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Special Ep1 - Chill out: When Behavior Meets Anesthesia
152 Plays2 months ago
In this unique episode of the Random Anesthesia Topic podcast, we’re joined by a board-certified veterinary behaviorist for a dynamic conversation with our trio of anesthesiologists. We explore the fascinating intersections of behavior and anesthesia—discussing drug overlaps, anxiolytics, the ever-popular "chill protocol," and the nuanced use of gabapentin. Whether you're managing pre-op anxiety or fine-tuning sedation plans, this episode is packed with practical insights and expert perspectives. Don't miss this collaborative deep-dive into the art and science of keeping pets calm and safe.
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Transcript
Intro
Introduction to Dr. Chris Pockel
00:00:40
Gianluca Bini
tonight with us, we have Dr. Paco, which is a board certified behaviorist and is the owner and lead clinician at the animal behavior clinic in Portland, Oregon.
00:00:51
Gianluca Bini
He lectures worldwide. He teaches a bunch of courses. I met him at DVM 360. So welcome, Dr. Paco. And I want to break the heist with our first question.
Chill Protocols in Veterinary Practice
00:01:06
Gianluca Bini
And my question is, so do you accept consults for chill protocols for surgeons? Can we drive...
00:01:18
Dr. Chris Pachel
but Are you talking about the surgeon or the patient? Which which one are we chill protocoling here?
00:01:21
Ryan Bailey
Yeah.
00:01:21
Gianluca Bini
It's urgent. It's urgent. Can we...
00:01:24
Annatasha
You know, that's a great point.
00:01:24
Dr. Chris Pachel
Okay.
00:01:25
Annatasha
And you could do me a favor and apply it to the surgeons, please.
00:01:28
Gianluca Bini
Yeah, yeah. Can we come up with a protocol so that we just chill them out before they come to work in the morning?
00:01:34
Dr. Chris Pachel
Right. So I, i had full disclosure, my husband is a veterinary surgeon. So I, I hear everything you're saying. i will say he's kind of an exception.
00:01:45
Dr. Chris Pachel
He's kind of a unicorn in the surgery world, but also I have to mind my P's and Q's slightly because he and I have been together 25 years. And so, uh, you know,
00:01:54
Annatasha
We don't, k Chris, because surgeons aren't going to listen to this podcast because they already know everything. well
00:01:58
Dr. Chris Pachel
also true.
00:02:02
Annatasha
Yeah, you can say what you want.
00:02:03
Dr. Chris Pachel
not wrong not wrong fair that is fair
00:02:04
Annatasha
You can say his name wrong. Yeah, you just like have at it. But yeah, surgeons aren't going to listen to our podcast. So, you know, that's why we're able to lay into them. so
00:02:13
Ryan Bailey
you
00:02:15
Gianluca Bini
No, they definitely don't listen to this. So you can say whatever, feel free, you're good. But on a serious note, so, you know, there is a lot of overlap from, you know, drugs that you guys use and, you know, we use, right?
00:02:29
Gianluca Bini
So we, you know, for example, aspromazine is one of those, right? It's, for us, it's more like considered like a sedative, quote unquote, right? Versus in behavior, you guys use it more like a,
00:02:44
Gianluca Bini
Sort of like a chilling, like tranquilizing.
00:02:51
Dr. Chris Pachel
So now here's the question before I tell you what I think about it. How would you differentiate should sedation from tranquilizing?
00:02:59
Annatasha
Jan Luca, this is an exam question in anesthesia.
00:03:02
Gianluca Bini
There you go. And Ryan, what do you think?
00:03:05
Ryan Bailey
I'm going down for zero on this one.
00:03:11
Ryan Bailey
this is like This is like the attack the other day is taking the VT&E and she's like, what's the difference between emergence delirium and dysphoria? And I was like, I don't know.
00:03:21
Annatasha
Well, there is in fact a difference because usually dysphoric patients, you can't actually comfort them. Whereas emergence delirium They tend to self-resolve with time, not due to a dysphoric overdose of one of the anesthetic agents.
00:03:34
Annatasha
And you can actually comfort them and their eyes will track.
00:03:39
Ryan Bailey
There you go. All right. So like,
00:03:40
Gianluca Bini
Yeah, Ryan.
00:03:42
Ryan Bailey
There you go, Bartell. Why don't you tell us about tranquilization sedation, and I will...
00:03:46
Annatasha
Well, the difference is one of them, you can actually rouse the patient out of it and the other one you theoretically can't.
00:03:46
Gianluca Bini
There you go.
00:03:51
Ryan Bailey
Hmm.
00:03:52
Gianluca Bini
Boom.
00:03:52
Dr. Chris Pachel
Which is which, just so I know, because not in your world.
00:03:55
Annatasha
Right. Well, see, this is where I start to have semantical and philosophical argument with myself, because I would assume that in terms of tranquilization, that would be the one where you can actually like calm them down and then they're arousable. And then sedation is the other way around. But actually, the last time I checked the textbook, it's the other way around. So.
00:04:14
Dr. Chris Pachel
Yeah, my brain put them in the other direction.
00:04:14
Ryan Bailey
You passed
00:04:16
Annatasha
Exactly.
00:04:16
Dr. Chris Pachel
So, yeah.
00:04:17
Annatasha
Oh, yeah. Because like for me, like tranquilization means you have become. just going back to the you know the Latin root of the word, that you have been you are tranquil, still rousable, but it's actually, it's the inverse.
00:04:28
Dr. Chris Pachel
Yeah.
00:04:30
Gianluca Bini
That's okay.
00:04:31
Dr. Chris Pachel
Right.
00:04:31
Annatasha
Is that the first time you heard
00:04:31
Dr. Chris Pachel
Learning all the things.
00:04:33
Gianluca Bini
good Good to know, thanks.
00:04:36
Annatasha
that?
00:04:36
Ryan Bailey
thats you that the exam, Bartell.
00:04:37
Dr. Chris Pachel
yeah
00:04:38
Ryan Bailey
You can...
00:04:39
Annatasha
I know, and I did it on the first time.
00:04:42
Gianluca Bini
I think you're done for tonight. Thank you so much for being here. That's awesome. So when do you...
00:04:49
Annatasha
Maybe we should tell the podcast to the senior anesthesiologist and the junior anesthesiologist.
00:04:56
Ryan Bailey
There's, what, one year of separation between all of us?
00:04:59
Annatasha
I actually have no idea.
00:05:00
Gianluca Bini
correct
00:05:01
Annatasha
yeah
00:05:03
Dr. Chris Pachel
Yeah.
00:05:04
Gianluca Bini
that's awesome so so when do you
00:05:07
Dr. Chris Pachel
Was there a question in there somewhere for me? I've completely lost the thread.
00:05:11
Annatasha
I thought we were still on the chill protocol.
00:05:13
Ryan Bailey
It's still at least one of you, I thought.
00:05:13
Annatasha
Yeah.
00:05:14
Dr. Chris Pachel
got it.
00:05:17
Gianluca Bini
I mean, the question was like, so how do you, so when would you prescribe ACE promising, right? Like it's, is what's the, what's the situation where, you you know, that triggers you to prescribe that over some other drugs or maybe, you know, some just, you know, some different training, I guess, you know, so what's your thought process when you guys prescribe that?
00:05:35
Dr. Chris Pachel
Yeah.
Sedation vs. Tranquilization
00:05:39
Dr. Chris Pachel
so the way i think about that from the from the behavior lens, right, is so acepromazine falls into the category of situational meds.
00:05:46
Dr. Chris Pachel
So we typically differentiate maintenance meds like your Prozac antidepressant every day, long term, four to six weeks for efficacy versus your situational meds. You give it, it takes effect in.
00:05:57
Dr. Chris Pachel
half hour, two hours, whatever drug you we're talking about, right? And then there's no residual effect. So acepromazine, for obvious reasons, falls into the situational med category. So then the question is, in terms of actual desired effect, are we actually likely to see any anxiolytic effects or any actual emotional arousal regulation, sort of a benefit from it? Or are we talking more about sedation or more about blocking or limiting motor activity.
00:06:27
Dr. Chris Pachel
And i will say in the behavior world, ACE has gone through kind of a variety of lifetimes, even in my career over 20 years or so, where back in the day, when I think back to even my pre-vet days when I was working as an assistant in a clinic,
00:06:42
Dr. Chris Pachel
Ace was one of the only things that was given situationally.
00:06:43
Ryan Bailey
Thank you.
00:06:44
Dr. Chris Pachel
It managed the clinical signs of whatever was there from a behavior perspective. Clients often loved it because the the know the animal who was destructive during thunderstorms, for example, just laid in the corner and slept and drooled all over everything. And so...
00:06:58
Dr. Chris Pachel
Clients loved it, right? And yet there was a limiting factor in that there's very limited anxiolytic effects. And so if anything, we may be sort of blocking some of the expression of anxiety or emotional distress, but not actually providing clinical benefit from a behavior perspective.
00:07:13
Dr. Chris Pachel
So for me, all of that to say when I'm prescribing ACE, it's typically when I'm looking specifically for that control of motor activity. So in my world, if I have an animal who has big feelings about life and I'm trying to manage that, ACE is typically, you know, the third or the fourth layer to that protocol when the anxiolytic effect that I've gotten from other drugs is insufficient to manage the motor patterns of the patient.
00:07:30
Ryan Bailey
Yeah.
00:07:42
Dr. Chris Pachel
And I'm often using it temporarily even to control that pattern. until we're able to get other training or behavior modification onboarded to actually address the underlying issue.
00:07:53
Dr. Chris Pachel
So I will say personally, i prescribe ACE twice a year, maybe.
00:07:59
Gianluca Bini
Oh wow, okay. okay
00:08:00
Ryan Bailey
Thank you.
00:08:00
Dr. Chris Pachel
It's really, really uncommon. Now keep in mind, I'm in the, on the behavior specialty side of things, as opposed to in the general practice where I'm needing to do injections and other protocols and procedures where the chill protocol becomes much, much more relevant.
00:08:14
Dr. Chris Pachel
So I'm advising on that when we have clinicians who need to be able to, to address that. And I, i will say, as I was saying with the the ACE life lifetimes issue, we went from that sort of ACEs everything to ACEs the devil because it doesn't do anything that we thought it did. And then everybody was like, No, no, no, never, never, never, never. never never And then with the emergence and the popularity of the SHIELD protocol, I'm seeing it showing up more frequently now in some of my referral records coming in, where it's being prescribed a bit more freely, again, as a way of managing or controlling longer term behavioral patterns.
00:08:49
Dr. Chris Pachel
I have mixed feelings about that, whether I think that's actually the right way to go. But it is, yeah, it's something that we're likely to start seeing a bit more frequently.
00:08:58
Annatasha
I have two questions. just, Chris, just for the the listeners, can you just give us a quick overview of the CHILL protocol and its it's indications and and how it's actually clinically managed just so the listeners can catch up?
00:09:11
Annatasha
That would be really helpful.
00:09:12
Dr. Chris Pachel
Absolutely.
00:09:13
Annatasha
Thank you.
00:09:13
Dr. Chris Pachel
Yeah. So a chill protocol was originally kind of put out into the world from the team at Tufts. At least that's my understanding of where it originated, right? So looking at typically a pre-visit pharmaceutical protocol, something that would be given most often to a dog, potentially for other species, but most often to canines as a way of alleviating some of that emotional distress or creating a bit more of a managed patient for the veterinary experience.
00:09:38
Dr. Chris Pachel
either in advance of other sedation or as a standalone, kind of helping the animal feel better about the experience. From a drug standpoint, standard chill protocol typically includes acepromazine, one we're talking about here, gabapentin, and melatonin.
00:09:53
Dr. Chris Pachel
Modified chill protocols, depending on who you ask, may also include trazodone within there as well, but the original version did not include that in the protocol. So we're looking at that again typically something that would be administered one to two hours prior to veterinary appointments plus or minus 12 hours before that as a way to kind of facilitate that sedation and overall behavioral regulation and calming and then presumably if it works then we're able to to more easily manage that patient within the clinical setting.
00:10:16
Gianluca Bini
Thank you.
00:10:21
Annatasha
Let's just highlight the presumably if it works, because that was highly conditional. And my next question was going to be, how often are you using the chill protocol?
00:10:26
Ryan Bailey
Oh.
00:10:29
Annatasha
But I feel like you kind of just gave up the ghost there. So.
00:10:33
Dr. Chris Pachel
Yeah, it's, you know, I think the thing for me that is is sort of an interesting thing about that, and this is actually where I love the intersection between behavior and anesthesia, is if I want an animal to, quote unquote, feel better, managing that patient with gabapentin, melatonin, and acepromazine is going to be really intermittently effective, depending on how you feel about gabapentin, right?
00:10:55
Annatasha
I mean, if but but tip top.
00:10:59
Ryan Bailey
Yes.
00:10:59
Dr. Chris Pachel
Right. If we get more trazodone on board, maybe it's gonna be more effective, but truly from an anxiolytic effect, I'm a much bigger fan of clonidine or benzodiazepines or some of the drugs where we're actually getting that anxiolytic effect.
00:11:02
Gianluca Bini
Thank you.
00:11:12
Dr. Chris Pachel
With that being said, I have a lot of practitioners who swear by it, who love it I don't know that I generally see that level of effect that would make me say, this is gonna be my default.
00:11:25
Dr. Chris Pachel
I'm not opposed to using it if it works for a particular patient, but yeah.
00:11:30
Gianluca Bini
Yeah. I mean, and some practices nowadays, you know, that's the standard, right? Like there is no, there is no option, right?
00:11:35
Dr. Chris Pachel
Yes. Yeah.
00:11:37
Gianluca Bini
Like every single dog, or it comes in with the chill protocol in, and know you know, and there is no, no option. Like even patients that do totally do not need it, you know, they just, you know, randomly blanket prescribe it to everybody.
00:11:50
Dr. Chris Pachel
yeah
00:11:54
Gianluca Bini
Right. It's like candies, know,
00:11:56
Annatasha
Oh, that has not happened yet in Canada, but that could be because of tariffs.
00:11:58
Ryan Bailey
Yeah, I don't see it.
00:12:01
Ryan Bailey
One question I had, and I, like, do you think, just everyone, am there's a big...
00:12:09
Ryan Bailey
so like, i personally feel very strongly it is a the night before and day of. You know, if you're really going to do it, it's got to be the night before and the day of because...
00:12:09
Gianluca Bini
Thank you.
00:12:22
Dr. Chris Pachel
Thank you.
00:12:23
Ryan Bailey
You know, like there's something, i don't know if it's it's our body language, our behaviors at home, something changes before the day before the vet visit. And I find a lot of times those patients who are coming in on these like calming, tranquilizing, sedating meds are not, they're like,
00:12:40
Ryan Bailey
there's no effect if they're just the day of. And I suspect it's like pulling food at nighttime, changes in some sort of behavior pattern that we aren't perceptive to, but I think our patients are. So I wondered if you guys have any thoughts on that.
00:12:55
Gianluca Bini
So whether to do it both night before and off or just...
00:13:00
Ryan Bailey
I'm pretty much, I'm like 100% across the board. It should always be the night before and the day of the procedure.
00:13:07
Dr. Chris Pachel
yeah i think what you're highlighting within that, at least from the behavioral world, is if we're going to use situational meds for whatever it is, thunderstorms, separation anxiety, veterinary visits, we really need to make sure that those meds are on board, give or take two hours before the onset of the stressor.
00:13:07
Gianluca Bini
Yeah.
00:13:26
Dr. Chris Pachel
It's not two hours before the veterinary appointments. And what often gets missed is, as you're saying, if there are changes to routine, especially if we're talking about anesthetic protocols where we're changing the mealtime routine, if I have clients who are not sleeping well the night before and that,
00:13:41
Dr. Chris Pachel
you know all of those things that get sort of wrapped up into it, then I totally agree two hours before the onset of stress would almost dictate that we're talking about night of. I would say the same thing is also true if I have a patient has more of a generalized or longer term anxiety issue, that even if the owner is not changing their routine, i think if we're leaning on a situational med, especially if that generalized anxiety is not terribly well controlled,
00:14:09
Dr. Chris Pachel
we're asking a lot of that situational med to cut through all of that and alleviate the distress of the actual experience versus can we, pardon the pun, chill them out the night before and then kind of top them off the morning of and kind of just ride that wave as opposed to trying to get through all of it morning of.
00:14:13
Ryan Bailey
Thank you.
00:14:29
Dr. Chris Pachel
Okay.
00:14:31
Annatasha
Nice.
00:14:31
Gianluca Bini
Yeah, no, that totally makes sense.
00:14:31
Annatasha
I like that idea. Yeah. because my cat, you can't even go into the closet where the cat carrier is before we all we all get collectively upregulated. So now, Crystal, I have something.
00:14:41
Annatasha
First of all, i'd like to thank you for being a guest star this evening before I say something controversial about behaviorists, which is just wanted to hear your thoughts.
00:14:47
Gianluca Bini
Bye.
00:14:52
Annatasha
For a long time, like you said, ace-pirmazine fell out of disfavor. I still think it has, right? Like I still have yeah ER doctors who are like super reticent to use it clinically for sedation. there was this, don't know which are ethos going around that acepromazine was actually not mindful of the patient's welfare because it was not an appropriate anxiolytic, which meant that what was happening is it was sedating the patients, but leaving them in a terrified mental and emotional state, which
00:15:11
Dr. Chris Pachel
Thank you.
00:15:23
Annatasha
I personally think is a gross overstatement and, you know, hogwash, because there are some, there is dopamine receptor activity, but more importantly, just chilling them out just in in a sedative capacity, theoretically, and feel free to comment on this, can secondarily just alleviate anxiolysis outside of a pharmacological pathway, right? Like,
00:15:45
Annatasha
If you gave me an Alprazolam right now, well, that's a bad example because Alprazolam is different. But if you did give me – shut up, shut up, shut up.
00:15:50
Ryan Bailey
Yes.
00:15:53
Annatasha
Edit that out. But, um like yeah, like if you gave me the Ace Prima Z right now and like took me down about five notches, I think apparently my anxiety drops secondarily to the fact that I'm literally just in a sleepy state.
00:16:05
Annatasha
Yeah.
00:16:06
Dr. Chris Pachel
And I think that the differentiation there, this like sedation versus is are we talking anxiety arousal? And think that differentiation there, tranquilization, anxiety versus arousal
00:16:15
Gianluca Bini
Where is she going?
00:16:16
Dr. Chris Pachel
versus arousal?
00:16:17
Gianluca Bini
What's happening to you?
00:16:18
Dr. Chris Pachel
Someone's at the door.
00:16:20
Annatasha
I'm sorry. I get my groceries delivered, which is ironic because I eat Rice Krispies for dinner. So
00:16:30
Annatasha
I didn't have time to go grocery shopping because I took a three-hour nap, guys. Okay. Like
Ethical Use of Acepromazine and Other Medications
00:16:33
Annatasha
it's one or the other.
00:16:34
Dr. Chris Pachel
and me for me to judge So, yeah, so back to what you were saying there, I think that one of the differentiating factors for me in the behavior side is are we actually getting anxiolytic effects, anxiety being that apprehensive anticipation of threat, which is inherently an emotional response, as opposed to activation or, or you know, arousal, kind of that degree of of physiologic activation.
00:17:00
Dr. Chris Pachel
And the difference is that for some of my patients, sort of deactivating does have a calming effect on an emotional state that it sort of prevents some of that wind up.
00:17:09
Annatasha
Thank you.
00:17:11
Dr. Chris Pachel
And so then I agree that I wouldn't say sort of as a blanket statement that sort of chemical straight jacket effect is is going to be there for those patients. Where I think it gets a little tricky is that for those who truly do have anxiety, where there is an apprehensive anticipation of threat and there's a level of worry, especially if those dogs are generally more active responders, where anxiety manifests as pacing, panting, whining sort of movement,
00:17:38
Dr. Chris Pachel
Taking away the ability to do that if we're not getting the anxiolytic effect, I think is the patient that I have concerns about.
00:17:42
Gianluca Bini
night
00:17:44
Dr. Chris Pachel
To then say in that scenario, which again, patient selection criteria for everything is is key. For that patient, do we take away the expression of that emotional distress essentially masking it and then know and and then potentially so the animals are still experiencing that so from a sensitizing effect or experiential learning we're actually still perpetuating that underlying emotional state and that's that is something I've had patients over the years especially back in the day when ACE was more commonly prescribed where the owners would say as long as I give ACE ahead of time we're great we're great we're great they run out
00:18:18
Dr. Chris Pachel
animal experiences, the storm or the separation without that support on board. And I've, you know, case examples where those dogs were significantly worse than their pre-medication baseline.
00:18:31
Dr. Chris Pachel
And one of the possible explanations is they've continued to sensitize, but we didn't have visibility of that. And then when the masking support was taken away, do we actually have patients who are actually worse off as a result of it?
00:18:43
Dr. Chris Pachel
Not that that's necessarily the case for every dog, but I think it's a relevant consideration when we're figuring out what are we actually trying to achieve.
00:18:51
Gianluca Bini
Yeah, that's fair, actually.
00:18:51
Annatasha
Thank
00:18:52
Gianluca Bini
I didn't think about that. That's... Hmm. Hmm.
00:18:56
Annatasha
Yeah, excellent. Thank you. That was a lot more eloquent than the question I posed, but...
00:19:02
Dr. Chris Pachel
I mean, again, remember, I'm a behaviorist.
00:19:04
Annatasha
But was surprised by the grocery delivery, I was knocking, and I was like, just put it on the porch, but he was very concerned about the ICE situation, so fair enough, grocery delivery guy, appreciate it. But...
00:19:14
Dr. Chris Pachel
Fair enough.
00:19:14
Annatasha
Yeah, yeah. I just, um know, so many times, you know, you would see on like listservs and like, you know, Facebook feeds going back and forth that like ACE as well as allowing the patient to be tortured while it was just being physically sedated.
00:19:25
Annatasha
And like I said, I feel like that's a bit of an overstep. And really what it ended up happening as a consequence was that it really like threw ACE-Promazine out of the toolkit um and and in a way that I think has been detrimental to the patient population because ACE-Promazine, particularly in cats,
00:19:35
Dr. Chris Pachel
Yes,
00:19:42
Annatasha
be a really helpful clinical sedative. So...
00:19:45
Dr. Chris Pachel
Yeah, and I think for me, I you know i think in coming that maybe not full circle all the way back around, but kind of what was old is new again, sort of an idea. I think there's ah ah there's there's a balance point in there somewhere where if I think back to when it was sort of the only drug and it was prescribed without any nod to selection criteria or patient need, I think that's problematic.
00:20:05
Dr. Chris Pachel
I think completely getting rid of it and not recognizing the value it can have, especially in a multimodal protocol, I think that's also doing patients a disservice. The question is sort of how are we identifying who within the middle would actually benefit?
00:20:20
Dr. Chris Pachel
Do we have awareness of what those factors are to then identify was it helpful in the way that we thought it was or not? And then to be able to use it on an ongoing basis in the patients for those who it actually is helpful for.
00:20:33
Annatasha
Yeah, the surgeons. So um think we can all agree on that.
00:20:37
Ryan Bailey
I do want to just add a little note to this ACE discussion, given that one of our, one of my coworkers has a big passion for the, the ACE anxiety issue.
00:20:46
Dr. Chris Pachel
Thank you.
00:20:48
Ryan Bailey
And she dug into some older papers, showing like, these are all human based human centric papers. So a lot of them were in very elderly people, I believe. And they showed, you know, improved anxiety scores and some of the older generations of,
00:21:06
Ryan Bailey
the phenothiazine, like tranquilizer family. And again, humans are not dogs. Dogs are not humans. I think there's a total difference in you know, what we are using the drugs for versus, you know, what you're going to be using the drugs for, Chris, you know, like, ah ah like you said, like, no, no,
00:21:24
Dr. Chris Pachel
Thank
00:21:25
Annatasha
You were going to say what you were using old people
00:21:30
Ryan Bailey
I mean, there's there's a total difference in dealing with someone who had like you know as someone who has a fair level of anxiety in my own personal life.
00:21:32
Gianluca Bini
Great.
00:21:38
Ryan Bailey
There's a difference in the kinds of drugs I would want to take to manage that level of anxiety I experience and be a functional human who can still do anesthesia versus like a dog who's waking up and is either experiencing emergency delirium or dysphoria and needs you know something to take the edge off for few hours.
00:21:55
Ryan Bailey
Yeah. few hours
00:21:57
Dr. Chris Pachel
Well, and I think, you know, especially when we make some of the the canines or feline comparisons to humans, one of the big differences there too, especially from a cognition standpoint, is the level of awareness of what's happening around you.
00:22:09
Ryan Bailey
Yeah. Yeah.
00:22:09
Dr. Chris Pachel
you You know, and to what degree do we have a human who's opting in for care and sort of feels better when some of that arousal has been reduced, but they're still sort of consenting, there's still a ah ah participation factor versus an animal for whom something is being done to them.
00:22:26
Ryan Bailey
yeah
00:22:27
Dr. Chris Pachel
depending on their coping strategies of how they would ordinarily navigate something like that, I think the chemical effect that we're that we're eliciting can really be profoundly different across those lines.
00:22:39
Annatasha
I mean, you're really giving humans a lot of credit, Chris. I don't know the last time you rocked up to an ER or you watched The Pit. Have you guys been watching The Pit?
00:22:48
Ryan Bailey
have not
00:22:48
Gianluca Bini
Wait.
00:22:48
Annatasha
You have to watch The Pit. It is the best medical show. It is. I mean, they they gave BiPAP the other day. They got attention pneumothorax. And I was just like, yes. um um So, yeah, side note, watch The Pit.
00:22:59
Annatasha
But, yeah, you're giving humans a lot of credit.
00:23:03
Ryan Bailey
I mean, what yeah
00:23:03
Dr. Chris Pachel
That may be true. That may be true.
00:23:04
Annatasha
Yeah.
00:23:04
Dr. Chris Pachel
I don't spend a lot of time in the yeah ER, especially on the human side. Thank God. But, you
Stress Management in Veterinary Settings
00:23:09
Dr. Chris Pachel
know.
00:23:10
Annatasha
Yeah, if you've had anesthesia, you'd be surprised how non-consensual some of this stuff is or like what like arm twisting. And then if you're my dad who wakes up from anesthesia, he opens his eyes and shouts, I'm alive. So he really has really exciting emergence.
00:23:10
Ryan Bailey
that's good point, though.
00:23:25
Annatasha
Yeah.
00:23:25
Ryan Bailey
Yes.
00:23:27
Gianluca Bini
That's awesome.
00:23:29
Annatasha
Yeah.
00:23:29
Gianluca Bini
That's awesome.
00:23:30
Annatasha
no
00:23:30
Dr. Chris Pachel
Thank you.
00:23:31
Gianluca Bini
so and So what do you think about, like from a behavior standpoint, right? Like, what do you think about this quote unquote abuse of the chill protocol, right?
00:23:41
Gianluca Bini
what's What's your thought on that? Like, do you think, do you think it's fair game? Like, you know, the fact that it makes your life easier as a vet, Sometimes.
00:23:53
Dr. Chris Pachel
right
00:23:53
Gianluca Bini
Do you think it's fair game or do you think it's something like, you know, people are a little bit like Gabapentin for pain management, right? Like where people are abusing it like fucking candies, right?
00:24:05
Annatasha
Gabapentin is the new thimodidine. yeah You can't get into the hospital without it being administered, right? Like the new thimodidine.
00:24:14
Gianluca Bini
It's default. but every On every...
00:24:17
Annatasha
It's like walk in the door, you get c serenia, you get GABA, you get, you know, like, and it's like, can we all calm down?
00:24:20
Ryan Bailey
I assume.
00:24:22
Dr. Chris Pachel
I
00:24:22
Annatasha
Okay.
00:24:25
Gianluca Bini
So what do you think, Chris?
00:24:28
Dr. Chris Pachel
i got I have mixed feelings about it. i On one hand, i support more widespread use of anxiolytics from the standpoint that what we often do in the clinic is stressful from the cap the patient experience. And I obviously see some of the, maybe not the worst of the worst in all cases, but those animals who don't have the ability, they don't have the resilience to withstand that trauma.
00:24:52
Dr. Chris Pachel
And so then I see them when we're really trying to rebuild an emotional coping strategy around
00:24:57
Gianluca Bini
Bye.
00:24:57
Dr. Chris Pachel
what for a lot of animals is actually relatively well compensated for. So so again, my my my lens is a little bit a little bit slanted in that direction. So I think being mindful of patient experience and being more liberal with the use of of support options, I absolutely agree with.
00:25:15
Dr. Chris Pachel
And I actually, as as you see with a lot of these patients too, an animal who is either, let's say, immobilized or is experiencing some of the
00:25:21
Ryan Bailey
Thank you.
00:25:27
Dr. Chris Pachel
I don't know what the right word for it technically is, but some of the borderline uptunded effects that we can see from either gabapentin or trazodone, especially for some of my hurting breed patients with generalized anxiety, they don't feel better, but they absolutely feel different.
00:25:41
Dr. Chris Pachel
And for many of them, that is a really uncomfortable way to be.
00:25:42
Annatasha
Thank
00:25:45
Dr. Chris Pachel
And so I worry that if we're looking at patients where we're basically just saying everybody across the board gets your chill protocol, gets your trazodone, gets your whatever, Number one, I don't know that we even know what our baseline was without that to know if it's making a difference for comparison.
00:26:00
Dr. Chris Pachel
Or if we then have a negative patient response or a negative patient experience without that baseline, did we actually precipitate a more difficult clinical experience for that animal by putting something else on board that they're not accustomed to navigating?
00:26:06
Gianluca Bini
Thank you.
00:26:14
Dr. Chris Pachel
And then we sort of label that patient as practice refractory to treatment, more meds, more meds, more meds.
00:26:20
Ryan Bailey
Thank you.
00:26:21
Dr. Chris Pachel
And if we're dealing with practitioners who may or may not fully have that ability to differentiate what is doable with lower, you know, low stress handling or fear-free protocols or reading the animal and truly sometimes people kind of roll their eyes when I say this, but truly engaging the animal in conversation.
00:26:38
Dr. Chris Pachel
I'm not talking about that in a way of saying what we're going to do today. is No, no, no But actually engaging in the body language conversation of, you know, when I move my body in this way, when I restrain you in this way, does that make you better, worse, or no difference?
00:26:53
Dr. Chris Pachel
And being able to engage that conversation in real time in a way that actually facilitates handling for so many patients in a way that minimizes the necessity of pharmaceutical therapy.
00:27:05
Dr. Chris Pachel
But that's not exactly a language that I would argue that most veterinarians speak fluently. And so then we create perhaps an unhealthy level of reliance on pharmacological support as a way of managing that patient.
00:27:21
Dr. Chris Pachel
And then it's a slippery slope because you get a couple of really, really nice successes out of that. And it becomes really easy to make that sort of tip into this is just what we do now. This is where we live.
00:27:32
Dr. Chris Pachel
This is how we do it. Here's our protocol. Easy peasy. And we don't have to kind of think about it anymore.
00:27:39
Annatasha
Oh, he says that to three anesthesiologists who just recorded a podcast about how we do 98% of our anesthesia the same
00:27:48
Dr. Chris Pachel
la
00:27:48
Ryan Bailey
Yes. and
00:27:51
Gianluca Bini
So... so
00:27:52
Annatasha
way. I was like, oh yeah, this sounds great. Awkward.
00:27:55
Ryan Bailey
yeah
00:27:58
Dr. Chris Pachel
There's nothing wrong with that as long as your protocol works for 98% of the patients or you have the ability to adjust in real time, right? It's it's an option.
00:28:06
Annatasha
100% Chris, I have 100% success 100% of the time. Like, hello. Oh, yeah, that was pretty funny. I was like, mm-hmm, mm-hmm, mm-hmm. Yes.
00:28:18
Gianluca Bini
but Oopsie.
00:28:19
Annatasha
that
00:28:20
Gianluca Bini
So, Ryan, you were saying, do you do you use the shell protocol a bunch?
00:28:25
Ryan Bailey
I do not. i The Chill Protocol came I don't know when it became popular, but it was not common.
00:28:26
Gianluca Bini
Oh, okay.
00:28:33
Ryan Bailey
So, like, I'm more... Yeah, i definitely fall in the you know, in the fractious patient who is somewhat less tractable and is coming in for their appointment. I do advocate for some sort of gabapentin or trazodone combination the day before and yeah, the night before and the day of just to facilitate our handling and our safety, you know, is it the best, like long-term, definitely not the best option.
00:29:01
Gianluca Bini
I thought you were just darting them out in the reception area.
00:29:04
Ryan Bailey
Yeah, exactly that's exactly. I just, you know, I do, i get the, I get the, the dexmedetomine gel and I just like squirt the whole tube all over their mouth.
00:29:13
Dr. Chris Pachel
I mean, that actually, that's not a bad philosophy for some of my patients. So that' that's all we get sometimes.
00:29:17
Ryan Bailey
Yeah.
00:29:20
Dr. Chris Pachel
So...
00:29:22
Gianluca Bini
Do you use the Sileo bunch, like the dex-medetomidin gel?
00:29:26
Dr. Chris Pachel
So I do. I mean, yeah yeah, we use it, especially for sort of at home usage. But now we for for a fair number of my patient population, even doing an injectable protocol is in in um it's either insufficient or unsafe to be able to get that close to some of them, especially i tend to pick on the adolescent shepherds a lot just because it's ah ah it's it's a population in and of itself.
00:29:40
Ryan Bailey
Yeah.
00:29:50
Dr. Chris Pachel
and And the biggest difference for some of those dogs, not just the adolescent shepherds, but the difference is, and this is actually a place where I get the behavior anesthesia interface is actually a real one, is that if you want that animal to feel better emotionally, you want them to feel more settled, more comfortable, more trusting.
00:30:08
Dr. Chris Pachel
i can prescribe the heck out of that either on a maintenance or a situational basis. But if you have an animal that has a learning history that suggests being in the clinic is an unsafe experience and they've learned that aggressing preemptively is the best way to maintain your own sense of safety and well-being, I don't care how good I make them feel with pre-visit pharmaceuticals, they're still going to do what they do in order to maintain safety.
00:30:15
Gianluca Bini
Thank you.
00:30:33
Dr. Chris Pachel
And so the moment I recognize that pattern within one my behavior, or within one of my cases, the pattern is then to say, well, you don't need them to feel better. You actually need them to do less, in which case then I'm defaulting over to anesthetic protocols to say, what does it look to just make them sleep so we can handle them safely, not just trying to kind of manage our way through with a feeling better, so to speak.
00:30:46
Gianluca Bini
Thank you.
00:30:57
Ryan Bailey
Damn, that's, like, so smart. Like, nothing i ever think about is, like...
00:31:03
Dr. Chris Pachel
Thank you.
00:31:04
Ryan Bailey
I mean, i do, like... You brought up a lot of good points, Chris. I think one of the best points is, like, we cannot... converse with the dog and this dog did not opt in to get the tpl0 at all in fact he's fine with the way he limps around the yard and whatever and he does not understand his knee needs to be repaired because the owner still wants to run him three miles a day or whatever it is and so like we can make this dog feel good but he learned a long time ago that
00:31:17
Gianluca Bini
right.
00:31:38
Ryan Bailey
he has this maladaptive coping strategy to like attack and that has worked for him. And like, yeah.
00:31:44
Dr. Chris Pachel
yeah
00:31:44
Annatasha
I feel like I'm being described um, that's exactly how I am in clinics, right? Like if someone rocks up with some dumb anesthesia comment, right? Like I'm going to be like, I'm an adolescent shepherd and you need to get out of my induction space.
00:31:57
Annatasha
So yeah. I, ah ah yeah. I, you don't know, if I feel supported or attacked or whether I need consult with Chris,
00:32:03
Dr. Chris Pachel
At the very least, I think you're seen. We see you in this conversation. We see you. We hear you.
00:32:09
Annatasha
yeah
00:32:09
Dr. Chris Pachel
We acknowledge your presence in the room.
00:32:10
Annatasha
Yeah, I feel like you you described my entire experience as an anesthesiologist, which is you basically have to fight. And so now that's the default.
00:32:18
Ryan Bailey
You
00:32:19
Annatasha
Like you could sedate the crap out of me and I'm still going to like come out sparring on the alprazolam. So. Yeah.
00:32:26
Dr. Chris Pachel
Yeah.
00:32:28
Gianluca Bini
Is it like one for you, one for them?
00:32:28
Dr. Chris Pachel
Yeah.
00:32:35
Annatasha
Well, Beanie, as you know, I prefer most human beings unconscious. Yeah.
00:32:38
Ryan Bailey
more
00:32:43
Gianluca Bini
you know, as anesthesiologists, we have this weird, like, you know I think it's actually a behavior issue, right? Like where we we have this like aversion to humans.
00:32:55
Gianluca Bini
You know, we have...
00:32:56
Ryan Bailey
Yeah.
00:32:57
Gianluca Bini
And...
00:32:58
Annatasha
That's because we spend most of our time with surgeons. Like, what do you expect to happen? Yeah. yeah Like, yeah yeah, no, I mean, one of the reasons a lot of us do get driven towards the specialty is because the client interface is either we've been traumatized or we find it draining or, you know, like I just really do not enjoy it. So that was definitely a part of my decision process.
00:33:24
Dr. Chris Pachel
It's fascinating because me, I got into vet med for animals. I got into behavior for people. Like I actually went in the opposite direction that the opportunity to meet them where they are, to ask questions, to get curious, to understand their pain points, to be able to troubleshoot and figure out exactly what can we do collaboratively?
00:33:44
Dr. Chris Pachel
What can I do for you? What do I need you to do?
00:33:46
Annatasha
This is like my worst nightmare. I don't care about anybody else's opinion. Yeah. And like, I'm working on my second career right now, which is fostering, like, to like buy myself a hermitage and become like a professional hermit.
00:33:58
Annatasha
So yeah, no, I could never imagine being like, Oh, i want to go to it for the people.
00:34:00
Gianluca Bini
one
00:34:04
Annatasha
Like, who who
00:34:10
Gianluca Bini
So so to to to lighten up the mood, what's your favorite hot dog, Chris?
00:34:11
Dr. Chris Pachel
yeah
00:34:13
Annatasha
yeah
00:34:16
Gianluca Bini
Because Ryan is a hot dog connoisseur, right? He has that books about hot dogs and he just... How do you eat your hot dogs?
00:34:28
Dr. Chris Pachel
In Reykjavik.
00:34:29
Gianluca Bini
and
00:34:30
Ryan Bailey
Oh.
00:34:31
Gianluca Bini
and Okay.
00:34:33
Dr. Chris Pachel
So as soon as you started asking the question, I can't tell you exactly what it was, but it was so we were I was speaking in Iceland about two years ago.
00:34:33
Gianluca Bini
How did you end? Okay.
00:34:42
Dr. Chris Pachel
And one of the things that is sort of if you're looking at the Reykjavik like things to do, there is this hot dog stand that is like one of the things to do. And my husband and I were like, man it's a hot dog.
00:34:53
Dr. Chris Pachel
Sure, we'll try it. We're here. Check the box.
00:34:55
Annatasha
I'm crying straight.
00:34:58
Dr. Chris Pachel
I know, I know, I know. Hold on, hold on. Don't judge me quite yet. Like, I'm not a connoisseur, so i'm like, i'm sure I'm sure it'll be good. Like, I'm sure it will be. I think we visited every single day we were in Reykjavik. I'm like, this is the best fucking hot dog I've ever had in my life.
00:35:13
Dr. Chris Pachel
And there was like, again, there was a crunch in there.
00:35:13
Ryan Bailey
Hmm.
00:35:16
Dr. Chris Pachel
i don't know if it was potato chips in the bottom or there was something else.
00:35:17
Ryan Bailey
Okay. All right.
00:35:19
Dr. Chris Pachel
And the sauce that was, again, it sounds completely bizarre. The texture, the pop, the bread, the everything about it was as close to perfection in a hot dog as you can absolutely imagine.
00:35:32
Dr. Chris Pachel
So yeah mate if you haven't been, it's a hot dog stand sort of just in the the kind of the downtown area.
00:35:34
Ryan Bailey
Yeah.
00:35:37
Dr. Chris Pachel
Again, you won't have to like Google it. Reykjavik hot dog, boom, you'll find it.
00:35:42
Ryan Bailey
Okay.
00:35:42
Dr. Chris Pachel
And it was the best hot dog I've ever eaten, so much so that I ate many of them.
00:35:47
Annatasha
Well, now we know where Ryan's going on his next vacation.
00:35:49
Ryan Bailey
That is a glowing endorsement.
00:35:50
Dr. Chris Pachel
I don't know what
00:35:51
Ryan Bailey
Like to go when you're in a foreign country and there's many things to eat and you're like, this hot dog is the one I'm going to go back to. all right. I'm sold.
00:36:00
Dr. Chris Pachel
Yeah.
00:36:01
Ryan Bailey
I'm sold.
00:36:01
Gianluca Bini
There you go, Ryan.
00:36:01
Dr. Chris Pachel
Yeah.
00:36:02
Gianluca Bini
You're booking the tour.
00:36:03
Dr. Chris Pachel
It's like, it's right up there with like the Greek, the Greek yogurt and honey on Santorini, like looking at the caldera, like it is up there next to this hot dog.
00:36:12
Ryan Bailey
Wow. That is like a, wow.
00:36:13
Dr. Chris Pachel
Yeah.
00:36:15
Ryan Bailey
Wow.
00:36:15
Annatasha
Ryan, maybe you should consider just becoming like a hot dog travel writer where you just like basically travel the world. This could be a great show where you just travel the world, visiting like famous sausage and hot dog stands.
00:36:23
Ryan Bailey
I mean,
00:36:27
Annatasha
And, you know, you'll be dead in five years from coronary artery disease, but it'll be worth it.
00:36:31
Ryan Bailey
ah I'll be happy. I'll be happy.
00:36:33
Annatasha
You'll be dead and happy. Yeah.
00:36:35
Ryan Bailey
I'll feel good.
00:36:37
Annatasha
but and
00:36:37
Gianluca Bini
You can be the new Stanley Tucci.
00:36:40
Ryan Bailey
I mean, that would be that would be my dream. Like to tour the world, just eating all the various hot dogs and sausages would be like, white what better life?
00:36:40
Annatasha
Yeah.
00:36:48
Dr. Chris Pachel
Thank you.
00:36:49
Ryan Bailey
Like what a good life.
00:36:51
Annatasha
mean I, you know, honestly, I don't disagree. Like it's clearly better than being an anesthesiologist.
Challenges in Veterinary Anesthesiology
00:36:56
Ryan Bailey
but Wah, wah. Which, to the earlier point, though, is probably a little bit because of the lack of client interface.
00:37:07
Ryan Bailey
Because our clients are co-workers.
00:37:10
Annatasha
Yeah. And they're the, honestly, i swear to God, 99.8% of the time, the anesthesiologist's worst enemy is another veterinarian.
00:37:18
Ryan Bailey
Yep. Yep.
00:37:18
Annatasha
Yeah, I feel so unsupported by other like clinicians and specialties. it is unreal.
00:37:24
Dr. Chris Pachel
crawl
00:37:33
Annatasha
So can we talk gabapentin, also known as vitamin
00:37:36
Gianluca Bini
<unk>s like wow
00:37:36
Dr. Chris Pachel
If I can shake off the sadness that I feel for your profession, sure
00:37:43
Annatasha
but you have to like, you just accept that we live under a little black rain cloud. know,
00:37:47
Gianluca Bini
We don't even... Most people don't even know us by name. They just call you anesthesia.
00:37:55
Gianluca Bini
there there ah There is no... there is
00:37:57
Annatasha
Jamie, at least your name is an Anatasha. Do you have any idea how much abuse I have to take for being Anatasha, the anesthesiologist? Like basically tell me,
00:38:05
Ryan Bailey
ah ah You were kind of destined for that. That was...
00:38:07
Annatasha
Like they call me anesthesia. Like, and I'm just like, yeah, no, I get it. It's still not funny. But yeah, like.
00:38:16
Annatasha
Destiny did not work out in my favor in this capacity.
00:38:19
Dr. Chris Pachel
No.
00:38:19
Gianluca Bini
Is that why you became a chief medical officer now? There
00:38:23
Annatasha
Yes. So people call me chief instead of anesthesia.
00:38:28
Annatasha
Wow.
00:38:29
Ryan Bailey
Wow.
00:38:30
Annatasha
wow
00:38:32
Ryan Bailey
upgrade, I guess.
00:38:37
Dr. Chris Pachel
So, GABA-pensin.
00:38:38
Gianluca Bini
Go abandon. That's the bane of our existence.
00:38:40
Dr. Chris Pachel
like
00:38:43
Annatasha
Well, that's not true, Beanie, because you have this real hang on for lidocaine.
00:38:44
Dr. Chris Pachel
Yes.
00:38:46
Annatasha
So and my and my true, my true arch nemesis is isoflurine.
00:38:48
Gianluca Bini
Fucking lie.
00:38:53
Annatasha
Yeah.
00:38:54
Ryan Bailey
Oh.
00:38:54
Annatasha
yeah
00:38:55
Gianluca Bini
It's true. and the percent 100%. As if you're in a sense, everything is shit. Isn't that what you say once?
00:39:02
Dr. Chris Pachel
So tell me from the anesthesia perspective, what do you, before I dive in on my thoughts on gabapentin, what do you hate about it? Like what's what's the what's the what's the animosity? What's the feeling here?
00:39:15
Gianluca Bini
Ooh.
00:39:15
Ryan Bailey
Not the drug itself. It's the utilization of the drug that we don't like.
00:39:18
Gianluca Bini
Yes. Yes.
00:39:20
Ryan Bailey
I also i also want to add
00:39:20
Annatasha
It's throwing it at pain, especially visceral and somatic. it's a mandatory part of a post-operative protocol that makes us squirrely.
00:39:30
Dr. Chris Pachel
Mm-hmm.
00:39:30
Ryan Bailey
I to add a thing I learned from the human side when I was in the pain clinic is like some humans, like to your to your earlier point, Chris, about how patients feel different.
00:39:43
Ryan Bailey
Some humans swear by it. It is like like, like it changed their lives. Like their lives were materially better by going on gabapentin. They felt better. They, they were like, it it's life-changing. Some people absolutely hated it.
00:39:56
Ryan Bailey
They described it as being in a fog state.
00:39:59
Dr. Chris Pachel
yeah
00:40:00
Ryan Bailey
And it was like, they just didn't feel in control and they felt like very foggy and they hated it. They never wanted to touch it. They never wanted to have it prescribed to them again. They thought it was like the absolute worst.
00:40:11
Ryan Bailey
And like, again, we can't ask our patients how they feel. And so like, I think that's, that's what happens to our patients when we use this drug.
00:40:15
Dr. Chris Pachel
Yeah.
00:40:19
Dr. Chris Pachel
yeah
00:40:20
Ryan Bailey
And I, it's not, you know, again, humans, dogs, you know, humans, cats, et cetera. But like, I can't imagine it's that different. Like, I'm sure some dogs feel that perceive that, you know, i don't feel comfortable, you know,
00:40:30
Dr. Chris Pachel
yeah
00:40:34
Dr. Chris Pachel
yeah
00:40:35
Gianluca Bini
yeah
00:40:35
Dr. Chris Pachel
and know and I absolutely see that may pre in my patient population. I mean, I have many of my patients where when we're looking at them objectively, what are the criteria, grab me video of what they look like on or off at various various doses, where it's absolutely not helpful.
00:40:52
Dr. Chris Pachel
And others, I think the the tricky thing for me with gabapentin sort of in my world is, you know For some of those patients who do seem to have ah beneficial response to pain control, again, do I think it's effective across the board? No, but we do have some of those patients where it does seem to be effective for whatever it is that we're treating. But the big question that I have is when we're looking at a med that can have some degree of sedation, depending on the patient,
00:41:16
Dr. Chris Pachel
And potential for pain control. Again, potential, depending on the case. We also know that at least on the on the human side, some of the there's not a lot of controlled studies on the anxiolytic effects, but it is sometimes used as an adjunctive for a maintenance and anxiolytic protocol in combination with an antidepressant.
00:41:33
Dr. Chris Pachel
Then I do have some of those patients where as a mood-altering substance, it can absolutely be incredibly profound in the effect. But again, patient selection and really asking the question, not just this is what I prescribe because you've got behavior issues. So here's your Prozac, here's your gabapentin, here's your trazodone.
00:41:53
Dr. Chris Pachel
But what am I actually trying to support for you from a physiologic standpoint, actually looking at? that psychopharm angle of things, what am I actually trying to do?
00:42:03
Dr. Chris Pachel
and And I agree, almost all of my patients at this point, when they're referred in, assuming anybody's been managing from a behavior standpoint, all of them have some degree of of clinical history with gabapentin, most with trazodone, about half with fluoxetine.
00:42:20
Dr. Chris Pachel
So it's it's it's pretty common. So I understand the kind of ubiquitous nature of it.
00:42:24
Gianluca Bini
Yeah.
00:42:24
Annatasha
i Yeah. And I also think, I mean, chime in everybody, but have an ethical consideration for discussion, which is, you know, if we're giving every single, you know, patient X drug and three out of a hundred are reacting, like, I'm not sure that's the appropriate way to practice, right?
00:42:29
Dr. Chris Pachel
Thank you.
00:42:41
Annatasha
Like giving gabapentin specifically in case there's a, you know, benefit from a, particularly from an analgesic point of view, which I find highly tenuous, like, I mean, I've had cases refer to me, know like huge, like dental root abscesses with like facial cellulitis and they get transferred over on gabapentin only.
00:43:00
Annatasha
And it's just wild to me how inappropriate that is. But if you give, you know, 100 patients, you know, gabapentin and three for whatever reason react, for me, that's an ethical consideration to what happened to the other, you know, 97% that population.
00:43:03
Dr. Chris Pachel
wow yeah
00:43:13
Dr. Chris Pachel
yeah
00:43:13
Annatasha
Like I said, it's the new famotidine. Like we hand it out, like it's a multivitamin and really don't spend a lot. we We treat it as being so ultimately benign.
00:43:22
Dr. Chris Pachel
yeah
00:43:22
Annatasha
um um And I, and I disagree with that both physiologically and probably in your case, like behaviorally. Right.
00:43:29
Dr. Chris Pachel
yeah Yeah, it's it's not benign. And I think that's that's one of the concerns that I appreciate you bringing that up, Tasha, because its it's one of the things that, you know, at least when I'm talking with my clients and we're trying to come up with whatever protocol we think is the the right thing to do for them, you know, I try to be really mindful within the conversation to say, yes, you know, based on X, Y, and Z pattern or concern, we are trying to do this for them as a way of bettering their condition through prescribing, obviously in combination with other interventions, but
00:43:34
Ryan Bailey
but
00:43:58
Dr. Chris Pachel
But I never want to lose sight of the fact that because they did not opt in for whatever that therapy is ultimately, it's something we are doing to them. And I want to be really mindful that from a welfare standpoint, that we're never sort of overlooking that. Again, if they truly are drugs that work even in a portion of the population, the likelihood of them being benign for the rest is would seem pretty low.
00:44:23
Dr. Chris Pachel
And so just because it's tolerated doesn't mean it's innocuous. And I very much appreciate that perspective.
00:44:28
Annatasha
I like that. Just because it's tolerated doesn't make it innocuous.
00:44:30
Ryan Bailey
Ha ha ha.
00:44:31
Annatasha
I'm going to slap that on the back of every surgeon's jacket that I know.
00:44:32
Gianluca Bini
Yeah.
00:44:36
Annatasha
love But yeah, no, I think it's interesting because specifically like utilized in a pain fashion and not having any consideration for what the other effects may be to the patient, lack of analgesia being one, but whether or not it does cause like mood or alteration or like a a difference in, in,
00:44:37
Gianluca Bini
machine
00:44:52
Annatasha
sensory perception, you know, in humans, again, a big species extrapolation. However, you you know, you look at a lot of those pain studies cause we're, we were so over focused in veterinary medicine. I think at pain management at this point that we're actually over analgesic a lot of cases, and not thinking well through the protocol, but more importantly,
00:45:12
Annatasha
you know, the the adverse side effects of a lot of these drugs, particularly in combination, particularly a lot of the clinical doses that I see getting used.
Gabapentin in Veterinary Medicine
00:45:19
Annatasha
I mean, humans will report that if they have a choice, for example, between pain and nausea or pain and dysphoria, or even pain and severe puritis, they choose pain, right?
00:45:29
Ryan Bailey
Thank
00:45:31
Annatasha
Like if you look at the the obstetrical papers and women who said that, for example, like they were so profoundly nauseous after
00:45:37
Gianluca Bini
yeah.
00:45:37
Annatasha
the epidural or just associated with labor in general, that actually the nausea was worse than the childbirth, you know, and the patients that they have who, for example, they put on methadone because they're addicts, right?
00:45:39
Dr. Chris Pachel
Wow.
00:45:44
Dr. Chris Pachel
but
00:45:50
Annatasha
And so they're trying to do like a weaning protocol for an opioid addiction. They will tell you that that dysphoria is worse than withdrawal, is a massive statement because opioid withdrawal is a horrendous physiological experience.
00:46:02
Annatasha
So yeah, I just, you know,
00:46:05
Annatasha
I wonder what happens sometimes to critical thinking and clinical reasoning. um And right now, like I find like the, the abuse of gabapentin is, is overall like landing in a way that actually i think is detrimental.
00:46:19
Dr. Chris Pachel
Thank you.
00:46:19
Gianluca Bini
It's huge. like People dispense it like if it's an actual true tried and true analgesic, right? Like, you know, you have patients that just go home on that, right?
00:46:31
Gianluca Bini
And I'm like, what the heck is wrong
00:46:33
Annatasha
And instead of like, for example, an NSAID because, oh, he threw up once 25 years ago. So we're not going to give meloxicam, but I'm going to send him home after an X lab on, you know, a hundred megs of gabapentin. And I'm like, well why don't you just dance around with a stick and sprinkle like rain over Like, it's just, it's ridiculous.
00:46:50
Annatasha
Like, yeah. But I'm like, yeah, we tossed NSAIDs out, you know, and there's so many preclusions or exclusions for NSAID use and there's so much more efficacious, but God knows we'll give gabapentin.
00:46:54
Dr. Chris Pachel
right?
00:47:02
Ryan Bailey
I feel
00:47:02
Dr. Chris Pachel
Yeah.
00:47:03
Annatasha
Yeah.
00:47:04
Gianluca Bini
Yeah, it's is definitely abused.
00:47:05
Dr. Chris Pachel
Yeah.
00:47:07
Gianluca Bini
you know that's I think that that's definitely bad. you know when
00:47:12
Dr. Chris Pachel
Yeah.
00:47:12
Gianluca Bini
When something goes from being a tool in the toolbox to being blanket dispensed to everybody for dubious reasons.
00:47:21
Dr. Chris Pachel
yeah
00:47:23
Gianluca Bini
like And and and you know people forget about this, but there placebo effect is real, right? Even in Batman, right?
00:47:31
Dr. Chris Pachel
Absolutely.
00:47:32
Gianluca Bini
And it's huge.
00:47:32
Annatasha
It's real for the client. It's not real for the patient, right? Like if you have a limping dog, you put them on gava and they limp, right?
00:47:38
Gianluca Bini
Of course.
00:47:39
Annatasha
Like the patient is still painful unless obviously it's a functional limp. So the only thing perceive that it's improved, but an animal can't fake a placebo effect, right?
00:47:43
Dr. Chris Pachel
However,
00:47:49
Dr. Chris Pachel
They can't, however, and this is again, when we're when we're working through the client, you know, basically on on sort of who is reporting benefit or not, it's one of those things that's really important. There was a study that was in the popular press, at least i think it was the New York Times, probably four to six weeks ago, and they were reporting basically observation skills in sort of your average human.
00:48:10
Dr. Chris Pachel
And if they were shown video examples of dogs in variety of scenarios, based on the story that the individuals was sort of told about what they were seeing, the interpretation of what was observed as the same video clip across different scenarios was interpreted completely and totally different.
00:48:28
Dr. Chris Pachel
And so it's a fascinating sort of a thing about the the trick of observation. And so if I'm told that this is a pain medication and I give it, and then I see 17 tail wags in the next two hours, I'm more likely to see those as a positive indication of, of affect and comfort.
00:48:46
Dr. Chris Pachel
And that's going to stand out because of that observation bias and then i'm more likely to report which perpetuates the perception that it was actually helpful both for the prescriber as well as for the administer and now we've got again that kind of dogma being perpetuated with or without actual objective data support it
00:49:03
Annatasha
Exactly. We give humans way too much credit, like I said, but,
00:49:07
Ryan Bailey
Yeah.
00:49:08
Gianluca Bini
i and you know i think that that applies also to the prescriber as well. right like the the The observation bias, it's yes, from the Horner standpoint, which of course is going to help what they report about their fate their dog but or cat, but you know, also out people that do prescribe it, you know, if they have that mindset that that's going to definitely work, they have that observational bias that, oh, this thing is actually working.
00:49:29
Dr. Chris Pachel
Yes.
00:49:39
Gianluca Bini
Like, you know, and we see it with several drugs out there, right? Like there is drugs that have been advertised to have a super long duration of action for analgesia. And in reality,
00:49:50
Annatasha
Like subcutaneous ketamine?
00:49:53
Gianluca Bini
Yes, that's one of them. You know, and there's zero evidence behind any of that, right? Like, and and it doesn't even make sense whatsoever, right?
00:50:01
Dr. Chris Pachel
Yeah.
00:50:04
Gianluca Bini
But people still believe that that's, some people still swear by it, right? and And it's probably placebo and it's probably some observational bias in there, but it's hard to get rid of it, you know?
00:50:09
Dr. Chris Pachel
and
00:50:17
Dr. Chris Pachel
yeah
00:50:17
Annatasha
It's hard.
00:50:17
Gianluca Bini
It's really hard.
00:50:18
Annatasha
I think that placebo, I mean, I'm all for placebo. If you're, for example, like, you know, in if I'm the patient, because obviously like that, the mental processing and the emotional regulation associated with healing is an important part of like
Placebo Effect and Serotonin Syndrome in Veterinary Practice
00:50:32
Dr. Chris Pachel
Yes.
00:50:32
Annatasha
the mind body balance.
00:50:34
Annatasha
But you can't, like, I can't give my cat with pancreatitis, like an Assisi loop and explain to her that it's like analgesic and that, you know, and like set her up for bias. So either she improves pain wise or or she doesn't.
00:50:47
Annatasha
And then I have to be cognizant of my own bias towards that. But like I said, the placebo effect can have improved medical outcomes in people. But I really, really struggle to believe that that is true in our pet populations.
00:50:59
Dr. Chris Pachel
So it's it's interesting when we look at some of the human-animal bond dynamics.
00:51:03
Gianluca Bini
Thank you.
00:51:04
Dr. Chris Pachel
I do wonder, though, how much there can be some of that, don't know what the right terminology would be, but transference of placebo benefit, that if you have an owner who is, you know as ah ah as an example, who is sort of worried about the overall health and well-being or or physical comfort of their animal,
00:51:21
Dr. Chris Pachel
But now I've got gabapentin to give you. So I feel better. So I'm breathing more easily. And therefore, that cumulative stress is less impactful in a negative way. you know, does the placebo effect actually have some carryover if it changes the conversation or the dynamic, which, again, wouldn't be an actual direct effect on pain per se.
00:51:44
Dr. Chris Pachel
But if we're looking at, you know, so some of the other the other pathways that we're that we're sort of looking at there, I I do wonder.
00:51:53
Annatasha
Yeah, no, in other words, we should also sedate the owners. That's what you're saying, Chris?
00:51:57
Ryan Bailey
You
00:51:59
Dr. Chris Pachel
We would talk through it a fair amount before I would go down that pathway necessarily, I
00:52:03
Annatasha
and
00:52:05
Annatasha
Yeah. At the end of the day, you're secretly going to end up being an anesthesiologist because you realize that everything is better unconscious.
00:52:06
Gianluca Bini
I
00:52:13
Dr. Chris Pachel
we I have to laugh. So I'm one of these people at conferences, Beanie knows this. So I'm at conferences and I am like the social butterfly. Like I am in the midst of it. i'm Like give me an exhibit hall and the opportunity to like socialize and you know engage in conversation. And I'm the one at the front of the room answering every single question, literally until I'm the last one in the room and they're turning the lights out on me.
00:52:35
Dr. Chris Pachel
So that that is my worldview of how I approach things. So very much at opposite ends of the delivery of veterinary care perspective, perhaps.
00:52:47
Annatasha
Yeah. Now, if you go to an anesthesia conference, there's always a social function, which is attended by less than, I think, half of the people because people like they'll the other anesthesiologists will be like, I'm not going. i don't want to see the other anesthesiologists.
00:52:58
Annatasha
Like that's how little we like people.
00:52:59
Ryan Bailey
Oh
00:53:00
Annatasha
We don't even like each other.
00:53:02
Ryan Bailey
but
00:53:02
Annatasha
oh Right. And like if you go to like the actual exhibit hall between lectures, like everyone just walks with like their face down because they don't want to make eye contact and have to talk to a rep. Right.
00:53:14
Annatasha
Yeah, this it's a, to like, this is wild. Like, I'm going to, if I went to behavior conference, I'd be like, oh, overstimulated.
00:53:16
Gianluca Bini
hello
00:53:20
Ryan Bailey
my god. For sure.
00:53:22
Annatasha
yeah
00:53:22
Ryan Bailey
For sure.
00:53:24
Gianluca Bini
We should do that. We should hijack and a behavior conference.
00:53:28
Dr. Chris Pachel
I would love to see y'all sitting in the corner just like watching, watching the craziness that unfolds.
00:53:28
Gianluca Bini
And...
00:53:34
Dr. Chris Pachel
Like we, the last behavior conference at, well, granted this was after the bar closed, but we were doing a human pyramid on the streets of Minneapolis. And I think we had four layers to the, I mean, literally this is what was happening.
00:53:47
Dr. Chris Pachel
I have a picture of it somewhere. Yeah. Yeah.
00:53:51
Ryan Bailey
I can't imagine that happening at an anesthesia conference.
00:53:51
Dr. Chris Pachel
different
00:53:53
Annatasha
The last conference I went to with Bailey, he texted me telling me he was refusing to come to the social function and to meet him at the tequila bar down the street, but don't bring anybody.
00:54:02
Ryan Bailey
And that tequila bar was the best margarita I have ever had.
00:54:06
Annatasha
That tequila bar is one of the most fun bars I have ever been to in the world. But yeah, you were just like, it only has like room for eight people. So you're like, don't bring anyone. And I was like, who was I going to bring anyway?
00:54:15
Ryan Bailey
yeah It, it,
00:54:16
Annatasha
I don't like anybody. Yeah.
00:54:17
Dr. Chris Pachel
but
00:54:17
Ryan Bailey
It was like a car garage length. It was as big as the room I'm standing i'm sitting in right now.
00:54:24
Dr. Chris Pachel
Amazing.
00:54:24
Ryan Bailey
And
00:54:25
Annatasha
And the drinks were just amazing. And it was just like, yeah, it was like beside a dumpster and like, it had like a metal like drop down.
00:54:28
Ryan Bailey
the mullets.
00:54:32
Annatasha
I'm like, Oh God, it was Sydney, Australia,
00:54:33
Ryan Bailey
Yeah.
00:54:33
Dr. Chris Pachel
Where was this?
00:54:34
Ryan Bailey
And the mullets. I'll start sitting in.
00:54:38
Annatasha
but Sydney, Australia.
00:54:38
Dr. Chris Pachel
next
00:54:39
Annatasha
But yeah, he literally texted me from outside the conference being like, yeah, I'm not coming. Meet me somewhere secret.
00:54:45
Ryan Bailey
I had been there for a few minutes and I was like, I get it I'm going to go now.
00:54:49
Dr. Chris Pachel
right Yeah, i'm I'm early in, I'm laid out, I am i am here for it. So, yeah.
00:54:58
Gianluca Bini
You're always there.
00:54:58
Dr. Chris Pachel
Different.
00:54:59
Gianluca Bini
Yeah.
00:54:59
Dr. Chris Pachel
Different strokes.
00:55:01
Gianluca Bini
So, you know, do you guys, you know, behaviorists sometimes they do prescribe fluoxidin, right, to a bunch of patients.
00:55:09
Dr. Chris Pachel
Absolutely.
00:55:10
Gianluca Bini
Have you ever seen any like serotonin syndrome or whatnot, like from an anesthesia standpoint? You know, it's like I, it's described. I can't say I've anesthetized a bunch of patients on fluoxidin.
00:55:25
Gianluca Bini
I can't say I've ever seen it.
00:55:27
Dr. Chris Pachel
So my answer to this, when I'm talking with veterinarians or when I'm teaching my students, like I say, you know, back back in the day when I was going through my educational process and, you know, every, anytime you talked about anything that was serotonergic in function, it was like, but be cautious because if you overdo it, serotonin syndrome.
00:55:44
Dr. Chris Pachel
And it sort of stands out in my life now as sort of the way that I thought about things like quicksand when I was a kid watching like television cartoons. Like I thought it was going to play a much bigger role in my life.
00:55:56
Dr. Chris Pachel
than it actually does as an adult.
00:55:59
Ryan Bailey
I thought the same thing.
00:56:01
Dr. Chris Pachel
Right?
00:56:01
Annatasha
I also had an irrational quicksand phobia as a child.
00:56:04
Annatasha
Like I was like, like going off know I'm going to step in it.
00:56:05
Dr. Chris Pachel
Like, everywhere.
00:56:05
Ryan Bailey
i was like, it must be everywhere.
00:56:10
Annatasha
My sister's going to let me sink because she hates me.
00:56:12
Dr. Chris Pachel
Right?
00:56:12
Annatasha
Like, yeah.
00:56:13
Dr. Chris Pachel
Right, right. i'm And it's gonna happen in like seconds. Anyways, so like to me that serotonin syndrome within my world and the perspective, like can it happen?
00:56:18
Ryan Bailey
like,
00:56:22
Dr. Chris Pachel
Absolutely. With that being said, the only times that I'm ever typically even kind of aware of it as a potential is either in cases of acute overdose So the cat that ODs on venlafaxine, for example, because it tastes yummy to them. I don't know why, that but it does.
00:56:38
Dr. Chris Pachel
So like something along those lines. Or if we have a patient who's been on, let's say, maintenance fluoxetine and they go into a new clinic and someone's like, oh, I think they have cognitive dysfunction. Let's throw Anapril or Selegiline on top of that. And we're doing an SSRI-MAOI combination.
00:56:52
Dr. Chris Pachel
Okay, that's one of the times where it's more likely to be reported. But standard dosing, clinical usage, monitoring just for routine, you know, function and tolerance.
00:56:56
Ryan Bailey
Mm-hmm.
00:57:05
Dr. Chris Pachel
Now, I can't think of a single case truly in 20 years where was like, that was that. Not to say that it couldn't have happened, but, and I see some cowboy doses coming in but for some of my patients, um including, oh God, this morning, literally I was doing a consult and I'd like to, this owner doing, doing their due diligence of doing what's been, giving what's been prescribed, but they were listing, it was just crazy doses of all of the medications.
00:57:13
Gianluca Bini
Yeah.
00:57:33
Dr. Chris Pachel
I was like, wow, and your dog is bouncing around like an out of control Labrador. So clearly they're doing okay. And not dying of serotonin syndrome. So mindful, not concerned, generally speaking, as long as I'm only sort of when I'm using one antidepressant at a time.
00:57:51
Ryan Bailey
the
00:57:51
Dr. Chris Pachel
That's my main concern.
00:57:53
Ryan Bailey
do you Do you have any like idea or speculation? like is it a ah ah like a specific interaction with humans or is it a ah ah dose relationship that we use in dogs? like we In the anesthesia world, they are lectured hard about this. like If a human is on...
00:58:12
Ryan Bailey
you know like antipsychotic type drugs, you have to be really cautious with drugs like methadone and like ah ah many of the drugs in the opioid family because serotonin syndrome is real and happens in the OR in the pre-op period, not infrequently. And I just, I wonder why, like it's, it's such a fear for them where it's like, we are so lackadaisical about it.
00:58:37
Dr. Chris Pachel
Yeah, no, no not at all.
00:58:38
Gianluca Bini
Okay.
00:58:38
Dr. Chris Pachel
So what, so of the drugs that we're using routinely in the veterinary space, which would be the, which would be the parallels, right? In terms of where that's likely to show up.
00:58:47
Ryan Bailey
I mean, that I always think of like the fluoxetine and the trazodone as being like culprits from the human side.
00:58:51
Dr. Chris Pachel
Yeah.
00:58:54
Ryan Bailey
But I don't know if there's other like they're they're also on like try to get antidepressants not uncommonly and like oh but a litany of other drugs that we are we don't see as regularly.
00:59:05
Ryan Bailey
And so maybe that's a piece of it.
00:59:06
Dr. Chris Pachel
thank
00:59:08
Dr. Chris Pachel
Maybe. I mean, I know that there are some differences from a metabolism standpoint. I know even on the TCA side of things with ah with with that, kind of the older generation antidepressants, there are some of the drugs like clomipramine, the generic of clomacolm that we use in the canine world, where one of the one of the big concerns there with that particular drug in humans is an arrhythmia. I forget.
00:59:27
Dr. Chris Pachel
Don't ask me about arrhythmias. So it's it's one of those... prolongation things that I don't remember from my boards.
00:59:33
Ryan Bailey
Yeah.
00:59:34
Dr. Chris Pachel
And anyways, it happens because of one of the secondary metabolites of clomipramine in humans.
00:59:40
Ryan Bailey
Hmm.
00:59:41
Dr. Chris Pachel
But the difference in the metabolic pathway is so different in dogs that even when it's looked for, it's not appreciated, even at high doses. So, I mean, I know that there are clinical examples like that where there are substantial differences either in metabolism or side effect profiles, you know, including some of things, and obviously this is a very different example from what you were mentioning, but, you know, if we're looking at dosages of benzodiazepines, for example,
01:00:06
Dr. Chris Pachel
You know, when I think about the doses of an oral benzo that I would prescribe from an anxiolytic standpoint, I know that I'm going to get a call from the pharmacist thinking I'm trying to like uptunned that animal into like next Thursday based on the doses that I'm prescribing. like
01:00:23
Ryan Bailey
one
01:00:24
Dr. Chris Pachel
yeah ah ah One of my first cases, i was a baby resident. I was like, probably like my third day of seeing actual cases on my own. And I was seeing a Labrador sized dog, probably 30, probably 27 kids, something like that.
01:00:36
Dr. Chris Pachel
And we were going to be using diazepam on an oral basis to be able to support the dog at home separation anxiety. I didn't know it, but the owner was a psychotherapist. And so I'm like, well, oral diazepam, you know, half to two migs per kg up to Q4.
01:00:52
Dr. Chris Pachel
And I'm saying, okay, we can use 15 milligrams all the way up to probably 65 or 70 milligrams of diazepam. And she looked at me and then she looked at my mentor and she looked back at me and like was completely dumbfounded by the fact that I would do that routinely And, you know, so again, it was one of my first introductions into the mindset that people are not dogs, dogs are not people and cats are completely different in and of itself.
01:01:15
Ryan Bailey
Totally.
01:01:17
Dr. Chris Pachel
So.
01:01:18
Ryan Bailey
yeah
01:01:18
Gianluca Bini
Oh, yeah. I mean, I was i had some interactions when you know i was at Ohio State and with, you know, their, you know, they they collaborate with the children's hospital there. And some of the researchers were struggling to keep pigs asleep.
01:01:35
Gianluca Bini
And they were using kids' doses of like fentanyl and drugs. And i was like, yeah, that needs 50 dines more. That's not...
01:01:46
Annatasha
is made of pure fat and you're getting those doses right up.
01:01:50
Ryan Bailey
ah
01:01:51
Gianluca Bini
I that's not a kid. It's a pig. you know what
Conclusion and Thanks to Dr. Pockel
01:01:56
Dr. Chris Pachel
Yeah.
01:01:56
Gianluca Bini
And they were they were like struggling, right?
01:01:58
Gianluca Bini
and They were like, why do they keep waking up? They don't go to sleep. I like, yeah, because...
01:02:03
Annatasha
yes Because you're not actually hitting effective dose.
01:02:06
Ryan Bailey
Waving the wand at us.
01:02:08
Dr. Chris Pachel
You're whispering anesthesia to them, but that's about it.
01:02:11
Annatasha
Yeah, get the gabapentin.
01:02:13
Ryan Bailey
yeah.
01:02:13
Annatasha
native
01:02:18
Gianluca Bini
That's awesome, guys. Well, we're coming up on the hour. So I guess thank you so much for being here, guys. Thank you so much, Chris, for you know coming in as our first guest ever for the Random Anesthesia Topic Podcast.
01:02:33
Annatasha
Perfect first guess. Like great sense of humor. Yeah.
01:02:36
Ryan Bailey
if
01:02:37
Gianluca Bini
It is the best. That's how I was like, if if it has to be one, it needs to be you.
01:02:38
Dr. Chris Pachel
Thank you.
01:02:42
Gianluca Bini
And so...
01:02:44
Dr. Chris Pachel
I will take.
01:02:44
Annatasha
praise indeed Praise indeed, because as you have may have discerned, we don't like anybody.
01:02:49
Annatasha
so
01:02:49
Dr. Chris Pachel
Well, and the fact that I survived an hour hanging out with three anesthesiologists, like this isn't this is an epic new for me as well.
01:02:49
Ryan Bailey
So, barely like each other.
01:02:57
Dr. Chris Pachel
So, you know.
01:02:58
Annatasha
And didn't even cocktail tonight because we were trying to a little bit seem professional and be in somewhat good behavior, but normally we cocktail when we do this, so...
01:03:05
Dr. Chris Pachel
Well, if you ever invite me back, I will totally do that. I'm still at the office today. So I'm, you know, I'm i'm i'm still in in work mode being on the the West or the West Coast, depending on how you interpret that.
01:03:13
Ryan Bailey
That's true.
01:03:15
Dr. Chris Pachel
And so I'm still at the office.
01:03:17
Annatasha
It's better than the ice storm here in Ontario. So.
01:03:21
Dr. Chris Pachel
so True. yeah
01:03:24
Gianluca Bini
Well, thank you so much, guys. We appreciate you See you next time.
01:03:30
Ryan Bailey
Bye.