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Alright let's have some fun. Take some pictures..

- Good morning. Thank you for the invitation. Dear moderators. I don't have disclosures for my presentation, and to understand the importance of venous symptoms, we must start from the beginning. And the beginning is to understand

the part of physiology of chronic venous disease and special the importance of the leukocyte-endothelium interaction and dysfunction with the release of inflammatory mediators. So this answer that it is the specific venous inflammation and consequently the abnormal permeability of capillaries

and this can be potential. The explanation for the venous symptoms as having this release of inflammatory mediators. This can activate the C noci receptors fibers and provoke this umbrella concerning the concept of venous pain,

that it is diffused, it is not localized and it is unpleasant and being unpleasant means that these have a huge impact on the quality of life. And we can measure that. We have scores to assess the impact on the quality of life

and that we'd like to remember the largest epidemiological study than until today. The vein consult program where using the CIVIQ-14, it was possible to assess, the impact on the quality of life due to the presence of each specific symptom. So, why we need a consensus on venous symptoms?

Because even in the middle of us, there is a frequent confusion between signs and symptoms and if you go into the literature, you can read that. The fact that venous symptoms are non-pathognomonic adds to this difficulty because linking these symptoms with their etiology and their cause

is still matter of debate. The severity of the signs and the results of investigations do not always correlate with the intensity of symptoms. The pathophysiology of the different venous symptoms has not been clearly established. And this is in particular important in those patients C0s.

And precise physiopathologic knowledge should lead to more targeted and specific treatment and this is quite important for example for venatic drugs. For all these reasons, the SYM VEIN group built a reference document with these five chapters: Definition and description of venous symptoms,

ascription of symptoms to chronic venous disorders, the pathophysiology of the different venous symptoms, how to score the symptoms, and how to investigate the symptoms. This group, it was an international group with 23 members from fourteen countries

that include not only vascular surgeons but also angiologists, dermatologists, a neurologist and even a healthcare economist. And you can see here the distribution per country and the distribution per chapter under the coordination of Michel Perrin and Bo Eklof.

Of course it is difficult in five minutes to highlight all the document. And you can read chapter by chapter, what means for example the definitions of the different symptoms. In the chapter concerning the ascription

of symptoms to chronic venous disorders. Those venous symptoms that should not be described as non specific and those that are poorly documented. Other developed items were that, venous symptoms does not mean symptoms of varicose veins.

Absence of physical signs of chronic venous disorders does not mean absence of chronic venous disease. Locomotion disorders does not necessarily rule out chronic venous disorders. And no abnormal test does not mean absence of venous dysfunction.

How to score the symptoms and the current available tools and how to investigate and this more important to investigate the microcirculation and this is quite important for example for C0s. We have new data that was published this year. You can read all the documented,

it was published 'International Angiology'. And to finalize. This is a provocative question to the audience and to the different speakers. Are symptoms, the different venous symptoms, predictive of disease progression?

This is a provocative question. Thank you.

For us anesthesiologists the NORA challenges

are the ergonomics, or unfamiliarity with the landscape, limited help, we're consultants to consultants. And this is like, you know you read, you turn the book and you read, everything is the same story you know. And I find these excuses,

because I don't think we've, we hide under these challenges. And I think a lot of people refuse to accept that we're here, and we're here to stay. And you know, you're gonna love us. You're gonna love us, and we're gonna

love you no matter what, so these challenges are just the misconceptions I think. Traditional misconceptions that I hope that I can, for you, invite you, and tell you that, you know, these are just misconceptions.

In looking back, one thing that actually popped into my head is, we came, we saw, and instead of we conquered,

I actually thought it was we helped actually. We can help. And we didn't do anything novel at MGH. I wish we did. But what we're doing right there, is with that full time team,

we're making everything, we're mainstreaming all these nice studies that have shown anesthesia to benefit in patient care. So right now we're, there's these, just a couple studies that I pulled up. Five, and two on the left are just using

this very cool Jet ventilation, an advanced ventilation technique that was traditionally used in the operating room. And in was invented in 1960s, 1970s. And you see these papers are from 2011, and the other one I think is from 2012,

about using this ventilation modality for ablations. We're also doing paravertebral nerve blocks. And we talked about pain blocks for chronic pain. But these actually for acute pain for biliary drains we can actually use these paravertebral blocks that's been written about.

And was written about in 2011. So actually relatively, just, it's new. But nobody kind of got written up and kinda forgotten about. But now since we're there, we actually are bringin' these things back.

The newest paper that came out is using a block for, a brachial plexus block for fistulogram to enhance patient comfort. And actually that's what we're doin'. We are doin', peripheral nerve blocks for fistulagrams. Especially of the forearm.

We've noticed that those are actually very, very painful. So we actually go in and do a nerve block that lasts for four hours, something very, very short. And the patient's get still, they still need sedation.

But the pain is gone, and we find out that they actually, they don't need as much versed, or fentanyl, that they're much better satisfied. And this is where we're still doin' this. And we're still formulating this. We're also doing advanced,

right now we're doin' a Swan-Ganz catheter to measure cardiac output for percutaneous banding of these fistulas, where several patients have had issues with blood pressure, cardiac outputs increase with a fistula.

So the question is, if you actually band it, and you stop the blood flow, or decrease the blood flow, can it improve the cardiac performance. And we don't know that but we are able to place these lines, measure cardiac outputs.

We can actually compress, and you'll see actually right there in the bottom picture, over there I should say, where there's a tourniquet, and they're compressing the fistula, and we're actually shooting cardiac outputs

to see the decreased blood flow actually makes a difference. If it does make a difference in terms of decreasing cardiac output, the cardiac performance, they proceed with banding. And I think what we're gonna do next, in the future is, you know, in the anesthesia world,

we actually have this device that measures cardiac output non invasively, without a PA line. So I think we're gonna continue doing that to kinda guide our management. And this is anesthesia and IR working hand in hand, you know, applying novel ideas,

where existing, merging of actually two different technologies which exist down there, we just don't talk to each other. The other thing that's coming to light as well

So, how do you define competency? We're gonna give you a minute to just do a brief definition of what competency is to you. Keywords, phrases, bullet point type things. Yes. Now you just text continue a text conversation with that.

So just type in, and your response to that is whatever your definition of competency is. Ain't this nice? You're all participating in this. You're running this lecture.

Wow. Alright, I'm seeing knowledge up there an awful lot, really an awful lot. I see skill. Understanding. Expert.

Confidence. I see annual. Thank you, whoever put Totally Rad. I really appreciate that very much. Probably was one of my Hopkins friends. Ability to do a job.

You guys have good point. These things are part of what competency is. When we sat down at our institution to come up with a standard definition of competency, we started by going to the dictionaries.

There is no one definition of competency that you fill find that exist everywhere. So we had to come up to one that fit us, that worked for us. Oh, somebody put necessary. Yes.

We're gonna talk about these things. So this is just Hopkins definition of competency. This is not just the competency definition for nursing at the hospital. This is the competency definition for everyone at the hospital.

Competency is the application of knowledge. We saw that an awful lot. Skills, we saw skills, and behaviors. Now that was one thing I didn't see coming up in the Poll Everywhere results.

That are needed to fill organizational, departmental, and work setting requirements and include interpersonal, technical, and critical thinking skills. Does that blow anybody's mind when I talk about something other than technical skills?

How you communicate with one another is a competency. How you critically think is a competency. So, competencies are much more than, "Can I do the dipstick on this urine?" And then the other key thing with competency is that are needed to fulfill

these goals. So it is actually taking knowledge. Knowledge is a part of it, but it's transferring that knowledge into actual practice. That's really what competency is. And if you look at all the definitions out there.

That's really what they're trying to get to. Alright, somebody said necessary. Do you have, at your hospital, are you required to take a course on HIPAA annually every three years, some point in time? Anybody not required?

Yeah, I didn't think so. Are you required to do fire safety every year. Yeah. Are you required... Hey, in my hospital, as much as I hate to admit this,

we have to do a required training on active shooters. And keep in mind, tomorrow morning there is a wonderful lecture on violence in healthcare and I would strongly encourage people to attend, because it is unfortunately too much of an issue in our society in this point in time.

So, those things that you have to do, they're regulatory requirements. Joint Commission is coming and saying you have to do that. Your lab folks are saying you have to do this. CMS is saying you have to do this.

Your hospital is just saying, like I said, for mine, my hospital is saying everybody has to do active shooter. This is required education. Competency is not just education. Competency is taking that education

and putting it into practice. So, required education does not equal competency, and this is a struggle we're still working with, but it's really incredibly important to understand the difference. All right.

So, we're gonna turn it over to Nikki.

- [Kristina] Alright, everybody still awake, right? Alright. Sound familiar to some of you? Good. Alright, so what is the essence?

When we talk about the essence of a job, it's what makes a radiology nurse different from a med surg nurse. What makes a radiology nurse different from an OB nurse. If you've ever heard Donna Wright speak, she talks about the essence of something

that we took from her process. She'll tell you for an ICU nurse, one of the essence of an ICU nurse is you gotta have a little bit of a 'tude. Because the advocacy that you have to have for your patients is a little different than in med surg.

You could be a phenomenal med surg nurse, but not a be a great ICU nurse because you just can't stand to those physicians to say, "Ain't happening on my watch." So, but you have any successful ICU nurse who is not wiling to put his or her foot down

and say, "This is the way it's going to be." So, pull up our phones again, last time for this one, and what makes a radiology nurse a radiology nurse? What's specific to us? What specific knowledge, skills, behaviors

do we need to be successful radiology nurses? Independent is huge, flexible, safety. - [Nikki] Works in the dark. - [Kristina] Works in the dark.

Yes, you gotta be able to see in the dark. Scope of cares. Can do anything, who said that one? Yes! Collaboration. (laughs)

Okay. Those on my staff, development team, we're gonna have to find a way to add that one to ours. Multi-tasking, conscious sedation. You're absolutely right. And this, we did the exact same thing.

I sat down with both my gen rad staff and my IR staff and said this exact same question to them. And then these are kinda sort of the things,

the themes that came out of their brainstorming session. Environmental safety there is safety on the floor, but the floor doesn't to worry about an MRI magnet. The floor doesn't even realize

that the magnet is always on. It doesn't mean anything to them. It means a great deal to us. Nuclear medicine safety. Yeah, standard precautions for them, well it is for us, too,

but I'll be honest with you. I was doing nukes one day and I was doing a pediatric patient. We're doing a urinary study and I took his catheter out at the end, and this little boy decided he wasn't done peeing.

And it ended up right here. That is not necessarily a concern for a floor nurse. They don't have to take their clothes off and leave them at work because they've been peed on with radioactive urine. I had to do that.

If you ever worked in nuclear medicine, always keep a pair of change of clothes in your locker. Always. Shoes, too. Because I've also walked into a patient who has peed all over the floor

and it was in the dark. Now my shoes are radioactive and I can't walk around the rest of the hospital with them. So, shoes, too. Collaboration. That was one you guys mentioned.

Independence you mentioned. How many times are you the only nurse around? Attention to detail. Critical thinking. Again, you're the only nurse around in a lot of times. You don't have another nurse

to bounce things off of, so you have to have incredibly strong critical thinking skills. Flexible because things are constantly changing. Picking up the changes with little information. We're not floor nurses.

We don't have a chart this thick. When they come down to the lab, we're only looking at, the most recent labs, what meds have they had, and what's the diagnosis, and why are we doing this procedure.

We don't know the rest of the history. And in gen rad, you know less than that, because more often than not, the technologist has put them on the table, done their scan. They've had a contrast reaction and then you're just brought in.

You have no idea what meds they're on. You have no idea what they're allergic to. You're just responding to that symptoms and treating from there, problems solving, communication, assessment, monitoring, advocate for the patient,

responding to emergencies. We have to respond to emergencies a little bit different than the floors do, because again, we don't have the volume of people. If a code happens on the floor, every nurse on the floor is there to

lend a hand or try to help pick up the other patients while the code is happening. If it's Saturday morning and you're coming in on call, it's you, your tech, you might be lucky have an extra tech floating around, but probably not, and your radiologist.

And I mean no disrespect to our radiologist, but let me ask you, and you don't have to be honest if you don't want to. Who runs codes in radiology until the team gets there? We do.

Yeah. So, we have to have that knowledge above and beyond because our docs care about the procedure. They are care about the image. Yes, I actually was doing some mock codes,

and I sent out to our chief radiologist. We're gonna start including the physicians in our mock codes. Any problems with that? She wrote back to me, "Oh, I think that's a great idea.

"I'll gladly come and follow directions." And then I went to her and I said, "Hey doc, do you realize "that until a code team arrives, "you're running the code?" Uh.

So, medication administration. And as Nikki already mentioned learning on the fly, IR procedures change all the time, that the procedure we did today, we're not doing anymore because tomorrow we've got a totally different way to do it.

And so there isn't a way to orient you to that so much. So you've got to figure it out quickly. For us, our thrombolysis, the thrombolysis dressings, I've worked really hard on ongoing competences because my IR nurse has went thrombolysis dressing

on as an ongoing competency every year. When Nikki mentioned ongoing, you shouldn't keep repeating ongoing competency because if you've shown your competent, like riding the bike, you don't really forget. You don't necessarily lose competence.

You just need to refine it a little. And I finally got them to... You're coming in on call and you have that thrombolysis dressing, whatever competency we did for you six months ago, you're still not necessarily gonna remember

because you wanna do that thrombolysis dressing. There's enough nurses that you may do to a year. depending on the flow. You still have to know where your resources are. So do we have the resources in IR to tell you how to do a thrombolysis dressing

if you don't know. And if we don't, we need to add that. And then when we have it, where is it? Can you find it?

So let's look at this very last video we had about the heavy patient.

So a couple of things. So we got this state back,

and it was important in IR suite, it's patient satisfaction. You know CG CAHPS, HCAHPS, that's very important for patients how they felt during a procedure, right. The other thing that's very important in IR right now is the opioid epidemic right, pain.

Prescription of opioids. And actually one of these, these two things anesthesiologists are good at.

So now I'm gonna take you through our journey of how we came up with our introductory competencies. So, it can be very overwhelming when you're implementing this into your organization. So, what we did, Kristina and I, led a group to work on introductory competencies

and really taking that checklist down to just a couple pages. So we went to eight pages, generally speaking, from the 23 pages. And then her radiology specific might even be a little less. So, the first thing that we did was we gathered nurses

from all over all different disciplines. We had medicine, surgery, pediatrics, OB, et cetera. And so we all got into a room with a whole bunch of white boards, post-it pads, and got all of their knowledge together. So the next thing we did was a literature review

to see what competency models are out there. Has anybody here done the lit review or use specific competency framework in your organization? A couple hands. So if you're not familiar with Donna Wright. Donna Wright is probably the most talked about name

when you're looking through competencies and we've actually adopted her for our ongoing competencies. As we were looking through to do our introductory competencies, it wasn't just the exact mold that we wanted.

However, one of her main premises is really as Kristina said in the beginning looking at interpersonal, your critical thinking, and then in addition to your technical skills. So your technical skills are going to be,

"Can you take vital signs? "Can you insert an IV? "Can you give contrast? "But interpersonally, can you speak with the physicians, "or the tech, or the patient?" And then critical thinking,

so if you're in an emergency situation. So a lot of our introductory competency is really focused on technical skills and don't have these other domains. And so we thought it was very important to bring this

tenant of Donna Wright into our introductory competencies. What's that? (speaking off microphone) Oh yes. Kristina just reminded that

the employee is at the center of all of these domains, and that is super duper important. Because one of the most prevalent things that it does is put the accountability back onto the employee to ensure that the competencies are getting finished. So that we're not handholding and running around

and saying, "Did you do this? "Can you do this appropriately?" And so they need to demonstrate to us that they can do these things. So, the next thing that we did was we looked at the Carrie Lenburg, the COPA model.

And so, the COPA model basically has eight high-level core competencies that can be used for any particular nurse coming in any kind of practice environment. And so, these are the eight core competencies that COPA or Carrie Lenburg

is the author of this model. And so, what we had done was we had all of our nurses from our practice environments go up on a white board and we wrote down what are the things that are essential for all nurses.

So, regardless if you're an OB or if you're in the ICU, or if you're in med surg, neuro, oncology. And so, when we were finished, we had about 200,

220 things listed on the board. And it was like, "Oh my goodness. "We don't need 220 core competencies." But as we started to loo through those, we saw some kind of trends and themes,

and we said, "Okay, how can we narrow "these particular things down." And so, that is what we did. So we got the minimal skills and knowledge that we thought all nurses needed to do. Alright, so my question to you.

Again, if you go back to your Poll Everywhere, you shouldn't need to do anything from when you've texted before, you can just text back. Keeping in mind, generally speaking, not radiology specific

or IR specific or anything like that. So what is something that you think all nurses need to know regardless of their practice environment? Communication, bingo. Advocate is huge.

Med admin, yeah. Assessment. They're going so fast. These are great. - There was a lot of communication ones. - [Nikki] They must have been paying attention to our...

(speaking of microphone) So these are really great, and these look very similar to the ones that we had also come up with on our whiteboard. Perfect, yes.

So, and if you keep in mind, these are a lot of things that the nurses, when they have a license, should already know when they come in. So you're really just validating that they have these particular skills.

So what we did, like I said, is after we had all of our 200 things on the board, we kind of narrow them down based upon our themes. And so, for us at Johns Hopkins, we came back with four. We narrowed 200 down to four.

Practice communication which we just saw very heavily in the previous slide. And then safety QI EBP, because we're an academic teaching institution and we really rely on that for our staff, and then our core values.

And our cor values really are aligned with the core values and the mission of our hospital. So those are the four that we came back with. So from there, what we were able to do was take those 200 things

and kind of then layer them out very specifically as you just saw. Somebody had written med admin and assessment. And so these are some of the things that we have. So demonstrates and documents head to toe assessment. Demonstrates tolerance and respect for others.

So that would fall under our core value. Follows infection control practices. That could be our safety QI EBP, and then identifies own learning needs. And so, one of the things as we go back to our meaningful

and then narrowing down our checklist is a very good competency learning on the fly. You're not gonna teach that orientee every single thing that they could possibly ever see in 90 days or six months. So do they have the competency of learning on the fly

that they have a patient come in that they have never taken care of? Do they know how to use their resources and figure out on their own how to appropriately take care of this patient? And so that's one of the things

that we really felt very strongly about adding. And so one of the last things that we did was then we went out to our specific departments. We went out to OB, we said, "What's specific about being an OB nurse "that could exemplify and continue on

"with our competency statements? "What is it that means an ICU nurse "that's very specific to them?" and then more importantly, "What is very specific to be a radiology nurse. So, I'm gonna turn it back to the radiology expert

since that is not me.

brought down at MGH, we could not do it without the IR nurses. And I thought before that oh, I'm just gonna go ahead and do a block, and it's gonna be fine. And then I'm like oh my, just wait a minute. You know actually, there's actually more

to taking care of a patient with a block, like how do you take care of 'em. How do you assess 'em, and you know, yeah the IR nurse, had to collaborate with the IR nurses. And Alexandra's here and you know, she's, it was up. Brought it to my attention, like yeah,

when you're utilizing all these, when you bring in other technologies you at least have the people that live there, you got to educate them, because they'll be taking care of it. They have to understand what you're doin'.

You know it's not a one way street. This is a practice change you know. So we had our nurses train in regional safety. You know have some share point slides for knowledge of how to take care of a block. The recovery protocols which is another thing.

You know it's like everybody comes here, and says, oh yeah, do a block. And you're like okay so how do we take care of it. Who's right, who's wrong. Where are the discharge instructions. Who takes care of that?

And it's the nurses actually. You know so there's a beginning, a middle, and a conclusion to a procedure. And it seems like, you know I'm guilty of this. We just concentrate on the procedure, but we never actually concentrate on the followup.

But anyway, we've been good with the nurses in terms of educating them. Our nurses, what I've noticed is that number one, patient advocate, you know, they're always getting pushed to do more and more. You know nights we don't have anesthesia

or this patient doesn't need anesthesia. Or you know proverbial like, mismatch. And you know they're always there fighting. And I encourage you to continue doing that because you know you are the patient's advocate. No I'm not saying that as an anesthesiologist,

but just you know, if I, you know as a third party, you know our nurses at MGH, consider they're truly truly a patient advocate. They just care about the patient. Their comfort. And doing the procedure, they just don't sit back,

they have to also pay attention and help us out. If we have a patient here who's from cardiac ICU who's on you know, eight drips, and we're not a one person machine you know. This patient needs a lot of care you know. It's good that we have the nurses.

And I don't wanna forget the IR technologists who are also key and vital in patient safety. And what we've been doin' is administering. I administered a survey to identify gaps in knowledge. Like I just wanted to see how much do the techs actually know about anesthesia

because they're the first ones to come in when we have complications. you know or if the table is turned, and we're doing you know a MAC anesthesia, and now the patient starts aspirating. You know the tech actually has to know to turn the bed.

Right, recognize that. When we have a difficult airway, before when we are anticipating one we have to know, we have to be able to rely on the tech to say hey, you know, I notice that you talked about a difficult airway,

do you want me to tilt the bed? I can tilt the bed. I was like oh, I didn't know that this table, that it was capable of doing that. Or we have a pneumothorax, you know, like hey why don't we shoot a quick xray.

You know, so and so can you shoot an xray. Stuff like that. So what we've done is administer a survey and asked questions about techs have speaking up. So we are actually actively working on this. So you know, how important are the techs

recognizing the anesthesiologist is struggling. When the anesthesiologist is struggling can you speak up, and see how. You know we kinda have a wishy washy world where people are not really comfortable to approach the anesthesiologist.

Is that appropriate, is it not. Do we appreciate it, do we not? So I am actually very excited that we can actually intervene. And we're gonna give another survey afterward. And well, we're gonna provide education.

And you know, educate the techs on hey, you know, you can always speak up. You know it's okay if you know, nobody's gonna get offended if you say, hey do you need help or anything. Also being familiar with our equipment,

anesthesia equipment. The second survey on the bottom, you can see it asks about a glidescope, do the IR techs know what a glidescope is? It's our video laryngoscope that's used for difficult airways.

So you see the top right patient, the top right the patient has a huge neck mass. And it was gonna be cryoablated. We've learned about cryoablation, it's great. Yeah. And patient is, can't really breathe.

So we have to do an intubation. So a patient like this, and the cryoablation is not gonna be straightforward. It's gonna take hours. We know that. So we need anesthesia.

But this patient was very, very challenging. And we needed the nurse, the IR nurse, and the IR tech to help us with securing the airway. Not an emergent situation, but they need to know the equipment that we use. Again is being vital.

The other thing I mentioned earlier that we're going at Mass General is jet ventilation. And the jet ventilation is a very cool concept that's been around since the 1970s, but hasn't been employed in IR in mass.

So there's been studies that I showed you. But that creates a static field, so you get these little short bursts of 15 mls at 100 times per minute. And that creates actually a static field in the internal organs, the lungs.

And imagine a radiologist, if he knew about the static field, no patient moving, no apnea, he just goes in there and does the procedure. That actually increases the procedure accuracy, decreases radiation exposure.

Actually lesions that were thought to not be amenable to you know, some cryoablation, are now amenable to cryoablation. So if there's a lesion at the base of the lung, you traditionally couldn't get it. But now with this jet ventilation,

we brought it downstairs, we actually treat that lesion, treat that patient and offer, other treatment benefits, or modalities that the patient wouldn't otherwise be a candidate for. And you can see the jet ventilations over there. In one of the screens, the middle screen

you can see us putting the jet catheter, and then the jet ventilator's right there. But this has been, this technology has been in existence since 1970. It's old to us, but it's novel now in IR. And I think it's gonna gain traction.

so our story starts out at MGH, the IR, you know in grade two, where we do it. We have six rooms where we do anesthesia. Every room is actually outfitted with anesthesia equipment. So room four's our CT. Room six we do our anesthesia cases.

Room two we do our complex cases, CERTs, pre CERTs. Room one, neuro IR. So it's typical IR program I think. But I think a lot of special things happen. And although it doesn't seem like that at some point. But I believe that we're at the leading edge

of the contemporary trend that's coming. So IR at MGH our case growth has increased by 20% over the past year. From 2016 to 2017 we went from 1200 cases to 1400 cases with, this is IR anesthesia only. We're growin' pretty rapidly.

It's 20% growth. And I believe that we're gonna grow more this year just because, I'm not sure what's goin' on, put the patients just keep on getting sicker and sicker. And our services keep on getting more and more wanted, I suppose.

The top three cases that we do are G-tubes, tunneled line catheters, our fistulagrams. Our CT microwaves as well. So those are the top three, top four cases that you can see where general anesthesia is utilized. We do about 50-50% of inpatients and outpatients.

that we can verify competencies.

If you look through this list, we don't even have checklist listed here, which I think is super interesting. The other thing, we use more of these than we do some other methods. So like our return demonstration,

or our testing, or exams are really popular ways that we can measure somebody's competence, but we don't very often use the evidence of daily practice. So if Kristina was my new orientee and I am her preceptor, and I am watching her gift contrast,

I can see through her evidence of applicating the contrast to the patient that she's either competent or need some risky areas that she need some work on. And so I can sign her off according to that. I don't need to do all of these methods

and just go back through a checklist. The other good thing about here is audits and documentation. So a lot of you I know are quality improvement and we have some auditors. And so we can get some really good data from them,

and so we can also have them do some work, and that's also really important when we're doing our ongoing competency so that we can pull that QI data and really identify the high-risk areas that the staff need to focus on.

We're gonna talk about image guided blocks for pain syndromes. The goals of these blocks are often to reduce narcotic requirements, manage acute pain crises, and what we've learned is that the autonomic nervous system contributes significantly to many pain syndromes.

We'll talk about some neuro blocks, neurolysis, and nerve ablations. When we talk about neurolysis and nerve ablations, what we're trying to do rather than a block which is just a temporary fix and control of pain, we now wanna try to make it at least semi-permanent

to give that patient some time to allow them to ramp down their narcotics, maybe have an improved quality of life. The agents that we use for neurolysis are alcohol and phenol, but more recently, we're starting to use both thermal ablation,

pulsed RF ablation, and cryoablation.

is enhanced recovery after procedure. And is short term for ERAP for microwave ablations and our TACE procedures. So what we do there is we give, in the pre procedure area we give medications. Analgesics, Tylenol, Celebrex.

We do paravertebral blocks, or certain blocks for the patients who are in the procedure. And after the procedure we actually do, we use adjuncts to decrease the opioid consumption, increase patient satisfaction. And we've heard it before,

the previous speakers talking about how peripheral nerve blocks help. They do help. So they do enhance, patient's love it. And this is what we're doin' and it's actually very unique.

I think we're one of the first to do this, roll this out, is enhanced recovery. And this is what's been taken, we've been doin' in the operating room. So we went to the operating room. And I said okay why don't,

if we're already doing enhanced recovery after surgery, why don't we do it after a procedure. They're the same patients. They bleed, they have blood, they still have pain. And it's been getting a lot of traction. And this is just us doing a peripheral nerve block

in the IR suite, and you can see actually the IR tech and the nurses are in the background actually helping me do the nerve block. We have a little regional nerve, anesthesia regional nerve block that we've put downstairs, our offsite block.

Which is pretty neat.

So now we move from a potential case like this

where the patient has a large renal mass and a metastasis into their left femur, and that patient underwent a surgical resection here, replacement of that, a big operation for a patient with metastatic disease, now we take a similar kind of patient

with a left renal cell carcinoma and has two metastases, one in a rib and a small one in the acetabular region. And they undergo the nephrectomy and then ablation of these two areas. That may be the new model.

At MGH I believe we're special because we have, given this explosion we actually have had anesthesia full time in IR. So we reside there. We have a dedicated IR team. So there's no,

you know we kinda heard before, there's a stranger comin' in, and now you don't know, hey, anesthesia, you're on your cell phone. Now we actually attach names to people. We already know.

So actually that's one of the big cultural barriers I think, and misconceptions that we've kinda broken in. And you know I think a lot of people know each other by first names now. We run two to three rooms per day four times a week.

And again like I stated previously all rooms are outfitted with anesthesia. And the IR suite at MGH is the new IR anesthesia. This is the future. So it's no longer, you know, you go down, and before being assigned to IR,

as anesthesiologist it was a punishment. Oh my goodness I'm gonna have some sort of, you know, patient who's on death's end, and nobody knows a clue, and now I'll have to sedate 'em, or do general anesthesia.

I have no idea what's goin' on. That's no longer, you know, I'm just gonna give versed, fentanyl, or nothing, just hold hands. We're gonna use propofol, use a little sedation. That's long gone. I think my colleagues are kind of upset

that we've already broken the mold. That I'm gonna show you what we're doing at MGH, and this is coming to you, to your regional practices very soon.

IR in the modern era. It's busy. You know, this media you can see all the innovations, all difference of specialties. It's a very complex operation that's underestimated. And I think it's underestimated by the surgical people.

Because everybody's world revolves around their own world. So our world for anesthesiologists is the operating room. Anything off site of that is foreign. It's almost, you know we're almost dismissive of that. But vice versa, you know for the radiologist,

or you know, corresponding clinicians, their world revolves around their specialty. So IR, you know everything revolves around them and they don't really know much about us. And that is just cultural differences that I think we're gonna see less and less.

Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,

and how you might be able to change it, there we go.

So, some of the key points.

Competencies is the transfer of knowledge into practice. Required education is not the same thing as a competency. Competencies have to be meaningful. Not just those little check, check, check, check, check, check, check. They need to address all three domains of competency.

And if you looked at some of those, we actually did have those things. Now some people say communication is part of practice. What is the number one cause of medical error? Communication break down. We decided communication

was so incredibly important for that fact alone, that that's why communication is actually separated out on its own. We wanted to make sure people understood this was the key to a safe environment. Introductory competencies

focus on the essence of the job and you use a lot of different verification methods to verify the competency. And ultimately, sometimes a skills checklist is appropriate, but skills checklist realistically by definition is not respiratory therapy,

trait care, inner cannula, outer cannula. That is not a checklist. A skills checklist by definition sits there and says they do,

start an IV. They gather all their supplies. They wash their hands. They identify their patient. They tell them what they're doing. They select the appropriate vein.

They clean it using whatever policy your hospital says it's supposed to be cleaned with. They get their vein. They secure it. That's a checklist. This competency checklist that we're using for new hires,

these skills checklist, they're not skills. There's not a checklist. The checklist tells you what behaviors you're looking for. And please don't get me wrong, checklist don't go away. They are still important.

But if you really wanna know that your employee is competent, you need to look at what do you want out of them.

- [Nikki] Good morning everybody. Thank you so much for having me and thank you Kristina. So, I am going to talk to you more about the very broad high level

more than just the radiology kind of competencies. Competency should be assed for all employees at three main stages. So when they're hired, which would be typical of an HR. In our department, it's career services

or nurse requirement. And that really just makes sure that folks have the things that they need in order to get their job. Do they have a nursing degree? Did they successfully passed and have a license.

Do they have CPR? Things like that. And so, those are all done before somebody is hired. The next stage is in the introductory or sometimes known as initial.

And that is usually done in the orientation phase, so when they first start through the end of their orientation. And this really just focuses on the essence of their job. And then the last stage is their on-going. So these are done every single year.

They change every year. They're fluid and they're dynamic, and then they can be very specific to the person's role or they can be very generic in, that they need to practice patient safety, hand hygiene, things like that.

So, for today's purposes, we are gonna focus on specifically the introductory phase. So many of you, I'm hoping, already have some kind of ongoing competencies outside of your required education. And if you don't, you can certainly come

and talk with Kristina and I about that. But for today, we're gonna focus on our introductory. And so, as I said, those are unit-based and they're very specific to the particular unit, because their work required for a nurse or a tech or somebody to practice independently

once they're off of orientation.

But the most important thing is that out of all the important, you know, all these new techniques that we're using, we're utilizing, it wouldn't be possible if we didn't have a close IR collaboration. You can see Dr. Ronnie, one of our premier

interventionists, he's lecturing the CRNAs, and our MD anesthesiologists on the procedures that they're doing with our banding for fistulas. Explaining the concepts between cardiac output. So we had this little conference just to increase understanding of what's goin' on.

and there's no hey, you know anesthesia's comin' in, they're interrupting us, you know, actually we know what they're doin'. And paramount to this is communication. And you know, it's the old cliche, communication, communication.

You know a lot of break down in communication leads to patient mortality or bad outcomes. But we've been really, really pushin' it. And enhancing this. So the nice thing about our program is that the phone call nurses,

you know when they screen their patients ahead of time, if they have any questions they reach out to us, to me personally. Contact us either with questions, or you know, manage, they ask about consults in terms of what patients

are appropriate for conscious sedation versus anesthesia. We also are pushing a daily IR schedule so people actually know who's who. So we actually highlight the anesthesia floor walker. We have the IR physician. They're the IR lead who we call to make changes.

We have all the rooms with all the fellows names with the anesthetist, their names, and also the nurses, their names, in case there's any questions. You know it's a big deal. It's just small, but it's big when somebody knows your name.

You know you can attach a name to a face. It just makes everything so much better. We also have a operations meeting that happens biweekly right now. So we talk about issues that happen with scheduling, that have to do with anesthesia,

and in particular, you know, what goes right, what goes wrong. and this continues, it's a lot of work actually. And for every, it seems sometimes, for every two steps forward, we take three steps back. But we're always movin' ahead.

And it's not easy but I believe that this is what makes us special. And what this is kinda, I think this is the model for what we need to achieve in other institutions. Now with all the innovations that we've

So, competencies are really supposed to be meaningful. In our hospital, we had tons of competencies or an orientation skills checklist, and it was very lengthy,

and it was one-word statements, maybe just a couple phrases. I'm gonna list out every single thing that everybody needed to do. So I would like everybody to stand up. I know it's morning, we all had our coffee.

Everybody standup. You all get to sit down in a minute, I promise. Alright, so, if your organization has a competency or an orientation skills list and it's more than 20 pages, stay standing. Wow.

All right. Okay, so one more time, everybody back up. Sorry about that. Everybody back up. Alright, so now we're gonna do the reverse. If your organization has an orientation skills list

and it's more than 20 pages, go ahead and sit down. Alright, so if it's more than 15 pages, stay standing. So if it's, let's say if it was less than 15 pages, stay standing. If it's more than 15 pages, sit down.

- [Kristina] So, 15 to 20 range? - [Nikki] Yeah, 15 to 20. Alright, if your orientation skills checklist is less than 10 pages, stay standing. Wow, these guys are good. Alright, if your orientation checklist

is five pages or less, stay standing. My goodness, we need to find these people. - [Kristina] Well, honestly, to be really fair, a handful of them are my staff. (laughs) - [Nikki] Okay, so, next thing

if your orientation skills checklist is two pages or less, stay standing. Alright, so we need to find and talk with you at the end because that's what we need. And then everybody else in the room, you need to find them at the end.

Wow. Applause for you. - [Kristina] No, no, no. - [Nikki] Oh you don't have one. Oh, no, no.

Okay, I take the applause back. Alright, so we definitely need... - [Kristina] You need to find us, Kathy. - [Nikki] The other way around. So when we started this journey, our orientation skills checklist was reaching 23 pages.

And that, in my opinion, doesn't mean anything, it just means at some point or another somebody heard the topic during their orientation. They may have just a one-on-one discussion when they couldn't get through, and they just had to sign that off

in order to meet the joint commission requirements. So this is an example, very high level, of something that would be on one of our orientation skills checklist. So, if you read through there, does that tell you if I'm competent?

Does that tell you that I practice safely that I can do these things? It's more of a yes or no, but you don't know how to validate that, or you don't know how good I could really be at that. So this is an example of how we transform

those very long list into something that's a lot more meaningful. And if you notice, it went from seven lines of text down to four. So while it's more meaningful and gives more insight

as to how a practitioner could be deemed competent, it's also a lot shorter. All right. So how many of you in here know how to ride a bike or at least knew how to ride a bike when you were a kid.

Alright, me. So, I have not ridden a bike in a very long time, about 10, 15 year. And so, as I was teaching my son how to ride a bike, I was like, "Here, let me show you." So I got on the bike and I'm like, "Oh my goodness."

One, I'm a lot more scared and my fear factor has gone up, but number two, I was very shaky. But after about five, 10 minutes, you knew that you have to put your feet on the pedals, you knew you needed momentum in order to keep going,

and so I could then ride a bike. So I was very shaky. For all of your new hires to come in, at some point, they have passed some kind of licensure, they were deemed competent, they passed the boards, they took a fundamental or a transitions course,

they know how to take vital signs, they have a license. We need to give them credit for things that they should have already experienced. When I look around in this room today, everybody has a shirt one, your arms through the armhole,

at least I think so. Everybody has appropriate pants or skirt or dresses on. I don't need to have a 10-list page of can-put-shirt-on, can-put-pants-on. I'm assuming you have under clothes on. We'll add that on the list.

But what I can mostly say is that everybody is competent that you showed up here dressed appropriately today. Okay. So, just kinda just some other examples that we give.

So documentation, before I show you these next slides, there are a couple of things I wanna make you aware of.

As Cathy said, she has no introductory competencies. Hopefully there is no one else that's in that same ball of wax. But Joint Commission does require a couple of things in their competency forms. They do require that the employees name is on there.

They want a description of the competency, an identification of the verification method and the signature of the person validating and the date it was completed. Then this does need to be maintained as part of the personnel record.

So remember that 23-page checklist. This is the first page of our introductory competencies for IR. And you will see our hospital came up with those four core competencies.

So this is the first page of the practice, core competency. And those core statements, we took those core competencies and made overarching headings for those. The five that we came up with from a nursing perspective,

oops sorry, demonstrates and documents vital signs accurately and appropriately, demonstrates and documents head to toe assessment, administers and documents medications accurately using the five rights,

and appropriately responds to patient condition. Those are the things that the hospital says... Whoa, what did I hit? Okay, sorry about that. Those are the things that hospital nursing said is the key elements of practice.

So then when we met as my radiology team, how do we demonstrate and document vital signs? Well, our checklist, our old checklist, had temperature. Oral, rectal, axillary, tympanic.

Okay, how many of our nurses graduate in nursing school? All of them. So, was temperature oral, rectal, axillary, tympanic

all part of fundamentals of nursing? Could they have graduated nursing school if they could not take vital signs? Absolutely not. So why do we have a list that says oral, tympanic, and all of those things.

It's ridiculous. So instead, we looked at what we do in IR. In IR, can you use our monitors? That's where the competency is. So, independently places the procedure required assessment, equipment.

And we actually changed this a little, so it's more consistently places required. So we've changed this a little bit. Including correct alarm settings. That's what matters. And I'll tell you we didn't spell them out

because things change. Example, admittedly we're not doing capnography in the IR lab at the moment. It actually is an equipment issue tat we are actively working on fixing. So if I had put everything in there

and didn't include capnography and then three months from now, then I'd have to go change it. And I have a lot of work to do. I don't need to just update for everything. So we want these statements somewhat broad.

But if you were a Joint Commission inspector that came in and wanted to know if my new hire was competent in doing vital signs. Would this give you an idea without seeing a check mark next to blood pressure standing, sitting, lying,

left arm, left leg, right leg. It tells me everything I need to know. Head to toe assessment. We had to alter this a little, because we put as appropriate to procedure. Because in all honestly,

how often do we do a full head to toe assessment? We don't. So why should I be checking my nurses off for absolutely everything if it's not relevant to what we do. So it's focusing on the relevancy,

but we have a neuro IR so part for that for neuro IR absolutely includes a neurological assessment. That is big for them. And skin, we do care about skin to some extent, but we only care, are we positioning them in a way

that we're gonna cause some sort of friction burn from the way we're positioning them or they're gonna get radiation burn because of the way they're positioned and how they're being scanned. That's what we care about the skin,

care to the detail. The floor nurses have to put every scare and every... We don't care. Five rights of medication. Responding to patient condition. I will tell you, on this, it only says

catheterize the patient as per policy. There is a few more pages to the practice version of this. And what we did with the procedures for example. I went through with my team and I said, "Okay. "What procedures does an orientee

"actually have to physically experience "and be part of and be somewhat comfortable in "before they can come off orientation?" And I don't have it in this presentation, but then there is a list. And then we have the other ones that if they get great,

but we know we only do IPSS, inferior petrosal sinus sampling, five times a year. The odds of an orientee getting that is next to impossible. So, we can't expect them to do that. So that then comes to our validation methods.

You see all those 11 methods are up here. So for this, the only way we're allowing them to sign off on these is direct observation. So that evidence of daily work. We have to see them do this. But when you look at head to toe assessment,

it could be signed off because we've watched you do it. It could be signed off because we've done a mock scenario. So we've sat here, and Nikki comes in, and we're gonna do, she's here for a stroke.

Let's go through and talk through her neuro assessment, or the case scenario where the patient is coming in and they can't lift their left arm. What is are assessment of those?

Sorry, I keep hitting the buttons. And then you see exemplar. Exemplar, how many of you hire new grads in IR? Okay, there's a couple and there's a push to more of that. But in general that doesn't always happen.

So if I have, and it is in here, if I have emergency response, you may not have an emergency during orientation, but can that orientee sit there and say "You know, we had this code in my last job,

"and we did, this is what the scenario was, "and this is what happened, and this is what I did." And you still know when they tell you that they started with compressions. Great. That's what they're supposed to be doing.

If they tell you they started with airway and the patient was dead, you know that's not current BLS standards. So you can kinda judge, are they competent? Are they following the approved standards. The next overarching was communication.

Here's our communication ones. A lot of these were actually based from the hospital, but demonstrates tolerance and respect for others using courteous and caring behavior. That is the entire competency statement, overarching statement for every nurse in the hospital.

That's what communication means. How do we do it in IR? Oral and written, documentation in EMR demonstrates acceptable institutional department guidelines

for professional use of IT resources. So, are we finding that our orientees are on Facebook, why they're supposed to be monitoring the sedated patient. If they are, they're not showing competency because one of the lectures yesterday talked about

being distracted. Huge distraction, really easy to miss things that way. They have a whiteboard that tells them what's going on in their area for the day. So do our new orientees know that, that whiteboard exist, what it is, how to use it,

that's what we're looking for with them. Safety quality, improvement in evidence-based. Some of these are some of your standards. You know where your firepools are. Joint Commission likes to know, your staff knows where these things are.

The rooms are cleaned appropriately, following whatever your hospital's HIC cleaning policies are. But then you see the ones that are really specific that you won't find any place else in the hospital. Consistently follows standard of care

and policy to minimize radiation exposure to self, patients, visitors, and other staff. Consistently follows... There's a button on the back. That's what I keep doing. That's why I keep going backwards.

Consistently follow standard of care and policy to maintain magnet safety. - [Participant] You learn on the fly. - [Kristina] There you go. See how important learning on the fly is. If you redo your competencies,

please make sure every single competency sheet has learning on the fly. And follow standard of care and policy to minimize exposure to radiopharmaceuticals. I mean that is big in what we do. Then the core value

tie back in the Hopkins core values. What the larger group came up with was collaborating with the patient family and healthcare team to provide patient care in a healing and caring manner, prevent positive image of...

That should be of, not off. Of Johns Hopkins Hospital through professional appearance and behaviors. And here's our introductory competencies. Identify own learning needs and steps and resources needed for meeting those needs.

So demonstrates the concept of learning on the fly or just in time education to find information needed for at least three patient skills, patient populations or procedures that were not experienced and orientation. So if that

person never saw venous vein sampling, then they have to be able to tell us who can I talk to, where's the resource material, and what am I going to do if the six months after I'm off orientation, I'm now assigned to the room that has venous vein sampling.

So we want to see. Again, we're not gonna see everything, but we've asked them to do this three different times. So we kinda sorta know they understand the importance of knowing what I don't know and finding it out.

And this is interesting that since 2000, this paper, there's came out is Anesthesia Practice and Clinical Trends in Interventional Radiology. Even in 2000 they were saying there's a rapid growth of IR.

And we kept on sayin' that, and sayin' that, and sayin' that, but it's finally here. You know the procedures are so complex. And me bein' down in IR, and I say down in IR because see, this is me talkin' about we're up in the clouds,

and IR for us in the basement. But it's not, it's really not. It's actually on the second floor. And we're on the forth, third floor. That's all the difference. But it seems like another different world.

But the things that we're able to do, that the radiologist's are able to do, the IR team's able to do with very sick patients is amazing. I mean you know, treating cancer percutaneously. You know, pain issues.

The services that are rendered are very, very impressive. I'm very amazed and I'm happy actually to be involved. So we can see the procedures are more complex, more time consuming. The patient populations keeps on getting sicker and sicker.

And from the previous presentations we've seen that a lot of the slides start with a patient, non surgical candidate. Patient non surgical candidate. So you know they're very sick. And then the next question is like,

okay so what kind of support do they get? Can they lay flat? How's their heart? Is it barely beating? you know, they have a tomato for a heart. Or not.

But these is a study of the amount of off site anesthesia cases that are bein' done. And you can see since 2010 to 2014 the trend is increasing. So now we're up to like 40%. And that's nationally.

These have been looked at and there's meta analysis of over a thousand patients that shows that this is a highly effective way to control pain if offered early. The later you offer this, these blocks,

the less effective they are. But 70 to 90% of patients experienced either partial or complete pain relief at some time prior to their death.

And for us, for anesthesiologists when we practice outside of anesthesia we call that non-OR anesthesia. It's NORA for short. And for us that's the final frontier. So you know I'm a big Trekkie,

and I always picture myself, you know, like being in the you know, Enterprise. And I'm havin' my little journal, Star Date 2019, 2018, you know, I'm goin' down to IR world, and we're gonna see the different life forms.

And they have really advanced techniques. We're not really familiar, but we're gonna you know, get ourselves, or equipment and see what's goin' on. These people can be hostile. (laughter) We're not sure.

You know, so you can see that. And that's what I felt like. That's why I put this in. So that's our final frontier for us. Again non-OR anesthesia is anesthesia that's practiced outside of the operating room,

our comfort walls. So NORA sites for us is IR, EP, endoscopy, cath lab.

is the effect of cancer recurrence and anesthesia. So the effect of anesthetics and cancer recurrence.

Do the anesthetics actually, can that impact cancer recurrence for these surgeries. You know can general anesthesia, do they you know, do they impair the immune system. And when you ablate, you know, if you impair the immune system

do you render the patient more susceptible for recurrence. If you start giving a lot of opioids, and there's evidence that opioids can actually cause or contribute to cancer recurrence. Is that an issue. So should we concentrate on decreasing opioids,

maybe avoiding general anesthesia, or certain anesthetics that are linked to cancer recurrence. Well that is a new thing that we're actually bringing, discussing. So we came up with, at MGH,

And in terms of talking about understanding our culture, our knowledge,

I just wanna give you a reminder of what anesthesiologists actually do. And give you a brief description. An anesthesiologist is a perioperative acute care physician. We evaluate patients. Give recommendations on how to optimize them.

We provide advanced life support during procedures. We formulate perioperative anesthetic plans of care. So we administer general anesthesia, you know when a patient has a breathing device, a breathing tube, they don't have any recollection, they're still.

We can also do a neuraxial anesthesia for a laboring patient where we do a spinal, epidural, and we get rid of the pain, and you know we have a safe delivery. We also can do peripheral nerve blocks. We've kinda heard about nerve blocks,

'cause that's one of our specially for shoulder surgeries. You know we do general anesthesia, and we combine these sometimes. We also offer various levels of sedation. Anywheres from really deep sedation to conscious sedation.

And you know, people who practice here and give sedation, they know that there's different levels and that's where our specialty is. In addition we also manage post surgical pain. And also complications, and support the patient.

We've talked a little bit or touched on some of the traditional blocks, Demetrius has kind of run through some of those, so I won't be covering those. But the concept is that basically you put your needle

in the space, you inject a little contrast to make sure you're in a safe position and then you give a combination of lidocaine and a longer acting agent like bupivacaine with a steroid and then that's the block. Once you've done that and diagnosed that that's actually

addressed the problem and is addressing the pain, you can then move on to the neurolysis and ablation where you're sort of more permanently blocking that. We started incorporating some of the more complex sympathetic blocks into our practice which really, many of the pain specialists out there

shy away from because they're much more heavily reliant on imaging and that's where we shine, and that's where you all come in to help us to use the guidance techniques that William talked about to sort of get us to some of these more difficult places to reach.

And last but not least, in anesthesia we have these emergency manuals, cognitive aids. That when people know here when we actually have a crisis your cognitive, your attention span, right, decreases. We kind of learned that before.

So what do we do? We have these emergency manuals. And this is in our culture, in the operating room culture we have these emergency manuals ready, available. We put one in in every single IR room.

But we haven't actually educated the providers how to use it. We also haven't really had much work in terms of a crisis situation, of going over drills. And this is what we're doin', because again if the patient starts vomiting,

we need to be able to, everybody needs to know their roles. What does the nurse do? Who do they call for help? What's the tech do? What's their role?

Move the bed. Can they help us with mask ventilation? What's the IR fellow, or the IR attending, what's their role? Can they help us out as well? Because we are removed.

We don't have many hands on deck. But you guys are our first hand, you know first responders. And you should be able to know what we do to help the patient, because every second does count.

So I wanna just finish out by saying that, you know, the world is your oyster, and this is just a talk to motivate you, and tell you that you know, the future is here. That you need to collaborate with your anesthesia colleagues in terms of you know,

coming up with ideas of how to increase patient safety. You know don't be ashamed to ask them, hey, you know, what are you doin'? What's goin' on, how can I help you? And in your institutions, I say go back and maybe look at your practices

with anesthesia cases and you know, it's not just two different people comin' in. You're gonna see more and more of this. And I strongly believe that. And you know I hope by attending this talk you could be more cognizant of that.

And then maybe be a little bit more proactive in terms of you know, what's goin' on, and maybe preparing yourself. Thank you. (applause)

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