28 - Disaster Medicine and Emergency Care

From Kerkow media coming up on the show,

when I became an EMT in high school, one of my history teachers who was an EMT in L.A., he looked me square in the eye and he said, I know you're going to get out there and do great things. He says, you just better remember one thing. You're OK. Your patient is not. And that has stuck with me my entire career. Doctor, Dr..

Disasters, earthquakes, pandemics, hurricanes, floods, fire, nuclear accidents, poisoned water, heart attacks, drug overdoses, strokes, car accidents, all common issues that don't necessarily occur in convenient, clean or even accessible locations. One thing is constant, however. Our assumption that in such an event, emergency care will be available to us. We even take for granted that that emergency medical care will be organized, practiced and prepared to deal with an onslaught

disease, critical care

in neuro critical care, and my very best friend, Dr. Steven Tayback. How are you doing, Steve?

Hey, Bill, good to see you.

Are you still feeling the covid starting to wane a little bit?

Definitely starting to wane at my facility. Just found out today where we had one hundred and seventy three covid patients in January. Today we have seven.

Oh, that's fabulous. Well, we got an interesting guest today. Our special guest, Dr. Matthew Levy, is an associate professor at Johns Hopkins Department of Emergency Medicine. He leads Hopkins Division of Special Operations, which provides for Central Command and coordination of emergency medicine operation. And Dr. Levy is board certified in emergency medicine and a subspecialty certified in EMS.

Oh, good afternoon. Greetings. It's wonderful to be here. Thank you so much for having me and for that very warm introduction.

So Division of Special Operations, what exactly is that?

Sounds more military than civilian? Well, it's structured is what I would say. And and indeed, our division of special operations at Johns

Hopkins, the division

really got its roots nearly two decades ago in being the central

focus for all

of the out of hospital medicine

activities that Johns Hopkins

Emergency Medicine oversees. And that includes the entire facility transport program and includes some of our operational medical programs and support of tactical and law enforcement medicine, special event medicine and a few other topics, and initially had some roots in disaster medicine, which has also grown into its own unique and blossoming flourishing specialty area or focus area. So we work closely with some of our disaster colleagues as well nowadays.

So are you coordinating and training the guys on the line, the guys who show up for those first responders that were so appreciative for?

Well, it certainly is a team effort. I would say that I'm one of the people doing that training in my role as an EMS medical director. I certainly work very closely with our EMS educators and helping to design, implement and facilitate the delivery of that educational content. And yes, I do spend a good portion of my time as an

educator, not only educating

our physician colleagues, but also

educating our pre

hospital emergency medical services clinicians in those lifesaving conditions, recognition, treatment management. So I don't understand, though, because obviously you're handling all the ops relative to Johns

Hopkins, but every

hospital has their own emergency room or most hospitals, not an emergency room. And how do you interface and coordinate their process with your process? It seems like institutions that generally work in silos now suddenly have to coordinate.

How does that take place?

Well, it's such a great question. And to answer it, we have to take a bigger step back and look at how emergency medical care in the U.S. is currently delivered nowadays. And we'd like to think that there is one national EMS system the end user calls nine one one.

of specialty

assets, hospital emergency departments, trauma centers, stroke centers, all the types of facilities that we want to be able to get these patients with very high acuity conditions, too. And so that coordination, that planning is guided by expert recommendations from from professional organizations like the American Heart Association, as well as other organizations who help credit these centers. But ultimately,

Are you busy coordinating with police departments, fire departments, local municipalities, government officials? How do you manage all this?

Yes, it really is a collaborative effort, as you would imagine. As you mentioned, some of the different disciplines that are present at the table. A lot of it comes down to how EMS is operationalized and in your neck of the woods, if you will, in many parts of the country, the predominant delivery system for EMS through the fire department. And so in those cases, you have fire rescue agencies that also spend a big portion of their time delivering

If we anchor

on providing the best patient care possible, the rest has a way of figuring itself out. And so when we build these systems, it's one of those paradigms that I believe very strongly in. It's also one of the ones we try to teach. And when we teach our EMS clinicians or EMTs and our paramedics

about how to deliver high

quality patient care under sometimes suboptimal conditions, we really try to remind them that it's about that patient. And that's true on a daily basis.

We can talk

about when that sometimes gets really challenging, when we have resource limited situations that we've experienced this past year with covid we've experienced during disasters. But then we have to kind of look at how do we do the greatest good for the greatest number? And that's a whole other layer of complexity.

I wonder if you could take us for a little tour about how things have progressed with emergency medical care covid was during this past year. Maybe you could tell us what you've learned, what treatment has

changed and how you've

handled the emergency side of this pandemic.

It's a great question, certainly we continue to learn

every day there was so much we didn't know earlier on about covid and we drew from

metaphore experiences and prior tranches, including the H1N1 pandemic that occurred in August 2009 and then more recently, the SARS

and

murres coronavirus pandemic and then also recent experiences with other highly

infectious pathogen

conditions such as Ebola. And we had to start making certain assumptions very early on. Steve, I'm sure you guys did the same thing in the ICU and about about how do we safely care for people? How do we minimize the spread? And one of the things that we started doing very early on and many Ms. Abrams' did this around the country, was we began we started at the start and that started with a 911 call asking the 911 operators to ask some additional

questions to help understand is this person

displaying signs or symptoms of potential covid-19 illness? And that would get them

identified as what we call a pouye or person

under investigation for covid-19 illness and to give the EMS clinicians a heads up and a warning that they could be walking into a potentially dangerous situation.

So how did you advise them in that kind of situation? How did they stay safe? Well, actually executing on this job,

one of the things that we did very early on and there was variability in this across the country is everyone implemented higher levels of PPE, personal protective equipment, to be warned all times. Now, it's one thing to wear a gown and gloves and masks.

And for me to do it in the

emergency department, for Steve to do in the ICU, it's another thing to do it inside an ambulance or in someone's living

room.

And so one of the things that we started

seeing, our

EMS clinicians are very talented and very smart. And we can build processes, protocols and algorithms. They'll follow them. But we began to see some of the unintended consequences of that.

And let me give an example.

Take the emergency that is cardiac arrest, sudden cardiac arrest. When someone spontaneously goes into a lethal arrhythmia and their heart is no longer pumping and they need immediate CPR and immediate defibrillation. And for every minute that their body is in that

state where they don't get

those resources, their chance of survival goes down by 10 percent. Well, if it takes those EMS clinicians an extra few minutes to get all that PPE on and to safely get into the house, that's negative energy. That's the consequence of that. The unintended consequence of that was it was actually quite huge.

But we have to protect our responders.

We have to protect our personnel. I just recently

looked at the death numbers of EMS personnel

in the country who died of covid-19 illness in the past year. And they are some of the unsung heroes of this pandemic, as are so many others.

But what I would say

is that the problem got even more amplified, because if you remember early in covid-19, Steve, I know how it was in your in your hospital. I could tell you in mine, census dropped really, really quick. We couldn't get people to come to the hospital who needed to

come to the hospital and our

rates of heart,

attacks of stylization,

demise of of an emergency where there's a blocked coronary

artery. Those rates

went way down

and the rates of cardiac arrest went up. That's not coincidental.

People were afraid to come to the hospitals.

So people were afraid

to call 911 early on because they didn't want to get sick at the hospital, something that we had to work very hard from a public education campaign to reassure the public that, know, if you're having an emergency, we want you to come in.

So it wouldn't every EMT have to arrive on scene, assuming that there was covered in a house?

Well, it's interesting that you frame it that way because it quickly became that way.

Early in

covid-19, we were still asking questions about had you traveled to a hotspot area or had you had known contact with a covid-19 positive person or someone

under investigation? And I'm not

a public health expert, but I've learned a lot this year with the intent of trying to still isolate and contain and mitigate this. But once we began experiencing community spread of covid-19 illness, the scenario that you described, Bill, is exactly correct. At that point, everybody is presumed potentially infected. And there's all these metaphore cliches of during the pandemic,

mask on any time you're coming in

contact with a patient in eye protection. And we took those measures because we couldn't tell early on in the symptomatology of who was going to be positive became so broad it could have been someone with a febrile respiratory

illness which was pretty passive demonic

armonica, pretty typical. Or could could've been someone with a runny nose. And it was very hard to tell who was truly covid positive. What we're witnessing now and you tell me whether you're seeing it as well

now that the surge,

at least in our area, has really

subsided.

The acuity level is extreme with multisystem organ issues that we've not seen before. I mean, we always see patients here and there with multisystem

disease, but the numbers

of people who are coming in with complex medical issues that quickly turn to renal failure or. Stems and non stem is the various forms that the heart attacks, as I'm describing, and strokes, that they seem to be at a much higher number, as if these

were people who left their

health go for the past year and now they're suddenly flooding into the hospital once they tip over their threshold. Are you seeing that more in the EMS system or is this just something locally that I'm seeing just in my region? You know, I certainly wouldn't

dispute

what you're saying. I think I've had similar observations. I think of it somewhat akin to something that we've probably seen in our clinical practice,

which is no one wants to

be in the hospital over the holidays. So everybody tries to stay home. And then after the holidays is when we get really busy and everyone who tried to kind of hold off and could no longer do so. And I think while that's probably a crude metaphor, I think the principal is probably similar here. We saw a decline

in overall

EMS call volume, at least in my region over the past year. And that call volume is starting to pick back up a normalized.

But indeed,

it seems as though the acuity at least certainly feels that way, is getting back up there is getting

higher. One of the

things that we also

saw which experienced

it firsthand during the height of the

pandemic, particularly over the winter, was

as people were still home and kind of socially isolating and trying their best to adhere to public health recommendations. There was a lot less traffic on the roadways.

And I saw and respond

to some of the worst motor vehicle collisions in my career because I guess people were driving a lot faster. And that's my own observation. I noticed that as well, just because, you know, with knee, they weren't going to be stopped by the police because police were afraid to stop people for fear of covid.

And so

people felt that they could just speed and they were suddenly on the American autobahn, going just as fast as they wanted

to go.

OK, guys, we're going to take about a 30 second break. And when we come back, Matt, I'd like to dig into the process that EMT goes through when they arrive on a scene and get that illustration from you. We'll be right back.

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So I wonder, Matt, before we dig into process, could you define the different types of individuals, EMS, the EMT, and tell us what their role is in the process?

So EMS is the system. The emergency medical services is a system that is comprised of human beings and equipment and technologies to save lives within that system. There are a variety of levels of training, certification, licensure. The most common

level of EMS

clinician or emergency medical services personnel in the country is someone that's called an EMT or an emergency medical

technician.

And on average, these individuals have around one hundred and twenty to one hundred and sixty hours of training. It's the equivalent of about a college semester's course,

and their scope

of practice and knowledge

includes CPR to some basic airway

management. How to ventilate somebody

with a bag valve

mask resuscitator, how

to deliver a baby, how to control

severe bleeding, how to immobilize someone and safely transport them to the hospital and the basic operations of an ambulance. There are other variant levels of an intermediate type levels of EMS provider, but

keeping it big and simple,

the other very common level

of EMS clinician or provider that staffs

these ambulances and helicopters, for that matter across

the country would be a paramedic.

And in order to be a paramedic, you have to first be an

EMT and paramedic

is an EMT

who's gone through about the

equivalent of a thousand to 1500 hours of

training in all

aspects of advanced cardiac life support

and the recognition

and diagnosis or field interpretation of a medical emergency and the advanced interventions. These folks can do things like inserting

breathing tubes to secure

someone's airway, to put in

IVs, to give a host

of different medications, to stabilize someone having an emergency, and to deliver a variety of types of other interventions, including the specialty types of

defibrillation or pacing someone's heart.

So these folks

really are experts

in the resuscitation of people outside the hospital. The other group that I do want to specify and clarify is there are emergency medicine physicians. These are physicians. These are doctors who graduated medical school, have gone and done a residency in the field of emergency medicine. They are then board

certified in emergency

medicine and staff, many of the emergency departments, if not the vast majority across the country. There are other folks who are not emergency medicine trained who also staff those front lines, particularly in smaller hospitals. And by no means is

that meant to deflate or to minimize their role.

My specialty practice is in that of emergency medical services medicine. So after doing a residency in emergency medicine folks and then go on to do additional training, additional time called a fellowship in Emergency Medical Services, which is really

focusing on how to

do many of the things we've talked about already oversee, run, facilitate emergency medical services systems and how to practice out of hospital medicine. And that represents the highest level of emergency medical

services specialty

that exists in the country. There are a couple other levels, but for the sake of simplicity, I would stop there.

Are these fields properly funded? Is there enough of a political and governmental dedication to the field that we need? Is it working or is it a mess? Where are we?

I think the

answer is it's not a yes or no

answer. Certainly we could do a lot more with a lot more funding. It is the easy answer. What I would say is that historically EMS has not been very well funded. Most EMS programs operate based upon a billing and reimbursement structure that was intended and designed with the recognition that ambulances were just a service, a transportation service to move a patient from point A to point B, not a highly

sophisticated mobile, in some

cases intensive care, capable environment capable of delivering that level

of care. So certainly there is a need for greater funding.

I will say specifically regarding medical direction and the physician oversight of EVMs that historically had been very poorly funded on average across the country. And it wasn't very long ago that many medical

directors served in their roles

as a community service and didn't even get a salary. I mean, Steve, imagine working in the ICU to serve your community at a voluntary level in addition to your other practice and pulmonary medicine or in another one of your other disciplines. I mean, that's to be asked nowadays. It's like, wow, that's a lot to ask of people. But it wasn't very long ago that that's where this evolved from. So, again, we're moving in the right direction of opioid. We we have some way to go. Is

Medicaid reimbursement

amounts for ambulance transports. But those reimbursement amounts, we're talking about hundreds of dollars per ambulance transport. That's not usually a lot to sustain these operations. So that helps augment the operation. It doesn't actually completely sustain it. Most E.M.S. programs do receive local funding, in some cases they're funded better than others. And with that comes the ability to innovate,

So I can't help but bring up the difficult subject. I want to talk about insurance for just a minute, because this is one of those cases where the better the job that you do and the better the job that the EMTs do, the more it costs the insurance company. So it must kind of keep the two at loggerheads a little bit. Are you having challenges there?

By no means am I an expert in health care economics. But from my perspective, what I would say is that EMS has actually been in some ways a victim of this in a different manner because there are only two or three levels of reimbursement that EMS programs can bill for bill insurance or bill Medicare for. So you quickly reach that cap and it's just the rest of it is just part of the service. It's part of the public safety service that's delivered.

For example,

if a patient is in the hospital and Stephen are taking care of them and we have to put a central line in or put a breathing tube in, each of those things are billable procedures that because there is risk, there's expertise there, sophistications need

to do that.

That's not necessarily the way that it works in EMS billing, where you bill for either a basic life support level of care or an advanced life support level of care. And there are some echelons in there.

So it is a

bit of a challenge. The opportunity, I think, that we're seeing now and there is a national initiative, it's a pilot initiative that CMS, the Centers for Medicare and Medicaid has implemented.

That's called ETTY

three. And this is an initiative that started before the pandemic. And this is the Emergency Treatment Transport Initiative where they're looking at allowing EMS agencies to be reimbursed even when they don't transport someone.

So it used to be

that the only way these EMS programs could actually be reimbursed is if they transport someone to a hospital. That, to me, seems like a flip logic. What that then does is it then incentivizes to not transport people or to not transport them to other locations, such as alternative destinations, urgent care centers, other

places that if the patient

meets the appropriate triage criteria,

could safely and

effectively get their care in a manner that's both appropriate and also fiscally prudent,

which is why the consumer often goes to an emergency room for something that really isn't an

emergency.

Yeah, I am always interested when I speak with my patients in the emergency department. We have a finite amount of time that we can really spend at the bedside with our

patients because it's

just the acuity and the volumes. But when I talk to my patients and I ask them some questions about you have a primary care doctor? Oh, yes, I do.

I spoke. Have you

talked to your primary care doctor about the condition that brought you in today in circumstances when it's not a time critical or high acuity emergency, to your point, at least

some of them don't necessarily

recognize it. Oh, wow. I could have called my doctor for some of this. Let me be clear. I'm not saying that we don't want them coming to the emergency department if they need to be. But another example of how the pandemic has really revolutionized care delivery and it's

really been a

catalyst I think has sprung us forward probably a decade or two, has been the use of

telemedicine where people can now have

a television with their doctor from the comfort of their own

home and then

decide what the right intervention or right diagnostic workup is.

So I imagine there's a moment of real stress that occurs when an EMT has to make a decision about do we put this poor fellow in the back of the ambulance or do we call for air transport? Tell me about how you train people for that kind of decision.

So one of the things that we do really well in EMS is we try to bring

structure to chaos

and we try to bring an organized and methodological

approach to

a complex and chaotic and potentially life threatening situation to the point that the same assessment that I do, the same fundamental assessment that I do now is a practicing emergency physician for over a decade and a half is based upon the routes that I learned as an EMT 25 years ago, because it works. And so what we teach and it starts off in the classroom, it starts off with an assessment of the safety of the environment. Is there a potential for harm for the clinician, for

First, severe bleeding and airway issue.

Someone's in respiratory

distress or circulatory

issue like shock or cardiac arrest.

And then they build and they start

fixing the fixable problems. They find them in that order and then they build upon that.

And then

very quickly, they are then able to fill in the blanks of additional information, what we would call the history of present illness or what's going on at that

moment in time that led to that

emergency happening and the patient's background and medical history. And all this is done very sequentially for two reasons. Number one, to be time efficient.

We'll get back to that in a second. But number two, so that we

can

avoid variability

and avoid unintendedly missing a potential injury illness, because there is no rule that says patients can only have one emergency going on at once. And we do see that, particularly in traumatically injured patient. So based upon that assessment and the interventions that are done then need to make a decision about where this person needs to go to get the care they need, and that decision is informed based upon geography.

It's based upon

whether it's based on a variety of things. And how do they get that person to the closest appropriate facility, which is the doctrine that we teach and we operate under the closest appropriate facility for the emergency that they're having.

And once

that decision is

reached, it then becomes a

means of, OK, how do we facilitate that transportation, if it's going to be many, many miles or there's going to be severe traffic or other barriers, it's going to translate to time delay. The right answer may be to utilize an air asset such as a helicopter that can quickly move that patient from the scene to that definitive care. Or alternatively, the answer might be we're going to go to the closest appropriate facility by ground or close the

facility because this

patient is so unstable, we just have to get them stabilized and then secondarily transfer them. Are you familiar with the Israeli drone

system for EMS

delivery?

And could you

speak to that a little bit? And is that something that could be translatable to a country as expansive as ours with a population of three hundred and thirty two million versus a tiny geographical parameter? If you're referring to the drone delivery of automatic external defibrillators program, is that what you're referring to? Exactly. Super exciting and super hopeful technology that is now realistic and

is now within reach.

Let me come back to that in a second. The other really neat

thing that is done in

Israel, there's a program called United Hatzalah, which is a smartphone based program that uses medical volunteers

who are trained and

equipped and given medical bags to serve as first responders before the first responders get there, because there's so much traffic and roadway congestion in Israel that

they have

a delayed response time in some

parts of the country, no different than

we have here. So they're able to use smartphone technology and if you will, a civilian reservist corps who's agreed to participate and be medically

trained and carry some

medical equipment to slice that

time down the enemy

here is

time. The enemy when

we have one of these emergencies is time. And that time directly translates

to the absence or how long our body

tissue is going without oxygen or perfusion for whatever the emergency is. If it's a stroke, it's how long the brain is going. That auction, if it's a heart attack, it's how long the heart is going. That oxygen.

If it's someone who's bleeding on the street,

it's how long they're bleeding for before someone stops the bleeding and can allow circulation to resume.

So as we

look towards exciting, innovative and disruptive

technologies and disruptive technologies

are a good thing because they force us to kind of

rethink things.

Drone delivery is one example. I think that we will see more of that in the U.S. I know that there's a lot of interest in it. There are some complexities with what are referred to as these unmanned aerial systems or these systems. The term drone has

kind of an uncomfortable

connotation for some people, but how do we leverage technologies to do that where we can get that lifesaving piece of equipment out to the scene, the emergency as quickly as

possible? One of the very first research

projects I engaged in when I was in graduate school was my graduate research project. We did an analysis of the location of cardiac

arrests in a community and the

location of AIDS.

And what we found is

that the lines

crisscrossed quite literally

the locations with the most AIDS, automated external defibrillators, those things that hang on the wall

that you pulled them off the wall

and someone's having an emergency and they can deliver a shock right away. And that, combined with CPR, can really help save a lot of lives. But it's got to be done quickly.

Well, we found that the location

of those things was inversely coordinated with where the cardiac arrests were occurring. You guys know where the most common location for cardiac arrest are

in the home. So there

is a movement

afoot to

have more beds and homes. There are certainly we've looked at and toyed with the idea of, boy, could we work with the automobile industry on having an IED that is part of your vehicle's purchase. And it's just equipment. You know, you have it in the car. There are some really neat technologies that are coming

online that are linking IEDs

and making them what's called smart ads, which will actually, instead of it just hanging on the wall like a fixture.

If there's a cardiac

arrest nearby, that IED would have the ability to be monitoring the nine one one system and can alert and see someone take me to this location using technology that we already have that's in all of our pockets on our smartphones. So drone delivery is very exciting. Steve, it's one piece of this, but really what it comes down to is

how do we engage bystanders, engage the

people around the emergency to do something, to see something and do something. And if I can just embellish for one minute, I want to talk about a topic that's very near and dear to my heart, which is to stop the bleed initiative because to Stop the Bleed Initiative is a program that I've been very involved with at the national level. And Stop the Bleed is a program that we've really

focused on not. Just the actions of recognizing

life threatening hemorrhage and what to do about it, but also empowering the public to do something.

And, you know, what

we find is that the same

people who are going to stop to

do CPR or who are going to stop to put an ad on or stop to hold pressure on a bleeding wound, these are the same people who are going to help jump start your car in the parking lot or change your flat tire. These are these civically minded, altruistic people.

They're the helpers.

So how do we empower the helpers to help and how do we use technologies to do that? More a more interesting thing.

I wonder,

Matt, I've had the opportunity to visit Johns Hopkins a number of times, a beautiful facility and in a nice part of Baltimore. And I have to ask you, you know, Baltimore is an interesting town. There's some areas of absolute beauty and there's some really difficult areas of Baltimore. I wonder, could you share with us an experience or two that you had in Baltimore that really was a deep challenge and had to do with some of the areas of

Yeah, it's it's a hard question, to be quite candid. I was not born and raised in Baltimore, but I've been here more than half my life. It is my home. And Baltimore is a very special place. People who find their way to Baltimore for work or academia who live here, I have great pride in Baltimore is a city of neighborhoods like many other East Coast cities. And the disparities in health care or a huge challenge? You have life expectancies that can vary upwards of of a decade based

of issues that are

finally OK and socially acceptable to talk about from systemic

racism through health

care inequities, through years and years of mistrust that that is rooted from someplace and it's likely from experiences and all those things come together and find themselves in the E.R., sometimes not just the E.R. and my hospital, any E.R. across the country, because our emergency rooms, our emergency

departments, our

society safety net, it doesn't matter to me how many zeros in your paycheck and in what side of the decimal point those zeros

are when you walk in that

E.R.. I'm taking care of you like you're my family. That's what that's my oath. And that's what I'm going to do. And that's what my colleagues are going to do. US getting emergency physician with the hardest part of their job, as they will almost certainly tell you, it's telling the parent, a parent, that their child has died.

If I never

have to do it again, it'll be too soon. It is one of the hardest parts of my job. And how and why and by what means that happened, whether it's intentional violence or an unintentional mishap or an accident or flu thing, it's a tragedy nonetheless. But it is one of the hardest things that we have to deal with in emergency medicine.

And I would

say that that isn't necessarily unique to my institution or my city, but it's it's a tribute to the hardworking emergency physicians that are manning these front lines. And you're right, you don't know what's going to come through that door. And I find myself driving to work on my clinical shifts, going through a little bit of a meditation process and preparing myself for what those next eight or 10 hours

career because

we're there to take care of others. That being said, violence, the trauma associated with violence is, I think, one of the things that that maybe some listeners are envisioning right now.

But it goes beyond that.

It goes beyond just the gunshot wounds and the assaults. It has to do with access to care, preventative medicine, preventing diseases like diabetes,

obesity,

dealing with nutrition, dealing with education, mentorship. It's all of these things that need to happen

to unravel

this very complex web that

has been woven in America's urban environments.

Well, Dr. Matthew Levy, thank you for joining us today. I hope you'll come back because I have a funny feeling. We just touched on the absolute outer shell of this subject. There's a lot for us to talk about. Thank you for joining us today.

It's my absolute pleasure. Thank you guys so much.

Matt, how can people follow you?

My Twitter hashtag is at Dr. Matt Levy DRM levy. I'm on there. I'm on LinkedIn as well. My email address is just my last name, Levi Levi at JH. Am I ready? So those are my big ones.

Matt, thanks for being with us today. And of course, Dr. Steve, as always, my good friend. Thank you for doing this. We really appreciate it. We're Still Practicing is produced and edited by A.J. Mosley, mastering by Steve Rexburg Music for We're Still Practicing as composed and performed by Celeste Anorectic. Don't forget the hit that follow button so you don't have to hunt around for our next episode. We'll catch you next time, everybody. Thanks for joining. From Kerkow media

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