A Podcast Series With Dr. Cook & Dr. Iqbal Mirza: A Discussion On The Advances In Anesthesia, Medicine & More

 He was drowning in his own lungs. Three weeks later, he walked out of the hospital. I mean, and I don't do this for appreciation, I only do it because this is what I love doing. But that's the kind of, uh, exhilaration that went, Theo. He's saving somebody like that. You're listening to a Bio Reset medical podcast with Dr.

Cook. If you have questions, we'll wanna talk more about your symptoms and issues. You can always reach us at 6 5 0 8 8 8 7 9 5 0. Hello and welcome to the show. Uh, today I have a very good friend and. A long-term friend, Dr. Iqbal Meza, and I'm delighted and super excited to interview him today. He's an anesthesiologist and we've been, we've been friends for 20 years and have, uh, seen all kinds of interesting things that happen in the anesthesia community in the South Bay.

He's an anesthesiologist. Uh, I came to town and we worked in different groups and we'll talk, we'll talk a little bit about it cuz this could be super interesting. And then, uh, I ended up helping him get a job as a medical director of a surgery center. And then when I evolved into my current role, um, at Biore Reset Medical, I actually handpicked, uh, Dr.

Mariza to take over, uh, my practice, uh, which he did amazingly. And, uh, he has a super interesting perspective cuz he's a practicing anesthesiologist. He's a medical director of a surgery center and he's also an I C U doctor and has been working at the, uh, local, uh, trauma center taking care of patients with Covid and working in the I C U and managing these patients.

So, I'm delighted to have you on and I can't wait to hear about your experience and find out what's going on. And it looks like I we're doing kind of a classic two for one cuz I'm, I'm, I've got two people on the podcast. Who do we have here today? Morning or good afternoon. Good talking to you. And, uh, I'm honored that you, uh, invited me onto your podcast.

It's been a, it's been a great relationship that we've had over almost 20 years. And, uh, I know you as a young doctor just coming outta residency for the most part and now evolving in very, very experienced and mature anesthesiologist, clinician in the community. It's awesome. And I'm also very blessed to have, uh, this is a fourth of my four grandchildren.

Uh, there's Gira Eel. He is about 16 months old. Um, and I nicknamed him potato because he loves to sit on my lap. Uh, every chance he gets if he, even if his brothers and sisters are playing, he'd rather come and sit with me rather than go hang out with them, which I'm just totally honored that he loves to, to be with me.

So, uh, I'm delighted cuz he is my youngest, uh, podcast guest so far. You wanna wave to Maddy? You wanna wave to Dr. Cook? You wanna say bye? He knows how to wave. Can you say bye? Bye. You got shine. God, that's awesome. So, um, so well maybe we should just go right to the elephant in the room and kind of talk about, uh, this whole covid experience because you've had a Tell me what, tell me what your experience has been and maybe tell me a little bit about, because I, you have quite a background in ICU medicine.

So I became a intensivist, uh, after completing my fellowship at Stanford, uh, back in, uh, 1996. And, uh, then I resumed ICU practice approximately 12, 13 years ago. Got back into doing some ICU work along with anesthesia. And over the last, uh, 10 or 11 years, I've maintained privileges at Regional Medical Center where I practiced, uh, the intensive care practice.

And, uh, they even at one point asked me to be medical director, but I declined over there just because there was so much internal politics and I had my anesthesia practice that I was trying to grow. I didn't want, I really didn't have the time to dedicate to that. Mm-hmm. And, uh, so I said, I'll, I'll continue to come here and work here and support the staff and take care of the patients.

And it's been really good experience for me to be able to do that. I think it kind of really rubs me out well with my anesthesia practice. No doubt. So then take me back. I want, I wanna sort of take me back through, back into February and March when all of a sudden it, it seems like the world starts to fall apart and we start to find out that, um, there's this, this new viral illness.

What was it like being over there and, and how did the hospital respond and what was that like? It was, uh, an incredible coming together, the whole medical community. Mm-hmm. Um, to see the level of response from, uh, all the frontline people in the er, the nurses, uh, the various, uh, paramedical personnel that I'm talking about, X-ray technicians, lab technicians, everybody else.

Uh, everybody just totally got ready and prepared and were dealing with this in an amazing fashion. And, uh, it was a real privilege to work there. Uh, the, the intensivists were, were by far the most responsible group in terms of taking care of these patients, uh, initially. Uh, as you may have read in some of the, the literature, uh, the, the thought was to go with early innovation, uh, which means to go ahead and put these patients, uh, with the breathing tube and put them on the ventilator.

And, uh, subsequently the data showed that, uh, delaying ventilation or putting them on the ventilator was probably more beneficial. So we, it was actually a learning process since this was a new disease for all of us, and management of it was not like a typical, what we call a R D S, uh, adult respiratory distress syndrome.

And so it wasn't like that at all. Um, and so how, how, what, tell, so let's lean into that a little bit. What would a typical a R D S patient present like, and then how, how is this different? Typical a R Ds patient would come in and they would present with shortness of breath, uh, and, uh, with manifestations of, I can't get enough air, I'm having trouble breathing.

Um, and when we get the necessary, or the, the labate, uh, cor corroborate that it would show that in fact they were hypoxic, that their oxygen levels were low, uh, their chest x-ray would manifest, uh, ground glass appearance, top typical fogginess consolidation, a lot of fluid in their lungs. And, uh, whereas these patients were coming in and sometimes they were not short of breath.

Uh, they may have cough, they may have fever, uh, but they were also hypoxic, meaning that their oxygen levels were low, but they were not responding in the typical fashion of, oh, I'm hungry for air. I, I can't get enough oxygen. I can't, you know, I'm working too hard to breathe. So it really was a different manifestation in that regard.

Hmm. It's what they called silent, uh, the silent hypoxia. And when they would put these patients on an oximeter, they would find that these oxygen levels were really low and yet they weren't gasping for air. How, how low? Uh, even as high as the high 60%, for example. Wow. Because normally if somebody was in 60% oxygen saturation, they would feel like they're dying.

Right. They feel like they're dying. They may even be comatose, they may not be responsive. Right. But these people were awake. Uh, I remember seeing patients, uh, just a few weeks back when I was there that they were in, in this, uh, kind of hypoxic condition and I'd go and see them cause the nurse was concerned about the numbers.

And I'd go evaluate them on in the hospital room and they're talking on the phone. So they were calling up their relatives and everything else cuz they're in isolation and they couldn't have visitors. And, uh, yet they were able to talk on the phone and carrying on a conversation. Wow. So then what was, what was the cornerstones of, of your management in, in that situation?

So we would evaluate them. So they basically, we look at kind of trajectory. How are they doing? How are they progressing? If they're progressing really rapidly to where their hypoxia or their oxygen saturation was dropping quickly, uh, or the respiratory rate, which sometimes the patients didn't even know they were breathing, uh, fast.

If we noticed that all those things were happening, um, and they were developing signs of other things like low blood pressure, uh, shock, uh, other manifestations, uh, then we would intervene at that point and tell the patients, uh, we feel it's best for you to come to the icu. Um, and some patients, as we learned later on, we would ask them to self prone.

And self prone means to lay on their stomach, which helps the, the mechanics of ventilation. It helps the distribution of. Oxygen to areas of lungs that are working better than other areas and now would help alleviate, alleviate some of the hypoxia. Yeah, that I was, I found that super interesting and I wanted to kind of ask you about that cuz you, uh, you mentioned an anesthesia term called VQ mismatch, but in common terms for the average person listening, how would you explain how lying prone and, and the reason I I ask this is because I actually have a lot of patients who've started to call me from all over the world and they're at home with symptoms.

And so e explain how this lying prone could potentially help you increase your oxygenation and how that relates to blood flow. So our breathing, uh, mechanics are such that, uh, the lung has the ability to shunt blood, uh, into areas that are ventilated appropriately. Uh, and in a disease state, it's not able to do that, and thus you have areas of lung that are not as badly affected by the disease and the, the, uh, ability for the blood to go there is improved by repositioning the person.

Awesome, awesome. Did you have, did you see any, my sense is that this, once people get septic and once people get systemic viremia, my sense is that it, it can, it can have an effect on the vasculature, whether it's in the kidney, uh, whether it's in the heart with like a heart attack, or whether people, some people are having kind of a hypercoagulable experience where they're having some strokes.

Did, did you see any of those patients? We did. And so it's very interesting that there are neurologic complications, as you mentioned, the strokes, the, uh, one of the tests that we normally look at, it's called ddi. Mm-hmm. Look at the hypercoagulable state. So we would see that was elevated in certain patients, uh, and thrombosis.

And those were things that we would see on occasion. Mm-hmm. And depending on the course of their illness, uh, they would, uh, occasionally get those complications. Uh, and fortunately, a lot of the younger ones would tend to just have the respiratory or their lung problem. And, and because we would sometimes put them on, on blood thinners to help them keep from getting the severe complications from the thrombosis.

What, do you have a sense of what, what is, uh, behind the hypercoagulability? The, the increased probability of having clots? Nobody seems to understand why this virus is able to do that. Uh, and I just did some, uh, research again this morning in preparation for this podcast just to see if I could find that any more information.

And I still didn't find anything that mentioned or went into the cellular mechanisms of why this, uh, increased thrombosis, uh, is occurring. Mm-hmm. Yeah, it's, it's, it's super interesting cuz from our, it's almost like every second of every day for the last 20 years, it's like me and you we're having in, in inside our minds we're having kind of the same conversation.

It's like, oh, what's happening with the oxygen? What's happening with the blood flow? We're constantly thinking physiologically, right? So I've been really thinking of you over there taking care of these patients. Yeah, it's been a real, it's been a real honor to be able to be, uh, uh, in that position, uh, take care of these patients.

And some of the patients, as I mentioned to you previously, is that they would, uh, deteriorate quite rapidly. Uh, I can give you an example and, and, uh, so your listener can, and kind of understand the severity and what's going on. Uh, I was called up to the floor. I was the admitting intensivist for the day.

And my pager goes off and said, you know, come upstairs to one of the hospital, uh, rooms where there's a patient with known covid. She's 58 years old, Hispanic. Uh, and, uh, she is experiencing, uh, worsening oxygenation as we talked about earlier. And, uh, so I explained to her through a translator that my Spanish is, uh, limited to five sentences basically.

And, uh, they explained to her that, uh, we need to put a breathing tube in and you need to call anybody because you won't be able to speak on the phone. And, uh, so she said, yes, I wanna call my daughter, et cetera. I said, okay, go ahead, let them know. And then we proceeded to innovate her. At the time when I went to her room, her respiratory rate was about 30 her oxygen saturation with what we call high flow oxygen.

That's like 30 liters of oxygen being delivered through a nasal through her nose, cannula. And even with that, she was at 88%. And, uh, so, uh, we said this is not a good situation. And, uh, so went ahead and gave her the medication necessary, uh, to go ahead and put the breathing tube in, had her transported down to the I C U.

And when I got her to the I C U and put her on the breathing machine, the ventilator, uh, her oxygen saturation continued to decrease. So we tried many maneuvers. We tried adjusting what we call a positive and expiratory pressure. It's called pee. We, we adjusted, uh, by, uh, her. Giving her muscle relaxants known as paralytics in order to facilitate the compliance.

We did that as well. Even despite all that, her oxygen saturation continued to drop into the low eighties, high seventies. And I was doing all the things that I knew and couldn't seem to make any headway with her. And, uh, so I decided the best thing for her was to call the cardiac surgeon and put in what's known as a venous, uh, venous cannula, in essence, put her on circulatory bypass.

This is analogous to what, uh, we do for cardiac patients, and that's how everybody knows, uh, when people have heart surgery, is bypass surgery and it's bypass surgery because they're going on an external machine, which is taking their own blood, oxygenating it, removing carbon dioxide and giving it back to the patient.

And I felt this was the last dish effort. Uh, and this entailed. About an hour of phone calls with family members because they weren't allowed to come into the icu. They weren't, oh God, that's crazy. And convincing them that this was a last ditch effort that their mother, their relative, may not even survive this.

We're trying to save her life. And, uh, calling the cardiac surgeon, having him come in, he said, did you do this? He made, made me go through all the checklists, make sure that I hadn't forgotten anything before we put her on this therapy. And I said, yes, I've done everything. And then so he came on in. And, uh, we got prepared and it took about two hours after she came to the I C U that she was finally on bypass.

And, uh, we were able, it took about two weeks for her to be on this, what they call ecmo uh, machine before she was weaned from that. Wow. Yeah. And she's one of the survivors, uh, at Regional that was on ecmo. And she went through de Canulation and got extubated, got the breathing tube out, and she left the I C U.

So this, oh my God, this is an amazing story in about three weeks, what she went through and what we as a clinicians and healthcare providers went through with her. Oh my God. And is she still in the hospital or did she get outta the hospital? So I believe she's still in the hospital, but she's in the recovery phases now, Uhhuh.

And as you know, that the longer somebody remains on a ventilator is immobilized that for almost every day that they're in that condition, it takes them almost. Five to seven days of rehabilitation. Mm-hmm. So if somebody has been in this situation for two or three weeks, we're talking probably two or three months of rehab for them to get back some degree of strength and, and, uh, physicality where they can resume their normal life.

Wow. Was what, how did, how did it, did it, what was, what was, how did it, how was it emotionally for you to be in that situation where you're talking to the family and you're talking to the heart surgeon? Like, that conversation is something that me and you have done a thousand times before in an emergency.

Like, uh, normally something like that happens and we just do that all the time. It's like, just like we would do a good job. How was it? But with the pressure of kind of all in the pressure cooker of this experience, what was that like? No, it's, uh, something that we've never experienced before. Yeah, it's radically different for sure.

And, uh, you know, I always tell myself that every day is a school day. And, uh, sir William ler, one of the greatest physicians of, uh, you know, prior generations who was, uh, practicing medicine in the early 19 hundreds, uh, he said that every day if a physician doesn't learn something, if every day the physician is not a student, he's no longer a physician.

And, uh, I may have misquoted his, his thing, but in essence, that's what I remember. And, uh, so I take that, uh, to heart. I try to make every day a school day for myself, uh, try to learn from my experiences and benefit from it and grow with it. What was his name, sir? William Osler os O Oh Osler. Oh my God. Yes.

Oh my God. Yeah. So then, considering that how, you know, it was interesting for me to watch. The healthcare providers on the front lines who are, are themselves for the first time in this life and death situation. Cuz I know there's been a bunch of healthcare providers that have died Yes. And got sick. And yet you're one of the coolest cucumbers that I've ever met in my life.

So it's kind of interesting to talk to you. What was your experience of, of going into running into that burning building? Um, I basically had the attitude and my family obviously was very concerned about me as well. Cause I'm actually one of the people initially that they felt was the highest risk, the ones who were elderly and, uh, in the healthcare profession, you know, opposed to somebody like yourself, uh, in the younger age bracket, they were not high risk risk and, uh, so they were saying, you really shouldn't be working here.

I actually had one of my intensivist colleagues, uh, at Regional, uh, telling me, he says, what are you doing here? He says, you should go home and you shouldn't work. I said, no. I said, actually, I, I, this is what I signed up for and uh, this is what my whole career is all about. And I have wanted to go to situations overseas where there's medical emergencies and disasters and have done some overseas work and I felt this is my calling.

Yeah. And if personally I get sick or something happens and so be it, I'll be a martyr and uh, you know, that would be a good way to go out. Yeah, that's how I, that's exactly how I feel. That's exactly how I feel. That's interesting. Did what was, and what did you guys, so as you were there, and it's kind of amazing to, because this is at regional, this is at the big trauma hospital of San Jose, and we, we kind of live in the suburbs of San Jose.

What, um, what, what was, what standards did you guys have in terms of the p p E? What were you wearing? How did, how did that go? Uh, so we were using, uh, what they called, uh, normal mask for the most part. We had N 95 mask and eye protection. And then whenever I'd go into a patient's room that was known covid positive, uh, and had to do the intubation of the breathing tube, I would wear a pepper that's a purified air filtration unit, basically like a hazmat suit.

Uh, it has a little powered unit that I put, I put on my belt and, uh, go in with that. So in essence, I'm getting purified N 95 air that I'm breathing. Oh, okay. The, I spoke to a, a friend of mine, uh, who's the ER doc who, who was doing some, some intubations. His name's Matt Dawson. And what, um, he talked about mask, ventilating these patients and that being a little bit of a risk of spreading to other people.

And obviously he was running around in the hospital without, The the type of p p e that you, you did, what was your, what's your sense of that? How did you, did you think about that or what was your experience around that? So, you know, again, the literature doesn't bear that out actually. Oh, okay. Interesting.

Yeah. So I don't, you know, I think there's still anecdotal, I think people were obviously very concerned early on. They felt that this virus was very easily transmitted. I'm not saying it's not. Uh, and, uh, but I don't know that, uh, doing mass ventilation on these patients necessarily increased, uh, my risk of, of getting the disease.

I see. I see. The, it's. How, what do you think the infectiousness is? Do you have a sense of that? I don't know. Uh, I don't know anybody, uh, who has come down with it personally. None of the providers that I know at the hospital. Okay. And so, yeah, two of them were taken care early on of a Covid patient. Um, and they had symptoms, uh, and they were asked to self quarantine, but they never got tested.

So I don't even know if they turned positive or they had a, a coincidental, uh, viral infection or they just were quarantined for protection of everybody else. So I don't really know. I, from everything I read and what I'm sure all your listeners have, have read as well, and it's pretty easily transmissible and it stays on surface for a long period of time and everything else.

And I don't really have data to, to say one way or the other to say one. Yeah, that's kind of how I feel. What, what did you guys do for testing? So currently testing is available, uh, for the patients that were coming in, uh, to regional, we would do the nasal swab. And now as, uh, in the last I think two weeks, we've been able to get the antibody testing as available, uh, for providers if they wanna get it done as well as for the patients.

Are you gonna do it? I was thinking that I, I probably will not. And, and the reason is, is that, uh, if I'm, if I'm positive, if supposing my antibody test shows, uh, that I've been exposed and I got over it, I may become a little cavalier. Uh, and I don't wanna be that way and I might take off my mask. Um, and I don't know whether have any antibodies will in fact, uh, make me immune from a repeat infection.

Uh, and if I'm negative, then I'm gonna be behave the same way as I am right now, which is to continue to protect myself. Mm-hmm. How long do you have a sense, what's your sense of the trajectory of social distancing? Um, And the, the, the care that we're taking now, how do you think that that's gonna play out over the next month and two or three months and even six months?

So I think that's a really good question. I think the evolution, uh, is going to be somewhat where we're going to start to go back. Resuming some of our normal, uh, daily work activities and, and recreational activities, uh, with some caveats that is, that we're going to, uh, need to wear a mask because obviously the transmission is, uh, through our respiratory passageways and that's how it's, uh, somebody else may absorb it also.

Uh, so wearing a mask will minimize the amount of, uh, fluid, the droplets coming out. And, uh, distancing will help because the droplets have a certain space that they can fall down in. And, uh, that'll be very helpful. Clean hygiene, which we're all practicing. So I think all of that will help and I think we're gonna be able to get back to some semblance of normality, uh, observing these.

And I'm guessing probably in the next two months we should be back to where we, where we can do that. Mm-hmm. It's interesting cause uh, I wanted to talk to you a little bit about right now there's a lot of patients who probably need elective surgery of some kind. And they're afraid. What, um, are you, is your surgery center open and then what's your, what's your perspective around that?

Uh, and and what would, what would you say to people as if, if they, if they need to have a surgery, um, So we really appreciate the fact that they've held off and they have not stressed the system, which is really great. And, and being patient with your condition, uh, we have continued to operate, uh, and do cases whenever somebody was having, uh, uh, a possibility of disability from their injury.

People that were going outside and biking cuz they couldn't go to the gym. They were getting hurt, they were getting wrist fractures, ankle fractures. Uh, we would take care of them at the surgery center. Uh, and somebody who was having debilitating uh, pain from chronic arthritis, we would take care of them as well.

Uh, and so, but now we've opened up the centers and we practice very safe, uh, uh, standards there. Every patient is, uh, asked a questionnaire when they arrive, even before they arrive, and, uh, if they have any, uh, symptoms or have had any exposure, then we ask them postpone having their surgery or coming into the center.

Mm-hmm. Uh, we monitor their temperature. We monitor all the employees, all the physicians, every staff member, it has a temperature check upon entry into the surgery center every morning. Uh, everybody at the surgery center, including the patients, are wearing masks and, uh, so we're trying to help save it, whether I have it or a patient has it, we're trying to keep each other from infecting other people.

Mm-hmm. And we're doing all of those precautions and as soon as these patients wake up, uh, in the operating room, we put a mask right back on them. We minimize a number of visitors. Uh, so visitors are not allowed to stay in the, in the waiting rooms. We ask them to wait in their cars or go home and we'll call them when their relative or a friend is ready to be picked up.

So with all those things that we're doing, we feel that we can proceed safely, and it'll certainly make it a little bit harder to be as efficient as we were before. Uh, but we are still, we're still moving forward. Mm-hmm. God, that's interesting. Such a, so interesting. As, as you hear, as I hear that, I'm thinking, oh yeah, I used to do all of, and, and it's so interesting how quickly an entire field can change overnight like this.

Totally how you think it'll, you'll continue in that genre for the next three or four months, or do you think it'll go beyond that? I think if the, if the vaccine comes out and if they can prove that, uh, one of these antiviral therapies works, I believe that we're gonna probably loosen our, uh, standards, uh, by wintertime and hopefully we won't get hit with a second wave nor really bad influenza, uh, virus this winter.

Uh, in which case then we might have to resort to these measures again. What do you think the probability that a vaccine that's works, what do you think the probability of that is? Um, I'm, I'm. Hopeful. Um, and a good friend of mine works for, uh, the Bill Gates Foundation. I spoke with him yesterday. Oh yeah, that's cool.

Cause, uh, that, uh, the clinical trials are underway and he's very optimistic that we should have a vaccine. Uh, this by this winter is what he, okay. Yeah. So he's very optimistic. And, uh, the initial studies with, uh, with Rems Avir, uh, the Gilead drug has been shown to be effective. Uh, and again, they need to finish doing some more trials.

Even though it's been approved for use, I feel like all the clinical trials have not been completed. Uh, did you had, did you get, did you get an opportunity to use Mdes Avir? We did, and, uh, we were using it at Regional and are using it there. Um, and I conversed with the infectious disease specialist there, uh, every time that I was on shift there.

Um, and they felt that it was effective and, uh, they definitely felt it was effective if it was administered early and initially before the FDA gave approval, we couldn't do it to the very, you know, the ones who were already on ventilators because we had to obtain consent from them. So we, oh, yeah. It was one of those things where we couldn't just give 'em the drug because of the side effects, and we had to, uh, get their permission to do that.

What, what are the side effects? Uh, there's neurologic side effects and gastrointestinal side effects, liver side effects as well. Oh, okay. So that's significant. What, how, how did, how were you dosing it? Um, you know, I'm not sure I would, the ID people and, and the pharmacists do it if we, if they felt that this was a clinically indicated situation, okay.

Then we go ahead and write the orders for that. Wow. So it's just kind of like the most interesting medical moment of our lives, you know? Sure. For sure. And kind of, and then it's just such massive social ramifications and kind of watching, watching it play out is so interesting. I'm so delighted that you're, I I, I, I just want to congratulate you.

I love every ounce of your attitude. It's like, oh, this is what I was meant to be. If I go down, So be it. Yeah, I mean, like I said, I'm really, I really feel really blessed. I could have opted to not go in, I could have said I quit. I'm not gonna go to work anymore and give up my job. Um, but then I said, no, this is not what I went into this for.

And uh, I can some other time give you all the other experiences I've had where I felt like I was really blessed to be a doc and take care of people in your moment of need. And this for me, this is what it's all about. It's amazing that, like that lady that you talked about, like it would be amazing if, if she lives and you have, you make contact with her, let's have her on the podcast and talk to her.

Cuz it'd be really interesting to talk. It's like, it's interesting that's like somebody that there's no way that she would've lived if you hadn't made that decision to do that. Right. Correct, correct. Yeah. I'll, I'll just give you a little throwback. When I was, uh, doing my fellowship at Stanford and, uh, you know, it was early on, probably in my third or fourth month though, I was still like trying to figure out what to do, where to go, all that kind of stuff.

And, uh, so one night I was on call and, uh, we had this 30 something year old father of two or three children who had a R d s, as we mentioned early on in the show. Uh, and it was from probably some bacterial viral, cause I don't recall what it was. Um, and he was really sick and we couldn't, we did all the usual peat maneuvers, oxygenation, all that kinda stuff.

And nothing seemed to be working. And my attending at five or six o'clock, he said, you know, do whatever you can. If you could save this guy, that'd be great. I said, okay. So as soon as my attending left, I called the troops together. I said, we're gonna put this patient on his stomach. And we prone him. And, uh, here he is, Maddy, he's on like two or three pressors cuz he's in septic shock.

He's, he's hypoxic. And so we flip him over. And the a r d s of that day was different than the, uh, the A R D S of Covid. Uh, and, uh, about two or three liters of fluid poured out of his endotracheal tube as soon as I turned them over. Really? Oh God, really clear, watery fluid. Like he was drowning in his own lungs and we couldn't do anything.

And there's no way to suck that out with a catheter other than to turn him over. And then it by gravity, it just came pouring out that man, Maddy, uh, about a month or three weeks later, he walked out of the hospital. Oh, really thinking about those kids I so appreciative of. It's so unbelievable. I mean, and I don't do this for appreciation.

I only do it because this is what I love doing, but that's the kind of, uh, exhilaration that one feels is saving somebody like that. Biore Reset Medical is a medical practice specializing in integrative therapies and advanced wellness protocols. At Biore Reset Medical, we treat some of the most challenging to diagnose and difficult to live with ailments that people suffer from today, including Lyme disease, chronic pain.

P T S D and Mycotoxin illness. Our team has a wealth of experience in advanced integrative strategies to get you to optimum wellness, many of which can be conducted remotely from the comfort of your own home. Right now, our team's approach is to use the most non-invasive, natural, and integrative way as possible.

Find out how we can help you by reaching out to us at 6 5 0 8 8 8 7 9 5 0, or at our website, www.bio. Reset medical.com. It's going to be amazing. So then I'm just gonna imagine there's a person that's lying on their back, and so then because of gravity, What happens is, is more of the blood flow goes to the, the, the dependent part of the, of, in the body.

So there's more fluid in the bottom half of the lungs when they're lying than in the top half up here. Correct. So then basically this is, I'm just sort of trying to explain this for people so that what happened is when, uh, Dr. Mariza flipped them over, now all of this fluid that was on the top had to go somewhere and some of it got into the airway and just drained out, and that got enough fluid off of the lungs so that they could ventilate and push gas in and out.

And that just, we we're just, sometimes John Lennon has a song called Whatever Gets You Through the Night. Yes. And, and there's, it's kind of like a lot of times we're just trying to get somebody, and this like the ICU experience where you're with a patient and you just sit there and you stay up for 24 hours.

Trying to do stuff to just buy them and a coup a couple hours and get through to the morning. Yeah. It's amazing. And, and you know, so the, what you're mentioning is what they call BQ mismatch. Mm-hmm. Um, and it's called ventilation perfusion. So when he was on his back, the oxygen oxygenated air is going to the, as you were showing in your example, the top half of his lungs.

Mm-hmm. Bottom half has got the blood and all the fluid kind of bottom and down, so it wasn't able to get oxygen in there. Mm-hmm. And then by flipping him over, getting all that fluid out so it wasn't so boggy, and now the oxygen is going to that portion of the lung and markedly improved his VQ matching.

Mm-hmm. And we're able to save him. Um, so interesting. I don't want, I'm not gonna go too far into this, but we do. A whole bunch of things that are integrative approaches that I believe are eventually gonna be adopted in I C U medicine. Like I, if I could get into regional, I have a bunch of stuff that's kind of interesting, but like, one of the things we do is we'll have people nebulize glutathione and, and nebulize hypertonic sea minerals.

And, and I've had a whole bunch of people who did that and that got them through the night. And they would, they would set their alarm for like two in the morning and wake up and do it because that helped their, it helped them be, they, they would tell me that their cra their air, air hunker would go down for two or three hours afterwards.

Very cool. And so it's got, I'm, uh, I'm actually enormously sort of interested in, it's, it's because I like to say that I came from the heart of the medical industrial complex. Because I, I came from, this is like straight outta the ICU and the operating room, right? And then now I'm doing these things that are a little farther afield.

But I look forward to bringing those things back to the icu. Cause I think they may, they may be, they may have some, some potential to help some people. Definitely, definitely worth's exploring. Now I wanna, um, talk a little bit about anesthesia and, and kind of the experience. And it was, it was, it was interesting for, for me because it, it was so politicized, like who owned groups and hospitals and I joined a big anesthesia group that came in and tried to kind of take over the, the care at the hospital where, uh, you were working and where you had been working for quite some time.

You're kind of like a seasoned mid-level guy. You'd been out for 15 years, you know, kind of almost like a, almost kinda like me. Now. And, uh, and, and I will, I will always remember this cuz I remember I was down on OB and putting in epidurals and stuff like that. And I remember I had a conversation with you and I said, here's the thing, I'm always gonna be friends with you and I'm gonna support you as regardless of the chaos of all of this stuff.

And interestingly, that was also around the time of nine 11 and I felt a, there was a, uh, anti-Islamic kind of thing going on, on top of that whole thing. Um, and so then, and, and so then I loved my experience of that. Speaking of that, did, did you feel that, was that stressful for you at that time? There was, um, and, uh, there were not only things going on at work with the group and the practice, but there were things going on in the community as well.

Yeah. Um, and um, I, um, I had the F b I come and visit me at my home four days after 9 1 1. Um, oh my God. And, uh, were, you know, basically trying to figure out if I was a supporting jihadist and all this and what my political views were, et cetera. Um, and so I knew I was being followed. I was being watched possibly wiretapped.

I might still be, um, I don't know. And, uh, so that was, there was a lot of things going on in my life at that point. And yeah, uh, the, uh, the group situation, uh, was very interesting. I really appreciated You were the only real friend from the large mega group that was there, uh, that was willing to even take some of my calls that I couldn't cover.

Weren't that crazy, nobody else would take my calls from me. And so if I had certain obligations and I couldn't work, you were there, Maddie, to bail me out. And so that's really good. Uh, but the group itself, the dynamics and everything else, yeah, I was there for a while and you know, the hospital kinda flipped back and forth.

When I got there, it was like this old, the old guard was there and they unfortunately kinda, uh, kind of gone by the wayside in terms of ability to do anesthesia effectively and safely. And the hospital wanted to replace them, but they had all these issues about how to do that. Um, right. And we couldn't just kick them off staff because they would face lawsuits from them, Uhhuh.

And uh, so they instituted this notion of. Surgeon selection. So surgeons were allowed to designate the anesthesiologist they wanted to work with, and they thought by selection that eventually these old timers would not be selected and would not find it worth their while to come to work. Um, and, uh, that was okay for a while.

And, uh, uh, fortunately I turned out to be one of the more popular ones. I was always very busy, which unfortunately creates resentment among those who are not busy. Mm-hmm. And then there was a whole backlash and we went back and the hospital decided the best thing was to give the contract to the group, and then they could decide what the exclusive contract, who they wanted to keep in the system.

Mm-hmm. And, uh, that's when I became, uh, you know, a subcontractor with the large group with whom you were working. Right. And you, so it's interesting. It's a very, it's a, it's the conversation that I think infuses a lot of how I think about the world. And so we were talking about the, the arc of the interaction of anesthesia with ho the hospital and with how care is done with respect to surgeons, because people have to remember anesthesia was ridiculously dangerous back in the sixties and seventies.

And, and so then, and technology got better and better and better and better. And I was telling you this, this story, there's a, a super famous anesthesiologist named Ted Eger, who I guess you, you're aware of him, right? Right. Very much so. Very much so. And so I spent my first week with him. And so I did every case of the week and then he, every, every patient, um, he would walk up, he would say, hi, I'm Dr.

Eger, and this is Dr. Cook. And then he would say a few few and, and then he would always say, we're gonna take. Excellent care of you, and there's a chance that you may die today. Like, and he, he said that because, you know, it was a, it was like a somewhat real probability of dying when he started his practice in, in the seventies.

And he was really trying to communicate how crucially important it was to, for safety and kind of risk management. And so I came in and with that as my, my worldview of safety. And then on the, at the, at the sort of the end of my career in anesthesia, it was surgeons, zoning, surgery centers, wanted to operate on everybody.

Right. Left and central. And sort of the, I'm curious what your, your take on, on, on that change was over, over those years. So, very interesting. Uh, as, uh, when I started, uh, getting into anesthesia, I did a rotation in med school. And, uh, at that time, uh, anesthesia was just starting to evolve with the technological advancements that we have.

And this is one area where technology has played a huge role in making anesthesia safe so that somebody like your old mentor, Dr. Eger, uh, was very appropriately, uh, correct in mourning the patients beforehand. This anesthesia could potentially kill them. And because we didn't have the technology to adequately monitor all aspects of their body functions mm-hmm.

And we relying a lot on clues. For example, the, we would look at the color of the blood when the incision was made. Do you remember that Blood is dark. Okay, well maybe the tube is not giving enough oxygen. Maybe the tube's in the wrong place. Mm-hmm. Or something else. Maybe the blood pressure is low. All of these kind of things that we would, uh, start to conclude based on that.

Um, and, uh, so over the time anesthesia has evolved, Aaron, and thanks to technology, we've made it relatively safe whereby even nurse anesthetists now feel that they are capable of doing anesthesia a safe way. You follow? We've gone from being a physi physician driven specialty to nurses to now even they have aas, what they call anesthesia assistants.

Mm-hmm. And maybe in some states they may even start to allow them to do anesthesia under certain circumstances. I see. Exactly. So technology has really changed the whole flavor of anesthesia and, and the fact that it's relatively safe that even the surgeons now feel compelled to push the envelope in an outpatient setting.

Mm-hmm. And they have patients sometimes that are probably best not done there. Uh, only because, not that we couldn't get 'em through the anesthesia safely, but they may require postoperative care, which is not available in a surgery center. Mm-hmm. That's the reason. And I, and then it would require transfer to the hospital, which entails a lot of logistical, uh, arrangements.

Right. And so then, uh, before we get into that, like it's interesting to, to think, like right now we have something that goes on the finger. We're able to measure the oxygen level that continuously, and we're constantly checking the blood pressure. Now what was that when you first started? Where, where, where, what was the arc of, of that whole, the monitoring conversation?

So as a med student, I remember doing a week of anesthesia and, uh, I was with a senior resident and we had, did not have an automatic blood pressure machine. We did not have an end-tidal carbon dioxide monitor, and we did not have pulse oximetry. So all we had was your anesthesia machine with your EKG rhythm, and we had temperature monitoring.

That's what we were doing. And every five minutes, my resident would tell me, would you please, uh, check the blood pressure so manually with the stethoscope in my ear and, uh, the other end on the patient's, uh, forearm, uh, inflating the cuff and checking the blood pressure is what we were doing. And, uh, that evolved to when I became a anesthesia resident and we had pulse extre available, but sometimes not in every room.

And we had end title CO2 monitor again, not in every room. So this became over the course of my first few years in practice where we started to get these monitors in every location. Mm-hmm. That's interesting. And so then the imagine in those times, most anesthesiologists would've an earpiece kinda like what I've got on now, and then they would, uh, hook it up to a little metal stethoscope that would just be sitting right here on the trachea.

And when somebody breathes in. You'd hear that in your ear and they'd breathe out. And so then that's actually one interesting kind of arc of anesthesia is you're sitting, and you may be having a conversation with me, kind of like a surgeon or a resident, but then every second you're monitoring that sound and then that evolved into slowly adding in more and more things, adding in oxygen and as adding in blood pressure, adding in now, then you could stick a, a catheter in the artery and monitor the blood pressure continuously.

So, correct, correct. Yeah, it's really evolved. Uh, and I, I tell people that if it wasn't for, for a few invention inventions that have come along during my career, I probably would've quit anesthesia like yourself in my younger days. Uhhuh. And one of those is, is uh, the drug propofol. Which I, it's really a wonder drug, and some people have obviously labeled it, uh, as the Michael Jackson drug.

Right, right. And, uh, but it's a great anesthetic in induction drug. Uh, the second is, uh, post oximetry is a second invention, which I would like, uh, it would be very difficult to practice anesthesia without that. And the third is the, what they call laryngeal mask airway lma. Mm-hmm. Which we used. And if it wasn't for these three things, I think I would've probably quit anesthesia five years into my career.

Uh, but this has really helped a lot. So was, uh, now the Michael Jackson Drug Propofol. That's, is that the drug that you used to intubate patients when you were with Covid at the trauma hospital? Actually, we use, uh, etomidate. Uh, okay. Okay. Good one. Yeah. Because we don't know, some of these patients have, uh, such a, There's a cardiac myopathy cardiomyopathy that occurs with some of these covid patients as well.

And, uh, by using propofol, it may drop their blood pressure to the point where they may become, uh, uh, resuscitate. So iDate helps to preserve their blood pressure better. So then that's a good one. Just to go back in time, cuz this is an interesting one. Michael Jackson should have had an anesthesiologist with him instead of a cardiologist.

Correct. But, but, um, propofol is this amazing drug that can make you sleepy and make you fall asleep, but it can lower the blood pressure a little bit and then it can it, and if you give benzodiazepines and narcotics in combination with it, then it can even more lower the blood pressure, which is what happened to Michael.

But then he was at home with nobody there and nobody that knew how to use resuscitation equipment. Um, like the l m a might have been probably amazing for, for him and probably would've saved, totally saved his life. Um, So it's just kind of interesting to, it's interesting to think, to think about, but, so then etomidate is a drug that's kind of like propofol, but it doesn't lower the blood pressure so much.

And so then he's saying that they use that in the trauma hospital. So then you can just think about all the, the many levels of decision making that are going into managing some someone through something like that. Correct. Yeah. And it's interesting, throwing back on to Michael Jackson, he didn't have an oximeter probably either to measure his oxygen.

Mm-hmm. Didn't have oxygen in the room and the tank or something that he could use. Mm-hmm. Right. And uh, for what he was paying the cardiologist, he could have easily afforded an anesthesiologist to be there with him 24 7. Right. Uh, but anyway, that is what it is. And, uh, propofol very interesting history on that drug.

Uh, if you ever get a chance to look it up, it was actually in, uh, determined to be an effective drug, but it took them. Took a, a chemist, I believe he was in Sweden or Norway somewhere. It took him about 10 years before they figured out an effective transmission vehicle, in essence, in order to be able to administer it safely.

Uh, and found that the soy base formula was the best one. And that's why it's got that whitish color. Right. Right. And, uh, whereas initially the, the initial chemist felt that this is a good drug, it works, but then how do we give it to people? And that's where it was kinda stuck for a while. Right. So then you, you know, on the anesthesia topic, it's to me, so, you know, you and I both, I think came from this, I think all anesthesiologists, our entire and total conversation is risk management and safety.

It's almost like the, it's like, it's like whatever else you want to talk about is like 1% because all that's all we care about. You know what I mean? Just kind of walk. We, we may want, we, we may like different types of coffee or tea, but that's, but we're, we're like brothers and that sense. And so then I wanna, I wanna hear your perspective and talk about it a little bit about this, this sort of evolution because I think it's interesting for people to, to begin to kind of think about and, and learn about of surgeons having progressively more and more control over where procedures are done.

Because I feel like that's somewhat evolved kind of in the era that I was practicing. And so it went from, if, if anesthesia said you can't do that case in, in the nineties, people would be like, Oh, I'm so sorry that I asked. And you know, in, in, in 2014 if you said you can't do that case, they'd be like, I would hate to fire you because I'm probably gonna fire you if you ca if you cancel any anymore cases.

Like, I remember people talking to me like that and, and the kind of the, it's so, it's so and so I'm curious a about your perspective of that, cuz you, you seem like Teflon cool. As you kind of talk through it. I'm curious about that and then what your sense of the trajectory of that, of that's gonna be over time.

Well, unfortunately the pressure is on, uh, the surgeons and the whole, um, medical arena, uh, in terms of economics. Uh mm-hmm. I hate to say that that's playing a role in a lot of these decisions and it should not. Um, and, um, it's very difficult. I think hospitals and, and these insurance companies regulations have made it very difficult, uh, to manage patients in, in the best medical manner.

And so that drives a lot of decision making. Yes. Anesthesiologists. Now the pressure is not so much, uh, you know, as Dr. Iger was worried about the patient dying, uh, the whole pressure now is should this patient be done in a surgical center, uh, or should it be done in a hospital if it should be done wrong?

Mm-hmm. And, and that's the question that it raises. And I, and I believe that, uh, uh, I think good, uh, informed surgeons, patient surgeons who are aware of what the real risk factors are, uh, having patients who are informed and getting the opinion, the anesthesiologist, and, and, and listening to that and saying, you know, I think this doctor's right.

I think I better go to the hospital and have it done over there. Mm-hmm. And confirm, uh, then in fact, that's the right thing to do. Mm-hmm. I, that's to go. Yeah, that's, uh, and, and I think we, we have to take up the mantle kind of, of where we come from and to stand up for that. And I always enjoyed talking to you because I, I, I, I saw the wisdom of your kind of, like, I remember I would talk to you about that and because for me, I think emotionally, you're so wrapped up into the fact that you spend a hundred percent of your life with the surgeons, and if they're unsatisfied with you, there was always the threat of losing your job.

But then I, I prob I know that I've had probably 15 conversations with you over the last 18, 19, 20 years where you said, well, it's just not the right thing to do this. And so if they fire me, That's fine because people, other, some people like me and, and, and, uh, I have this theory and maybe tell me, I have this theory that a lot of patients or anesthesiologists actually get P T S D from being in that pressure cooker.

And I think that your voice has been a voice of wisdom and coherence through that. And so I'm curious what your perspective on that is. So I see that anesthesiologists should be, uh, patient advocates versus Yes. That's our number one role, right? Yeah. Um, if we take a patient on a journey of an anesthetic, we're responsible for them.

Yeah. We're assuming all their responsibility, they're not able to answer for themselves anymore. Mm-hmm. That's why we become the advocates. Um, and if we feel that it's unsafe for them to go on this journey of anesthesia, then we need to make it clear. Because ultimately I have to look at myself in the mirror the next morning, and I, I let somebody go.

Yeah. Bad decision. Um, and so that's where I come from. Um, and, uh, so it, uh, really, it's interesting. I don't know if you've, uh, seen this book, it's called, uh, meltdown. Yeah. And, uh, it's a really good book and I, I love, uh, trying to extrapolate, uh, industrial lessons into anesthesia, into medicine, Uhhuh and other parts of my life.

Um, and in Meltdown, um, they looked at some really interesting things, and this is kind of correlates with this whole surgical mentality. So a commercial flight, um, you have a pilot and you have a copilot. Typically the pilot is the experienced one. He is got 20 plus years experience, military experience, et cetera.

Then you've got the copilot, younger guy may not have military experience, cuz not many people go into the military these days. Uh, less than 10, 15 years of experience. And they're on this long trans, uh, oceanic flight every two hours. They, they, they'll swap is their typical routine. And one person is in charge and the other becomes a co-pilot.

Pilot. So this book Meltdown kind of asked this question, uh, is, uh, what percentage of time would you estimate that a, uh, major airline has a, has a major accident with this fatalities who was in charge of the plane at the time? The pilot now the co-pilot? Correct. It was about 70 30. Mm-hmm. So here it is that you've got this pilot who's got all this experience and wisdom and the co-pilot is a younger guy who may be a little bit intimidated.

Right. You know what I'm saying? Of speaking up. He sees the data, he sees there's a mountain over there. The readings show something is not right. And our innate tendency is to believe our gut, and this is wrong, especially in anesthesia as well as in, in, in, uh, in aviation mm-hmm. Is that to rely on your instrumentation, um, and then use your judgment and make the right decisions based on that.

Um, and so the younger, the, the co-pilots would be very afraid to speak out, uh, in fear of losing the job, losing the respect, et cetera. Right. And so they correct the pilot and say, sir, uh, maybe we should veer a little bit to the left. I see a mountain over there on my, on my diagram here. You see what I'm saying?

Yeah. And if we're in the same position Yes. We're kinda like, we're kinda like co-pilots and the surgeon sees himself as the pilot. Yes. And if we don't direct, and if we don't speak up, then we may certainly run new problems. That's, I think that's particularly true in certain cultures, like I remember in Korea and in some Asian cultures where, where, where there's such a, uh, uh, emphasis on respect and, and chain of command potentially more so than America.

Correct. That that's true. Right? Yeah. And you know, we always have, I always love going to the American Society of Anesthesiologist meetings, and then there's always like some airline pilots there that are giving lectures and stuff like that. Right, exactly. Yeah. The, there's a, a parallel to to that, which is, is that as you're doing a case and something bad happens and you're seeing it on your instrument, but there's a part of you that wants to say, Hey, everything's okay, which is the, it's like there's a, a, there's the, you as a pilot and your co-pilot ofs like your, uh, alter.

Ego. Correct. And, and you have to fight that thing too and then acknowledge as fast as possible because like somebody that's not anesthesiologist, sometimes it takes like two or three minutes where all the patients kind of circling, where we tend to pick it up quicker, but we still have to have a little bit of a fight with ourselves to be able to acknowledge that.

Correct. Yeah. Can I handle this? Will this go away or should I alert the surgeon that, Hey, we, we have a problem here, let's, uh, focus on getting this patient back. Correct. Actually, I had experience not too long ago. I was, oh yeah, I was doing a, uh, general surgery case with the surgeon whom you know as well.

And, uh, we were doing a hernia repair and the patient went ahead and insufflated, um, and the pulse basically because of what we call vasso vago, uh, in essence, he flatlined. And he slowed. And many times when they slowed down to the 30 heart rate, then I'll give him some drugs to counteract that and it'll come right back, usually within a few beats.

Uh, but this discontinued to progress and I had to pull out the stronger line medication and I had to ask the surgeon to withdraw the trocars out of the belly because that's the primary stimulus for this vasovagal and to let the air out. And, uh, he was very cooperative. He did exactly what I asked him.

And, uh, we had to initiate, uh, cpr, uh, for a few compressions to get the blood circulating in order for my next level of medications to take effect. Fortunately, everything worked out fine. We finished the procedure, the patient woke up. We did fine. But you're right, this is a kind of internal dilemma and then external dilemma to fight, uh, which we have to go through.

So I think I know who that surgeon is, who's probably from a certain perspective, the coolest cucumber in North America. Um, and yet, so it's interesting. So I'm gonna talk people through what you just said, cuz it's super interesting and it's like crystallizes everything that there is. So sometimes when there's a big stimulus to the body.

And so what they were doing is they're putting carbon, they're put in, they're filling up the, the pre peritoneal space with some gas, and that stimulates the internal organs and that stimulates what the rest and relaxed nerves called the, the parasympathetic nervous system. And it can cause this stimulus that causes the heart rate to go really low.

And so what this did is, instead of, let's say the heart rate was probably about 70 and then it went down to 60 50. 40, 30. And so at 30 the heart, there's only one heartbeat every other second, and then it starts to go below that. So that now Iqbal has, at this, at this point, he's got somewhere between 20 or 30 seconds before he needs to start doing cpr.

And so then, and so then now there's, you and I have both, no doubt, been in that experience no less than a thousand times where we gave a little bit of epinephrine or we gave a little bit of a roben, all glycopyrrolate, and then we got them back. But we, we, we pushed, and I have been there a hundred times with this person.

We, we pushed and then I'm sitting there going, Do I say something or am I gonna get through this without it? Because if I say, if I admit that this going on, I look like, I don't know. I, I could have prevented that. And it turned out I always would give people roben all whenever I worked with him to, to avoid that.

And yet sometimes the, the pressure and the intensity in the hurry is so much that you, you, you're, you're, it's like flying very low to the ground. And so, uh, there's a part of your mentality that's is, is worried, which is like the, the whole PTs d fight or flight part of anesthesia. And yet we always get them through.

And, and yet, and I've also been in that circumstance where I had to give a couple compressions and I never lost anyone and I, and, and yet you are flying so close to life and death. That's so interesting. Yeah, totally. There. Is it, how, for, for now, how, how is it for you emotionally to go through that? Like, do you, is that, do you, are you stressed about that, that night or do you just feel like I did, uh, I totally managed it perfectly and everything's cool.

Yeah. I'm just, uh, I, I don't, I don't, thank God I don't really carry it home with me. Uh, most days my wife will ask me, how's my day? Uh, et cetera, et cetera, anything interesting happened, you wanna talk about anything? And, and 99% of the time I said, no, I had a really great day. Everything was fine. And, uh, occasionally I'll just tell her a little something about what happened, uh, like this.

For, for example, I would, I think I told her about this particular situation, Uhhuh, and just, I'll let her know. Uh, and you know, she's, she's very acutely aware. My family's acutely aware of what I do and how. It's potentially, uh, lifesaving or potentially, uh, can endanger someone in your life. And, uh, so I think they're quite aware of that.

So once in a while I'll talk about it just to kinda keep them in the loop. Uhhuh. Well, once, uh, once you get all of that out of your system and keep doing this for a little bit longer and then figure out how to cure covid in the hospitals, then um, maybe I'll talk you into joining the dark side and coming over with me.

And then we'll, we'll, we'll, uh, continue to continue to try to do our best to help people and do amazing things for people. And it'd be my, it'd be my pleasure and honor to work with you, Maddie. I, I, I still feel like there's a few more anesthetics for me to give out there and that's awesome. Few more surgeons to butt heads with every now and then.

And, uh, once, uh, once it gets to the point where, you know, I feel like I wanna have a little more control in my time and be home with these, uh, little guys who are just so pleasurable for me, uh, then I'll certain give on your offer. I, it's, uh, it's, uh, it's been an honor to know you and it's been a, and it is just been interesting to walk.

It's been interesting through major moments. Like I remember, I remember, and I just wanna say it, I remember we, you, I, I, I, I asked the director Meza to turn up the light and, and then he was joking about, I gotta be white like Dr. Cook. But, but I, I was, it, you know, it seemed we were in, we're in Silicon Valley, and at that, especially at that time.

Now it's so multicultural, but at that time it seems so white. And I felt, I felt a profound existential angst about like, what was happening with, with the religious persecution that I was felt at that time, which is why I, I, that was the reason why I cultivated a friendship with you. And so then here we're the second big.

Cultural and, and, and, uh, world stress, um, of our careers. And it is an honor for me to see, uh, how you're handling yourself. And I can't, I I'm gonna have you come back and we'll continue a conversation about anesthesia and about any, any of your insights. And I hope that, um, I, I hope that this idea of the repositioning, if, if people are out there, yeah, there may be something you could try, maybe something that keeps you from having to go to the hospital and, um, and so we look forward to your feedback.

But thank you so much for coming on today. Again, my pleasure and an honor to be, uh, be on the show and to know you, Maddie, and look forward to chatting with you, uh, off the podcast. Okay, that's, that sounds great. Everybody out there. Okay. Okay, thanks so much. Bye. You can find this Bio Reset podcast and others on iTunes, Spotify, and all other top podcast directories, as well as on bio reset podcast.com.

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