Speaker 1: 0:01

Welcome to the Jack Hopkins Show podcast, where stories about the power of focus and resilience are revealed by the people who live those stories and now the host of the Jack Hopkins Show podcast, jack Hopkins.

Speaker 2: 0:20

All right, Dr Ellender, welcome to the Jack Hopkins Show podcast. Hey, thanks for having me. Absolutely, you know. I know you're kind of an outdoor enthusiast, like to spend time outdoors and the weather's starting to get warmer and as it does other people like to get out and go hiking and boating, things of that nature. And, as human nature goes, not everybody has spent the winter getting physically prepared. People are maybe overweight, out of shape, and accidents happen. It could be the result of they just don't have the strength or the stamina for what they are about to embark on. Or it can be maybe they are in shape, in great shape, but just something that wasn't planned on happens. How much of that kind of stuff makes up what an ER doc will see in the summer?

Speaker 3: 1:19

You know, I think it depends on where you're at right in terms of location. So I'm in the Midwest, so we see a small percentile of that. If I were like Colorado, maybe out in the West portion where you do have a lot more adventure hikers and people that will come out to, you know, enjoy the outdoors, you're going to obviously see an uptick of that. So it varies, I think, on where your location is. This time of year we generally see a lot more stress-related sort of issues with people that are kind of weekend warriors getting out. Finally, you know, putting in some miles, um, probably see more with, like some of the small races, the mini marathons and things in the local areas where you do have people kind of quasi training through the winter months, um, but putting a lot more time in in the early spring months and then finally getting to some sort of event, say like may, march, uh, may, june, july, and those individuals have a higher risk because they haven't really acclimated appropriately, especially in the midwest where your, your winter months are not allowing you to put in high level miles and you're making what you can of it maybe some treadmill time, maybe some indoor biking, that sort of thing, and finally getting outdoors, uh, to put in some time. But you know the the long distance stuff, the seven, ten milers are not there until the bitter end. And then, you know, you push it hard over a weekend and, you know, get into some temperature related stresses, perhaps just some physiologic stresses, things like where your glucose metabolism might not be appropriate. So we see that from time to time.

Speaker 3: 2:46

Obviously, with big shifts in temperature and weather patterns we see more. Perhaps, if you have an overly warm weekend where it is a planned event where you're going to have a lot of people out door because of a holiday or something like that, you'll definitely see an uptick of that. But you alluded to it, it's, it's most of the people who are, um, you know, enthusiasts but are not avid. You know users of the outdoor space where you're doing it weekend and week out. Uh, you have an event, you're planned, you kind of build up to it, you push yourself and then get into a little bit of trouble. That's probably the more common event that we see, um, for that sort of okay.

Speaker 2: 3:25

So given that because, again, geographical location, that you don't see a lot of that, I'm going to take a poke at this and see how close I am. I'm going to guess you see a lot of motor vehicle accident stuff, myocardial infarction or heart attack. Oh, absolutely, stroke any stones yeah things of that nature.

Speaker 2: 3:49

Let's talk about the life-threatening stuff that comes in. I, you know and can do it, and that's really the gist of it. I think to have people who know what to do and I've always found, at least for me, sometimes when I know a little bit more I'm not saying that this should be included in CPR certification, because you've got a limited window of time and if you make it too long, people are going to come. But post-certification, knowing a little bit more about why, what's going on in the body when I'm doing this, what's actually happening Do you feel that sometimes, when people know a little bit more about the, the inner workings of what they're doing, that they become a little bit more confident and knowledgeable in why it's so critical to do this right now?

Speaker 3: 4:59

Oh, absolutely. I think if you, if you take yourself from just a novice level like purchaser of the information and say, okay, I know I'm pushing on the chest, but why, and more importantly, why is it timing important? I'm not just doing it to the tune of my own head, but doing it at a rhythm that makes sense, because you're actually completing a pump mechanism type of thing, that makes a lot more sense. And I think once you actually engage even the learners right, the new learners and say, hey, listen, I don't want you to just bang at this with no rhyme reason. There's a reason.

Speaker 3: 5:30

We ask you to go two inches down and to be in this place and you press so often because there's a priming event, right, you have to. You know, have so many pumps to actually get the pump even started and then you're at motion. So every time you either overdo it or you're underdoing it, you're not completing the cycle, you're not effectively making the pump work. Or every time you break that rhythm, right, you have to start all over again. You prime it back up and then do it more. So once they start to realize, oh, okay, this is why they're telling me to do this to certain degree, you know, 100 plus beats a minute and try to not break cycle as often as possible Maybe not bag, you know, obviously I'm more in healthcare related, but we've we limited what even the laypersons will do because we want them to focus on the essentials, right, especially when it comes to CPR, right?

Speaker 3: 6:17

So it's basically you're establishing the pump, you're going to keep that going until you have additional resources because you're not carrying meds, and so focus on what we know saves lives and not really, you know, lose task of that practice and get off on tangents got a question for you regarding I'm not sure what year this happened, but when they they took the mouth-to-mouth aspect, the respirations, out of cpr.

Speaker 2: 6:43

Now I understand it's just compressions. Was that based on a finding that showed there was already enough oxygen in the circulatory system that the pumps alone would, the compressions alone would be sufficient, or how did they come to that thing?

Speaker 3: 7:02

it really is probably kind of a two-fold event. Uh, we realize early enough physiologically that when you inflate the lungs, right, you're competing with venous return, like, so the blood returning from the lower extremities, from the rest of the body back to the heart. So when you overdo that component, right, we over stress and over inflate the lungs, focus on this system primarily. Uh, we hurt the heart to some degree, right. So there's that problem and that's why even in healthcare settings we try to reduce the amount of bagging we're doing, how much air we're inflating, just getting enough to make it functional, and so there's a limitation there, right. So we know there's good science behind that. And doing all this aeration component sacrifices some quality of cpr, so it's a a one-in-one piece, so it's really become more of a cba as opposed to just abcs all the time, right. So really, focusing again on the heart is the primary pump. Uh, oxygenation is important, but you, you can get that done through a lot of different ways. Um, when it comes to laypersons, they just weren't doing doing it right and having people go mouth to mouth, which many people were sort of grossed out by, or not doing it appropriately, just was failing, and then you have people that not doing this, not practicing it routinely, now taking it to a bedside or a home space and then totally getting lost in all the steps, right. So that piece was there.

Speaker 3: 8:25

We realized that the actual chest compressions itself do push and compress the lungs right. So with recoil and re-expansion, if you're doing it right, you're moving some air. Not ideal, not perfect, but enough for those people really probably to be effectively ventilating to some degree. So we're moving air right. And so if you take that step away, we know there's risk with overdoing it. There's risk with having people fumble through the steps and losing track of what's really important and realizing that we can just do away with it. Right, we can limit the steps, make it simpler for the laypersons who are out there trying their best to do something they're not really prepared to do in the worst time of their lives, and making it a one-step, one focus process. Then we're probably going to get the best bang for our buck out of that individual right until, you know, experts arrive and can sort of take over control are you aware of any data, any information out there that has had a chance to look at?

Speaker 2: 9:20

uh, perhaps, perhaps how much more often CPR is performed, since it's dropped down to just chest compressions?

Speaker 3: 9:31

No, off the top of my head I can't quote numbers, but, yes, there has been an uptick of what we would say bystander activation, right, where they actively are engaged with CPR, reported by first responders, right?

Speaker 3: 9:42

So these are people that are like, hey, they are showing up and they are finding people more engaged with CPR.

Speaker 3: 9:48

And there's a lot of data looking at, you know, even these mannequins in a mall and things. Where you're, you're, you're teaching people, right, and so you're asking people to do practice and like they're already interested. So if you can get them engaged, then the likelihood of them actually taking it to their loved one is much higher, right? And so, even now, when you call 911 and you say, hey, I have a loved one that's down, I think he might be in arrest and they're going to walk you through some basic steps, they are teaching these people to try, right, and even coaching them through. Here's where you put your hands, here's what we want you to do the you know medics are on their way, but try this first, right? Um, the data would support that people who have taken these classes, who have some level of exposure and are coached actively, do it much more frequently, right. So this is good. It's a good uptake. It's sort of getting people in the medical sphere, even though they're not primarily medical focused, if that makes sense absolutely.

Speaker 2: 10:43

Yes, it does. Let's talk a little bit about the man or woman. They're at home in the evening watching television and they start to have some chest pain that it's. It's kind of vague, but it's. It lasted a while. It doesn't quite fit the classic symptoms that we all hear about, see in magazines, on television, but it just doesn't feel quite right. And we start to rationalize and say, well, it could be gastric reflux, reflux. What's something, when we are in that kind of confusing place, that the average person can do to decide? Do I need to call 9-1-1 or is this something that can wait till tomorrow? Go to urgent care?

Speaker 3: 11:37

right. Um, you know that's a difficult question because it really depends on your level of you know medical knowledge, right, and how can you ease out the sort of specifics of what's really going on? And we kind of default, at least when we talk about medical activation or when we talk about medical law and theory, right, we talk about prudent layperson, right? So what is the average person out there in the community able to decide and decipher from what is complex medical algorithms that they don't have privy knowledge to? So it's just like what would grandma know from basic functional human state. And it boils down to some really classic presentations that you probably ought not ignore. You hit on one, right, if you have chest pain or palpitations or anything that you think truly is cardiac in nature, it probably is worth a look, right? This is not something you want to default on, and sure, there are alternates. So, like you talked about aerodigestive things like is it reflux or could it be stomach related? Sure, it very well could be. But you probably want a good screening. You know for that, right, an EKG. You show up in any American modern ER with chest pain. The very least you're going to get is a quick screen like an EKG and maybe even splamp work, depending on what and how you describe it, right. So like if radiation of the shoulder, are you palerous or do you feel like you're going to faint those things escalate, right. So if you tell me these sort of conversations, or I feel really short of breath with my chest pain, and when my pain starts and I start walking it gets worse, and then when I slow down it gets better, those things feed me as to whether this is really heart related versus could it be stomach reflux or could it be lung, and there's so many things that fit in this box that could cause pain. But I would say chest pain, shortness of breath, should not be overlooked. And so, even from a prudent perspective, if you think that this is concerning, I mean I would go out there with 99% of the ER doctors out there would say you probably ought to have that looked at right, especially if it's new onset, you've never had it before. And this is a very different thing, right, which I think you hinted on right. The other is like weakness, right, say new weakness Can't move a body part, right, something's off where I feel like the functional control of a limb is not right, right, you know, is it both arm and leg? I don't know, you can't get into the nuance for a layperson, but that sort of new weakness probably ought to be investigated, right, either called out to your doctor or, you know, just show up to a specialist. Wherever that might be, you need to be seen. Er probably is most likely With that slurred speech or speech changes, something that it really you are unable to functionally speak because small strokes in weird areas can hit the centers.

Speaker 3: 14:27

So we're talking stroke related phenomenon, right. So that sort of thing probably ought to be seen. Vision loss or vision change that is acute, especially if they're in with it and or acutely different, right. So like one moment you're seeing. We're not talking about little blurring or something weird, but we're saying like a big definitive spot or something very different.

Speaker 3: 14:47

Double vision, especially with dizziness, and double vision or change in vision ought to be seen. I'm not all dizziness, because you know there are a lot of folks that get vertigo and things out there. If it's new and very concerning and you feel like you can't get balance and can't make it around room by all means, that probably ought to be investigated. But just basic dizziness, probably not a big deal, though if it's severe it's something that needs to be investigated. Probably broken bones with like tear to the tissue, right. So you've got not only I'm worried about a break, but now I've got exposure, so that bone accessible to free air means that there's potential for infection and that's a very time limited event that needs to be sort of seen sooner than later.

Speaker 3: 15:31

Massive bleeding, so bleeding that is uncontrolled for whatever reason they can't be controlled by your local pressure and or basic bandages, probably need some level of investigation. Head injuries, especially with loss of consciousness, if you passed out and you are not back to a normal state of health, you probably need some level of investigation, especially if you're on special medicines for bleeding. A lot of our population nowadays, because of heart-related problems or from strokes and other related problems, are on things that make your blood more apt to bleed, right, so you, you struggle to make things stop bleeding. I don't use the word thinning because that's not really what it's doing, but that's the vernacular people use. Like a blood thinner, right? Um, probably ought seek attention, especially if they have had major injury or risk of so.

Speaker 3: 16:19

Those kind of the big picture items, right, these are like life threat, right, the true emergencies. Um, and then you've got other, you know, belly pain, throwing up blood, that sort of thing. Coughing up blood is probably not something you'd sneeze at. Large volumes of blood coming out of any orifice, that isn't normal, uh, probably needs to be evaluated. So kind of sensical things, um, you know that's the the towing line. You know a stubbed toe probably doesn't need a 911 call and emergency visit. But if, if it's life-threatening or and or, like airway breathing, heart related, brain related, and you think that those things are very different, especially in time and scope, then by all means you probably should seek evaluation. It may not be a nothing right, but you really need medical professionals to go through a cluster of things and at least some base tests to help us tell you that it is in fact nothing.

Speaker 2: 17:11

Can you talk a little bit about what a differential diagnosis is, just to kind of give people maybe an idea of how a doctor thinks, yeah, when somebody comes in and you are looking at all of the things going on, kind of give us, give us general idea of what's happening in your head, how you're thinking yeah, absolutely, it was funny.

Speaker 3: 17:37

I we, you know, I work in a teaching institution. Actually, we're talking with a cluster medical students today. A little bit about that, right, because in medicine we teach it kind of in an off-kilter way. We teach you to go in and ask a million questions, you kind of poke at things, you listen to heart sounds and then you kind of report the stuff and then you think about it after the fact. In reality, when you walk into a physician's office or emergency department like ours, you're saying I am worried about X. Right, it might be chest pain. Right, let's use that as an example, we've already talked about it.

Speaker 3: 18:11

And then immediately I go to okay, what are the five or 10 things in the chest box that are emergent and could kill you? Right, that's the real worry, right, that my job is to protect you from death, not to find the you know 110th little nuanced weirdo that you know might take an mri and a gaggle of scientists to figure out. But what is the big picture items that could kill you, right? So, um, and then my, as we feed in history, the items start to like prioritize, right? So you tell me chest pain. That happened 10 seconds ago and brought you to your knees. Okay, now I'm thinking like could be big vessel injury, like aorta right Could be leaking. Could be heart related. You tell me chest pain that's been there for three weeks, right, that hurts. When you take a breath or cough, aorta falls down right, heart related falls down. Now, musculoskeletal could be pneumonia, especially if you tell me you've had fevers and you know difference in cough and you're putting out sputum and shaking chills at night, right. So our differential is like what are the potential causes? Right, and then, as you tell me and feed me more information, right, or I listen to you and hear a peculiar sound in one area versus another. Or you know we do an exam and I poke and push and you're like, oh, it hurts right there.

Speaker 3: 19:25

Now, this means this is more likely, not the order, because I can't get to your aorta with finger. This is more likely. Muscular, muscular, skeletal right could be a rib injury, type of pain. Um, if you tell me your blood pressure is like 230 and you have this very unique type of pain scenario that you can't quite get to, you seem terribly uncomfortable. Uh, your left arm is different from your right arm. I'm thinking more of your order. Right, we're going to go down a different level of questioning and tests, and the tests really are organized in order based on what your complaint looks like, right, and where that differential and the test should help us differentiate. Right, that a is the most likely versus b and c, not like every test known to man, thrown at it and hope for something valuable in the end, and that's that's really where the differential is. It's really like you're telling me these specifics. What do I think it is? And then how do we really hone down to the specific thing that is causing your problem right now?

Speaker 2: 20:24

are you you thinking worst first when you said the diagnostic tests are kind of organized off of the differential, as you are doing that, as you discover things that fit better than others, are you thinking worst first in terms of diagnostic?

Speaker 3: 20:43

Yeah, I think again, know, for again, emergency doctor is going to be different from neurologist in some ways, right, and yes, you might think of worse, but the worst may be buried in amongst other things. From my perspective, it's going to be what are the most timely conditions that will kill you, right, we got to get to those facets, right. So sure, it might be like dyspepsia or it might be, you know, reflux disease or some other weird things that are there, but I'm not going to worry about that right away because that probably isn't going to kill you. Yeah, it could downstream and if you have complications, but missing aortic dissection or a rupture, right, and playing around with doing a barium swallow and checking for stomach related problems and not focusing in on that possibility first. Right, because a leaking aorta is a time limited event where it's ticking right and and all hell's about to break loose if we don't recognize it. Um, likewise like a heart attack in motion, right, you want an EKG in your hand as soon as possible to better evaluate that. So you're prioritizing your steps based on what things are most time focused and likely to be deadly if missed or delayed, and then you kind of unfold it from there. Sure, pneumonia is bad, right, but the pneumonia unless you're, you know oxygen indices are way down there isn't really going to kill you right away. Um, I have a little bit of time to play with that. Sure, you're going to need antibiotics and we might do some special tests and we're going to get some pictures and ensure it's important. And you know, some pneumonias are worse than others, some you go home with, right, um, so we'll, we'll solve through that. But I don't want to miss the heart attack, right, I don't want to miss the big things, the bleedings, and so our differentials really escape on that.

Speaker 3: 22:26

How much of the story right focuses in or puts that at a high priority? Right, again, if you tell me something that's been there for six years, it's probably not going to be an aura thing. It could be right and we may want to consider that, but it's not going to be up there in A, b and C. It might be a low and so fin. It depends a little bit on like duration, what you tell me, how much of the features you're there, how bad do you look, right, I mean, if you look terrible, uh, as you walk in, uh, well, then our priorities are going to be a lot different, because certain things make you look terrible from the get-go right as opposed to like jocular and you're telling me jokes while you're telling me about it. I'm automatically. Not that I'm dismissive, but I my anxieties. Your inputs are changing a little bit and so we we prioritize based on how that interaction goes. That makes it so.

Speaker 2: 23:13

So part of that, then it would it be fair to say that it's to keep you from unnecessarily going down rabbit holes that will gobble up a bunch of time right, right, right, and you don't want to chase those, those evils, now.

Speaker 3: 23:27

It may be necessary as we kind of work through a process, right? Um, so you're going to probably be there a couple hours to get lab results back and we may have to discuss and discover other things. Some things I can easily get evaluated and or fixed in the emergency department. Some things just take time, right. So our job, especially as I explain to patients, my job is not to tell you every possible problem you might have, it's to tell you what are the worst things that could kill you and take those off your list. Right, I may not give you the answer to what you want, and that's. I have limitations, right, and quite frankly, frankly, I have limitations for your own benefit and for others benefits, because if we spent 10 hours on every patient going to the 50th differential, there wouldn't be time for the next person who is eagerly seeking attention, right? So you have to sort of share and share alike and spend the time wisely so what you have?

Speaker 2: 24:24

let's say somebody has has left the emergency department and they've gone to the icu. Now we know icu is still not okay. You're about to go home, but is that a place where they have a little bit more time to pursue some possible rabbit holes and things aren't as urgent?

Speaker 3: 24:44

yeah, yeah, and it's funny, I do that work too, so I do a little bit of everything. I kind of work on both sides of the aisle. So, yeah, I mean, you know, once we are able to hand off or talk to our consultants about what we've done right and what our concerns are and what we've often found, you know, we get to the at least the tip of the iceberg right. We might not uncover the mass below the waterline, but you got an idea of what's going on and next follows kind of the okay, here's the pathway to work up this mass right and this is the way we would work it up from a lung perspective and here's what the guidelines predict. And so we sort through all that.

Speaker 3: 25:20

Sometimes there are tests that take time to get right, or there are certain checkpoints you have to go through before you might want to order that test right, and it might be just additional labs that either take time to get back or specialize right. So you don't want some generalist just throwing like mud at a wall and hoping for the best. You want specialists to be involved. And so when you get to that point where you have an idea, you know that people need further evaluation, like in ICU, then that area is really focused on stabilizing someone that's critically ill and then you can start to dig into the nuance, causes, the why's right. Why would this be failing now? How is it related to the other things that are ongoing? What might have predicted how this occurred? What might have predicted how this occurred?

Speaker 3: 26:05

So lots of times for more questions. Because when I'm in the ER there's like at least in our shop there's about 100 beds right Now I'm not in charge of all of them, but I might be seeing and or participating in 10 to 20 sort of evaluations in a period of time. So my focus is broken right by the nature of the business where, once you get to me in the ICU, I'm down to maybe four, five, 10, 15 at most in general, and oftentimes with helpers around me. So my time and attention is less divided and more focused on your critical problem. And that's common within medicine that even though we might be busy and sort of busting at the seams at times, we have more than 38 and 45 minutes to an hour of time to devote to your specific problem and then also a additional regiment of specialists who collectively come in to help offer opinions about the next steps, offer opinions about the next steps. Um, so yeah, you're going to get a lot more focus, uh, in time, to involve and sort of.

Speaker 2: 27:10

You know, let this envelop murder and you mentioned that you you work both sides of yes, so I see you side in the emergency medicine side. Have you found that doing that benefits you on both sides because you understand how that opposite side is thinking and vice versa?

Speaker 3: 27:31

Yeah, it does. Number one probably the most valuable thing is just knowing all the players on multiple levels, right, and so you have your various ways that you can get to specialist access. You know common languages, right, they rely on you. So some of the roadblocks I might encounter in the ER, which is I'm waking somebody up in the middle of night and asking them for a favor, right, whereas now I'm the one providing that favor to someone else, and so there's a different sort of lingo there. Number two you know from an EM perspective, and so there's a different sort of lingo there.

Speaker 3: 28:05

Number two you know, from an EM perspective, there's a truncated amount of time that I see this condition, right, and it's generally hours, and then I hand them off and then days go by where this problem evolves, right, and or we uncover lots of phases of it and you're like, oh, wow, that's really what happened. So the beauty of my critical care job is I get to see that other side right, that two, three, four day period, um, and then the sort of aspects of critical illness and how best to treat that. You know, not hour one and two, but hour four, five, six. It does, it encroaches on what you can do in the ed and why, where you might jump to just moving to step two earlier, that sort of thing. So they do blend. There's a lot of similarities in what we do on both sides of the aisle no-transcript.

Speaker 2: 28:54

Were there lessons learned throughout COVID that have changed any aspect of how you think about emergency medicine at this point and how you treat how you think about it, approach it and treat?

Speaker 3: 29:07

it. Yeah, you know, I think there's a lot of things that have changed. Number one just level of illness and being comfortable with a level of illness in just a general space, right, I mean pre -COVID we would have said, you know, oxygen of 90%, oh my gosh, anything less than that scary bad needs to be in the ICU, right? Well, we had people out on the floor in COVID with stats of 85% and this is oxygen levels right. Right, for the common folk that are low, profoundly low to some degree. But we had so many people with sats that were all 85, if you put everybody in the icu we would have no space, right? We wouldn't even be able to put the clinicians into the space because it would be occupied by patients alone. So you had to become comfortable with nuanced things that you might not have done otherwise, just because it was just the nature of the beast. So I think that translates to comfort with nuanced abnormalities too, right? Not that we would be passe about it, but you can say this looks great with a sat of 85%. I would have freaked out about that five, six years ago, but I'm not, I'm just not. I mean, I'm going to approach that with a little bit more precaution. We're going to work this up appropriately if we feel the person needs a A, b or C space and upgrade by all means.

Speaker 3: 30:28

The other thing is just being patient with the nuances of the system. We learned that we just couldn't get everything right away. We were so used to, on demand, everything happening when we want it to, we just were overwhelmed. Right, you could not get those things like you want. So you have to be patient.

Speaker 3: 30:47

You have to kind of work with what you have, um, be willing to sort of negotiate around those, uh, shortcomings and be comfortable with not being able to do what you want, right, right, so, and be comfortable with not being able to do what you want, right, right, so.

Speaker 3: 30:59

Be just being patient. And then you know, making sure the average person that you're caring for is also aware of these things. Right, so, it's just being able to deliver on that goal and being very communicative to this. We want to assure you have the best care possible, doing everything we can to make you comfortable and make it safe for you, but there are limitations, right, doing everything we can to make you comfortable and make it safe for you, but there are limitations, right, and so we have to. I know you want to be out of here in an hour, but there are 30 people around you all wanting and begging for that same amount of time and attention because of it is divided and it's going to take three or four hours to get everything accomplished. And that's just the way it is right.

Speaker 2: 31:34

And I think if you're open with people, they realize that you know, and it doesn't always go perfectly, but it does make a difference if you were using this opportunity to say anything to someone who maybe has been fortunate enough not to have to come to the er at this point in life, but that may one day. What would be the one thing that you could let them know about that experience and what goes on behind the scenes that would give them a different way of looking at it and not become as frustrated so quickly?

Speaker 3: 32:11

um, yeah, I think it's easy to look at medicine and emergency medicine from a, like, a consumer perspective. Right, we've become this fast food frenzy society where you don't even have to go to the store anymore. Amazon delivers everything you want to you, right, so we're used to immediate gratification, right, more immediate than it's ever been. Um, in in the real world, nothing works that well, right, not no one's amazon and the way it delivers I, I mean, we're trying to be better than we have been. But even with all the modernization that we've gone through, it's still a like plotting process, right, um, and you want it to some degree to be that way. Right, because things evolve. I, you know if I was able to get results in even 10 minutes. Right, I sometimes need time to see things to fruition. Right, there is data in how you respond to certain things. Right, it tells me what might else be playing in, right, so if they give you a little bit of pain medicine, just a wee touch and you're completely normal, it makes it less likely that this is some catastrophic like bleeding type of process, right, so there is some validity in just being able to interact with you, right? So sometimes I need two and three hours to be able to see how you respond. Right, you're vomiting your brains out? Right, the meds have kicked in. You've gotten some fluids. Can you have a little sip of fluids? How about a cracker? Is that staying down right? Are you good enough to make it to the door and out of the hospital? I want to assure you that, but I might not be able to get to that in 30 minutes where you are feeling well enough to survive for the next six days, six hours. So some of the like, wait and stay process is built into the workflow, right, it is necessary to make sure that you are functional at the end and ready to go right.

Speaker 3: 34:01

Sure, we want the ankle sprain to get out fast and get your images. If that's what's necessary, get you wrapped and treated. But again, that ankle sprain is not an emergency. It doesn't get to trump the guy who's blue and having chest pain and shortness of breath, right. So we have to balance that. And I work in a specialty hospital where we have all these nips and crannies. But if you work in a 20-bed ER in small town USA, that guy is seeing chest pain with ankle sprain. Right, he's seeing the pregnant mom about to deliver a kid with your stomach problem, right, and so we don't get to pick what shows up through the door, we just have to bust and go, and it comes at us from all angles. So you know your worst day, and we respect that right. People aren't coming in for, you know, a coffee. It's people are having a crisis. We want to respect that, but your crisis is on top of multiple people's crises all happening at the same time, and so we're trying to do our best with what we can.

Speaker 2: 35:02

Yes, my most recent visit to the ER was with a suspected cardiac issue and when the ER doc said you know they'd already done the standard test, he said we'd like to keep you overnight. Now my philosophy on that I was like you know what, if you need to keep me three nights to figure out and be sure what's going on, great, you know that's. I remind myself the reason I came in the first place. I had concerns about my health and my life Right came in the first place, I had concerns about my health and my life right and I went to the er and not the electrician because the er is going to be able to tell so the I. It always seemed crazy to me then to to start to try and supersede the knowledge of the physician when that's who I went to in the first place. You tell me what I need to do, I'm happily here. But, as we both know, that's who I went to in the first place.

Speaker 3: 36:01

You tell me what I need to do, I'm happily here, but, as we both know, that's not the thinking most people have. You're the customer we want, right, which is A. You came in with a complaint. We're working our best to try to answer those questions. Right, but there are certain things that are sneaky, right, and there's certain diagnoses that we get a hint of, but we don't have the slam dunk answer and sometimes that timing is necessary, right, because you had something scary that brought you to me.

Speaker 3: 36:27

I paid attention and I'm telling you I'm not convinced sometimes that all the data we have is enough to make it safe for you to go, make it safe for you to go, and maybe it is in time. But perhaps a couple of ekgs right, that are normal are catching whatever you experience, right, because sometimes it's like the noisy wheel. Right, you turn into the mechanic and the minute you hit the pavement, the wheel noise is gone. I can't tell you what did it until I can see what it was like when it was happening for some problems, right, especially things like palpitations, if you're having a weird electrical problem inside of the circuitry of the heart, but you show up and it's normal, you're not having the symptoms at that moment I may not be able to tell you really what's going on, unless you were to do it again, right? So I might need either a little bit of your time and time on a monitor to be able to tell if that hiccup happens, especially if you've been doing it multiple times a day, right? Or I may have to send you out with a monitor that you wear for a while, right, especially if it happens once a week, maybe to really see if we can catch it right and catch what's going on In your scenario.

Speaker 3: 37:34

We have enough risk, right, where you give me a good story. Maybe there's some things in your background with high blood pressure and things like that that puts you at a higher risk for heart-related possibility, and so we need a tincture of time to really give you some shirts, right. We need maybe a couple of blood samples to show that whatever happened three hours ago, right, wasn't like the tip of the iceberg that might indicate heart attack. But that timing is like necessary, right. Your body heals and or feels over a period of time.

Speaker 3: 38:07

Sometimes all the answers are not there in that first hour, right. It takes several hours for whatever injury happened to show itself fully, and we need that you know blood testing or whatnot to be able to tell, and so some things. Just we need a little you know blood testing or whatnot to be able to tell, and so some things. Just we need a little bit of time to uncover and we use that, you know admission or that observation period to be able to give you that period to show or the disease or whatever it is to show itself and to give you more reassurance, right that hey, like I'm 99% sure that your event was not part, it was likely. This is an alternative, but we need a little bit of time and patience to get you a more defined answer, gotcha.

Speaker 2: 38:58

How distracting is it and how much harder does it make your job, particularly in the really critical cases when you have the family member who is trying to interrupt and tell you things and there's a tone of anger in it. They're stressed, naturally. Stressed, naturally. But how important is it for people to be able to back up and give the medical staff the space they need to think and to act?

Speaker 3: 39:29

uh, that's kind of a learned art, right, is how to address that? We actually do that quite a bit with kind of teaching the resonance, because it's something you know, uh, that you have to sort of recognize a that the loved one is overpowering the conversation, right, perhaps they have the most needed information there. So you got to respect that too. Right, that the right husband may be literally downplaying a lot of the issues, right, because he didn't want to be there. Uh, he's been convinced to come in because everyone around is worried about these symptoms and what it might mean. So there's that component. So you've got to respect it and make sure you're not losing vital information by just ignoring that loved one. But sometimes it's overpowering.

Speaker 3: 40:09

We're like the guy just needs to have a space to say what he has to say. Right, he's got vital information we need. So I generally try to ask and sort of approach it Listen, I'd like to ask and sort of approach it Listen, I'd like to get him to give me some answers. Right, I'm sure you have plenty of information that I need from you, right? I don't want to dismiss it, but I want him to be able to tell me, because his own words have meaning, right, and they tell me a lot of things that you can't get from a piece of paper, you might not be able to get from just an examination. Your reflection on what's been going on may be a little different from what the experience is like, right, so we've got to make sure that what you're seeing is not what they are feeling, or vice versa, right? So if he is downplaying it, by all means I want you to correct that.

Speaker 3: 40:53

Right, make sure that we know how severe it's been or how dangerous this seems or how everyone is worried about it, but want to make sure we get the word from the horse's mouth and then the word from the rest of the horses, right? So, um, you know there's tact in the way you handle that and make sure that you don't, you know, shut people down and lose that opportunity. Uh, so it's a, it's a skill, right, it's what grandmas taught you how to do when you were supposed to be polite, neighborly to your common man. Right, it's practicing that a little bit and kind of biting your tongue. Right, because you know we've all been there where these people are impressively aggressive and they can be off-putting.

Speaker 3: 41:31

Right, and you have to reflect on your own sort of tonality and say, okay, look, I'm having a visceral response to this person. Uh, I need to check myself, make sure that my tone doesn't escalate things, I don't bring my own biases into the process and inflate things in a negative way, right, I gotta make sure that I'm checking what's going on. Uh, be kind, but, you know, be stern as to what boundaries we're going to allow to make sure it doesn't derail the whole.

Speaker 2: 42:01

I want to kind of state a position that I have in my own head on something and then have you kind of elaborate on it and you know if you agree or disagree.

Speaker 2: 42:14

as I think we've discussed before, maybe you've seen in my profile I was a Navy hospital corpsman or a medic, yep, and what I've always told people that has done for me in civilian life, just life in general the degree of confidence I have when I go out with my family or maybe I'm traveling and I'm on a plane, the basic things.

Speaker 2: 42:42

For example, I know if I come upon a car accident that just happened, I have the skills and the knowledge that there's a pretty good chance that I'm going to be able to stop a hemorrhage that you would otherwise die from. I know that if your airway is compromised, there's a pretty good chance I can do something there. I know if you aren't breathing, your heart's not doing what it should do. I can do those basic things and I've always felt like that aspect of it gets underplayed or not mentioned enough, because I think if more people knew the boost in confidence they would have in what they could do for their family, for instance, if something at home or while they're on vacation on vacation, because in the absence of that very basic training, people freak out by and large and then they are useless, right? So I'm sure you are a huge advocate for learning basic first aid and cpr, but can you speak a little bit more about just how important?

Speaker 3: 43:52

that is, yeah, and and you know I'm still a consumer, right yeah, you know, from a wilderness medicine, survival perspective, like there are things I don't know, right, and I know there are limitations of what I do know. And if there are certain aspects that I want to enjoy more, there are things you got to learn. So it's like learning to swim if you're going to be on the water, right, those go hand in hand. So there's a certain amount of preparation you should do in life for the things you enjoy, right. So we talked about hiking and things like that. If you're going to go out there and you know that wilderness, adventure type things are your jam, you probably deserve a basic first aid course, right, maybe a first aid wilderness course, right. How to set a fracture or at least get through a splinting sort of modality to get yourself out of the backwoods, right. How to take care of basic, you know injury, brush, burn, laceration that you know anybody should be able to do. Just a basic set of knowledge, like a little bitty talking points. These are kind of the necessary parts of it.

Speaker 3: 44:49

But you know, the human body and sort of the sort of medical aspects are kind of a black box, right, it's like this otherworldly sort of you know event that you know people seem as like the nether regions if there's some complexity to it. But once you kind of understand the basic language right, which you have right now, it makes it less fearful. Right, you, there's some basic things that you know anybody could do. It's like you know a leaking hose you walk up to and you go like I put my finger there, look it, stop that. Right, you know, there are certain aspects of that. That works for the body too, right, so basic human skills can be applied once you get rid of the oh my gosh, this is like this untouchable thing that's so tangential I can't touch. Uh, you can apply yourself there.

Speaker 3: 45:33

So you know, I think basic first aid should be taught in school, right, everyone should walk away with basic nuts to bolts of how to handle basic wounds, bleeding type of things, stings, bites, little things that you're going to encounter in life.

Speaker 3: 45:49

Right, like grandmas and moms sort of passed on generation to generation that, as we've become busy in our lives and the sort of collective family unit has been divided every which way but loose, we've lost that right. So you see a lot of people just with like a fever. Here I am. You're like, okay, what'd you do for it? Well, without them. They're like, okay, like fever happens a lot, right, this is like something that you're gonna see many times over your little baby's life and I'm not downplaying your concern, but you should know how to take a temperature right. You should know that, like Tylenol works for a fever and these sort of bumps and bruises sort of thing happen. Basic life skills that I think we we probably are starting to lose, that we need to delve back into and know how to do the nuts to bolts type of things, right not that we're.

Speaker 2: 46:43

We're here to help you and have to do that, but but you probably should be able to do this for yourself right and to compare, for example, to compare the, the knowledge and training that I had as hospital corpsman and the education, knowledge and training you have. I mean they're light years apart in how many more layers there are have and as much education that with a lot of things that come into the er they are. The starting point is it's built up on those very basic things and it's just that you can go further from there would that be the same?

Speaker 3: 47:32

tenets, right, those abcs, those basic skill sets, still apply, right? I mean, when we talk about, like, the approach to every major problem, it's still built on basic like checkup, pulse right, which you've learned how to do right. Get some blood pressures, like how do they look right, what are the things that quickly go through your head? How are we communicating to each other as we kind of work as a team in a cluster around that? So you know, yes, we're going to do some hierarchical things downstream, but the basic approach to that person that just flops down in bed that looks sick is everyone's catching the same basic things, right. We're going to check for the ABCs. We're going to assure that the basic things are there right Putting in an IV, getting them on oxygen, checking vital signs, that sort of thing. Those are still trying, true, right. The same things you learned back in the corpsman days are the same approach to every problem. There's some nuanced things that we're doing right, where you know strokes are doing some different things now where they're moving faster in one way or another. You know cardiac. You know things might go in different ways a little bit, uh, as science builds right and we know more than we did 10, 20, 30 years ago.

Speaker 3: 48:41

Um, but again, the approach to common problems are still the very take your own pulse, take a deep breath, think about the process, don't lose yourself in emotion and panic, uh and.

Speaker 3: 48:52

And just start with abcs.

Speaker 3: 48:54

Right, and it's kind of the same thing I I would tell myself as an intern right, because you know a lot of stuff, but you haven't had a lot of contact with people in that phase of your life, right, and so things are still very scary because you're like, oh God, what if I come upon this by myself?

Speaker 3: 49:08

And I'm having to think for myself and, you know, I still feel like I know a lot of stuff but I haven't applied it yet. It's still very scary from that perspective, I can remember telling myself look, if you can do ABCs and if I can make sure you can breathe and I can check your pulse and keep your heart alive, the team can come for why the sodium is off. That can wait oftentimes for a later hour. The ABCs, if you can remember to do that, do that well and take your own pulse and control your emotion and just approach it like commonsensically, you can get through 90 of the problems right, 90 of what you're going to see. There's going to be some crazy things that you know everyone will struggle with, but that that's common common sense that was highlighted for me.

Speaker 2: 49:52

Last summer my youngest daughter and I witnessed the accident happen. And there was, I lived near some amish communities and there was a poor, strong buggy, a woman and amish lady and her young daughter and somebody hit them from behind, didn't, didn't see them going about 35, 40 miles an hour and ejected them both. And I mean I was right there, I was literally across the street. It happened in front of a service station. Now there were all of people there who witnessed it and a lot of people who ran up to the woman. But as I'm running up I realize I see it on their faces. They want to do something but they have no idea where to start, where to begin, what to do. And a gentleman that knows my wife. A couple of days later he said to my wife he said I was impressed, your husband got in there, took charge and started doing things and he didn't know the things. I was impressed. Your husband got in there, took charge and started doing things and he didn't know the things. I was, you know he just said things, he was doing things, but I guess what stood out is that I was doing something and that all comes back to for me that level of confidence of knowing what to do.

Speaker 2: 51:20

Can you speak a little bit about the essence of time and what is happening, for example, if somebody's having a myocardial infarction, a heart attack or stroke and we can kind of look at both of them, what's happening to the heart tissue when they are going? Well, yeah, I probably should go, but I'm gonna wait a couple more hours. Or yeah, um, I I'm not really seeing well out of this right eye. I've got a tremendous headache. I'm gonna wait a couple hours and see if it passes. Can you share what's, what the risk of that is and what's happening?

Speaker 3: 52:05

yeah, so for each of those, right, ischemic stroke which you mentioned, and then myocardial infarction, each of those, those organs, right, there's a sort of like motor demand. Right, the organs active, it's doing things. Because it is doing things, it needs a certain amount of blood flow to maintain that level of activity, right, um, it needs sugars, it needs oxygen, it needs on-demand supply fuel. Right, to keep the motor running. Um, when you're experiencing pain, the pain is a result of that organ suffering under the demand. Right, whatever load it is, it's not being able to. Or your body, the flow, the pipe and plumbing pieces are not meeting the demand that the engine is sort of requesting. Right, and many times the pain is a complex of that. It can be. You know, leg pain, when you have that same process and arteries in the legs. Right In the heart, it would be brought on by pain For the brain. You don't really have pain centers within the brain itself, so it just stops working right, and you have holes in the function and that is the organ suffering, right, essentially, the pain and the infarction as we describe it is muscle dying. Right, it is a time-evolving injury caused by a lack of blood flow. Right, you have an organ on overdrive and you're not meeting that demand, as that demand and the byproducts of whatever's happening right, metabolically or building that muscle is failing under that fatigue, that's the heart. Right, the brain is failing in its activity because it can't continue to function and live without the needed supply, right. So if you have a brig between the supply, the steady supply, and what the organ, whatever it might might be, needs for its demand, then you have injury. Right for the heart that seen as infarction. Some of that might be reversible if we have a time limited intervention. Right. So you know every minute counts because that is a dying number of cells. Right, they may be additive over time, uh, brain and or part, and so you have a window and each, each system is. You know, the kidney might be able to be hours, with some level of like flow, inactivity. The brain, seconds to minutes. Right, heart, maybe minutes to hours. Uh, the leg could probably be a day or more. But you know, under certain circumstances where there's resiliency or kind of tolerance to certain in and the level of demand, right, you're not moving the leg constantly. Where the heart's beating second to second, the brain is constantly active. So, depending on how active that tissue is what it needs in terms of supply is going to be different, right.

Speaker 3: 54:41

So, to your example, if you're having ongoing pain and it's still happening and it's getting worse and it's getting worse and you're trying to convince yourself that it's nothing, just be aware that that could be argan dying, right, that that could be the sign of, and you know, once there's a certain amount of death and injury, I can't get that back. In certain scenarios I can get you better, maybe prevent you from dying from whatever it is. But you know, if you present within minutes of the first starts of those pains, I might have a, an intervention that completely makes you normal. Right, your heart would never know the event occurred otherwise, where, if you wait days, the heart's died and there's a big patch of muscle that no longer works like it's supposed to.

Speaker 3: 55:22

So you know, waiting too long means that you suffer. Right, there is irreversible damage. I can't get back, even with stroke. Right, where the brain is so sensitive to immediate need. If I give you a certain medication or we go for intervention and we open up that vessel, right, we make the pipe hole again, you could absolutely have no symptoms whatsoever. Right, completely lost. One whole side can't talk to back to normal. You would never know the difference. Otherwise, if that intervention is done in a timely fashion, right a day later, it's a whole different story.

Speaker 2: 55:56

Kid can't get it back and am I correct in that if there is enough tissue death, cardiac tissue death where the heart is no longer able to serve as an adequate pump, then you're pretty much looking at a heart transplant.

Speaker 3: 56:15

Yeah or no, or it's done yeah, it's, it's, you know, debilitating, right. It's? Uh, you're a normal active guy cutting your grass in your yard, to you know, being housebound and on oxygen and struggling just to get to the bathroom without being short-winded, right? So, depending on what level of loss, it can be very destabilizing, right. I mean night and day, where you were the guy jogging down the street to looking like grandpa, almost right, because you can't just do the work.

Speaker 3: 56:41

And or worse, right, which you mentioned, where your heart's failed so badly that you are on specialty meds, you need mechanical devices to continue to live and you're praying that you make it to heart transplant, right. Right, and I have a hard time telling you where you're going to be in that spectrum. Right, where it's a nothing, a little bit of a bump, you know, until we know more information, and that's the thing to understand. Like you know, if you think it's something that's concerning, you got to get it checked out, because I can't tell you what it is underneath all of that. It very well could be enough, but it definitely could be a major cardiac event until you know more, based on what?

Speaker 2: 57:16

you've seen, just kind of anecdotally. I know there are studies you can reference, but just in your own experience. How much of a difference does it make? Your own experience, how much of a difference does it make when, say, somebody who's 60, 70 years old but they have stayed fairly active and so they are. They are better conditioned. What does that translate into in terms of survivability for some of the things that we're talking about? Is it significant?

Speaker 3: 57:48

Oh, yeah, yeah, there's. I mean, and it's significant in the fact that we even define frailty, right, which is, you know, as you age there is a certain amount of muscle loss and ability that is lost. That frailty translates directly to recovery, right, anything from a fall to you know, just the basic illness and how well your body can adapt and recuperate from it, right. So those that have lived a relatively healthy lifestyle, that are active, right, have continued to tune their body, even though there's failing conditioning right with age. That's just part of life. That failure is sort of attenuated by the activity, right. And so, you know, an individual that is sedentary, does very little and is 70 years old, is a very different person from the 70 year old that still walks three miles a day, jogs intermittently Because, number one, his body's been forced to kind of adapt and keep up with that, and so by their own daily day activity they've tested themselves right.

Speaker 3: 58:49

So it's unlikely that person that ran every day, uh, is having a major cardiac event, or less likely, right, not that it's off the table, but essentially that's a stress test. You've done exactly what I'm gonna do to you. If you show up at 40 with the first time you have chest pain. I'm gonna see if you have the same symptoms under a load, right? I'm gonna see if your ekg changes under a with the first time you have chest pain. I'm going to see if you have the same symptoms under a load right, I'm going to see if your EKG changes under a load. The fact that you run three miles a day means you're already doing your stress test day after day, right?

Speaker 2: 59:16

That's such a fantastic point and it's so obvious that I'd never. It's the elusive obvious. It's the elusive obvious I'd never even thought of that before that when you engage in a strenuous activity, you are doing your own stress test, in a sense.

Speaker 3: 59:43

And so it doesn't take the possibilities off the table. But, like we talked about ordering, right, the guy that runs three miles a day, that does it religiously, right, and it's probably going to change the heart as the primary focus because you're out there banging it away, you're doing the things and so it clearly has to be doing a fairly decent job and you have to have a decent pump function. Again, it's not off the table. Anything crazy can happen, but it changes the kind of conversation you know to probably more of a stress fatigue. Here's some MS key things that are more likely based on what you're telling me as opposed to. You know your lungs clearly are healthy enough to keep up with that activity, right. So it's probably not advanced COPD and it's not advanced lung disease with like a baseline oxygen problem because you're doing it right.

Speaker 3: 1:00:25

People barely can sat 90, you know, walk into the bathroom, aren't out running three months, right. So it's a different kind of conversation about what the likelihood is for you versus the other, right? Um, and so I'm not saying go out and run three miles today, but the fact that you can get out there and be active means that the diseases are held at bay to some degree and a lot of them more right In terms of advanced cardiac disease and other things. And that healthy activity definitely stresses your body to sort of be performing right and there's some recuperative things that in terms of disease processes that are improved with that stress and activity right, diabetes is better when you're out active and healthy and exercising. The fact that you're putting your body under stress and recovering from that has some protective means.

Speaker 3: 1:01:16

Without getting into nerdy science, but there are good protections that come with that right. So, yeah, we want you out there. We want you doing things build up right. Don't go out and run 10, you know especially. So, yeah, we want you out there, we want you doing things Build up right. Don't go out and run 10, you know, especially if you've not run at all. But getting out there walking and building into a pace and being active is a benefit at any age right.

Speaker 2: 1:01:36

How important is it to stay on top of your vitals? For example, I have hypertension, take medication for it, but I don't just take it and forget about it. I check my blood pressure frequently and something that's become kind of my best friend in the last few years. Diabetes is real heavy on my dad's side of the family so I've got a glucometer. I check my blood sugar usually once a day. Sometimes, if I'm curious just kind of how my eating is affecting things, I'll do a before meal and then wait two hours and do that. But how important are those basic little things that somebody over 40 can do to track what's going on with their body?

Speaker 3: 1:02:31

um, I think it's good, you know, we we obviously have seen a bevy of people kind of come online and become knowledgeable of their own health, right, sort of health literacy, which is good, right, um, but then there's a little bit of a risk to that as well. So having and being able to check yourself is valuable. How to understand what those numbers mean and whether that number is actively something to worry about today versus tomorrow, versus like if it's 150 for 17 days, that's a problem. 150 today, after you just ran and got home and decided to check your blood pressure? Probably not a thing, right? So it's important to understand that.

Speaker 3: 1:03:12

And even as a physician, right, I'm worried more about the trends. Right, are you elevated chronically for days, months, years? Right, that one 150 today is not going to be the end, right? It doesn't really matter If it's 150 from your age 10 all the way to 80, that means that your body is having to perform under a lot more stress, right? Your heart's pumping against a higher pressure load, forcing it to be more active than it needs to be. There's consequences there. So that's one thing, right.

Speaker 3: 1:03:43

But knowing what your blood pressure trends look like and maybe even reporting them, especially when you go back to your doctor and say, hey, you got me on dose X, look how good I'm doing. Or I noticed these fluctuations, right, so that it's not just that one time in the doctor's office, right, where you're like, oh boy, I'm nervous. Now it's jacked up to 170. But when I'm home it's still in 120, right. So what do I do with that? Right? What do I do with that 170 white boat hypertension versus the 120s at baseline? The more data points we have, the more we can understand the nuanced things in the background. But just realize, like that one number is not going to make or break. I have people that show up with blood pressure of 200, right On their worst day. Don't freak out about it, right, you're like 200, that's huge, right? 120 is normal, yeah, but you know in context, this is what's happening, right, and and if you plumbed, that number is going to go down and I don't need to put you on a special drip and admit you to the ICU for this one thing, unless you're having chest pain and unless you're having things that make that blood pressure potentially life-threatening, right and under the right circumstances. But if you came in after having a foot crushed in a, you know mechanical device and we check the pressure and you're like 180 and we're like, well, I'd probably be 182 if I had a mangled foot at this point in the day and in extreme pain, and so, know, you have to kind of balance that with what's going on. But knowing what's happening with your body is never a negative Right. You have to understand how to interpret it and you need help when you need help, right. And making sure you have good contact with a physician that can help you start through it If you don't have that medical literacy and don't understand the nuance of what's going on. But not freak out at every right and just say, look, we got to see what's going on, let's help the experts tell me what I need to worry about and what to do with it. Um, sugars, yeah, perfect.

Speaker 3: 1:05:36

If you have a diabetes history, you know, be mindful. Like. What are my sugar trends? Absolutely. Uh, do I need to avoid certain? Like sweeter foods, especially in lower contents? Like daily sugar intake probably ought to be avoided. Um, because there's some biology behind it, not to say you can't enjoy yourself and, you know, have a cake for birthday and that sort of thing. Absolutely, you need to live your life, um, but no, if you're at risk, those are things that you might want to share with your doctors make sure we check them. They're better tests than just a spot glucose, by the way. You know that. That tell us what your sugar trends do over months and weeks and and, if that's the case, we can use those things to help tell us. Are you at risk? Um, but knowing and being aware and self-aware what your risk factors are are always a good thing, right?

Speaker 2: 1:06:21

I think that's going to be something that's so helpful for listeners, viewers, to realize that it's the trends and looking at it within the context of what else is going on, because I I can only assume that you see the other side of that point which is the, the person who googles everything that happens, and then they find a million symptoms that also apply to a million other things. But because they are only concerned about this one thing, they are convinced that that's what's going on. Has that complicated medicine somewhat?

Speaker 3: 1:07:04

Yeah, I think it's good that we have people that have access to knowledge. We don't want to dismiss that Consumption of that knowledge, and how to put it into context is just that. It's why I have a job is to be able to understand the nuances and build on those layers and help you navigate it. So those are the things you got to watch out for, right. Googling a blood pressure of like 160 and then bouncing the car, you know lyme disease, and suddenly freaking out, losing your mind and showing up to an er with demands to understand why we're not going to be able to tell you that. Right, we can tell you why your pressure is up and we can tell you what the trends look like. Um, but that one number and by itself isolated, I'm not gonna do anything with. Right it's, it's not, it's not super scary. Right, it may be for you and I'll talk you off the ledge and I'm happy to sort of have a conversation about it. Um, but you know it, it it only is going to lead to just that a lot of frustration on on the consumer's part. Uh, sometimes frustration on our part too, because you know you have to unconvince people that they're not dying of this weird thing. They read on the internet, right, that somebody's cousin's brother's dog, friend's cousin might have once seen, and yeah, you get a little bit of that from time to time.

Speaker 3: 1:08:23

I think, though, as we talked about, the more people become health literate, right the sort of basic, commonsensical approach to things like first aid, and have some experience where health doesn't seem so passe or like hocus pocus, right, like this other realm that no one can touch. I think when people start to feel like they can touch it and be a part of it and not be so afraid of it, people calm down, right. So, back to what we talked about just some basic knowledge of nuts to bolts, sort of healthcare, right. We're talking first aid, like what to do with a fever, when to hear and listen to my body, that sort of things that can be easily taught in basic school approach type things. Those are important, and I think people worry less when they feel like they can, you know, understand it and own it a little bit more, if that makes sense, and I think you talk about it right.

Speaker 3: 1:09:17

That exposure you had just means you have some muscle memory, right, and that muscle memory puts you at peace with whatever you see and approach. You might not have a clue what to do at that point point, but you know a little bit about what the steps should look like, right, and how to kind of get there right. You might not have seen a, you know, hemorrhaging abdomen maybe you did, but maybe you didn't but you know you've seen a hemorrhaging limb and sort of basic principles apply, and so it's not so scary when you know that you can do a little bit of things and you have something to fall back on Right.

Speaker 2: 1:09:51

I've found that I enjoy life more because I don't have that subconscious fear of encountering certain things Exactly, not knowing what to do Exactly. So then I can relax Last question and this kind of relates to that. So then I can relax Last question and this kind of relates to that. Having been focused on emergency medicine and seeing the things that somebody in emergency medicine sees on a frequent basis, how has your approach to death and dying evolved, or has it? Is it?

Speaker 3: 1:10:27

any different now than before you went to med school. So like I think what you're asking is kind of a personal approach, right? So how do you sort of tussle with that experience right.

Speaker 3: 1:10:39

Well, we've brought a whole new like realm, right, I mean with regards to seeing people die with like constants. Right, I mean, we saw a lot of death in COVID. That was more than I think I've experienced in the prior 15 years of my practice. It truncated or toppled by one year of COVID. Right, so you became comfortable with dying, unfortunately, and comfortable walking people through the death process. Right, because it was something that people were not ready for and very afraid of and struggle. Right, especially with the, a lot of frustrations there that added to the already tough period of like death.

Speaker 3: 1:11:31

But yeah, you know, my approach to death has definitely changed. I hate to say calloused, but you change Right, with how emotional you become your own self. Right, like that first death you experienced as a child, it was was upending. Right, it was very emotional, it was wrought with feelings, and those things change a little bit as you do it more and more and more right, sort of like the fear of something. Right, you know, the first time you get up on a roof you're scared as hell. The, the 10th and 20th time you've done it because you're a roof layer. You become less and less fearful because your experience is there. Right that the emotional adrenaline rush changes and, in sort of, you're able to control it, right, that's really what's happening, um, and so I wouldn't say callous, but my emotional control is much different now.

Speaker 3: 1:12:20

Um, where you know, I I probably approach death with a much more logical process. Right, and a lot of it has to do with me walking other people through it and I've become pretty good at it, unfortunately, in terms of having the conversation, being able to really understand what the other person is, I think, feeling, right I mean, I think we've all had some loss, especially at this stage of my life and understanding the feeling, feeling, understanding the common problems that people struggle through, right, having done it so many times, and and sort of trying to redirect them, um, make them understand what, what's happening, um, and just sort of walking through the next steps, um, you know, as become I've tried.

Speaker 2: 1:13:03

I would assume you've seen people who, as they were going through med school, thought they wanted to go into emergency medicine, but that who got there and realized that this isn't my cup of tea. They weren't able to develop that same level of detachment Right.

Speaker 3: 1:13:22

Yeah, and there's definitely that there are people that are like, oh, the whole blood thing doesn't do it for me, okay, great, I mean there are other options. Right, there are lots of layers of medicine and you know, like, if you're that guy or not, right, you're not going to be the surgeon. If you're not really happy with blood, right, uh, if you're not happy with fluids and you know chaos, you're not going to do. Well, in emergency medicine. You have to be comfortable with not controlling every scenario like to your liking. You have to be comfortable with a little bit of anarchy, right, degrees of freedom.

Speaker 3: 1:13:56

Um, so I, most of us get that experience where you get to touch down for a month or two and practice what the other guy is doing and realize this is not for me, right, I'm more of a. I need it like very well walled off. I need this process flow to go very smoothly. This is just my neuroses and and I would not function well in that condition because of who I am right and just working through that process. Um, so, yeah, you kind of understand. You get to learn it in a little bit different way, right.

Speaker 2: 1:14:34

Dr Allender. I hope sometime down the road we can do this again, because there's so much that you bring to the table that I think can really help people live more confidently and have that knowledge that you know what bad things happen sometimes and, to the extent that I know, I can take care of those bad things when they happen, I can relax a little bit more and at the same time possibly save a life.

Speaker 3: 1:15:02

Yeah, absolutely. And, in closing, if your viewers are out there listening to this and they think to themselves, you know I've been contemplating a CPR class or a first aid class, so you haven't taken that step. Take it, right. It's not as scary as you think it is, and you might need it Right At some point in your life, or your loved one might need it. You never can tell. There have been people that I've encountered that you know just took it for a whim and it saved their loved one's life. You never know.

Speaker 3: 1:15:28

And so being armed with knowledge is never a bad thing, right, and it's something that makes the whole healthcare side of things less scary, in my opinion. Right now I mean, I'm in it day in and day out, but having just a touch of knowledge on something makes it much more tangible, right? Even if you aren't the best cook, cook but know the nuts to bolts, it seems less like fanciful, right. So get out there and do it. If you have some inkling about it, get out there, and and, and. It may not be for everyone, right, but for most of us, uh it, it might be an opportunity to delve into something new, that that that can make you a savior at some point.

Speaker 2: 1:16:07

Great advice and you've provided people with something in this episode that I know is going to be beneficial and may save a lot. So we'll touch base and in the future maybe we can do this again and expand or maybe even go in a different direction. But I want to thank you for yeah, thanks for having me, for being here today, because I know how busy you are. So thank you and I will be in touch. See you soon. Thank you so much. Bye-bye, we'll be right back.