am not anti-acupuncture. I think it has merits. I think it has a place. I think there's a way in which it works that we don't fully understand.
Ryan Bailey: That being said, think, I think this GV20 to me falls more into sub-Q sedation. And you know what? Sub-Q sedation fucking works. Like you can do it.
Ryan Bailey: It's going to be a little more pain in your ass. Your absorption is going to be bit more variable. Your onset is going to be a bit slower, but you can sedate things sub-Q just fine as long as you know what you're doing.
Ryan Bailey: So like in some of the, in some of the poster presentations, they sedated these cats. they use like 20 to 40 micrograms per kilo of dexamethatomine. So like they sure as shit got today and sure as shit happened quickly.
Gianluca Bini: Yeah.
Annatasha: Why do I need it to happen within two minutes anyway? Like, why do I want things to drop right over? Like,
Ryan Bailey: Well, so that actually is like a good point from us, the anesthesiologists who are like, our day happened.
Gianluca Bini: Yeah.
Annatasha: I don't like it when things just fall off needles as a general rule. It really relaxes my internal sphincters when you inject something something just keels over.
Ryan Bailey: I'm not saying need it.
Annatasha: Like, I don't love that. Yeah.
Ryan Bailey: I think in busier practices though, some people feel as if they don't have the time, like they're now so focused becomes this patient and until it's sedated and anesthetized, they can't work with it. And so that creates like this, I like, I'm not saying that.
Annatasha: Oh, they're just bad at time management, Bailey. They're just bad at time management, not sedation.
Ryan Bailey: Well, yes, I agree, but they view it as like, well, this dog won't get sedated or this cat is recalcitrant.
Annatasha: Is that what they shout out in their fit of rage is recalcitrant?
Gianluca Bini: Yeah.
Annatasha: I doubt that. You would.
Ryan Bailey: I mean, I would for sure.
Annatasha: You weird old grandpa, you would be like, we're going to get shot in the eye if this is recalcitrant. But yeah,
Ryan Bailey: Just another little random anecdote. One time, just speaking of IM injections, Carolyn had to get vaccine for tetanus, I believe, because our cat bit her hellishly in the hand because she's
Annatasha: Because Lucy is a psycho.
Ryan Bailey: But see, it is a psycho straight up.
Annatasha: Yeah.
Ryan Bailey: And so she had a vaccine for tetanus because she hadn't had it in a while because she's an adult. And they were like, like, where do you want it? And she was like, what do you mean? And he was like, well, you could have in your arm or like your thigh. And she's like, I don't know, maybe that thigh like why? And he's like, yeah, some people think it hurts less.
Ryan Bailey: And Like before Carol could really even like pull up her pant leg or whatever she was wearing, the guy fucking like blasted her in the thigh. And she was like, okay, that was fine. No big deal. So like, again, thinking about these big muscle groups like the epaxial, was like, dogs get bit by, you know, teeth that are much bigger than our stupid little tiny needles.
Annatasha: I mean, I will tell a side anecdote as a kid, like this is the early 80s just to qualify. So, you know, the late 1900s as it were. And we received like a routine childhood vaccination. I'd have to ask my parents which one it was, but I remember that at that point they had switched the protocol from the upper arm to the thigh, like, cause it was a school-based vaccination. All you anti-vaxxers, calm down. This is Canada.
Annatasha: But anyway, and we ended up with a neuritis, despite the fact they went in the quadriceps.
Annatasha: And I remember being like incapacitated for at least a week, if not longer.
Ryan Bailey: Are
Annatasha: And my sister was as well. And having numerous children, it was like this whole adverse injection site vaccination.
Ryan Bailey: you talking about the polio vaccine?
Annatasha: Like I said, I would have to go and ask my parents which one it was. But it was like, you know, like we had, I remember in the first couple of days, like you to get, mom would be on the sofa in bed and like she'd carry me to the bathroom and cause I just couldn't use that leg at all.
Gianluca Bini: And that's how you become an anti-vaxxer.
Annatasha: And listen, after the reaction I had to Moderna, that almost killed me.
Ryan Bailey: Oh my God.
Annatasha: still, oh, Moderna.
Gianluca Bini: I'm surprised you're still not an anti-vaxxer.
Annatasha: Yep.
Gianluca Bini: Nice.
Annatasha: Moderna almost killed me. I'm sorry, Moderna. I did report it as an official adverse event, but I'm still, I'm still, you know, I still, you know, I still get vaccinated with my regular routine for veterinarian for rabies and tetanus and I travel everywhere.
Ryan Bailey: Oh, smart.
Annatasha: So I get vaccinated for thrilling things like cholera and typhoid because I don't want die like a Somerset mom novel. Anyway, so the point is, is yeah, I, you know, I, I, this GV 20 situation and just to be clear, I'm a big, proponent of eastern-based medicine i mean they got 3 000 years of practice on our 150 and i also practice tai chi so i'm familiar with like the chi flowing through my meridians and things like that but i also understand human-based psychology from the point of view of placebo and i also don't understand and i don't know if this anesthesiology or does this happen to the other specialties but like
Annatasha: just like, like, it's like Elvis Presley crazy over anything new that ever happens. And I'm like, is our baseline of boredom so strong that like the tiniest like winds of change make everyone go completely mental and lose total perspective. But I'm always like, you know, one little thing comes out and all of a sudden that's the only thing we can talk about at conferences. And it's, and it's, everyone is doing it and oh my God, it's so much better. And I'm always like,
Annatasha: nothing has happened. Like subcuketamine is another example, right? Like now it, you know.
Gianluca Bini: I'm still waiting for the evidence.
Ryan Bailey: Where is it?
Annatasha: Yeah. And now I'm watching as like all these stuff coming out about like things are being over gabapentin and how they're actually improving things like they're mobility and their day-to-day mentation after you actually put them in GABA pension withdrawal. And it's just like people that are so, I don't know, impatient or they get so impetuous. I don't know what it is. I'm not a psychologist, obviously, but there's something in veterinary anesthesia where like one little thing happens and everyone just goes bananas about it. And you're just like, when did the rigorous process of scientific validation get tossed out the window?
Annatasha: don't know.
Ryan Bailey: I mean, at the same time, though, like it has to come from somewhere, right? Like we have to start, like we have to continue to try new things, advance the science, advance the medicine, et cetera, et cetera. But I do think, think there are always going to be early adopters. There's going to be someone, and this, maybe GV20 is going to be right. And maybe we're going to all change our tunes in five years when the evidence comes out. And like,
Ryan Bailey: papers, you know, theoretically with open access should be coming out sooner or whatever. I'm not like, I'll be honest, I'm not the most smart about all that journal stuff. I'm not gonna lie. But like, theoretically, papers should be, you know, coming out reasonably quickly, at least being able, like accessible online with kind of like print subscriptions being not as big a deal.
Gianluca Bini: Yeah. I mean, yeah.
Ryan Bailey: Just because you did on a cadaver and proved that it worked on the cadaver, you don't know that it's safe for the patient. To from... like the theoretical nerve block concept in, you know, taking from the human side, adapting it to the dog and then putting it in a live model takes, there's a whole process to go through and like GV 20 theoretically could speed run the process because we know, know, it's essentially a sub Q injection with like a little bit of a twist, if you will.
Gianluca Bini: Thank
Annatasha: Yeah.
Ryan Bailey: I'd love to see the evidence. I am willing to change my practice. I have changed my practice since I started residency to finishing residency to I've been out of residency, I don't know, eight, nine years almost. And I've changed my practice in multiple different ways based on evidence, based on things I read, based on conversations I have, and then going back and reading what people did.
Annatasha: I mean, and like, you know, you're not wrong, Bailey. You know, someone does have to push the envelope and maybe, you know, ruffle some feathers. And I, you know, that's not necessarily me clinically, but, you know, I'm happy that those people do it.
Annatasha: And I also, you know, I always say like, it's so hard in veterinary medicine where you get like one or two papers and it's like there's six cats in the and the six cats are healthy.
Gianluca Bini: Now it's
Ryan Bailey: Hey, hey, now, they are doing power analyses in most of the papers that I read nowadays.
Ryan Bailey: Like they, we have come a long way from six research cats.
Annatasha: No, we haven't. And-
Gianluca Bini: at 8.
Annatasha: No, we haven't. And you get these, you know, like 12 healthy beagles from the research population. And then, you know, like we tested pantoprazole versus famotidine while they were awake. And then all a sudden we make large extrapolations about efficacy in sick anesthetized patients.
Annatasha: And so know how we feel about the veterinary literature as a body.
Ryan Bailey: That's where the peer.
Annatasha: And like, you know, it's tricky because on the one hand you want the evidence, but on the other hand, the quality of the evidence and the bulk of the evidence is important too. And we just don't generate the data that humans...
Annatasha: human medicine does. But I also say to you know, like we always we joke that you know, clinical evidence is like the bottom of the pile, like it's the sixth lowest form of evidence that you should use in making clinical decisions.
Annatasha: Okay, fine. But I always struggle with the fact that it's like, you know, I've done this 21,000 times. And this paper in four healthy cats is telling me that I'm wrong, right? Like I worry a little bit that sometimes we dispel the art of experience and the art of practice. But then again, like how do you ratify that? How do you objectify that? And I understand that.
Annatasha: So the other thing too is that there's no way that a series of like, you know, three clinical trials or three clinical trials can give you the same kinds of outcomes and data that, for example, something that's gone to market gives you after 40 years, right?
Gianluca Bini: Yeah.
Ryan Bailey: Right.
Annatasha: Right. So, you know, everything does have its place and fits together in the whole picture. But like right now for GV20, it's too early on the teeny weeny spectrum of relevance that, you know, am I going to go in tomorrow and inject everything in its face?
Annatasha: No. Right. Am I open minded that it may become like the preferred route?
Ryan Bailey: Yeah.
Annatasha: 100%.
Ryan Bailey: To my mind, like if we have the right patient, you know, where I think it's something to try sure why not why not see if it works like
Annatasha: It seems to do well in like, you know, those happy go lucky, like dumb, dumb dogs, you know, like a golden retriever. Who's just like, just thinking about like peanut butter and doesn't really care. And you can just like pop the needle right in their forehead.
Annatasha: But like, I'm very recalcitrant about how that's going to go in a cat, especially a fractious cat, especially a fractious cat that requires five people to like, hold it down like a, you know, pot roast that has been lit on fire.
Ryan Bailey: oh my god
Ryan Bailey: Think about putting an e-collar on that. Like, how many times have you seen the cat, the e-collar's coming in, and they just fucking nail it with their teeth? And it is like, now you have the cat, and the e-collar's cutting its mouth, and it can't close its mouth. It's like, like, ah!
Ryan Bailey: And you're like, oh, my God, this is my definition health.
Gianluca Bini: For whoever is listening, please go. You can watch this in the interpretation of the cat stack with the collar on either YouTube or Apple podcast.
Ryan Bailey: Yeah.
Annatasha: That should definitely be the promo clip.
Ryan Bailey: For anyone who doesn't watch, you really should, because I have backed out the whole office.
Gianluca Bini: Yes, that's right there.
Ryan Bailey: We now have the Bears hat here. We've got the Bears hat here.
Gianluca Bini: Is the bears the...
Ryan Bailey: wearing my Williams shirt.
Gianluca Bini: Is it the baseball team of Chicago? The
Ryan Bailey: It is the football
Annatasha: Oh, God. Oh, God.
Ryan Bailey: Bears playoffs.
Gianluca Bini: one?
Ryan Bailey: They just beat the Packers in a thrilling game. man.
Annatasha: up bears it's an american football team not a soccer team
Ryan Bailey: Look at this mustache. Talk about things in the 1980s.
Gianluca Bini: Oh, I only care about the NBA, so sorry.
Ryan Bailey: Ugh.
Annatasha: if uh bailey gained about 250 pounds he would be straight out a guy from like the ditka skits of like the 90s snl like he's the plaid shirt he's got the hat he's got the stash he eats hot dogs
Ryan Bailey: fucking heroes.
Gianluca Bini: Nice.
Ryan Bailey: I had hot dogs this weekend, in fact.
Gianluca Bini: Nice.
Annatasha: We know. We follow you on Instagram and we see you post about all the dogs.
Ryan Bailey: They good as hell.
Gianluca Bini: Yeah. Everybody knows Ryan.
Annatasha: I'm a good friend, so I like it, even though I'm like, don't know what the fuck he's eating, but he is going to die.
Gianluca Bini: Yesterday, actually, I was at the OKC Thunders game and I got this, like, they have this hot dog flight. So it's like, they call it like the big three.
Ryan Bailey: Hell yeah.
Gianluca Bini: The company was like Schwab, I think.
Ryan Bailey: Sure?
Gianluca Bini: Schwab, me.
Annatasha: Like Schwab investments?
Gianluca Bini: I don't know. Whatever. But one was...
Ryan Bailey: They're in hot dogs now. Everyone's getting into hot dogs, all right?
Annatasha: Look, Bailey's never heard of Schwab hot dogs and he thinks he's like the god of hot dog knowledge.
Ryan Bailey: don't need to hear about these fucking non-Chicago-based hot dog brands because they're all shit. Chicago's the only place that makes them a hot dog.
Gianluca Bini: Okay, okay, Ryan. So I had this hot dog. hot dog.
Ryan Bailey: Dang. That sounds good.
Ryan Bailey: hate it.
Gianluca Bini: it was really fucking good. And then there was one where was a chili dog. And then there was like a classic one. I, I never had the brisket one. It was really fucking, I had the chili before.
Ryan Bailey: Yeah.
Gianluca Bini: but the, the brisket one is, was really fucking good.
Ryan Bailey: Both great questions. Sure.
Gianluca Bini: Uh, the classic was okay. Like it was good, but know, nothing special, but the, the brisket was legit.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Really good.
Ryan Bailey: It's just like I Am Sedation. It's the classic for a reason. You know, briskets need to eat toys.
Annatasha: I was so, so waiting for somebody to tie in hot dogs with IM sedation there. And I was just like, and boom, there it is. Because I was like, yeah, the brisket hot dog sounds like, the brisket hot dog is like the GV20 of hot dogs.
Annatasha: But like, you want to go.
Ryan Bailey: It's the Andre thing, but it's got no staying power.
Annatasha: That's right. All right.
Gianluca Bini: Nice. Nice.
Ryan Bailey: Not like the classic Chicago hot dog that we're still fucking eating like almost a hundred years later.
Gianluca Bini: Nice. I love that. Jesus. Yeah.
Gianluca Bini: So,
Ryan Bailey: you...
Annatasha: right.
Ryan Bailey: I think though that...
Annatasha: you supposed to be 20 for this whole podcast are you moving on to another hot topic?
Gianluca Bini: we were moving on if we managed to.
Ryan Bailey: One more thought. One more thought. Are we misinterpreting GV-20 as being successful are we just relearning about subcutaneous administration of drugs?
Ryan Bailey: That's been my big wonder. Are we just relearning that sub-Q is a route you can go? I personally don't love sub-Q because
Ryan Bailey: Right. Oh yeah.
Annatasha: which can be very, you know, esoteric.
Gianluca Bini: Yeah.
Annatasha: but at the same time, that's the real question. Like, is this a magic?
Gianluca Bini: mean, acupuncture does work. Like, you know, I think, I think it does work.
Annatasha: Oh, yeah.
Gianluca Bini: The question is, does it work because of the acupuncture point or does it work because of, you the vascularization and, you know, if we, if they claim that it's faster is real, right.
Gianluca Bini: Which that paper, at the World Congress seems to be disproved, but let's say it's real, then is it because of the vascularization or is it because of the acupuncture point? Nobody knows. So if you were to premed an animal IM, what's your spot? Do you have a preferred muscle group?
Ryan Bailey: Oh, Pax Heels.
Annatasha: Me too.
Gianluca Bini: Your back.
Annatasha: Me too, because I see so much like,
Gianluca Bini: Do you ever use the neck?
Ryan Bailey: Oh.
Annatasha: like if I do pigs or horses, pigs,
Gianluca Bini: Like, so...
Ryan Bailey: Interesting. haven't thought of
Gianluca Bini: I mean, yeah, pigs usually it's behind the ear, right? Because it's the last.
Annatasha: cows, like as a dog and a cat, no, I think the cat is small and vicious.
Gianluca Bini: So in dogs, during my residency, I've done a bunch of...
Ryan Bailey: it. Yeah.
Annatasha: Yeah.
Ryan Bailey: Okay. If I'm too many a cat, I want near the end.
Gianluca Bini: Sorry, go for
Gianluca Bini: Yeah, during my recines, I've done a bunch of doors with like pre-med in the neck.
Ryan Bailey: Yeah. Yeah, yeah.
Gianluca Bini: There were some papers where, you know, the dorsal part of the neck, of course, like not the, you know. But the, mean, let's put a disclaimer in there, right?
Annatasha: The old part. Hey, Richard Jones is a humdinger.
Gianluca Bini: There were some studies then in England, I think, where they looked at different muscle groups and uptake from the different muscles. And it sounded like the fastest were in the coastal, which usually you don't really want to inject there probably. Yeah.
Ryan Bailey: YOLO.
Annatasha: Whoever injects in the intercostal, I'm going to hold you down and inject you in the intercostal. See much you fucking like it.
Ryan Bailey: Yeah.
Annatasha: Let's just put like side note here that intramuscular injection is actually not that comfortable, right? Like it's, it can be quite ouchy.
Ryan Bailey: Yeah.
Annatasha: And when you do it in a place that has like confined boundaries or is like a high degree of sensitivity, like God, I mean, when I used to play rugby, the worst thing was, is like, if you bruised your ribs and like your intercostals, like that's just, ugh.
Annatasha: Just the worst injury. I was like, I'd rather break a finger or a toe or have a concussion. I swear to God, then do that.
Ryan Bailey: Well, long term, don't want to have a good company.
Gianluca Bini: And, but the second must, the second fastest muscle was the, was the neck. And then there was, I think, semi-member noses.
Ryan Bailey: Huh. Yeah.
Gianluca Bini: And then there was the box cells in the end, I think.
Ryan Bailey: Cheryl?
Gianluca Bini: I don't know
Annatasha: You know, the one I actually use a lot and, you'd be surprised like more than I think the average bear is the triceps.
Gianluca Bini: if. Okay.
Annatasha: especially because a lot of times like if we're doing hind limb procedures and i need to top up something like let's say i'm going to do i am diphenhydramine or something that's having a reaction i actually give it the triceps because the triceps has a nice bulk of muscle before you get to that like that radial nerve right and you know in most animals they don't have tricep wasting like you will see for example in like a tpl who's been chronic and they you know like their hind limb musculature
Ryan Bailey: Oh yeah.
Gianluca Bini: That makes sense.
Annatasha: is really poor. So I do use the triceps a lot that one. And like, it's a good one to get to if you're kind of having a little bit of a struggle with the pet as well. And I, you know, whereas Ryan stays right from the biting end, I like to stay away from the poopy end. So,
Ryan Bailey: That's what gloves are for.
Annatasha: well, that's why I went into anesthesia because I'm not interested in bodily fluids.
Ryan Bailey: my God. Yeah. Not at all.
Annatasha: Yeah, I can really walk through dermatology because I'm like, oh, yeah.
Ryan Bailey: I will.
Ryan Bailey: know we're talking more about sedation here, but for I am like the radio is a great, you almost always have access to it in the anesthetized surgical patient or even like the dent, like, well, I guess not the dentistry patient, but like,
Gianluca Bini: Yeah.
Ryan Bailey: You have access that muscle group in a lot of the cases you're going to be running. And so it is really nice accessible spot. So you don't have to like get, first of all, don't want to get out of your chair if you don't have to.
Ryan Bailey: You can access the patient. You can go back to sitting down. don't have to like go finagle into the drapes and move whatever surgical instruments they're going to touch next.
Gianluca Bini: Ryan is a
Gianluca Bini: typical anesthesiologist, right? Doesn't want to get up from his chair.
Ryan Bailey: I mean, who does?
Gianluca Bini: Must be nice now that you work remote, right?
Ryan Bailey: That's true. I don't ever get out my chair.
Gianluca Bini: You don't have to even like move your ass from the chair. You need a coffee machine right next your laptop. So you don't even have to get up at all. You can just do everything.
Ryan Bailey: What dream. I'm more like a cold brew right in the morning. Just get all that caffeine right away and then pretty much done for the day.
Gianluca Bini: Why would you do cold brew?
Ryan Bailey: I find that hot coffee tastes acrid. It tastes too bitter. I love espresso. Espresso, fine. Like, I'll drink straight espresso shots.
Gianluca Bini: Yeah.
Ryan Bailey: Like, I have no problem with that. But, like, hot coffee, like, it'll be this weekend. It's going to be super cold, they're reporting. I'll be drinking cold coffee. Yeah.
Gianluca Bini: Oh, wow. So do you ever go to Starbucks, though?
Ryan Bailey: I hate Starbucks.
Gianluca Bini: You hate Starbucks?
Ryan Bailey: We're not getting, hey, Starbucks, listen up. We don't want your sponsorship, all right?
Gianluca Bini: OK.
Ryan Bailey: I think all their coffee tastes burnt.
Gianluca Bini: And you rarely go to Starbucks because the coffee is good, right? You usually go to Starbucks.
Ryan Bailey: Yeah, I mean, the only time is like if we're in an airport and we're like desperate, and even then I'll be like, I don't know, I think I can survive.
Gianluca Bini: Do you go to Starbucks, Tash, or do you go to like Tim Hortons or some shit like that?
Annatasha: Well, Bini, at all, at every opportunity, will intentionally select Canadian over American when possible.
Gianluca Bini: Look at you.
Annatasha: uh, but I'm also not a big coffee person. I'm a tea person. which means that in matcha, you can matcha and yerba are like, no, I'm a tea person and you know, it's hard to justify spending $7 and 50 cents on a tea when I can buy a box of a hundred tea bags for three 99.
Gianluca Bini: How about matcha?
Annatasha: So, You know, if there's like an order going in from like the anesthesia group and I'm on clinics that day, I'll toss like a chai on or something. But for the most part, nah.
Gianluca Bini: Okay. Do you like matcha, Ryan?
Annatasha: Nah.
Ryan Bailey: I cannot say I have had matcha. I love tea of all varieties. I will say the quarterback, Kim Williams, he loves matcha, and the Bears do super well when he's seen drinking matcha with his wired headphones.
Ryan Bailey: So, just went on.
Gianluca Bini: Okay.
Ryan Bailey: I swear to God, matcha had a moment in Chicago this summer. Every farmer's market where there was a matcha stand, it was like, you knew, were like, oh, look at that line wrapping around the block.
Ryan Bailey: I bet that's a matcha stand. And then you walk by to go buy your produce and it's fucking matcha.
Annatasha: Are there matcha hot dogs?
Ryan Bailey: I'm sure there are. am sure there are.
Annatasha: Disgusting. Just like GV20, you're either really into it or you're not.
Ryan Bailey: Yeah. Like hot dogs.
Gianluca Bini: I love matcha.
Ryan Bailey: Really?
Annatasha: Do you?
Gianluca Bini: Yeah.
Ryan Bailey: What's it taste like?
Annatasha: grass
Gianluca Bini: Like, yeah, it is a little bit grassy.
Ryan Bailey: feel like green tea.
Gianluca Bini: So there is this place here in OKC, which actually, so there is a huge Asian community, which I love. And There is this place that does like this drink where it's like the bottom is like ube and the top is matcha.
Ryan Bailey: Oh, cool.
Ryan Bailey: So you get the good flavor from the ube and then the grassy flavor from the matcha?
Gianluca Bini: Correct.
Ryan Bailey: Yeah.
Gianluca Bini: Correct. It's just actually really, really good. There is a couple of spots in New York that make amazing matcha. One is called like Haiti and it's so like they hand whisk it in front of you. Like it's like
Ryan Bailey: Yeah.
Gianluca Bini: It's legit, really good.
Gianluca Bini: It's expensive, but...
Ryan Bailey: mean, green tea and yerba mate were my, like, gateway drug to caffeine. I used to drink yerba mate all the time when I was in vet school.
Gianluca Bini: Oh, yeah. I love Yerba Madi.
Annatasha: It's just the bottom of an ashtray has been rinsed out.
Ryan Bailey: I mean, the ones I had tasted very grassy, I did not
Annatasha: The ones that I had were made by true Argentinians because I trained in Cornell and everybody there is from South America.
Ryan Bailey: Sure, sure, sure.
Annatasha: And I was just like,
Ryan Bailey: I did not have the fancy Yerba Mate cup.
Annatasha: Yeah, yeah, yeah, of course.
Ryan Bailey: I did not.
Annatasha: And they would be like, here, let's drink some yerba mate while we study the physics of gases. And I'd be like, you know, what's worse than the physics of gases? This yerba mate.
Ryan Bailey: Oh.
Annatasha: So.
Ryan Bailey: Gas physics.
Gianluca Bini: You're so bad. Fucking worst.
Annatasha: Yeah, I'm becoming a real curmudgeon.
Ryan Bailey: becoming
Gianluca Bini: Oh my God, Tasha. All right. So moving from, you know, master groups to do you,
Gianluca Bini: so, you know, what?
Annatasha: Nothing. It was just like, you got like deeply philosophical.
Ryan Bailey: Yes.
Annatasha: Like leaned back and you looked at the heavens and Bailey and I are like, what is he going ask?
Ryan Bailey: There we going.
Gianluca Bini: Yeah. Yeah.
Annatasha: Hmm.
Gianluca Bini: Yeah, no, nothing too deep. So I'm trying to think, so a lot of places,
Gianluca Bini: the way we were trained, I mean, all of us actually have been trained in a vet school, residency-wise. So usually the typical pre-med, it's IEM, or rarely we do pre-med IBE in a vet school.
Gianluca Bini: Do you think there is any disadvantage in IV pre-med versus IM pre-med?
Ryan Bailey: Yes.
Gianluca Bini: Such as?
Ryan Bailey: I know if anyone else wanted to chime in and be a counterpoint, but yes, I think there are advantages and disadvantages to both.
Ryan Bailey: I think...
Ryan Bailey: I think from a clinical standpoint, I see a lot of people pre-med and then go straight to induction and it drives me bonkers. I think when we're, I'm talking about IV. So we, we give the IV pre-med and then we like put the dog in the mask and then we get our induction drugs. And I'm like, that patient's not sedate. Induction is going to go for shit. Good luck.
Ryan Bailey: Or we we give the IV premed and then we've had a bad experience of patients arrested, whatever, like we've had some sort of bad event in our life because the IV premed hits hard and it hits fast. And we left that patient unattended and something bad happened. So now we do things like we give the IV premed and then we sit in the busy induction suite with everything moving around and the dog is in the middle of everything. There's all this movement and the dog does not become sedate because it's a very stimulating environment and it overrides the sedation. And then once again, induction goes to shit.
Ryan Bailey: I think, I think they are equal. Like, I think they each have their place. and I, yes, exactly.
Gianluca Bini: A situation, right? So like depending setting.
Ryan Bailey: I would not, I would not say like, Oh, I'm never going IV pre-med an animal or like only I am pre-meds or whatever, whatever. Like, I think all of it, all of it has its place.
Gianluca Bini: Right.
Ryan Bailey: I think we just like, love IV pre meds because I can also get away with a lot lower doses though. And that's great too.
Gianluca Bini: Right.
Ryan Bailey: So like I can use a lot less dexmedetominine. I can use maybe lower doses of opioids potentially. Yeah.
Gianluca Bini: Let me. Yeah, I think it depends how you use
Ryan Bailey: And it opens up an arsenal to some drugs that maybe you wouldn't give IM or whatever. Like, no, the propofol or faceline really counts. Those are more induction, but Like lidocaine can be given IV as a sedative because it does at higher doses cause a degree of sedation.
Gianluca Bini: Yeah, you sound like somebody from the OVC.
Annatasha: Beanie, what about you?
Gianluca Bini: Well, so I think that, you know, as Ryan was saying, I think that it has its place, right? So it depends, I think, a little bit also on what drug you're giving as an IV premed, right?
Ryan Bailey: Yeah.
Gianluca Bini: So if you are planning on giving opioid only, maybe the sedation you're going to get is probably known.
Ryan Bailey: Agreed.
Gianluca Bini: don't think that the purpose of giving the opioid only then So what Ryan is talking about is the fact that if the patient does not get sedated, you do not get a good sparing effect on your induction agent or your induction combination if you have more than one, right?
Ryan Bailey: Yes.
Gianluca Bini: So if your plan is to just give an opioid in pre-med, whether you give it a M or a V, I think that probably doesn't fucking matter, right? Because the sparing effect you're going to get from point 2 or point 3 make the cake of methadone or it's probably almost none, right? Regardless of how the fuck you want to give it. Once you start playing with like Ace Promazine, if you give it a time and you give it time, probably you do get sedation. If you give it a IV,
Gianluca Bini: and five minutes after you induce, yeah, good luck getting any sedation from that, right?
Ryan Bailey: Yeah. Yeah. Mm-hmm.
Gianluca Bini: If you are planning on Dexmed, different story, right? Dexmed IV, it's actually relatively fast. And so like, I think that the drugs you're choosing play a big role as well, not just the setting, right? So I think, so I'm very much of a Dexmed guy,
Gianluca Bini: So if I need to pre-med IV, I'm heavily relying on an opioid and a dexmed, even one mic peckig. And that five minutes after, you can totally induce 100%.
Gianluca Bini: If I was more of an ace-promazine guy, probably that's not going to work. If I pre-med and then five minutes after induce, I'm not going to get what I want.
Gianluca Bini: or not as much as I want, I think. Right? Yeah. What about you, Taisha? What do you...
Annatasha: I mean, I think you guys make a lot of good points.
Ryan Bailey: You're
Annatasha: What?
Ryan Bailey: just like sitting back like silently judging both of Yeah.
Gianluca Bini: Yeah, she's judging both of us 100% percent.
Annatasha: I like the IV because, yeah, like mic drop.
Ryan Bailey: Interesting. Lean
Ryan Bailey: in.
Annatasha: can use lower doses and also, know, it doesn't hurt. Like I am very needle adverse.
Gianluca Bini: Yeah, but you had to shove a guy in the rain without pre-math, which does fucking hurt.
Ryan Bailey: Ding, ding, ding. And that fucking hurt. Yeah. That feels way weirder.
Annatasha: What hurts?
Gianluca Bini: Huh?
Ryan Bailey: Catheter.
Annatasha: Yeah, the catheter hurts for sure. But so, well, if you have to put a catheter in and give an IM injection or you just put a catheter in, what's your net total of discomfort?
Gianluca Bini: Isn't that the same as the fucking needle?
Annatasha: It's higher with the IM injection.
Ryan Bailey: Well, okay.
Annatasha: The other thing I've had happen to, which I've been burned for with IM injection,
Ryan Bailey: You're picking some assumptions that I think are not true in clinical practice, unfortunately.
Annatasha: Well, they are in clinical practice because I can get an IV in almost anything before I have to sedate it. But mean, also too, I've also been burned and this is little more academic, but, you know, know, give an apaxial injection and then send something to MRI.
Annatasha: And then if that is anywhere crossover on where the lesion may potentially be, you look like a massive dodo.
Annatasha: But like I said, I don't enjoy intramuscular injections myself.
Ryan Bailey: right.
Annatasha: I think they're uncomfortable and I think they leave you being sore. And then I also feel really terrible for those dogs who, you know, like they get poked like multiple times. I mean, just think about like, oh, like, you know, when they do the heartworm treatments,
Ryan Bailey: Yeah.
Gianluca Bini: Oh, fuck.
Annatasha: those injections, like those injections hurt so much, you to hospitalize them and put them on narcotics.
Gianluca Bini: Melar Ximenez.
Annatasha: You know, so I just, you know, I also come from clinical point of view where, you know, my clinical peak, you know, I was seeing 20 to 30 cases a day as the only anesthesiologist with my team, right?
Annatasha: And so I am, know, and I'm great at time management, but I am with no, no, no, no.
Gianluca Bini: Are you saying that you're not at your peak anymore? You're in decline.
Annatasha: Yes, I'm in the slide towards annihilation and death. Leave me alone. And yeah, aka, I don't give a fuck at 46 anymore.
Annatasha: But yeah, just don't have time for patients to take 30 to 40 minutes to sedate and then potentially sedate poorly. And the other thing too is I actually think that you do have to really monitor those sedated patients and that's when they're getting really hypothermic.
Ryan Bailey: Okay.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah.
Annatasha: You know, so yeah, I actually go for the catheter and then the IV, although I understand the timing of my medications and how long they take. Like, I don't just like slam fentanyl in and then give propofol. In most instances, I can think of a couple where I'd actually probably would do that.
Annatasha: Yeah, I was like, I might actually do that a couple times. But yeah, like for the most part, like something straightforward, like if I can get your catheter and give it to your IV, I feel like I have a better sense of what I anticipate the outcome to be.
Annatasha: and moving more efficiently. I think it's more comfortable and less distressing for the patient. And I just think, you know, there's less fuck ups, right? Like how many times than I am of like the patient jumps and you bend the needle and I don't know how much it got.
Annatasha: And then like, you know, or how much went on, went on, how much did I just, ketamine did I just squirt in my own eye? And like, did it go in fat or did it go in muscle? you know, like, it's just, it's just messier.
Annatasha: And I just, I don't like it.
Gianluca Bini: I agree.
Annatasha: But like, it's also not to feel like I'm,
Ryan Bailey: I just want to bring up a couple of counterpoints here.
Annatasha: It's not the hill I'm going to die you know?
Ryan Bailey: So you are proficient in your catheterization. You're one stick queen. One stick every time. But, but you are incompetent with I am injection and routinely spray drug everywhere, break the needle, get it in your eye. So somehow the dexterity of catheter placement is in your wheelhouse. But I am injection, not, not for you.
Annatasha: I don't mean personally, Bailey.
Ryan Bailey: Oh, okay. Okay. Okay.
Annatasha: You know, think that, you know, when I watch different sets of teams do IM injections, and you're right, you might jump to from a catheter placement type thing, but in those cases, we're
Gianluca Bini: Okay.
Annatasha: Where I anticipate like if that patient is going to be fractious for the catheter, then I do when you're on the side of the IM injection. But like I said, my preference is if I can place the catheter and give your pre-med or your pre-med sedative IV, then that's my clinical preference.
Ryan Bailey: Yeah.
Ryan Bailey: Sure. Sure. I think one reason I push back on the IV pre-med over everything else, and it's not a hill I'm going to die on, but I do feel a little strongly, is people are really confident in how fast they are, and I'm like...
Ryan Bailey: Bet you're not as fast as a fucking IM pre-med, man. bet I can give this IM pre-med while you're goofing around, doing whatever you're doing, running blood work, getting this and that together. by the time everything's done, the patient will be cooked and I'll be ready to go off to the races instead of like waiting for you to get the catheter and pull the blood and then give like... To me, there's lag time in even some of those add-on emergency cases that are coming in where I can hit it with IM premed, go about, be setting up, da-da-da-da-da, doing all this other stuff while someone else is holding the patient and doing the monitoring for me, if you will. And then by the time they get the catheter in, that dog's ready for me, and I'm ready to go.
Gianluca Bini: Fair. Yeah, I you both have good points on this. Yeah.
Annatasha: Yeah, like I said, it's not a hill I'm going to die on because I think at some point it just comes down what kind of clinical scenarios you need to run or your team's skill level.
Gianluca Bini: And there's prevalence.
Annatasha: I don't know. I think it's multifactorial, but yeah.
Ryan Bailey: For sure.
Annatasha: I don't like cam injections personally, so I try to avoid giving them.
Gianluca Bini: Yeah.
Annatasha: That's all.
Ryan Bailey: Yeah.
Annatasha: That's really the crux of my practice is I think it's uncomfortable and anything I can do to mitigate that is I try to err on that side.
Ryan Bailey: I mean, I get yearly eye injections and I survive them every time.
Annatasha: I know you're surviving them, Bailey, because you're here to annoy me continuously.
Ryan Bailey: I don't like the needle though. know, it's a needle.
Ryan Bailey: I'm like, oh, that needle scares me. I can't look at it.
Annatasha: If I didn't have to get another IM vaccination to go to some weird tropical buggy country that I apparently can't stop going to, then, you know, I'd be, I'd be okay with that. Yeah.
Annatasha: Yeah.
Gianluca Bini: You guys, that's awesome. And last question, then I'm going close on this. Do you always change? So you withdraw from the bottle, right, whatever drug it is.
Gianluca Bini: Do you always change your needle to give the AM injection?
Ryan Bailey: Always.
Ryan Bailey: Always.
Annatasha: Even if
Ryan Bailey: There's that... There's a really cool...
Gianluca Bini: At least we get angry on something.
Ryan Bailey: No literature here. There's that cool paper that shows the needles. don't want that.
Gianluca Bini: Oh yeah. Yeah. It's pretty bad.
Ryan Bailey: I don't want, they change the needle when they give you a vaccine, they drop the needle.
Gianluca Bini: They do, they do, but you know, some people don't, right?
Ryan Bailey: Oh yeah.
Gianluca Bini: Like, so I'm,
Ryan Bailey: Yeah.
Annatasha: Sort of doing like a para-incision, a line block for something or like a ring block or something, like one of the cruder, less specific blocks. I change my nail like constantly throughout the block.
Annatasha: And I'll tell you this too.
Gianluca Bini: yeah.
Annatasha: So I get, you know, personal health disclosure, but I got 37 Botox shots to my skull and the base of my skull, my neck, my shoulders and my forehead fork. chronic migraine syndrome, right?
Annatasha: And what they is you get, it's like multiple needles.
Gianluca Bini: in one shot.
Annatasha: I get like, you know, but each needle has five injections in it, right? So I get all these, whatever, but they don't change the needle on that syringe, even though it's five to seven injections per that syringe.
Annatasha: And let me tell you, will tell you this by the fifth and sixth and the seventh poke with that same needle, even though it's like a 27 gauger and it's only going into it's going to my Like they literally will,
Ryan Bailey: I
Ryan Bailey: was going to say, maybe they just see one injection right in your GV20 and then you'll be just fine.
Annatasha: They hold me right like here in one of your chakras and then like up here at the base of my skull. Those are two of my main injection points. Hurts like stink. But let me tell you, by the time you're past, like the second and the third poke, I can feel the needle getting blunter because it hurts more and more progressively as we inject.
Ryan Bailey: Okay.
Gianluca Bini: Yeah, that's fair.
Annatasha: And like Bailey said, like you can look at those electron microscopy photos of how blunt the needle is per usage. So Like I said, do not enjoy needle discomfort. I'm needle adverse as a patient. So I changed my needle like the Dickens.
Ryan Bailey: You can I mean, another good example for anyone who's like out there practicing clinically is like when you're using a 24 gauge catheter, notice how dull that thing gets within like the first two or three pokes like even like.
Annatasha: I don't like, like, even if you don't, like, like the catheter doesn't seed blood and you don't clot it or whatever, like my catheter per poke, I don't even poke with it twice.
Ryan Bailey: Yeah.
Gianluca Bini: We don't reuse it ever.
Annatasha: Because I know, think catheter pokes also hurt.
Ryan Bailey: Yeah.
Ryan Bailey: Oh, I totally agree.
Annatasha: Yeah, like when you put it in the back of your hand, you're like, uh, but like I said, you know, I, you know, going through thick skin and like you sometimes hit the bone or muscle or what have you, especially if you're, you're new to the skill and it's just like, and it's not as sterile as it should be ever.
Ryan Bailey: Yep.
Annatasha: Like that's very rare.
Ryan Bailey: Right.
Annatasha: So I actually, I don't poke multiple times with that catheter. That's a one poke situation for me.
Ryan Bailey: Yep.
Ryan Bailey: But those are good examples where you'll notice that dullness come in just so fast.
Gianluca Bini: Yeah, I agree.
Ryan Bailey: Like those catheters, like you can feel it in your fingers of like how, like it all of a sudden, it's like you're pushing a catheter through fucking concrete and you're like, well, there's no, like there's no chance at that point.
Annatasha: Yeah.
Ryan Bailey: Like just get new, get a new catheter.
Gianluca Bini: Yeah.
Annatasha: Yeah. You
Ryan Bailey: So like, I think it's worse in the smaller gauges because I think they're less sturdy.
Gianluca Bini: Yeah.
Ryan Bailey: It's like that 20%.
Annatasha: know, honestly, I feel like I can feel it too. Like, let's say you're putting the same needle into like, and you're poking it multiple times into like whatever, like maybe a multi-use vial or like a bag of ceiling that you're drawing from or something. You can feel each time too, like the poke is harder, the poke is harder, the harder, right?
Ryan Bailey: Yeah. Yeah.
Annatasha: And like you think about something like you know, a geriatric cat who's got that like delicate chicken-y paper skin, you know, how much does that have to hurt if you wail them like five times with the same needle?
Gianluca Bini: Yeah.
Annatasha: Like it's just friendly.
Gianluca Bini: Yeah.
Annatasha: I also think it's making whatever technique or skill you're trying to achieve more difficult.
Annatasha: And it's just, it's one of those things too, like needles are not cost-preclusive in most instances. So it's like, why am I, why am I, you know, this 2.1 cents that I'm saving the hospital today is probably not going to make a difference in like, you know, yeah.
Gianluca Bini: Absolutely not.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Yeah. Yeah. Agreed. All right. Well, thank you so much for being here tonight. I guess see you next time.
Annatasha: Thanks guys.
Ryan Bailey: Bye. Go bears.
Annatasha: Don't be a waste of a pump.
Gianluca Bini: Thanks.
