Joe Finney - How do you know when to stop?

Joe Finney is a Pediatric Emergency Medicine and EMS physician. He is the medical director of the Missouri EMS-C and host of the Pediatric EMS Podcast.

In this episode, we talk about what it's like to practice medicine at the limits of Evidence-Based Medicine, what it’s like to start a career in Academia, and why hosting a medical podcast is literally the most important thing one can do.
 
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Email: Tama.TheMDM@gmail.com

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Host: Tama Thé | Pediatric Emergency Medicine
Producer: Melissa Puffenbarger | Pediatric Emergency Medicine
Communications Director: Katrianna Urrea | MD Candidate

Transcript

Hello and welcome to the MDM, a show about the ways medicine is adapting to the modern world. I'm Tama Thé, so I work in the Pediatric Emergency Department and we see a vast spectrum of cases ranging from minor injuries to life threatening conditions. It's a unique little microcosm of both medicine and the human experience in general. The kids who come to the E.R. are scared, but their parents are terrified. And it's why the hardest skill to learn is actually not resuscitation, but reassuring a family that their kid's okay without running any tests. But how do I know that she doesn't need a CT scan? Well, about 15 years ago, the biggest pediatric ERs in the country studied 42,000 kids with head injuries. So that I can confidently say today that she is going to be fine. This is the power of evidence based medicine. It's the cornerstone of medical decision making in physicians involved in academic medicine, advance their understanding of diseases and their treatments, leading to continual improvements in health care. It can make a lasting impact on population health. But to really make a difference, to fundamentally change medicine, it requires a dedication to research that most of us just don't really have because research is tedious and slow and mostly boring. These are the true unsung heroes of medicine. You know, they're like our Navy SEALs going above and beyond where most of us would never go. And when I see them in the airport on the way to a conference carrying their posters in that giant cardboard tube, I think them for their service and let them board before me because I am not going to write a bunch of grants and spend my life fighting with the IRB. We should be standing in front of the research building, banging pots and pans as they go to work. And so on. The show today is a very good friend of mine who is dedicating his career to the noble pursuit of clinical research. Joe Finney is a pediatric emergency physician who is also fellowship trained in EMS. He serves as the medical director for the Missouri EMC and is the host of the Pediatric EMS podcast, which he uses to disseminate cutting edge research directly to paramedics in the field. In this conversation, we talk about evidence based medicine from a variety of perspectives. One of them is about how decision making can be difficult when there's not a large body of literature to rely on. The example that came up is pediatric cardiac arrest and when it is appropriate to stop resuscitation. I think the conversation is handled with sensitivity, but we do talk briefly about child mortality. So if that's a difficult subject for you, maybe give this one a pass. Otherwise, welcome to episode four of the MDM. How do you know when to stop? Joe Finney, thank you so much for being on the show. Tom, thank you for having me. I really appreciate. It's great to see you again. It's so good to see you, man. I'm super excited about this conversation. So we did fellowship together in pediatric emergency medicine, and then you did a second fellowship in M.S. in prehospital care pretty much from day one. You knew coming in that that was going to be your thing. How did that start for you? Yeah, so I was an EMT before I went to medical school and I worked for about a year and I did about half of paramedic training. And during paramedic school I was involved in an encounter for a child who came in with essentially a mortal head injury, little toddler that the you know, this was back when TVs were heavy. And so the TV fell over when mom was changing one of the other kids. And I remember just that experience. I was like, you know what? This is something that I want to do, you know, so so that my background had been in EMS, but that shifted me to the emergency department where I felt like we could do more in terms of following a patient throughout a longer course of care, providing more interventions, those sorts of things. And I'll be honest, I didn't think about EMS after that. I kind of moved on and that was going to be my future. And I got through with residency and started Emergency Medicine Fellowship at WashU, and it was Katie Leonard, my, my fellowship director at the time said, you know, you have this background in EMS. The guy who does EMS for us is going to be retiring. Is this something you'd be interested in? And I said, Yeah, absolutely. I mean, you know, when you're a fellow, you're looking for anything to to set you apart. And and she said, Well, there's two ways you could go about it. You could be a you could do an EMS fellowship. Or you could just kind of be the EMS guy for our division. And I worried about with the way the landscape of medicine is changing that if you don't have that stamp of approval from those bodies that make those stamps, my career future in EMS would be always kind of in question. Someone comes along who's fellowship trained, and suddenly they're the guy. And even though I had been doing it for years, I would be out. And so I was like, It's that time with my wife. And I said, You know what? It's going to be one more year, let's just do it. And it was awesome. I mean, EMS is is amazing. And especially from a medical director perspective, it's just such a cool experience. It gets you outside the walls of the hospital. You get to be at the doorstep where I feel like a lot of real medicine happens. You get to work with some amazing people who are just putting it on the line every single day to help people in situations that those of us who like to wear white coats in the emergency department would be like, I can't do that. Yeah, I'm not going in there, you know, no way. But they do it. They do it all the time, you know, dragging someone out of a ditch on the side of the road at 3:00 in the morning in the rain. That's just part of the job. And that has been very invigorating in my own career. But in addition to that, it it has shown me that the prehospital education on pediatrics is lacking. You know, when I was a paramedic student, we got 6 hours of paramedic training on pediatrics. It was like, this is a kid. They're kind of different than adults. And and and here's how you do. House You know, it showed me that, hey, you know, I have an opportunity to educate on the care of children in the pre-hospital setting. And I was lucky because I had a little bit of a background in EMS. So I kind of talk the talk enough to be able to be credible. You know, I just enough street cred to get in the door and I could simplify it because that's how my brain works. I have to break everything down. And I found that that has been very valuable and rewarding work. And that's really how I got into podcasting, was I wanted to reach a broader audience to educate about pre-hospital pediatric care. You know, at the very beginning, you were telling a pretty scary story about somebody who had a mortal head injury. And, you know, what do you do in that in that moment? Were you in the truck like were you there on the see? They came in by EMS. I was in the emergency department doing my paramedic clinicals and they called I think it was a pediatrician. I don't even think it was a pediatric emergency medicine doc because it was rural and it was 15 years ago and they called him in from army had been like cleaning his garage and he came in in like a fishing cap and he's running this, you know, this what we would essentially was, you know, traumatic brain injury resuscitation. And I just remember watching and being like, I got to do that. You know, I got to be that guy. I don't even know who this guy is, but I got to be that guy some day. And now I look back on that experience a lot because there's only a couple of things you need to really know how to do pre-hospital when it comes to traumatic brain injury. And if you can do those two or three things, well, you have checked the box on you providing excellent care to that patient and giving them the best possible chance at survival. And they may not. Right. Because a lot of, you know, traumatic brain injuries is a leading cause of pediatric death. But you've done your part. And I spend a lot of time thinking about that because we make things too complicated, you know, a lot of the times and. A lot of what we do is is evidence based ish. Right. It's like there's a paper out there on that. And if you really dig into it and get into the methods, it's not that strong that we all do everything because of that paper. And and so what are going to be the three or four things in any given situation that you have to do? And that's kind of been my approach to pre-hospital medicine. And I like it because I don't it's not like the E.R. where. Everybody's got an opinion. Everything is so nuanced, you know, it's just it gets into the weeds where you're like, I don't I don't even know we're talking about, you know, like we're talking about the 1% of the 1% of the 1%. You've never even seen that patient in your life. Yeah, yeah, yeah, yeah. But I have strong opinions of it. So just because I'm dying of curiosity, what are the two or three things that you tell your M.S. Riggs to to focus on for head trauma? Yeah. So Dan Speight is a trauma surgeon in Arizona, and he did a trial called the Epic Trial. There were two studies. There was one epic and one epic for kids. And the epic for kids was just a secondary analysis. But what they did was they said, hey, you know, the things that are evidence based for the care of traumatic brain injury are avoid hypoxia, avoid hypotension, and avoid hyperventilation which which he termed the age bombs because he thought that was something people could remember in the ditch on the side of the road at 4:00 in the morning. And that's it. That's all he did. And so they went around and they trained 6000 paramedics on the bumps and they said, all right, if you have any patient who has a head injury and a loss of consciousness for any period of time, then they get an I.V. and a bolus and they get a non rebreather mask at 15 leaders. And if you end up ventilating them, you target an antidote CO2 of 45 so that you don't hyperventilate that and that was it and he in the pediatric population overall survival in pediatrics not neuro intact survival. They didn't look at that but overall survival in pediatrics had an odds ratio of eight when you went back and did these interventions, which is just shocking. I mean, that's just I think it was seven or eight. It's just an unbelievable odds ratio in adults. It was two or three, still very, very amazing, but just unbelievable in pediatrics. So I took that. I listened to him talk and I said, you know what? That's all I'm going to teach. I mean, that's literally there's no reason for me to get into the weeds on all this other stuff that's not evidence based. They're going to have a patient for 15 or 20 minutes. Just don't let them be hypertensive, don't want them be hypoxic, and don't hyperventilate them. If they can get them to the E.R. in that condition, then we could maybe do some stuff and that's it. So that, you know, and that's how I approach seizures and cardiac arrest. And, you know, those are probably the the biggest ones that I look at. But general trauma I approach in the same way. It's just I just think of it like, you know, when I'm in the E.R. resuscitating a patient, I'm really only thinking about a couple of things. You know, I we like to sort of wax poetically about all of these different factors, but we're chasing a couple of different things usually. And I try and just take that to the pre-hospital setting and say, just forget everything else. Just do these three things. If you got a pediatric patient at the beginning of the conversation, you alluded to the fact that when you are making the decision about whether or not to do a fellowship, the question was, do you need that career stamp? You know, to be able to say that I did a fellowship in EMS. And what you're describing there is is I imagine the difference between doing a fellowship and just doing it, you know, like if I were to have walked out of my PDR fellowship and said, Yeah, I'm going to go be an EMS director, what I would do is I would go look at what my benchmark institutions are doing and saying, and they're just repeating that, you know, I wouldn't be able to cite the epic trial in Dr. Speight and what he did in his shot in order to build the best curriculum and the best, you know, structured education for them, like 100% I wouldn't do any of that. When you talk to pediatricians nowadays, one of the big things that they all that that pediatricians are complaining about or groaning about is do we need this hospital medicine fellowship? Yeah. Like the idea is that are you not training to be a pediatric hospitalist when you're doing pediatric residency? And and then do we need to have an outpatient fellowship where we learn how to do outpatient medicine? You know, where when does it stop? But I think truly, if you're talking about excellence, if you're talking about I want to be the best at whatever it is, I think you do need to spend that time and you do need to completely deconstruct whatever is going to be your professional life forever down to its rivets and say, these guys have 30 minutes from beginning to end. What are the things that they can't miss? What do they need to do? And I think that's beautiful. And I'm and I'm glad that there are people out there who are doing these extra fellowships to be able to get to the bottom of that. I, I think that fellowship training is critical, and I think that in some ways the system is broken in the sense that the compensation for fellowship training and residency training and some of that could be optimized. But if you take fellowship in isolation, it is for next level expertize. I mean, the goal is to to immerse yourself in the topic so that you come out on the other end with a level of understanding and knowledge that you wouldn't have if you just kind of did something. And you mentioned these other areas hospitals, medicine, outpatient medicine. I don't know that it's a bad idea. I mean, I used to think like, this is crazy. I think the crazy thing is how little we pay hospitals after they come out of fellowship training. But I think that it's it is important and we don't. Go into medicine to be okay at something, right. This is what you guys talked about in the first podcast that resonated with me so much. It's a little bit about what you learn, but it's also about the expectation that you will learn everything about something, right? You're not going to just be like, Yeah, I think I remember Intramuscular said, I want to say five milligrams. That seems right. That seems like the right dose. That's fine if you want to just be a guy who does something. But if you want to be someone who is really the expert on a topic, then you need to know what study that came from and you need to know who the study population was and why that was chosen and what they've looked at since then to make that decision. And I think that's what paramedics expect of EMS medical directors. Otherwise, what is the point? You're unnecessary, right? You're just signing protocols, which a lot of unfortunately, a lot of medical directors do. But and this is a big argument I'm having in my home institution right now is the way we do cardiac arrest resuscitation. And I sit down and I'm interesting. I'll say, like, okay, what is the evidence behind this thing that we're doing? Why are we doing that? And nobody knows. Right. Well, that's what the palace guidelines say. Who makes the palace guidelines? Why? Where do they get their evidence from? Right. A lot of this is just consensus statements on some study that was done 20 years ago. And I think if you want to be a pediatrician, just like the bare minimum, then it's okay to not ask these questions. But if you really want to be like I like to say in the emergency department, we are emergency medicine physicians, but we are also resuscitation, meaning we are experts at resuscitation. Your job is to find the most cutting edge evidence to support the best possible clinical care you can provide for your patient and not guidelines that are updated every 3 to 5 years. We owe it to our patients. And so, you know, I think it just it becomes sort of a responsibility on us to make sure that we are doing the absolute best, most up to date care. And this is where, you know, like then that's how I got into academic research and all sorts of, you know, stuff that goes along with it. You mentioned that you are questioning some of the things that you're doing in cardiac arrest. What are those things that you're that you're pushing on? Well, I mean, if you look at the evidence to support epinephrine in cardiac arrest, there's enough studies to say that it's harmful, as there are, to say that it's helpful if you line up 20 physicians and ask them, why are you giving epinephrine in cardiac arrest? Do you think on a physiological level, I wonder how many physicians really can answer that question? I mean, a lot of them would say, well, because it gets the heart to pump or something like that, or it increases vascular resistance. And I would say, all right, let's let's think about it for a second. On a physiologic level, if you have a heart that is ischemia from being in arrest in a low flow state, and you give it a medication that is demanding that it push harder and faster, how good is that for that art? Right. I mean, I just wonder if if you're running a marathon and you're at mile 24 and you're about to fall down and someone runs up behind you and started beating you with a whip like, you know, yes, you will run harder, but will it be good for you? You know, and so I ask myself, like, nobody's going to get away from from epinephrine in cardiac arrest. And I'm not saying that we should, but I wonder, is there a limit? Right. I mean, where how many doses of epinephrine should we be giving in the emergency department for a patient in cardiac arrest? The evidence that we have shows that if you're going to survive a cardiac arrest, you're going to survive in the prehospital arena, meaning you will get lost prior to arrival to the emergency department. Patients who show up to the emergency department, who have been in a non shock able rhythm without Ross for the entirety of their prehospital resuscitation, have a very, very poor chance of survival. And there's, there is a study. So so actually the Japanese do this amazingly because they have a huge pre-hospital cardiac arrest registry that where they have all this data. So they put out all of these studies that we wish we could do in the United States. And there's evidence out there to show that if you are down for 45 minutes without a pulse and without a shock wall rhythm at any time, your chance of neuro intact survival is zero. It is it is nonexistent. And so if you think about a patient who goes into cardiac arrest, pediatric patients are often unwitnessed cardiac arrest right there. They're found in the crib 3 hours later or something like that, or mom put him to sleep and then they don't know what happened, you know, that kind of stuff. Or they all wake up and the baby's not breathing. So you have you don't know the time of arrest, unlike grandpa who goes into cardiac arrest at the kitchen table and everybody's there and sees it. So we don't know when it happened. EMS shows up on scene. They take 15 or 20 minutes to get an IO, to get fluids, to give AP, to put in a super robotic airway, to start ventilating the patient, to do high quality CPR. And then they transport a transport 15 minutes to the emergency department. You're now, at least at a minimum, you're 40 minutes into this cardiac arrest resuscitation. In medicine, a less than 1% chance is considered medically futile. We're talking 0%. For these people, you know? And so I just wonder, should we be doing so much? And I will tell you, you have a child. I have little kids. I spend a lot of time daydreaming about what if my son was hit by a car? What if my son went into cardiac arrest? What would I do? Right. Well, how would I manage that situation? Or you're running down the street and you're thinking, okay, that kid riding his bike, if he gets hit by a car right now, what am I going to do? Right. And so I think through a lot of these scenarios, just sort of as philosophical thoughts of like, what are we going to do in the situation? And then I wonder, okay, it's my own son. What do I want done to him? But when you are the physician caring for that child, your job is not to be the parent. Your job is to be the expert, to be the absolute final say on what is the best way, most likely of getting this child back. And so you have to know how to navigate the emotions of the family, your own emotions and the medicine itself to choose the right route for that patient. And I think because that is such a daunting task, that gets me feeling overwhelmed, just saying it out loud. People say, Well, we have panels, and panels tells me what to do and I can just follow panels and then I will be safe from having to make those kinds of calls about what's best for this patient. You do a lot of ultrasound. Yeah. Had you ever put a probe on a heart that still is slightly moving and terminated a cardiac arrest? When you say slightly moving. So so, you know, kind of, you know, quivering like no organized movement. Yeah. I want to be clear. There is no organized movement. Yeah, I don't think so. I think if there's some movement there, I think we this is a great question, right. Because this is what we have to ask ourselves is, okay, what's going to be the cutoff for termination? And I will just tell you full disclosure that I have terminated those research cases before, but the evidence isn't clear. And that's where we need clear evidence based research to say what this is, what the evidence shows. Right. So if I were to say to you, okay, if you have a pediatric patient in cardiac arrest who'd been down for 45 minutes, you put a probe on their chest. There's there's like disorganized rate of cardiac movement. And you're like, I'm not turning. I'm going to keep resuscitating them. No one would argue with that decision. But if I were to say to you, okay, but there was a study done on 5000 pediatric patients, and they found that in this situation there was a less than 1% survival. You know, one patient survived for ten days in the hospital and then had to ad withdraw care. That would make it easier for you to say this is not going to be a good outcome for this patient. Right. When you do this in the adult world, they have a different perspective of termination. They have criteria, strict criteria that's been studied. And they say, you know, okay, you have a patient who's got X, Y and Z and no good outcome, then you can terminate that patient. And actually, there's a big discussion now about pediatric termination of resuscitation in the previous block. And I think that is important because we often say, well, families want to see us do everything right. Yeah. And I would say, do they do they want to see you do everything or do they just want to see you doing some We need to start saying, okay, and I'm doing this right now is I'm pulling 250 cardiac arrests from our institution and looking at, you know, some parameters. How long were they down? What interventions did they get pre-hospital and looking at the overall survival? Because if you can show 30%, you know, make it to the ICU, that'd be amazing. I would love that. I would love to be able to identify more markers that we could use to guide us. And it's hard in things that come to life and death. And I'll say people will listen to me talk about this and they'll be like, That guy's an idiot. He doesn't know what he doesn't know what he's talking about. You should follow pals. I don't know why he's saying this, and that's not evidence based and he's killing people and that we shouldn't be doing that. And I would say that I think there's truth on both ends of the spectrum. I'm not saying I'm right. I'm saying we need to find out what is right. You use the phrase daydreaming about what happens if my kid got hit by a car. We 100% need a better phrase for that you were talking about, you know, what would I do in those situations? And then we're talking a little bit about when have you done enough to demonstrate to the family I was in recently had a child die who you know, the family was there for the last 25 minutes of the resuscitation and we did the standard, pull them aside and say, these are the things that we've done. These are the things that we're seeing. At this point. It looks like it's futile. We're going to try one more round and then, you know, we're going to look at his heart. And if his heart still isn't beating, that we're going to we're going to terminate the resuscitation. And, you know, this family couldn't speak English. And so all of this was happening through an interpreter. There was a lot of emotion in the room. And after we stopped the resuscitation for an hour, the family was in the room praying it would come out about every 20 minutes or so and say, I think I saw him move. Oh, I think I saw. Yeah, he's still warm. Will you check his heart again with an ultrasound? And we went in there over and over and over again to show them that the heart was a beating and they didn't understand. You know, to make a long story short, it was one of those things where it's framed the way that I think about how much the theater of medicine is important, you know, and and even, you know, you think about ultrasounds sometimes we do ultrasounds just to show the family that that we've thought through whether their gallbladder could have a gallstone. Look, there it is. There's there's nothing there. And so I think that I. 100% here. Yeah. You know, is it is it futile? But am I still going to do it? I think I am. And I think I'm still going to do it. And I'm not saying that's wrong. I am not saying it's wrong, but I think how much we do might change. Right. Because, yeah, if we're getting a cardiac arrest that's been down for 45 minutes or an hour or whatever it is, we get them in the E.R. and it's pretty clear either from them being stiff or them having a core temp of 88 degrees fixed in dilated pupils, whatever it might be that this resuscitation is probably going to be futile. Do we need to put in an end to tracheal to, you know, do we need to get three lines and give another five rounds of AP? I would say we probably need an ultrasound, chest compressions and a discussion with the family. And I think then you don't have to do all of these other things because, you know, because we think about, okay, we do it all for the family. It's hard on us. It's hard on nurses. It's hard on medics in the emergency department to resuscitate these patients over and over again and get nothing. You know, it's like, yeah, I remember from 911 that they would have to give the cadaver dogs, they would have to plant something every once in a while so that the cadaver dogs could find something because they would go so long without finding anything that they would become despondent. They would, you know. Yeah. So they would have to like go through these scenarios where they would just give the cadaver dog a find and praise and then they would feel more motivated to keep doing it. Yeah. And I think we run a bunch of cardiac arrest that we don't get them back on and we're just like, What the hell is going on? It makes you wonder if the interventions we're doing are the wrong intervention. And so, you know, it's not that I say everybody should stop. The patient comes in, you put a probe on their chest and you're like, their dad were on my back. They do do that sometimes in the adult emergency bar. But I will tell you it it's a real thing. But then the family shows up. They're like, Yeah, Grandpa was 95. This is what we expected. In fact, we weren't sure yesterday if he was dead or not, but I don't. But I think we just that's what we need to be doing. And I think this is this is the value of academic medicine. You need to always be questioning every single thing you're doing and be okay with questioning that and not saying that I'm questioning it. Meaning that you who practice X, Y and z method are wrong. Just saying that I just want to find what's right. And if you're right, then great. If you're not, then let's do it the right way. And you know, it's the humility of medicine that I think is the most challenging part of it, is to be like I don't know, can I keeping you humble, I got to say, there's not a day that goes by an emergency department that I don't feel like I need to be studying 1000000 hours a day. You know, it's like I can rattle off all the best papers, but at the end of the day, there's there is just such a volume of wealth of knowledge that will never quite totally master. I am humbled every single day. It's like, you know, the old dogs will come to you and they'll say, like back when we were, you know, practicing. And I was like, when you were practicing, when there was like one scan and penicillin that was before, like we even knew about autoimmune diseases, you know, here's some more blood today. Yes. Let's yeah, yes. I get the allegiance. There's so many things. I was like haha those old guys. But how many of those things are going to actually be like radiation? You know, in 30 years people are going to be like theses radiation on human beings. Yeah, 100%. Yeah. What the hell was that? You know, one of the things that that's kind of a through line in the conversations that we've been having is what is the next step? You know, how do you master something? And we talked about, you know, training and going through a fellowship and becoming a master there. And then, you know, you started your podcast, which I still want to talk about, but you started your podcast in order to try to spread some of the good word and to better just the general level of mastery of pre-hospital medicine What else are you doing in your career? What is the next 5 to 10 years look like for you? A research, clinical research, I think, is going to be the future for me of trying to close the gap a little bit on some of these questions. And here's the problem with academic research. You pick one question and you spend 15 years trying to answer it. If you're someone who's lucky, not lucky, she'll kill me for saying that. But if you're someone who commits themselves to a task and works hard enough, you can end up like Julie Leonard. You can retire tomorrow and say the future of pediatric care is better. Because I was there, because I did this research. And you and I see, you know, we spent so much time talking about cardiac arrest. We see one cardiac arrest patient a couple of times a year, probably. I mean, I probably see 6 to 8 in a year. And we spend so much time thinking about those one patients. Julie Leonard has written a model based on evidence that would prevent cancer in countless patients in their future, kids who will be 40 years old and develop cancer because of scans they got when they were children If they follow, this new guideline will not have that happen. And this would go on indefinitely, right. I mean, the number of lives that she could touch through a single manuscript is mind boggling, you know, and we imagine over a single patient that is amazing. And so I look at that and I say, I what can I do? What can I do? That's going to impact a lot of children? And so I have focused on ventilation for the last two years, improving the way we've been, the quality of ventilation for children using a ventilation feedback device similar to like CPR feedback. It gives you real time feedback on how fast you're ventilating, how much volume you're giving, those kinds of things. And then I, I have recently begun work on what is really my passion is that improving the management of prehospital pediatric seizures. So depending upon what you read, 30 to 40% of adult and pediatric seizures will be refractory to benzodiazepines, which are the standard first line care. And we know that seizures that lasts longer than 30 minutes carry up to a 19% mortality. The so the more quicker and more effectively we abate seizures or abort seizures where you like in the emergency department or in a pre-hospital setting, the better that is for our patients. And so I looked at it and I said, okay, this is this is awesome. I mean, this is a great this is this an opportunity. And I had some amazing people because no one ever comes up with an idea in a box who had implemented ketamine for the management of some complex seizure patients in the pre-hospital setting. And they had good results. And so I took what they had done and I said, What about using ketamine for everybody who is refractory to benzodiazepines in the pre-hospital setting and stopping seizures more effectively? And so I've gone down kind of the rabbit hole of, you know, you start with a retrospective study, you look at a database Well, was there any benefit? Okay, now look at a larger database. You know, now tease out some question. Now look at a case series and and then, you know, build towards what is the Holy Grail, which is a prospective randomized trial. Looking at this and I'll be honest, I think it will probably consume all of my career, probably the next 20 to 25 years of my work to to look at this. But if I retire and I can look back and say, you know, of those 30 to 40% of patients who were refractory to benzodiazepines get treated and don't have continued seizures, what an impact that could be, right? What a change that could for people. So you you are the host of the pediatric EMS podcast and one of the people that you've referenced quite a lot, Julie Leonard and also Nate Cooperman, were just on your show at the beginning of the month. It was a great conversation. And so for anyone who's out there who wants to hear about either the way that one of these multicenter studies comes to life, I would highly recommend listening to that episode. What this was about was everybody knows about peak hour and head injury guidelines. Peak Aan is a research network. It's not just a head injury tool. They just put out a prediction rule for C spine imaging. So the exact same kind of things that you think about with. Head injuries. You can now apply to see spines with the confidence and the backing of a multicenter study looking at thousands of patients around the country. And so that actually just came out this month in your podcast was excellent. You know, I recommend everybody read the paper as well. But in the show itself, you pretty much hit on on all of it. I mean, he says in the podcast and I made it the title, which was Evidence Powers Judgment. And when I heard that, I was like, that's it. Like, that's why we're doing this research, right? Because the evidence will empower you to make the decisions that are right for your patient. I know. Cooperman, you know, and Julie both. Somebody said once I went to a conference and I'm like, That's so-and-so or whatever, X, Y and Z paper. And they're like, Dude, it's like baseball cards for you. Wow. And it is a little bit because I mean, these are people like, you know, who are who have done stuff that would put most average people to sleep. Kind of amazing work. But it is I mean, it really like when you get down to it and I wonder, I actually want to ask you, does the importance of research come up in in med school? I don't. It didn't much when I was in med school, if ever. You know, we do talk about evidence based medicine and we have evidence based medicine, you know, lectures and kind of workshops where they have to go and research a question like something that comes up on their third year clerkship. The expectation is you you have to identify a question. You get to that finer, you know, research question is like, how do I make this explicit about my patient population and outcomes, etc.? And then they go out and they try to figure stuff out. And so so there is that evidence based teaching that that we tried to instill. But the conversations about like how to build a career in academic medicine is just that's the one that doesn't exist. You know, it's whenever you ask anybody, it's like, so how did you build your career? You know, how are you going to be in charge of this research network or something? And inevitably, it's like they've always been doing it and it's, it's, it's the only thing that, Yeah. Has like, driven their lives. And I'm like, that can't be, that can't be real for everybody, right? Like, we can't all dedicate everything to it. But to your point about, could we be so lucky that in 20 to 25 years we have mastered this one single question and can then put it to rest that these are the patients that you need to get ahead of these other patients that you don't need to get head CT on. Wouldn't that be nice? Is like, yes, that would be nice. Well, also, how am I supposed to do that on a day to day basis? You know, your percent. I completely agree. And no one tells you. No one tells you. One of the things that I've been getting into is artificial intelligence. Yeah. And a lot of people are kind of pushing on the artificial intelligence because I ominous, by the way, I appreciated it. It sparked some fear, which I think was appropriate. Yeah, I so I, I love that you brought that up. So that was episode two. I wanted it to be ominous, if only because I think that oftentimes when you hear about people talk about AI, everybody is all like, Oh my God, it's going to change the world. When in reality, yes, it's going to change the world. How is it going to change the world? But, you know, I think it's going to be so powerful. And I was sitting so I'm doing a fellowship right now with the National Board of Medical Examiners of on artificial intelligence in academic medicine. And we were sitting in this room, there was eight of us and then our faculty mentors. And we were just kind of going through, you know, where can we take this project? We have two years to build something. What are we going to build it? Every single time one of us would say something, they were like, Yes, that sounds reasonable. However, know that you have three months to gather data and we're like, No, we want to change the world. And I feel like, you know, you go through your entire life's training and once you become an attending, the walls come down. If you are a pluripotent cell, you could do anything you want, you know, how were you going to make a difference? Is it going to be churning it out in the clinic? Is it going to be in the emergency department touching lives that way or is it going to be I'm going to take the vast amount of knowledge and stand on the shoulders of giants and project that into the world and try to bring everybody up to my expertize and level in. And I love that you're doing that with a podcast, you know, because I listen to podcasts constantly and in almost none of them are medical. They're all like comedians talking about what it's like to do comedy. That's kind of why I started this one, because I wanted I want this conversation, you know, I want I want to hear how the person who is trying to be the next Nate Cooperman is starting his career because I want other people to be able to do the same thing. There are podcasts out there that I listen to that have totally altered not only my perception of medicine, but the way I practice medicine. I think it's such a great tool and the people who do it, who do it much better than me are really amazing at the work that they can do to put this out because it's it is a ton of work. And there's the Scott Weingarten out there who have a subscription and get paid. And those people are very rare and most of people are out there. I mean, it's like the palm currents or the pen playbook. Those guys, you know, they don't make any money to do their podcast. You know, they're just they're just doing it for for, you know, for their own love of doing it. And I think this is where it all ties in. You know, when we talk about going into fellowship and what people should do and and academic medicine and all this kind of stuff. I would say first, learn how to do the job you're supposed to do. Second, learn how to educate people so that you can translate the knowledge that you know to them so that they can do the things that you do. And then once you have feel like you are adept at educating, which is a career in itself, then start thinking about how to make things better. How am I going to improve the institution of medicine? And that may be through working in residency programs, working in hospital administration, working as a clinical researcher, working as a bench researcher, you know, working in social aspects like, you know, improving injury prevention, things like that. There's a million different ways. But once you've kind of identified that, hey, you know, I feel like I know this. I feel like I can teach on this now. I need to figure out a way to improve it. And that's when, you know, research putting yourself out there on a podcast where everything is recorded and your stream of consciousness is known to the world. It is is so important. And I think I wish there was a talk about this, you know, in in med school, because I don't think people think about it. Everybody wants to become a doctor and be done and, you know, quote unquote, start making money. But the real work I feel like I started after I became a attending physician, because then you then the walls come down and you're kind of like, alright, now what do I do? How do I do? I do something with this field that I, that I am in. Yeah. And that's I think, honestly, that's where it gets exciting. Joe Finney is the host of the Pediatric EMS podcast. Highly recommend that podcast. And then also check out his episode with Julie Leonard and Nate Cooperman. Nate Cooperman, we didn't mention he was the guy who did the podcast head injury study. And so if you've ever cited the Picard study, you were citing Nate Cooperman, who was on his podcast. Joe, thanks so much for being on the show, Tom. Thank you so much, man. I really appreciate it. So this was the first interview that we recorded after the podcast launch last month, and it was a little challenge to see whether or not we could turn it episode around in two weeks and we almost made it. I'm very excited to say that the medium now has our very own. Communications director, Catriona Uria is a second year medical student at Texas Tech, planning for a career in one of the surgical subspecialties. I had mentioned in episode two that I was floundering on social media and she has generously offered to take on the challenge of building a community around this podcast. So if you are listening to this because you saw it advertised on social media, that is Katrina's work. The stuff that she's made so far is super professional looking, and I'm excited to have her on the team. I've had a lot of people give me feedback from that first episode with Amy Holshouser, where we talk about classes in step one, both going pass fail and whether or not that is affected the way that students are motivated to learn. In that conversation, we had talked about whether schools should go back to assigning grades in order to motivate students to master the content instead of just trying to get a passing score. And I received an email from Alex, a second year medical student, who says, quote, To be honest, I think pass fail classes are necessary now because of step one going pass fail. I think when residency programs stratify students without a number score, they will just find another number, whether that's the number of volunteer events or the number of research papers. So in my opinion, actually having classes being passed fail gives us more time to do these things that we all feel now is a requirement. In I've heard this perspective quite a lot. And I have a follow up episode coming up where we talk about this in the interview. And so if you have any opinions on the subject, I would love to hear them because it helps me frame the show. You can find us on Instagram and now on Ex, thanks to Catriona. Or you can email me at Thomas at the MDM at gmail.com. This podcast was produced by Melissa Puffin Berger. Catriona Uriah is our director of communications and I will see you in two weeks for episode five.