Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: The golden hour is a concept we have adopted from the trauma literature.
Speaker: It defines the first hour post-traumatic event and highlights the importance specific interventions during this first hour have on the ultimate outcome of a patient.
Speaker: The golden hour is a critical window that requires systematic evaluation intervention with time-sensitive therapies.
Speaker: In today's episode of the podcast, we will discuss the first hour post-cardiac arrest with return of spontaneous circulation, the golden hour post-ROAC.
Speaker: Our guest is Dr. Haney Malamud.
Speaker: Dr. Malamud is a critical care intensivist and emergency medicine clinician at Cooper University Health.
Speaker: He is also associate professor of medicine and of emergency medicine at Cooper Medical School of Rowan University in Camden, New Jersey.
Speaker: Haney is a great Batesat clinician, an ultrasound guru, and a master educator.
Speaker: He is the editor-in-chief of Critical Care Now, an amazing educational platform from Critical Care.
Speaker: He is the founder of ResurceX, a conference focusing on state-of-the-art resuscitation.
Speaker: I encourage you to explore both.
Speaker: Haney, welcome back to Critical Matters.
Speaker: Hey, Sergio.
Speaker: Thanks for having me back on again.
Speaker: Well, today we're going to talk of a very important topic.
Speaker: I know dear to your heart, we've talked of different topics throughout the years on Critical Matters.
Speaker: And today we're going to really focus on a narrow time window, which is that first hour after we have success or we think we have success in a cardiac arrest and have
Speaker: return of spontaneous circulation or ROSC.
Speaker: So I guess the way we get started is you get ROSC, great job, now what?
Speaker: So I just want to hear your thoughts in terms of this critical hour, this, let's call it golden hour, and perhaps something that a lot of people are not paying as much attention to other topics, post-cardiac arrest, but that might have a very important impact on the ultimate outcome of our patients.
Speaker: Yes.
Speaker: The one thing that I noticed after many years of training and then being a young attending and being an older attending is that there's so much excitement.
Speaker: There's so much adrenaline.
Speaker: There's so much effort put into a cardiac arrest.
Speaker: And I don't want this to sound insincere or, you know, and insensitive.
Speaker: You know, downplaying the matter by any means, but the act of cardiac arrest, resuscitation is actually very, very simple.
Speaker: It's algorithmic.
Speaker: Certainly we can add things like ultrasound to help augment our decision making.
Speaker: But what I'm trying to say is that there's so many people who are in that room who are fighting for that person.
Speaker: And once we get ROSC, you'll see everyone just migrate out of the room.
Speaker: And the thing that I've noticed is that it's the things that we do post-RASC that probably matter the most to the patients, yet we have the greatest loss of resources right after.
Speaker: So what I have done is made a scheme or a framework where I could put into place what we're going to do for the first 15 minutes post-RASC, the next 45 minutes after-RASC.
Speaker: And then if your patient is stuck in the emergency room for a period after or even up in the ICU, the things we do for an hour and beyond.
Speaker: Because much of what we do is preventing the person from arresting again and ultimately improving their neurologic outcomes.
Speaker: And I believe that this whole idea of time-sensitive interventions is something that started in trauma but then became, I think, a common realization in cardiac care with STEMIs and time to balloon or door to balloon time, also with strokes.
Speaker: Then we talked about it in sepsis.
Speaker: But really, it's the...
Speaker: the realization that what we do early on in critical illness does have an impact downstream.
Speaker: And I think we're seeing that more and more in other areas.
Speaker: But today, I believe that, like you said, there's a lot going on post-cardiac arrest, and perhaps it's an area of opportunity for our listeners because it might be not something that they have systematically approached in that first hour.
Speaker: So I love your framework, and we'll start with the first 15 minutes.
Speaker: So we got ROSC.
Speaker: And the clock starts now.
Speaker: What do you do in those first 15 minutes, Haney?
Speaker: The first 15 minutes is about preventing that person from going back into cardiac arrest.
Speaker: I have looked for the statistic that I heard quoted, and I can't find the reference for it, but I heard it quoted once at a conference, and that is that 50% of people who get ROSC will go back into cardiac arrest.
Speaker: So again, I don't know how accurate it is, but based on my experience, it is a pretty high number of people who will flip back into cardiac arrest after we get our initial ROSC.
Speaker: So that first 15 minutes, everything in that package is done to prevent that person from slipping backwards and going into ROSC because, as you know, the more times you go into a rest, the worse off that person is.
Speaker: So we can go through these things, but again, the goal here is to push the patient forward to resuscitate them so we don't
Speaker: lose ROSC.
Speaker: Perfect.
Speaker: And I think it's important for our critical care listeners that you got ROSC.
Speaker: Your job is not to just go back to the ICU if you were in the ED or if you were on the floors, but really to keep leading the team in those first 15 minutes.
Speaker: So what's the first thing you would do, Changi?
Speaker: The first thing I do is I need some means of monitoring this person.
Speaker: And for me, if I'm, whether I'm on a rapid response on the floors or the person's in the ICU, doesn't have an A line or they're in the ED, I need to know what their blood pressure is constantly.
Speaker: The monitor's typically cycling every 15 minutes.
Speaker: That's not good enough for me.
Speaker: I need to know when this person is starting to lose their blood pressure.
Speaker: there's a higher likelihood that they're going to go back into a rest.
Speaker: So I cycle that cuff every one to two minutes.
Speaker: Now this is something you can tell your nurse to do, but I like to know how to do it because the nurses that I work with are probably doing other things that are important that they can only do.
Speaker: So I learned the monitors, I know how to adjust them, and I set the cycle time for every one to two minutes so I can constantly know what that blood pressure is.
Speaker: Excellent.
Speaker: And would you bring end tidal CO2 into the picture?
Speaker: Yeah, absolutely.
Speaker: Now, hopefully I'm using end tidal CO2 during the arrest for other things which are beyond the scope of this lecture, but I like end tidal CO2 to be on and waveform capnography for that matter because I'm not using it to see what their respiratory rate is or their CO2 necessarily is for ventilation.
Speaker: What I'm using it for is a surrogate for their cardiac output.
Speaker: And
Speaker: If you've paid attention to this and you've seen it before, you might have seen somebody's end tidal CO2 actually dropping right before they're about to code.
Speaker: And that's because their cardiac output is dropping and their CO2 is going down.
Speaker: I start to see their CO2 dropping.
Speaker: I know that I need to do something.
Speaker: If not, they're coding again.
Speaker: And I think that perhaps an underutilized tool, right, especially when you're outside of the ICU or in the initial phases, when you might not have an A-line, you might not have other hemodynamic monitoring, the end tidal CO2 in most of our patients with ROSC would be intubated.
Speaker: It's going to be very helpful in terms of giving us, like you said, that early warning sign, but also as a monitor of how we're perfusing, right?
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: It's an underutilized tool I find in resuscitation.
Speaker: What comes next?
Speaker: The next thing I like to do is I'm probably going to be doing some procedures and managing my team.
Speaker: I don't want to lose sight of that patient and I can't constantly have my eyes glued to the monitor.
Speaker: So what I do is I set the pulse oximeter to have an auditory tone to that.
Speaker: And we all know how that sound is, the change in the pitch that we hear, you know, classically in the operating room.
Speaker: But this can be helpful when someone is for their heart rate.
Speaker: So the, the,
Speaker: The pace of the beeping is telling me what's happening to their heart rate.
Speaker: Are they getting more bradycardic?
Speaker: Is the signaling an appending arrest?
Speaker: Or are the SATs dropping indicating decreasing perfusion for the person?
Speaker: But this is just a nice auditory feedback that I have.
Speaker: And it's not blasting in the room because I don't want to distract the team and I don't want to have alarm fatigue.
Speaker: But it's just there enough so I can be doing other things, putting in lines, doing what I need to do, but I can constantly be monitoring the person with my ears when I'm not looking at that monitor.
Speaker: So really the initial interventions are all about being able to monitor that patient in a way that is sensitive in terms of potential changes that could indicate another cardiac arrest or the patient deteriorating once again.
Speaker: And you talked about cycling the blood pressure cuff, using entitled CO2 in these situations, and obviously setting up pulse hocks, alarms,
Speaker: to have that auditory feedback.
Speaker: And you did mention earlier, Haney, that other people can do this for you, but you obviously are a hands-on guy and knowing how to do it is probably something that we should all learn so we can teach other people, but make sure that our co-team takes these as ABC, right?
Speaker: We just do this, this, this, and this every single time and help the team understand how this can help us take care of this patient.
Speaker: I really like that.
Speaker: What would you be at this point considering once you've set up all these monitor devices?
Speaker: What's coming through your head right now, Hany?
Speaker: So my next step is why did this person arrest?
Speaker: And, you know, if we're looking at a out-of-hospital cardiac arrest, we want to look for things like ischemia.
Speaker: That would be the things that we would want to intervene on early on.
Speaker: Inpatient, we know it's more hypoxemia or something metabolic.
Speaker: But I want to know the why, because I have to fix that underlying problem, otherwise they're going to arrest again.
Speaker: And it seems very obvious, but I see this missed a lot.
Speaker: Look for ischemia.
Speaker: Try to be aggressive about finding it.
Speaker: Get your ECGs.
Speaker: Get serial ECGs.
Speaker: I actually call cardiology relatively early when I'm in the emergency department and I have these arrests because I want them on board and I want them to know about this patient.
Speaker: So ischemia, being aggressive about it.
Speaker: And again, if you're thinking about hypoxic or metabolic causes, get the diagnostics.
Speaker: And we'll go into that a little bit later.
Speaker: But that needs to be the next step because if you just worry about fixing numbers and doing things and you don't fix that problem, they almost certainly will go back into arrest again.
Speaker: And I think that an important point that often is missed by our clinical colleagues is that having the right information and the basic information and being able to share that with people we're consulting is very important, right?
Speaker: So if you were to call a cardiologist, the first thing they would ask you, what did the EKG show, right?
Speaker: So making sure that you're getting the EKG, that you're making sure those are going to be serial, that you get whatever tests you need to get, but that you have the available information.
Speaker: I think a lot of people are very eager to put a probe on somebody's chest, but that EKG can actually determine if the patient goes to the ICU or goes to the cath lab first.
Speaker: Yeah, you find STEMI, STEMI equivalents.
Speaker: And frankly, even if you don't find something that is a smoking gun, getting cardiology involved early in some centers might be the key to that patient's survival because they are the gatekeepers to things like intra-aeric balloon pumps, impellas, and VA ECMOs, things that will sustain that person.
Speaker: So getting the team involved and knowing that this patient exists in your center in some places is the way to start moving things forward.
Speaker: Excellent.
Speaker: In previous podcasts, we have discussed the use of ultrasound during cardiac arrest.
Speaker: What's the role of ultrasound in this phase?
Speaker: Well, hopefully people are using ultrasound during the code to try and find reversible causes.
Speaker: But even then, I want people to take away that you shouldn't be doing a detailed exam during arrest.
Speaker: The studies show that people spend more time than they should looking at ultrasound rather than getting the hands back on the chest.
Speaker: So our ultrasound during arrest is looking for immediately reversible causes, and we covered that before.
Speaker: What I want to do now that we got ROSC is now is the time we do a detailed exam.
Speaker: You can pick the exam that you want to do, but essentially I like to do a high map exam or a rush exam.
Speaker: That's looking at the heart.
Speaker: I'm looking at the right ventricle.
Speaker: I'm looking at the left ventricle.
Speaker: I'm looking for pericardial infusions.
Speaker: I'm looking for a hemothorax, a pneumothorax, blood in the belly, anything that could explain why this person arrested if I don't have a cause already.
Speaker: But my point here is now is the time you're going to do a detailed exam with ultrasound, not during the cardiac arrest.
Speaker: Excellent.
Speaker: And I would imagine that while you're doing that ultrasound as the bedside clinician intensivist, hopefully somebody is trying some blood work and laboratory work that you've instructed them to.
Speaker: And what would those be?
Speaker: You know, and I'll speak more so from an out-of-hospital arrest because sometimes as intensive as we get consulted to these arrests, but I want to know lactate.
Speaker: I think that's something we're very comfortable and we know the reasons why.
Speaker: It tells us how sick this person is, how much resuscitation is needed.
Speaker: But I also like to get not only an ABG, but I call it an ABG plus, and that is a lab with electrolytes.
Speaker: Some places have hemoglobin.
Speaker: I've seen some of these point-of-care ones even have
Speaker: creatinine, but it just gives me a little bit more data.
Speaker: And it is always perfect, as accurate as the serum tests, but it starts to tell me, oh, wow, the potassium is elevated.
Speaker: Maybe that's the reason why this person arrested.
Speaker: Then get your basic labs.
Speaker: I do like to get toxicology labs for patients who are out of hospital cardiac arrests.
Speaker: You know, we have this
Speaker: fixation when someone comes in cardiac arrest, it's got to be something cardiac, but we forget that people, they do stuff on the outside.
Speaker: Maybe it was a salicylate toxicity.
Speaker: Maybe it was acetaminophen.
Speaker: Maybe it was some other toxic congestion that may have led to this arrest.
Speaker: So I like to send those labs if I have no other reason why this person is arresting.
Speaker: And the final thing I get, I don't always send, but I draw is cultures because as I'm getting more history, which we'll talk about next from the family, I might find out that this person was actually very, very sick for the past couple of days, maybe even septic.
Speaker: And perhaps that's the reason this person arrested.
Speaker: So I'll pull those cultures while we're getting blood.
Speaker: I won't necessarily send them unless I have a history or a physical that leads to them being sent.
Speaker: Okay.
Speaker: You mentioned obviously getting more history and that takes different forms.
Speaker: But this is usually the time when we might be asking if we were responding to a code on the floors, the nurse was caring for this patient, what else do you, can you tell me about this patient, why the patient was here, what was happening.
Speaker: But you also mentioned, obviously, a lot of times these patients come from outside of the hospital into the ED, and this is a time when you would try to touch base with family there at the unit or at the bedside and really try to get more information.
Speaker: Can you give us examples of things that you're always curious about or things that you should be asking?
Speaker: Exactly.
Speaker: I never take for granted that this person is just arresting.
Speaker: There has to be more to the story.
Speaker: So if they're inpatient, I take one of the thousands of people who are in the room just watching this cardiac arrest happening.
Speaker: I point to them.
Speaker: I say, I need you to go look at the chart and give me a little bit more history because I'm running the code.
Speaker: But there are lots of people who are just basically holding up the wall, if you will.
Speaker: They're just standing there watching.
Speaker: So I send them out to get more history.
Speaker: If they're out of hospital cardiac arrest, then I get that same person who's staying there to call the family to talk to paramedics.
Speaker: What was the scene like?
Speaker: What are we missing for this person?
Speaker: Sometimes you will find some valuable information there.
Speaker: And so that will help me to integrate why this person's arresting.
Speaker: The other thing is doing a physical exam.
Speaker: In the hospital, maybe a little less important.
Speaker: But I like to look and see if there's any lines.
Speaker: Is there an AV fistula that we missed?
Speaker: As a person comes from out of hospital cardiac arrest, don't forget about things like traumas.
Speaker: This often gets forgotten because you might have an older person who's having cardiac arrest, and the assumption is, well, this is just simply cardiac.
Speaker: But there are people that have MVCs who fall, they rupture their spleens, their own warfarin, they bleed, and that's why they're arresting.
Speaker: So a very good but very quick physical exam can help you.
Speaker: And again, I'm looking for lines.
Speaker: I'm looking for fistulas.
Speaker: I'm looking for any signs of trauma.
Speaker: Excellent.
Speaker: Now, as we're approaching, I guess, the 15-minute mark, are there any initial drips or therapies that you are concerned with at this point, Haney?
Speaker: I think at this point, what I'd like to do is I want to not forget that the person was getting pushes of epinephrine, and that's likely wearing off now.
Speaker: And now we want to get some continuous blood pressure going for this person in the sense that we want to maintain their map, essentially their coronary perfusion.
Speaker: So I'll make sure that we have a norepinephrine drip is what I like to do.
Speaker: Hanging at the bedside.
Speaker: And I'll even ask for that as we're getting ROSC because that still takes a few minutes.
Speaker: Let's run that peripherally and let's get the person's blood pressure better.
Speaker: If we were giving, you know, amiodarone or whatever antiarrhythmic, do we need to convert them to a drip to treat their arrhythmias that they had?
Speaker: And then the last thing not to forget is that this person very well might be aware as you're getting perfusion back, even though they may not be doing anything purposeful.
Speaker: Do we need to give that person some opioid?
Speaker: Do we need to give them something that's hemodynamically neutral as sedation?
Speaker: Maybe something like a ketamine type of drug, but always try to remember that there's a person there and they may be somewhat conscious of what's happening and making that person comfortable in a hemodynamically neutral way.
Speaker: Perfect.
Speaker: So I would like to take an imaginary pause here after the first 15 minutes.
Speaker: And there's something that we talked about offline and that I've heard you talk about a lot during cardiac arrest that I believe is crucial for our learning and improving what we do.
Speaker: But it's something that is not done routinely at all cardiac arrest.
Speaker: And that is debriefing the team.
Speaker: Could you talk about that?
Speaker: And is this the place where you might consider doing that and why?
Speaker: Every time I give this talk live and I talk about debriefing, if I listen very, very closely, I'll hear like 100 eyes clicking and rolling because people always say debriefing.
Speaker: There's no time to debrief.
Speaker: You know, we have to keep going and the department's falling apart and there's other patients to see.
Speaker: And I appreciate that.
Speaker: But if you don't strike when the iron is hot, you're never gonna change anything.
Speaker: And I just simply go for five minutes of a debrief for the people who are in the room.
Speaker: I pick one thing that could be done better, one thing that was really good, and some things to consider for the future.
Speaker: I just keep it as low-hanging fruit, and if it turns into a more formal discussion, that's great.
Speaker: We can do that later, but I can't let all the people who invested time, who have literally sweat over this patient, to walk out of there thinking that everything was great.
Speaker: And I choose this time, as we're doing things, just to say, let's go over this.
Speaker: And there have been times where we find some time later in the shift to go back and talk about more detailed things, but more times than not, that's the only time we'll debrief.
Speaker: So just take that time out with your team because you'll never make progress as a healthcare group.
Speaker: Just don't take those five minutes.
Speaker: And we always have five minutes to spare to talk to our team and make them better.
Speaker: And I think it's worth emphasizing that if you truly believe that you don't have time to debrief, what you're saying is we don't have time to learn
Speaker: And we don't have time to try to be better.
Speaker: So we're going to do whatever we do every single time with no intention of improving.
Speaker: And that obviously is something that most people would not want.
Speaker: I find it very interesting that when I think of a cardiac arrest team that really kicks ass, I would think of something equivalent to the Navy SEALs, right?
Speaker: The most proficient and efficient and badass unit within the military.
Speaker: And what I've read, Haney, is that the SEALs will have an after activity review for every single mission that they do, no matter what the nature of
Speaker: the outcome, the duration.
Speaker: And it's something that is really embedded in their DNA and they keep it simple, right?
Speaker: And they have a different algorithm, but I think that the three things that you mentioned are a perfect framework that we can apply to
Speaker: at any given time during our clinical shift.
Speaker: And we can definitely utilize for these cardiac arrests, which are, what did we do well?
Speaker: What could we do?
Speaker: What could we do better?
Speaker: Or what didn't go so well?
Speaker: And what are we going to do different next time?
Speaker: Three points that really can be discussed very quickly.
Speaker: It can help us.
Speaker: And I think it's also important to recognize that the reality for most of our intensivists is that they're not going to run cardiac arrest with the same people every single time.
Speaker: There might be some overlap, but if you go to the floor, the nature of what we're seeing in healthcare right now, it is very possible that there's new people there.
Speaker: And not only do you want to teach them, but you also want to learn from their perspective.
Speaker: Yeah, absolutely.
Speaker: And I'll tell you one more thing to build on that point.
Speaker: When you do that, when you plant that seed, you're teaching somebody else that person is going to teach the next person.
Speaker: And then it just spreads through the hospital.
Speaker: Because when I go to the floor, as you said, I might never see that person again.
Speaker: But that person...
Speaker: who you've taken the time to teach and you've changed them is going to teach the next person during a code.
Speaker: And I used to be very upset when I was a young attending, very hot headed when people didn't do the right things during the code.
Speaker: But it was only after a short period of time where I realized it's my fault that people aren't doing the right things because I'm not spending the time to teach them.
Speaker: We all know that we're time constrained.
Speaker: We all talk about sim, but the reality is, is that very few people get to do simulations.
Speaker: Very few people get to improve their practice.
Speaker: So that moment right there in real time might be the only education that that person gets on cardiac arrest.
Speaker: So it's up to us.
Speaker: It's up to us who are running the codes to spend that time and make the team better.
Speaker: Not to mention that no matter how much you know,
Speaker: and how proficient you are, you have blind spots, and there's probably opportunities for you as the lead of that code to also improve.
Speaker: So it's about learning as a team, right?
Speaker: And there might be things that you can actually take home to make your leadership or your cardiac arrest performance better.
Speaker: I'll give you, can I give you one quick example of that?
Speaker: Yes, absolutely.
Speaker: Oh, I should wait to get your response.
Speaker: Would you like to hear an example of that?
Speaker: Absolutely.
Speaker: Always.
Speaker: So last year, I was running a code with one of our fellows, and this fellow, getting ready for graduation, phenomenal, one of the nicest, kindest people, and we were doing this same exercise after a code.
Speaker: And, you know, me always wanting feedback was asking, you know, what could we do better?
Speaker: And in a circle of people, the fellow said to me, I think you could –
Speaker: you come across as very aggressive during the code barking orders, you could be a little kinder when you deliver your orders.
Speaker: You just don't have to be as aggressive during code.
Speaker: Everyone's listening to you anyway.
Speaker: And for all my years during a code with having that game face on that, like Kobe Bryant, you know, like stare during a code, all business, I realized that I could be doing things better.
Speaker: So
Speaker: What I'm trying to say is that this isn't just for you as the code leader imparting wisdom to others.
Speaker: There's very well changes that you could be making that you're not realizing that you're doing incorrectly for your team.
Speaker: Absolutely.
Speaker: So we've done the debrief and now we're embarking in the next 45 minutes.
Speaker: So what do we think about here, Haney?
Speaker: Haney.
Speaker: Well, there's one more thing that I put in the first 15 minutes that I'll just touch on briefly, and that's the airway.
Speaker: My personal belief, and this is backed by data, is that during a cardiac arrest, we shouldn't be doing endotracheal intubation.
Speaker: It's a talk for a different podcast.
Speaker: But I believe doing a supraglottic airway, whether that's an LMA, eye gel, whatever you want to do is the way to get your initial oxygenation and ventilation.
Speaker: But during that first 15 minutes, that's when we're going to change it out after we get ROSC and put in a definitive airway, whether they're pre-hospital or in-hospital.
Speaker: That's the only point I want to say to close out that first 15 minutes.
Speaker: Perfect.
Speaker: If you have other comments on that, we can go on to the next 45.
Speaker: Well, we could dive into that much deeper.
Speaker: And like you said, it might be a podcast for another day.
Speaker: But where the patient has been intubated or had an LMA, I think that your point is very well taken.
Speaker: During that first 15 minutes when we're going to probably eventually move the patient to diagnostics or the CT,
Speaker: to the cath lab, to the ICU, whatever, you want to make sure your airway is secured.
Speaker: So absolutely, I think that would fall in the first 15 minutes.
Speaker: So we debriefed the team, taking care of those critical items in the first 15 minutes.
Speaker: And now we're going to go to the next 45 of this golden hour.
Speaker: The first 15 minutes was about preventing the patient from going back into cardiac arrest.
Speaker: Now, hopefully, with the things that we've done and the patients more stable, we're moving into the fine-tuning phase of optimizing the patient for long-term success.
Speaker: I believe this starts at the ventilator.
Speaker: We've probably been bagging the patient or we've thrown the patient on some generic settings in the first 15 minutes.
Speaker: Now we have to start looking at the vent and saying, what's right for this person?
Speaker: Are we giving this person the appropriate amount of pee?
Speaker: Are we doing six to eight cc's per kg?
Speaker: Is the tidal volume appropriate?
Speaker: Now's the time we should be getting back our blood gases and avoiding things like hyperoxia or hypercarbia.
Speaker: And elevate the head of the bed.
Speaker: All these little things when it comes to respirations and ventilator are important.
Speaker: But I put this into the next portion of the 45 minutes because these are the things that are going to set the person up for success.
Speaker: Excellent.
Speaker: And what are things that you would consider important in the ventilator?
Speaker: Obviously, depending on what situation is, but as you think about what would be ideal settings, we talked a little bit pre-recording that there's been some new studies at the box trial that talks a little bit about this.
Speaker: But any specific recommendations that you have for our listeners?
Speaker: I think what we're looking for is we want to, the gas is going to help define.
Speaker: I think it starts there.
Speaker: We're going to look at the blood gas.
Speaker: Obviously, they're acidosis.
Speaker: We're going to increase our minute ventilation to adapt for that.
Speaker: But we just want to avoid doing too much for them.
Speaker: If you have a person whose blood gas is okay,
Speaker: We don't want to overventilate that person.
Speaker: We want to minimize the amount of positive intrathoracic breath to decrease coronary perfusion, all that usual stuff.
Speaker: So, you know, doing a normal respiratory rate anywhere between 12 to 14, I like to go for six to eight cc's per kg unless there's another reason to go above lung protective type strategies.
Speaker: And then, again, just aiming for a normal PCO2, if we allow them to be too hypercarbic, we run the risk of cerebral vasodilation and possibly increasing the ICP for that person, a person who might already have cerebral edema, reperfusion injury.
Speaker: Perfect.
Speaker: So we start with mechanical ventilation.
Speaker: Is this a time when you start thinking of what devices, catheters, this patient should have?
Speaker: Perhaps you're already in an ICU setting and start thinking about this.
Speaker: I know that there's been a huge push to not put central lines, to not do Foley catheters, but is this the right patient to have that attitude?
Speaker: What are your thoughts, Haney?
Speaker: My belief is that during a cardiac arrest and shortly thereafter, you don't need anything but a good peripheral line and an IO and an A-line.
Speaker: That's my personal belief.
Speaker: So if you're on the floor and you're getting this person resuscitated central line, there should be no triple lumen kit on the field.
Speaker: That's a lot of sharps and unnecessary when you can get two IOs in and now you have two central lines.
Speaker: When they get back to the ICU, sort of the home base where you can do stuff,
Speaker: My first go-to access would be to do an arterial line.
Speaker: There's a few reasons for this.
Speaker: The first is we already have a central line in the IOs and those can last for a good long time.
Speaker: The A-line is important because now it can monitor.
Speaker: We don't have to cycle that cuff every two minutes.
Speaker: Now on a second by second basis, we can know what the blood pressure is.
Speaker: I also know that if we lose ROSC,
Speaker: When we do a rhythm check, I don't need to go fishing around to feel for a palpable pulse.
Speaker: I have the arterial line there telling me what the blood pressure is or if there is in fact a pulse.
Speaker: And the last reason, well, there's actually two reasons.
Speaker: The second to last reason I like it is because I also have a measurement of the diastolic blood pressure.
Speaker: And we often don't think about looking at the diastolic blood pressure, but during cardiac arrest, having a diastolic blood pressure is going to estimate what the coronary perfusion pressure is
Speaker: That's really everything that we're doing in cardiac arrest is trying to get better perfusion to the coronaries.
Speaker: And the last reason is not for every center, but in some centers, you may be doing VA ECMO and getting an A-line in that patient.
Speaker: And we're talking femoral here, by the way.
Speaker: This is always a femoral A-line.
Speaker: Should have prefaced that.
Speaker: But when we get ephemeral A-line in, now we have a gateway to cannulate that person should we wind up doing VA ECMO for that person.
Speaker: So A-line is my first go-to procedure when we get that person in the first 45 minutes.
Speaker: And then after that, if you have the time and the means, you could put triple lube in catheters because certainly this person is going to require a lot of continuous drips.
Speaker: But that's my stance on A-lines and central lines.
Speaker: What about Foley catheters?
Speaker: You know, we talk about CAUTIs and all this work.
Speaker: This person just had a cardiac arrest.
Speaker: I need to know how well they're perfusing their kidneys, and I want a Foley catheter in.
Speaker: And we all know that the kidneys are great estimators for the internal physiology of a person.
Speaker: So I'll put in a temperature-sensing Foley for this person because we'll be doing TTM on this person anyway.
Speaker: But I get a Foley catheter, and I do use it as a means to measure how well they're perfusing.
Speaker: Perfect.
Speaker: I think that the point also on the A-line is an important one, right?
Speaker: Because we see these pendulums.
Speaker: We go from one extreme to the other.
Speaker: In the past, everybody got lined up.
Speaker: And then people are moving away from that.
Speaker: But I do believe that, like you said, these patients just had a cardiac arrest.
Speaker: There is useful information.
Speaker: There are clinical reasons how this can be helpful for us.
Speaker: And doing it early is actually going to always have an impact.
Speaker: So definitely something to think about.
Speaker: And I just want to go back to your first point about the IOs, which, again, I believe are underutilized in many places.
Speaker: And the old days when I was an intern, when people were fumbling around during a cardiac arrest trying to get access,
Speaker: No excuse for that, right, Haney?
Speaker: Just put in the IOs, get it done with, and you can figure it out later.
Speaker: There's so many reasons to not do a triple lumen during a code.
Speaker: I've seen people getting stuck during a code.
Speaker: I've seen people stick the retroperitoneum during a code.
Speaker: I've seen people just fishing around with needles during a code.
Speaker: And it takes time.
Speaker: All of that takes time.
Speaker: IOs, you can put four central lines in, two in the shoulder and two in the tibia, and you have all the access you need.
Speaker: You can put anything you want in an I.O.
Speaker: And I agree with you.
Speaker: It is underutilized, but the good news is it's starting to pick up and more and more people are starting to go for that first.
Speaker: Excellent.
Speaker: So we've talked about the devices and catheters.
Speaker: We talked about mechanical ventilation.
Speaker: I would imagine that during this next 45 minutes, also understanding our strategy for hemodynamic support is going to be important.
Speaker: Absolutely.
Speaker: And we're going to go back now, now that we have an arterial line and an accurate assessment of blood pressure, we're going to make sure that we get to a MAP goal that's appropriate.
Speaker: You know, obviously there's data now that shows us that the previous thought was that patients who are hypertensive, we want to go for higher MAP goals.
Speaker: It turns out that 65 just seems to be good enough for most patients.
Speaker: So get the vasopressors on, go for a MAP goal of 65, and then be aggressive about sticking there.
Speaker: I will say this is one of my casual observations, and it's one of the things that I do.
Speaker: is I aim for a map that is a little bit higher than a map goal.
Speaker: I noticed that there's a hesitancy to, if I say a map goal is 65, there's a hesitancy to stay at 65.
Speaker: They'll always go to 63 or 60 because they don't want to go up on the vasopressors.
Speaker: So I'll ask for a map goal that's a little bit higher, 68 or even just 70 as a round number, because I know we're going to,
Speaker: fail to hit that 70 and get to 65.
Speaker: But our goal should be 65 for our maps using, you know, the usual suspects for vasopressors using norepinephrine as first line and then second line vasopressin.
Speaker: Now we'll talk a little bit about what happens if cardiogenic shock is at play, whether or not we need to introduce onotropes, but if we're just talking about vasodilatation, those are the agents and those are the goals.
Speaker: Perfect.
Speaker: And in terms of other concerns regarding hemodynamic support, is this a time that perhaps you would consider getting a formal echocardiogram or a full echocardiogram?
Speaker: Are these things that are at this time or are going to be later?
Speaker: I'm lucky in the sense that...
Speaker: I trained with ultrasound.
Speaker: I feel very good at looking at echoes.
Speaker: We also have fellows who are very good at echoes.
Speaker: I would say at this point, if you have the means to look at the heart again comfortably, take a look at the heart again.
Speaker: If you have a patient who's climbing up on vasopressors, this is the point in the resuscitation where you have to ask the question, did something else change or is there something else?
Speaker: Is there cardiogenic shock at play?
Speaker: At my institution, I feel comfortable looking with the fellows at it.
Speaker: If you don't, then I would get a cardiology echo or one with a sonographer so that they can come and take a look at the ventricles.
Speaker: More or less what we're looking for is to see if there's any RV or LV failure in this person, or if you didn't do it before, to see if there's any other reversible causes that were missed, like a tamponade, for example.
Speaker: Perfect.
Speaker: And you did mention a little bit of cardiogenic shock.
Speaker: So let's assume that you now are putting things together and you are believing that there's a component of cardiogenic shock going on.
Speaker: What are the type of inotropes that you would consider adding at this time?
Speaker: Post arrest, I'm a fan of low dose epinephrine.
Speaker: Dobutamine is okay, but there's arrhythmogenicity with it.
Speaker: And the last thing I want to do for this person is create an arrhythmia.
Speaker: So using a dose of 0.01 mics per kilo per minute to 0.05 mics per kilo per minute, you want to remember numbers anywhere between one and five for the average adult would be just fine as an anatrope for this person for support.
Speaker: Milrinone is okay, but you know, milrinone brings with its risks of hypotension.
Speaker: And the last thing I want to do for a person who's at rising vasopressors is create more vasodilation for that person.
Speaker: So that's my approach when it comes to inotropy chemically.
Speaker: The other thing to consider and doesn't happen that often is if the person is having refractory bradycardia.
Speaker: And is that the reason why the person is in shock?
Speaker: And is there a need to increase the heart rate?
Speaker: I see that more on the ED side when people come in with overdoses, calcium channel blockers or beta blockers.
Speaker: So maybe we'll keep that separate.
Speaker: But those would be the inotropies of choice using epinephrine at the bedside.
Speaker: Perfect.
Speaker: The other thing that you mentioned earlier, Hengi, when you were talking about the A-line was ECMO.
Speaker: Could you just give us some thoughts on terms of when to involve ECMO?
Speaker: Is this the time you're thinking about it and who?
Speaker: And obviously, this might also be very institution-specific based on your capacity, your capabilities to do ECMO.
Speaker: But you did mention that earlier, and I just wanted to kind of ask you, where would that fit?
Speaker: This is one of the reasons that I suggested getting cardiology involved early in the case, because if your institution
Speaker: does ECMO, there's going to be a team that has to be notified and involved.
Speaker: In our place, it's critical care as well as cardiac surgery.
Speaker: But if you get to the point where you are confident that the person is having ventricular dysfunction and ECMO could be helpful, call for that early.
Speaker: Call for it early even if you suspect it in the first 15 minutes because it takes time to generate the team.
Speaker: Even if you don't have the capabilities in your hospital, maybe it's time to start calling other hospitals and seeing what's available in terms of transport.
Speaker: All these things take time.
Speaker: It's very rare you can get ECMO instantly at the bedside.
Speaker: Even in a place that has ECMO, it's still going to take about 30 minutes to get the entire team and perfusionists and all the lines and cannulations to get going, in my experience.
Speaker: So think about it and then call early.
Speaker: And if you're wrong, at least the team is notified.
Speaker: But if you're right, you're not wasting any time with getting those resources to that patient.
Speaker: Perfect.
Speaker: Is there anything else that you would consider within that first 45 minutes?
Speaker: So obviously the focus has been on supporting the lungs and the hemodynamic support.
Speaker: So mechanical ventilation, hemodynamic support.
Speaker: We talk about the devices and catheters.
Speaker: What else would fall in that next 45 minutes?
Speaker: that that's pretty much it at this point we're just making sure we're setting this person up for success with their physiology getting them back to homeostasis post-arrest perfect and really all the things that we talked about doing them right and doing them systematically and we'll lead up that hour very quickly right we talked about it go ahead
Speaker: I was going to say most people will probably find that it goes over an hour and that's okay.
Speaker: These are just frameworks for what you should be doing for your patients post arrest.
Speaker: Perfect.
Speaker: So we've done all the things that we've talked about, Haney.
Speaker: We've taken care of those first 15 minutes.
Speaker: We've debriefed.
Speaker: We've brought the patient to the ICU.
Speaker: We've focused on mechanical ventilation, on hemodynamic support, and we've
Speaker: What happens afterwards?
Speaker: So beyond that first hour, let's talk about at a high level of some of the big things.
Speaker: The way I think about this, and please, I mean, comment and critique my framework, is that probably between that first hour or first 24 to 48 hours, we're working on supporting the patient, minimizing damage, protecting the brain, setting expectations for the family,
Speaker: really trying to figure out what else happened, any diagnostics.
Speaker: But the reality is that it would take some time for us to really figure out what the ultimate outcome of that patient is from neurologic status.
Speaker: So we would talk about prognostication 72 hours and beyond.
Speaker: And then there's a lot of things that happen after that.
Speaker: We don't want to go that far.
Speaker: But in that first 24 hours beyond the first hour, what are things or items that you would consider to be relevant?
Speaker: I call this ICU stuff because if they're stuck in the ED, these are things that should be done, will optimize the patient's success.
Speaker: But sometimes you feel like, oh, that can only be done in the ICU.
Speaker: So we'll go into that a little bit.
Speaker: And, of course, if they're in the ICU, these are things that certainly should be done.
Speaker: The first thing is for the person who's comatose is getting an EEG for that person.
Speaker: We want to make sure that that person's not having non-convulsive status epilepticus.
Speaker: In the ICU, I think we get that.
Speaker: In the ED, it's easily forgotten because that person's stable.
Speaker: We sort of say they're admitted to the ICU.
Speaker: But just getting on the phone with neurology and just asking them to do a spot EEG is so important.
Speaker: It's in the AHA guidelines.
Speaker: And device manufacturers have come along and made these point of care EEG devices that are extremely helpful at the bedside and can help tell you whether or not that person is seizing.
Speaker: Because again, we went through all this work to get this person alive.
Speaker: We'd like to get them back home to their families in the best neurologic shape possible.
Speaker: And so getting a point of care or a spot EEG would be one of those ways.
Speaker: So again, that's after the first hour stabilization, but that's the first part of my algorithm after that first hour.
Speaker: Perfect.
Speaker: What about fluids?
Speaker: We talked a little bit about hemodynamic support, but a lot of research over the last couple of years about types of fluids.
Speaker: We've talked with you about fluid responsiveness extensively, but do you have any particular comments on fluids for these patients?
Speaker: This is typically where I go around and turn off all the fluids.
Speaker: Someone somewhere is going to flick on a maintenance dose because the person's hypotensive.
Speaker: I try to just turn off all the fluids.
Speaker: This person in the first hour probably got...
Speaker: More than the volume that they needed with all the antibiotics and all the pushes and all the boluses.
Speaker: They don't need any more volume.
Speaker: They're likely fluid resuscitated and they're more likely to be volume overloaded.
Speaker: So here's where I try to cut off any exogenous fluids for this person and just focus on the vasopressor management if they're still hypotensive.
Speaker: Perfect.
Speaker: What about, I don't want to go too deep because we've talked about this in other episodes and there's obviously ongoing debate right now based on the TTM2 trial, but in terms of targeted temperature management, where do you fall?
Speaker: This obviously would be part of ICU stuff at this point for sure.
Speaker: Yeah, I'm in line with, you know, keeping people 36 degrees.
Speaker: Obviously, let me start off by saying you should probably have the whole hospital on the same page about what you're doing.
Speaker: I do know that there are some centers that still want certain patients to be 33, you know, people at high risk for dental neurologic injuries.
Speaker: There's the TTM2 trial that was published not too long ago that says maybe we can even get to avoiding fevers and just keeping people normal thermic.
Speaker: Whatever you decide to do, just be sure that everyone's on the same page and with a protocol in place.
Speaker: And that involves talking to all corners of the hospital, the ED, the ICU, the PACU, so everyone's on the same page.
Speaker: But we're at, and where I'm at is 36, works just fine.
Speaker: And so that's the protocol that we do.
Speaker: Perfect.
Speaker: And I think that what people forget is that
Speaker: The term that we've all grown up to talk about was therapeutic hypothermia, which for many reasons had deficits.
Speaker: And after an international consensus conference, the term of targeted temperature management was proposed.
Speaker: And definitely we should have a target and we should manage the temperature.
Speaker: And I agree 100% with you, Haney.
Speaker: that the most important thing is for people to look at the available literature pending, I mean, further changing the guidelines, although the ill court guidelines have changed a little bit and agree as a practice, as a team, as a hospital, this is what we do and do it well.
Speaker: But you are definitely setting a target and you're managing that temperature actively.
Speaker: So I think that that's an important point.
Speaker: And that would be part of that ICU stuff that you're doing in that post first hour.
Speaker: Is that correct?
Speaker: Absolutely.
Speaker: You know, there's enough things going on that if you're in the ED, don't be mad at your ED staff.
Speaker: If it's 30 minutes out, they're not being, you know, cooled, if you will.
Speaker: There's enough things that need to be done and you have time to get that TTM, but it's definitely part of my after the first hour bundle.
Speaker: The other thing that I wanted to ask you about, since you live in both worlds, the ED and the ICU, is the role of setting expectations for families early and how valuable that can be.
Speaker: And I guess that would be part of that golden hour as well, since it's likely that in that first hour you might touch base with the family for the first time.
Speaker: Right.
Speaker: We're going to meet the family.
Speaker: We're going to talk to them.
Speaker: And they have questions.
Speaker: And they want to know what's next and what's going to happen.
Speaker: What I've observed in my career so far is...
Speaker: a lot of passive conversations with family.
Speaker: This happens with nursing, with techs, with residents, even with attendings who use things like, you know, the person's not moving or they're fixed and dilated or terms are thrown around and it sends mixed signals to the families.
Speaker: What I've seen in the literature and what I've witnessed is that the best thing to do is just to give them the facts that are present.
Speaker: Your loved one was down for 45 minutes.
Speaker: CPR was done.
Speaker: We had ROSC four times.
Speaker: The chances are that this person is going to have neurologic survival.
Speaker: It's somewhat low, but we're going to keep doing everything that we can.
Speaker: But...
Speaker: to avoid putting too much stock into just things that are at the bedside or physical findings, because we do have to give this person a proper period of time, 72, 96 hours, before we can formally neuro-prognosticate that person.
Speaker: And then we'll see what happens.
Speaker: So it's a mixture of honesty with the family without giving them false, you know, false, um, uh,
Speaker: it's not false hope, but, you know, a sense of panic and doom just by things that are classically being found, like fixed and dilated, or they're not moving, or they had a seizure.
Speaker: Those things don't really communicate.
Speaker: The time to prognosticate is after this, when they're in the ICU for a few days.
Speaker: And it also allows time for you to build rapport with the family to better understand them.
Speaker: It also gives insight into what you think the next step for that patient would be should they not wake up neurologically viable.
Speaker: And I think that that's a key point, right?
Speaker: Setting the expectations.
Speaker: And the truth is that the first 24 hours or the first couple of hours, it's very difficult to figure out.
Speaker: Even if somebody had findings of brain death, you would have to make sure there's no confounders, right?
Speaker: Which are very common in these post-arrest situations.
Speaker: So I do believe that setting the tone, like you said, for what's next and what to expect is
Speaker: is very important.
Speaker: And to be honest, the outcome of these patients in general can be poor, but we still don't have enough information.
Speaker: We'll have to see what happens over the subsequent days.
Speaker: So is there anything that we missed in that golden hour, Haney, that you want to bring back or you want to make sure that we emphasize?
Speaker: The only thing that I'll say is I see this newer tendency for people to get CT scans during this period, which I'm okay with.
Speaker: But my stance on CT scans are they should be the thing that the patient gets after all these other things are started.
Speaker: So if I have a patient who's in the emergency department, I would not put this in the first 45 minutes of getting a head CT for that person, unless I think that that is the reason for the person's arrest.
Speaker: If we think that the person is having blood in the belly and we need to diagnose that, certainly get that initial CT scan as part of your management.
Speaker: But I see far too often people skipping over getting definitive vasopressors and fine-tuning things because we have to get over to the CT and do a pan scan for the person.
Speaker: If you have a good reason or a good hypothesis for why that person did a CT scan, don't take them out of that first 45 minutes and just get a CT scan just as a checkbox.
Speaker: I'm more than happy to get the CT scan on the way up to the ICU and put that into the next hour
Speaker: I know that's controversial.
Speaker: I know that people want to do that, but the data just doesn't play out to show that early CT scanning for people post-cardiac arrest is very fruitful or helpful unless you have a reason to do a targeted CT scan to diagnose that patient's cause for arrest.
Speaker: And in any event, it's probably not going to change management substantially in that one first hour, right?
Speaker: So one of the things that we've learned during the arrest itself is that anything that deviates our attention from
Speaker: effective CPR is a problem.
Speaker: And during this first hour, anything that deviates us from supporting the patient and establishing all the right therapies could be a problem and it's not going to change the care of that patient substantially.
Speaker: You can get the CT scan a little bit later.
Speaker: Exactly.
Speaker: Avoid distraction, focus at what's in front of you, and then get the other information later.
Speaker: The one thing that we didn't touch on specifically, but I guess would be part of hemodynamic support or even in the first 15 minutes for the initial drips, any comments on antiarrhythmics?
Speaker: Yeah, I mean, if the person had an arrhythmia that was defibrillated or required intervention, then the continued use of them is what I would do.
Speaker: I'm not aware of any data that says that prophylactic antirhythmics would be very helpful for a person.
Speaker: Perfect.
Speaker: Well, I think we covered a lot that has to be compressed in a short amount of period of time post-arrest.
Speaker: But I do believe, Haini, that as you've done, I mean, by highlighting this in some of your talks, that it is a danger area or a danger time period for our patients.
Speaker: And that instead of talking about obscure neurologic findings that have no relevance to
Speaker: In this time period, we should probably be focusing on what are the items that I need to get in place so that I can provide this patient the best chance they have of having a meaningful recovery, recognizing that in many cases that won't be the case.
Speaker: But focusing on these time-sensitive interventions, finding a way to do it in a systematic way, I think is very important.
Speaker: We want to do it every time that we have a cardiac arrest.
Speaker: And I find the framework very useful.
Speaker: I like threes.
Speaker: So the framework I'm taking home from you, Haynie, is the first 15 minutes, debrief the next 45 minutes, and really focus on what happens in that time period, no matter what
Speaker: what the location of the patient is at that time, because eventually they'll come to the ICU most likely, but they might not be in the ICU during that first hour.
Speaker: Exactly.
Speaker: Exactly.
Speaker: No matter the location, these are things that could be done anywhere in the hospital.
Speaker: I'm,
Speaker: My own personal thing is that I think critical care happens everywhere.
Speaker: It doesn't happen in the ICU, and if we want our patients to do best, then we start critical care where it's needed.
Speaker: And the last thing I'll say about this is, as you're listening to this podcast, just reflect, there's nothing that I taught new here.
Speaker: This is stuff that everyone knows how to do.
Speaker: These are all very simple interventions.
Speaker: It's just putting it in a framework and an organizational manner so that it can get done every single time.
Speaker: And to be honest with you, when I first started doing it like this, I would have a checklist in my pocket and I would just take a look down.
Speaker: I was like, okay, what's next?
Speaker: And feel free to write this down or write down the steps that you find are helpful in order.
Speaker: But we have to be task oriented because codes are chaotic.
Speaker: Codes are crazy.
Speaker: During the middle of a code, you're getting called to another consult, but you have to be laser focused on these steps so that you make sure that the person in front of you has every chance for the best neurologic outcome possible.
Speaker: I agree.
Speaker: And I think that also it talks about that whole idea that excellence is not a skill, it's an attitude, and that by really making sure that we excel at the basic level,
Speaker: skills post arrest, we can probably provide the best care for our patients.
Speaker: Well said.
Speaker: Perfect.
Speaker: So you've been on the podcast before and you know the drill.
Speaker: So I would like to close with some questions unrelated to the topic of the golden hour post ROAC.
Speaker: Would that be okay?
Speaker: Absolutely.
Speaker: It's my favorite part of the show.
Speaker: Excellent.
Speaker: So,
Speaker: With you, obviously, I have to talk about what has been called foam, free open access medical education.
Speaker: But I think really it's just medical education in different forms that has really permeated all sorts of platforms.
Speaker: And just interested, since you introduced me to this whole world, what are the things that you would tell other people to follow on different platforms?
Speaker: We can start there.
Speaker: Yeah.
Speaker: So, you know, this, this open access medicine thing is, is a community of people who are sharing information and trying to make each other better.
Speaker: One of the interesting things when I first started on medicine is Twitter was the place where everyone congregated and this whole Elon Musk buying Twitter and Twitter potentially collapsing has put a fright into people and said, where are we going to go now?
Speaker: Where are we going to go for our education?
Speaker: If it can't be Twitter, what I,
Speaker: Realizing what I tell people is that this foam ad concept is not a Twitter thing.
Speaker: It's not an Instagram thing.
Speaker: It's not even a TikTok or YouTube thing.
Speaker: It's a community, and people will find each other online in some way, shape, or form.
Speaker: What I'm getting at is that...
Speaker: try to find multitudes of platforms that give you information because you never know when one platform is going to be shut down one day or anything happens.
Speaker: The government shuts down a platform.
Speaker: So it's important to know content on all the different platforms and then also have other sources of information where you consume New England Journal, for example, puts out some very excellent short blogs.
Speaker: There's something called Journal Files.
Speaker: a journal feed, which is a summary of articles all day long.
Speaker: So besides platforms, there are lots of individuals or organizations who are putting out free content every day.
Speaker: And it's all about picking your preferences, subscribing to those so you can get the information efficiently and, uh, and never relying on one platform for that, for that data.
Speaker: Perfect.
Speaker: And well said.
Speaker: Yes, it is interesting how the whole Twitter med community has been proposing different ways.
Speaker: But like you said, it's not the platform.
Speaker: It's really the content that ultimately matters and that can be delivered in different ways.
Speaker: And I also believe that you have to understand as a learner what speaks to you.
Speaker: There might be some generational differences, people think.
Speaker: But at the end of the day, everybody has
Speaker: a style of learning and gravitate towards platforms that provide that.
Speaker: But I do believe, Haney, that you hit it on the nail.
Speaker: It's like your portfolio, right?
Speaker: You want it to be diversified.
Speaker: I can't tell you how many people give me a hard time about being on TikTok.
Speaker: And maybe less so in 2022 than in 2020.
Speaker: But who's on TikTok?
Speaker: Well, it's younger learners, it's students, it's nurses, it's young residents.
Speaker: That's where people are.
Speaker: They're not necessarily on Twitter.
Speaker: So finding your audience, your voice, the way you like to learn is the most important thing.
Speaker: So you said it perfectly.
Speaker: Excellent.
Speaker: What are some podcasts that you enjoy outside of medicine?
Speaker: Outside of medicine, there's a few, but I'll give you the one that I'm absolutely obsessed with.
Speaker: It's probably an unhealthy obsession, but it's called Smartless.
Speaker: Have you heard of this podcast?
Speaker: I have not.
Speaker: It's Jason Bateman from, we all know Jason Bateman, Will Arnett, and Sean Hayes.
Speaker: The three of those guys are best friends in real life.
Speaker: And when COVID hit, they wanted to hang out with each other.
Speaker: So they just started doing Zoom and hanging out on Zoom.
Speaker: And then slowly, slowly, they just started asking some of their friends because they're best friends.
Speaker: movie stars, so they all have very wealthy and influential friends to come on the podcast.
Speaker: And then they finally just made a podcast where they did that.
Speaker: But the three of those goofballs together ragging on each other with guests that, you know, I think they had Kamala Harris on,
Speaker: And they have some really important people and influential people on there.
Speaker: But just to hear these three goofballs rag on each other while they're interviewing guests, it's the best mix of hysterical, heartfelt, honest podcasting that I've ever heard.
Speaker: And I'm now going through for the second time listening to all the podcasts.
Speaker: It's just endless enjoyment.
Speaker: Well, we'll definitely put a link in the show notes and we'll definitely take a listen.
Speaker: It sounds like something fun that we should be checking out.
Speaker: What are some platforms?
Speaker: What's that?
Speaker: I was going to say, you know, my second dream, my first dream was to be on your podcast.
Speaker: So I've already achieved that dream.
Speaker: There you go.
Speaker: My second dream is to be on SmartList.
Speaker: Well, maybe we'll pull some strings and get you on SmartList.
Speaker: If you could do that, I'd be indebted.
Speaker: Perfect.
Speaker: What about books, Haney?
Speaker: You know that I'm an avid reader, but is there any book that has had a big impact on you or a book that you have found you have gifted to other people on different occasions?
Speaker: This varies a lot, and I'll admittedly, I'm not like a huge book reader, so take that for what it's worth.
Speaker: The one book that early on in my career someone gifted to me and has been the most influential was Dale Carnegie's How to Win Friends and Influence People.
Speaker: As a young attending, getting started with a lot of nerves and sometimes
Speaker: being interpreted as being, you know, a little bit sharp or a little stern, learning how to influence your team and the people around you and just to be a good person.
Speaker: That book is something I give to residents and fellows and people that I mentor because there's just little things that we can do every single day.
Speaker: And it's not about –
Speaker: being a salesperson or to trick people.
Speaker: It's just little things that you can do to recognize what gets us to be better people and interact better as a community.
Speaker: And that could be in the hospital.
Speaker: It could be how you deal with your neighbor or someone at the store.
Speaker: But time and time again, I find myself listening to that audio book
Speaker: You know, I do it regularly, like every year or every year and a half.
Speaker: It just resets me and refocuses me and tells me the things that are important to just keep us all happy spinning on this rock as we fly through the universe.
Speaker: And I agree.
Speaker: And I think this is a book that has been mentioned by other podcast guests.
Speaker: And I've read it and find it very, very useful.
Speaker: And one of the things that my grandfather used to tell me is that read old books because only the good ones get to get old.
Speaker: And I think what he was really referring to is exactly what this book represents, right?
Speaker: It's been around for, I don't know, what do you think?
Speaker: Definitely more than 50 years, right?
Speaker: Probably even more than that.
Speaker: 70, 80 years, who knows?
Speaker: But it's been around a while.
Speaker: And yet a lot of the points it makes...
Speaker: are probably true throughout time.
Speaker: They're universal.
Speaker: And like you mentioned, they're super, super helpful.
Speaker: And a lot of what we talked about today are the skills that are required to do our jobs from a clinical perspective.
Speaker: But ultimately, all that falls short if you are not able to engage people around you.
Speaker: So I definitely will put a link in the show notes.
Speaker: And if you don't like to read, it's a great listen.
Speaker: I've read it and listened to it.
Speaker: And I think it's a great audio book, as you mentioned.
Speaker: 1936.
Speaker: Yeah, it wasn't too often.
Speaker: 1936.
Speaker: Yeah.
Speaker: That is when that book was written, and I got to tell you, every time I listen to it, I got to say every single principle holds up.
Speaker: It's super actionable, and definitely there's some golden nuggets there for sure.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: Well, I would like to close with anything you would want our listeners to think about or to know as we end the year also and hopefully move towards 2023 and away from all the craziness of the last couple of years.
Speaker: Oh, man, there's so many things I could say.
Speaker: Yeah.
Speaker: So the one thing I would say is, you know, we are coming out of a time where people are so divided about everything.
Speaker: You know, you talk about vaccines and masks and politics.
Speaker: And the COVID pandemic truly showed the worst in people and not just in America, really worldwide.
Speaker: A lot of this behavior was happening online and social media.
Speaker: I'm trying myself personally to get back to a point where we just start to have dialogue with people again, where I will force myself to sit down with somebody who has very different views from me and just listen to what they have to say.
Speaker: I'm not trying to argue with them.
Speaker: I'm not trying to convince them.
Speaker: I want to start listening to people that differ from me so I can truly understand what they're saying.
Speaker: And this is a growth for me.
Speaker: Because for the past few years, spent a lot of time just saying why someone was wrong or listening to what they had to say just so I can provide my counter argument.
Speaker: But I think we have to get back to a point as human beings, not Americans, not any nationality, but as human beings get to a point where we just start being together and coming together as one and accepting people's differences, different viewpoints,
Speaker: and find ways to just all live cohesively and still have different viewpoints.
Speaker: I don't know what the best way is, but that's where I'm personally trying to head.
Speaker: And that's what I advise people to do.
Speaker: Well, it's a great point.
Speaker: I think it's a perfect place to not only end the podcast, but as we close the year, right?
Speaker: But, Haney, I think that the way I've thought about the same concept a lot over the last couple of years and
Speaker: What I try to do is to be more of an active listener with true curiosity and trying to figure out maybe what Haney is saying is right and what I'm thinking is wrong.
Speaker: How can I learn from this person?
Speaker: How can I understand why they think like this or why they could think like that as opposed to just either being polite and waiting for them to finish or tell them why they're wrong but really trying
Speaker: you're not listening with an open mind, right?
Speaker: So I think that we have to open our minds and our hearts to really understand that people are different for many reasons and that there's something that we probably can learn from that other person.
Speaker: Yeah, well said.
Speaker: We're just, this is so aged, but I really believe that we're more alike in so many ways than we are different.
Speaker: So just accept those little differences and let's move on.
Speaker: We just came through a couple of years of just the worst human behavior that I've ever seen.
Speaker: And yeah, I think that that's what I'm trying to do in 2023 and beyond.
Speaker: Perfect.
Speaker: Well, Haney, I am always a pleasure to have you on the podcast.
Speaker: I really appreciate you sharing your expertise and your time with us.
Speaker: We definitely will have you back again and I will work on getting you on smart list.
Speaker: I think if you do 10 critical matters, you get on smart list, but we'll get there.
Speaker: Then sign me up for as many as you can.
Speaker: I got to get on the podcast.
Speaker: Thank you, Sergio.
Speaker: Thank you for having me on.
Speaker: Always a pleasure to talk to you on this podcast.
Speaker: Thank you.
Speaker: Talk to you soon.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
