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Summary

This on-demand teaching session is perfect for medical professionals with an interest in clinical neurology. Join us as we welcome Doctor Samantha Fernandez from the Baylor College of Medicine in Houston, Texas, who will be discussing her own path into neurology, her experience with gallbladder surgery, and how she navigated an unscheduled ECMO procedure. Come get valuable insight from her experience and learn more about ECMO - a specialized procedure for seriously ill people with compromised circulatory systems.
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Description

Many times neurologists are called to evaluate people who aren't waking up after a cardiac arrest. There are guidelines which help guide the medical field with respect to neurologic prognosis. But what happens to those patients who survive once they leave the hospital?

Dr. Samantha Fernandez shares her unique perspective as both a survivor of a cardiac arrest and as a neurologist and talks about her experience and what we as a profession could be doing better for patients and their families.

You can reach Dr. Fernandez on Twitter @DrSamanthaF

Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest

https://link.springer.com/article/10.1007/s12028-023-01688-3

Neurologic Outcome Prediction in the Intensive Care Unit

https://journals.lww.com/continuum/Fulltext/2021/10000/Neurologic\_Outcome\_Prediction\_in\_the\_Intensive.13.aspx

The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Learning objectives

Learning Objectives: 1. Explain the path of education and training that led to a career in neurology. 2. Describe the signs and symptoms of biliary colic and discuss the treatment options associated with it. 3. Describe the components and benefits of Extra Corporeal Membrane Oxygenation (ECMO). 4. Discuss the risks associated with surgical procedures and how they can be managed. 5. Explain the importance of emergency communication and medical care for patients in critical situations.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone and welcome back to the Neuro Transmitters Podcast podcast about everything related to clinical neurology. I am very fortunate today to have a special guest with me, Doctor Samantha Fernandez from the Baylor College of Medicine in Houston, Texas. Uh Doctor Fernandez. Thank you so much for joining me today. No, thank you so much for having me. I'm pretty excited that I get to, to have this conversation with you. We'll me too. So just to kind of start things off a little bit, you know, you are a fellow neurologist and just tell me a little bit about what path led you into neurology to start with. Yeah. So, um um I knew I wanted to go into in a row pretty early on. I think I was, I think it was almost two and um it just, it was the easiest like subject for me. I, I did, you know, it wasn't taking too long to, to learn things. Um I really enjoyed it, the localization part of it I really loved. Um You know, it's like, I feel like the one specialty that you don't need a bunch of like imaging or last two have to diagnose stuff. You just, it's helpful to have it. But, you know, if you know your anatomy, you know, you're, you're, you're off is you kind of have an idea of what's going on. So that, that's what drew me um, to neuro. But so I went to med school in Mexico. And, yeah, and we don't have, um, you know, like, as many subspecialties, I guess as we have here. So, like going into your, a critical care was not even, like, in my mind, but I did know that I really, really liked neuro. So that was like my plan for the longest time. Um, and I mean, clearly then it changed a little bit. But, um, but yeah, I just knew I wanted to do neuro pretty early on. And so you started, obviously you went through the whole medical school pathway you matched into Baylor, an excellent program. Yeah, I love it. So, you've been, you've been practicing Houston now for, or in training there for a few years and you had gone in, for surgery if I remember correctly. Is that right? Yes, that is correct. Tell me a little bit about that. So, it's, it's actually a little bit funny. But I, um, before residency, actually, before even, like, I, I was in research, which was like, four years before residency I started having some, you know, like, weird pain. It didn't, it wasn't related to, um, to anything that I ate but it was kind of in my back actually, like right side in my bag, I'm sort of the flank, but a little bit higher up and it was really, really hot. Like I didn't know what it was, then it would be epigastric. So I was super confused, but of course, I, I thought that I knew what was going on. I started taking NexIUM and for some reasons I'm like, it kind of improved. So, for the longest time I, I thought I had gastritis. I have good and, you know, NexIUM is helping me. Um, but then it stopped helping me and I was actually six months into winter, near six months into enter near, and I was having, like, biliary colic. Uh, well, before that I was, I finally went to D I two D A specialist, um, did an ultrasound and, um, she said that I had a pretty big gallstone, like essentially the size of my gallbladder. Yeah, I know. But in my mind was like, well, it's big. It can come out, you know. So I thought I'm not going to be too concerned about this. I'll just, like, change my diet and it's going to get better and it did, um, but, you know, eventually it, it started giving me more trouble. I got to a point where I was having like, an episode of Biliary colic, like, every month, at least once a month. And I said, well, yeah, like I might consider surgery down the line, but it wasn't anything crazy. And then November, I don't want to say 2019, 2020 2020. Um, I don't know what happened but it just got out of control. I was having constant biliary colic, like, every minute of every day I couldn't eat, I couldn't, I could barely drink water. Like I lost like 15 17 lbs in a month, which I was happy about. But, you know, I wasn't healthy. So I, I went to see one of the, one of the surgeons at Baylor. Um, and he's like, yeah, we can do it in three weeks. And so we scheduled everything. I was actually going to go on an anniversary trip with my husband because it was going to be our first year anniversary. And yeah, and so going for the surgery super simple. Um, and I was pretty scared. I, I just, I've never had any kind of surgery and so I just, I was pretty nervous beforehand but, you know, look, I was looking at statistics even like mortality rate and I think it was like a 1.61 0.9 mortality rate. So I'm like, ok, stop worrying. So go in and I remember was going to the or, and then starting to wake up and I hear like a just commotion in the room like everybody was kind of freaked out. Um And in my mind I'm just thinking, oh, like it's over there just you know about to change me like to another bad take me to pack you. But then I hear I don't have a pulse. Literally someone saying like I don't have a pulse and it freaks me out and you know, then I, I feel pain like it wasn't pain, actually, it was more pressure like on my chest. And I was thinking to myself, like you have a tube down your throat, like, why would you have pain? I feel like you can't breathe. And I remember even trying to take a deep breath and I felt the tube. So I wasn't sure why I felt like I couldn't, it felt like I had an elephant sitting on my chest and I, I could not breathe and it was just a lot of pressure. So there's still a commotion around me and all of a sudden I don't feel the elephant in my chest anymore, but I feel horrible pain on like the sides of my chest. So I had a pneumothorax and they had to place and chest tubes. But of course they think I'm, I mean, I was in pe a so they didn't, you know, like polite oh, came. No, it was just cut to the chest of sin and I can tell you it was the most excruciating pain like I have ever felt in my life. Yeah, it was, it was pretty painful. Um, but that's kind of when I realized that there's something really wrong, you know, going on. And I started, well, I'm thinking okay, what are they going to look for right now? They're going to try to see if I'm opening my eyes, if I'm wiggling my toes or if I'm moving my fingers because that's what we ask the patient's right when they're unconscious. So I tried to do that. I remember I had so I think they had me like this on the table and my head was turning to this to the left and my eyes were closed but not completely closed. I could kind of see my hand. I'm trying to move my fingers and I don't see it moving. Um I try to move the other hand. I don't feel anything moving. Then I try to wiggle my toes. I also can't and definitely couldn't open my eyes like I really tried. And so they're changing me, we're not changing me, but I think they would, they were like getting some X rays. So they were moving me around. Then I hear someone say like Miss Fernandez, I'm so sorry as they were about to place my IJ. Um Yeah, it was all fun and, you know, like all of this is going on. I hear the anesthesiologist say we're going to have to go the ECMO team and that's when it really hit me. And so, you know, I mean, I guess if anybody else had heard ECMO team, they don't know. Yeah, but that's when I was like, okay, this is pretty bad for people who are listening, who may not be familiar with, with ECMO. Could you just give a kind of 10,000 ft view? Yeah. So essentially they, like, it's a huge system where they, they, like, pump the blood for you and like, oxygenated because your body is not able to, to get the, the amount of oxygen that it needs to in the blood. So, essentially you have like a circulatory system that's not in, in your body, it's a machine. So that usually means that someone is really, really sick. Right. Right. Um, it's a, it's a pretty specialized procedure. I think most physicians that don't do ECMO are very scared of it. I know. I'm pretty scared of ECMO. It's, there's a lot of things you have to know to do it. Right. Right. Yeah, I know. And just, I mean, that, that, that the lines are huge. So, anyway, so I hear that they might need to call the AGM ot and they actually call them. And so I feel like I am about to fall asleep and you know what kept on going through my mind was not fall asleep because it doesn't mean that you're falling asleep, it means you're going to die. So I just kept trying and trying and trying to wake up and I wasn't able to, and then finally they were actually cleaning the area in order to put the, in order to put the, the line for ECMO and somehow I, I just woke up, they said that I opened my eyes first, which also kind of, it was weird. They say usually you'll start moving and then you open your eyes. But I went straight to opening my eyes, my oxygen, um my, my oxygen saturation went up. It was in the forties, I think thirties, forties and all of a sudden goes up to eighties, nineties. Um I mean, I have a pulse bag of course by then and, and, and, you know, that's, that's all I remember then. I don't know what happened. But um I know that they had the the interventional cardiology team come by. They were like a bunch of people in there and honestly, my thought was these are all my coworkers. I'm naked on this table and there's a bunch of people looking at me. So it wasn't the best. But yeah, it's really that night Mary one has in grade school. Yes. And it was happening to me. So um so then I, I remember feeling like a really big tube down my throat and I was confused because I, you know, I already had the ET tube. So, so the breathing too, um it turns out they did an echo like a te uh so it was a probe, very uncomfortable, um very, very uncomfortable. But um they, you know, they did the little procedure there. Um, after that, they take me to the recovery room and this is pretty tricky because it was the wrong code. Well, it was during COVID, the vaccine hadn't even come out yet. So, you know, family members are not allowed to visit. Um, my mom was here, uh, my husband was with her but they, they could not come see me. So that was, yeah, I mean, eventually they did, but my surgeon was amazing. He immediately called my, my husband told them what was going on and said, you know, we, she didn't have enough oxygen going to her brain for quite amount of time. So we don't know what she's going to be like when she wakes up. Um, you know, my husband tells my best friend who's an ob-gyn about this and then she calls the surgeon, he gives her more updates. My mom is having the most horrible night of her life and I'm, I'm pretty unaware by this point. Um, when I was in the recovery area, I, I sort of remember. So I wake up and the first thing I see is the surgery resident who's crying and she was bawling and she tells me you're really scared as in there. And, you know, I feel like that that really created a pretty special bond between us. I mean, I, I see her now at work and it's like you saved my life, you know. And so, yeah, um, she, yeah, she's falling and she says like, what can I do for you? Like tell me anything you need and I keep like pointing to the tube cause it's super uncomfortable. They had, you know, they have, they had me sort of sedated but even like, okay, so I remember it was so uncomfortable that I kind of had to teach myself to breathe with it as opposed to just like over, kind of breathing over the. But um because that was super uncomfortable. So somehow I got them to extubate me but like 3 a.m. or something, it was great, which we all know how people don't like overnight excavations. Yeah, they don't. So it had to be very convincing. Um The anesthesiologist remember came, examined me and I was, I mean, I was following commands. I was answering, answering questions. I was writing. Um they gave me know pad, I was writing. It was pretty funny because I remember they were checking my cranial nerves and they asked me to raise my eyebrows and I just shake my head and they freak out. I'm like, please, can you try, can you try and I ask them to give me the note pad and I just write Botox. Super relieved. But I wanted to mess with them a little bit more than I could not. I know. But finally they took the tube out. I was texting, you know, that night I was on the phone with my mom with my husband and I, I was just like, okay, something crazy happened but I'm here and my gallbladder was not taken out. Oh, my God. I know. I know. But it has not given me trouble in almost like, 2.5 years. So, I don't know what they did but it worked. It doesn't sound like, uh, an option that most people would pursue. Oh, definitely not. So, I have so many questions. Um, so, first of all, did they ever figure out why, why you went into cardiac arrests in the first place? Yeah. So there's, um, there's a few, a few full, a few theories that they have. One of them is that they, so they had already done the pneumoperitoneum. So essentially they put gas in my, my stomach right to inflate it because it was laparoscopic. So they needed the space to go in with all the little toys and, and do the surgery. So I have a pretty short torso. So, what they think is that it kept on pushing, like my diaphragm and my lung. Soft word. And my right mainstem bronchus was intubated and they kept on retracting, they pulled it back, they pulled the tube back because there are x rays, like I saw all of them. But every time after they retracted it would go to that one again. That's very strange. That was really odd. Yeah. And I mean, I had a pretty experience and a sociologist, pretty experienced surgeons like I trust, I trust that and I trust them all with my life. You know, so that's after a bunch of times that they did, that's what they think happened because it was respiratory arrest first for like 15 minutes or so. And then the cardiac arrest essentially. Okay. And I guess the second piece would be, you know, most people don't wake up uh in the operating room. So I know there are some people who are like, you know, fast metabolizers of anesthesia or I mean, what was uh was, was it similar or was it just that they had turned it off when all this other stuff started going down? So it was still on, that's why they couldn't explain why I was so aware. Um I'm pretty sure that when I first told him, oh, I could hear you. They were like, yes, yes he did. But, but then I started telling them things that did happen. They're like, oh my gosh, my, so the oxygen in my blood, my po two was in the twenties like the entire time. So they couldn't explain why. But I went to pop med and I did a little bit of, of literature search and it seems like it's about like one point I think, don't quote me on this, but I think it's like 1.21 0.6 of cardiac arrest where they are aware, not the majority. No, definitely not. There's crazy cases where people are, like, away talking to you as you're getting, you know, like chest compressions. Um, even though they're still in, like cardiac arrest, interesting, I'm sure you're familiar, you know, um, like with this monitors and things like that, you know, the by spectral index is which I know are not necessarily used in all routine surgeries. Um But I assume that they probably weren't monitoring uh functional brain activity in your case. Otherwise they would have known, like you weren't really in deep anesthesia. Right. Exactly. I, I don't remember honestly having any sort of, you know, um, like this monitor or anything like that. Um Another thing that I did wonder, I never asked to be honest, but I did, I did look at all my vital signs. Um, I don't know if like my heart rate at some point, like went up and, you know, like with the pain because it was a lot of pain. Like I, if I have ever had like an adrenaline rush, it was that moment. Um, I don't know if it did anything. I don't think it did so, nothing really objective for them to know that I was, I was aware that is, that is crazy. So, you know, you've been through all this now, move on to the recovery phase. What, what did that look like? So I, um so I had Takotsubo feel my heart pretty much took a hit from the, the arrest and I had an injection fraction of like 2025. I think that eventually went up to like 30 when I left the hospital, I was in the hospital for five days, 23 days in ICU and then two days on the regular floor. Um, I started getting better. I, I did not seem to need any rehab. You know, the physical therapist evaluated me and they're like, no, you're, you're fine, you can do everything. Um, so I just needed to take it easy, take my medications, um, and just slowly kind of, you know, work out, no workout, but just walk a little bit more and, and slowly try to go back to my normal life. So I called my program director. Um, so I was an intern year so it was, I was like part medicine and part neurology, but they were super understanding. They were like, how long do you need? Two months? I'm like, no, I don't think so. But, um, you know, they were willing to just give you as much time as I needed. Um, they were super, super sweet, super understanding my co residents actually one, well, not all of them, but a lot of them just want to see me when I was still in the hospital, which was, of course, pretty cool. And then I go back home and I was out for three weeks, I think, besides the hospital, I was out of, um, out of work for three weeks then I went back and, and physically, honestly, it wasn't too bad, you know, just had to take it easy. Working 34 hours would put me out for eight. Like I was so fatigued. Yeah. And I think, you know, for those who haven't gone through medical training, the life of an intern is one of constant sleep deprivation and long hours. Yeah. Capped quote unquote at 80 hours a week. Right. Which we all know, right. A little bit of blurriness around the edges of those numbers. But yeah, for someone who had just been through something like that, I can only imagine the physical strain, let alone the, the emotional or mental strain. Yeah. So, so it's pretty interesting because I was, so I'm a baseline. I'm a pretty positive person and I honestly don't think I realized how positive I was until this happened just that I was like a normal dist, average person. I mean, I, yeah, but you know what I mean? But yes, I, I just, I wanted to get back to work and like I saw my cardiologist, uh, they didn't and I was an ultrasound of my heart and my heart function was back to normal. They did an MRI and it was perfect. It's like nothing had happened to it. So they're like, you know, you're good to go. He was like, go back workout, do what you need to. Like, it's fine by me so slowly, like built that back up, the fatigue kind of got better. Then I started noticing a few things. So like I started having trouble sleeping at night. I started having really bad memory issues. My husband multiple times, we tell me we've had this conversation or I already told you and I legitimately did not remember this got not worse, but I started to notice more of it. Like maybe two weeks after going back to work things that I knew by heart, I had to relearn so somebody I think I was in consults and I was in, in Renal, I think. And so, you know, your acute kidney failure or dialysis stuff that I, I really knew. I didn't remember. And I had to study again a bunch of things and like reread them five times. Otherwise I wouldn't, it wouldn't stick. Um, it started getting a little bit difficult, like emotionally speaking when I was. So when I was back in the ICU where I was, um, we had a patient that we were seeing, he was on the floor and he went to have a heart surgery and he had a critic rest. And then of course, he wasn't in the, in the CBI. See you. And the next day I go to see him and I was, I was so upset, I was still upset that this had happened to him and, you know, he had a bunch of lines in him. Um, the tube, like I just, I, he also, by the way, I got chest tubes. So I knew like the pain that he was in and I started talking to him and the nurse was like, oh, no, he's super sedated. And I'm like, well, yeah, but you never know. So I, that was like the first one that hit me really hard and then it started being a few others where if I just heard, you know that the overhead calling a code blue Cornick arrest, I would burst into tears like no reason. Thankfully, I was alone in the, in the team room but several times I did, it was too much and it was the same hospital or were, you know, where my my surgery and everything happened. So start dealing with like all of these things. I keep on remembering like feeling well, everything that I was feeling during the arrest or feeling the pain, hearing what they were saying and it would just make me cry like multiple times a day. Uh There was like no warning at all and I was super confused because I'm like, I'm super positive and I was happy and I was grateful, but I still felt I, I felt helpless, you know, I was back to normal. I was working out already. I had my life bag. I was with my husband and my mom and I was happy, but I still felt like super helpless and nobody around me could really understand. So I tried talking to my husband, to my best friend and at some point my husband said, I don't know how to help you. Like, I think you, you need to talk to someone. Um, you know, that's, that's a professional and so Baylor actually they give, like, free, um, like therapy sessions for residents, which is pretty cool. Um, and I started seeing one and she was like, well, yes, you know, this is all very normal for um what did she say? Oh, yeah, for, for PTSD, I'm like, what? And she says, well, yeah, you know, your PTSD, like what do you mean? I don't have PTSD and she says, yes, you do. So that was the first time this was like three months or so um into it and she says, yeah, like you have PTSD. Then more things started to happen. Like I had, I had my first anxiety attack when we were in the neuro ICU, one of our patient's going into cardiac arrest and I was there and I'm like, oh my gosh, this is the first one that, you know, has a cardiac arrest in front of me and I don't know what to feel. I don't know what to do. And it was just like a bunch of emotions and she's like, yeah, that's an anxiety attack. So it was, it was, it was a learning curve. That's, yeah, it's, it's something that I think we don't, we don't really learn about it as students or even sometimes his residents you're probably familiar with, with the book, every deeply drawn breath. I'm not, uh, I think Wes Ely, he's, uh, yeah. Uh but yeah, he, he was like one of the people who did like a lot of storytelling and I think some of the initial research into like post ICU syndrome and things like that. And it's one of those things where I remember myself as a, as a neurology resident. You know, I would see these people in the clinic. It's like my memory is not, not quite right or things like that and, you know, older, less healthy people than yourself and, you know, you or even people who just had anesthesia for like a complex surgery, things like that and they just, they didn't come back out of anesthesia quite like themselves. And it's, it's this really thing that we don't necessarily talk about very much and it's, we're probably missing a lot of things for people who are going through these situations. Oh, definitely. I, I mean, like you said, even as a neurology resident, even though it was an interim back then, but, you know, I feel like all of us kind of come in knowing a good amount of, of things. Um, I just had no idea that these were things that were expected to be dealing with. Um, you know, after, like you said, a surgery or cardiac arrest or just being in the ICU period. Um, and I started paying more, to pay more attention and, like our patient, the ones that, that we were consulted on when they complained about those things, like the memory issues or I have worse headaches. I'm like, oh, my gosh, I can relate. Like, yes, that's true. Um, you know, and then I wondered why are we not seeing these people, like, as a neurologist in clinic? You know, they go home and like, particularly in, in cardiac arrest or even after I see you, they usually follow up with, like, their primary care or maybe one or two specialists, but very rarely with neurology unless they were seen by them in the hospital. Yeah. No, it's, it's very true. It's, and, you know, obviously I'm, I'm biased in favor of, of neurology assessments, like you said earlier. Right? A lot of the information comes from the bedside, talking with the patient's and having done this for a little while, I'm sure you can sympathize where it's perhaps the next day when they realize after a heart procedure, like, oh, Mr, so, and so is a left arm's kind of weak? Yeah. And you're like, oh, it's, it's because he had a stroke and it's like, uh, but, but thank you for calling us. But yeah, it becomes one of those things where and again, right, we are trained specifically for those assessments and people may not be looking for those kinds of things. Specifically and it can be, it can be subtle in some people. Yeah, definitely. I mean, I, again, I did not have any appointments with the neurologist. Um, so I was just trying to figure out what was going on and it's funny because when you look up stuff, you know, kind of what to expect after cardiac arrest, none of this is out. I mean, the awareness has, has definitely increased, um, the past couple of years and I, I see a lot more information on it and more resources, but still I just had to go straight to pop med and it took me a while to, to find, you know, something that made sense. Um, and I really was like, you know, I want to like, I would like to, to have neurologist just follow these people in the hospital and then also in clinic. And as I was kind of looking, if any of this was sort of the thing, I found such inaugurals neuro um cardiac clinic in Colombia. And I saw what he's doing basically following, you know, any cardiac arrest survivor and their families, they see them in clinic and it's like a, like a one step shop, sort of, they provide resources. Um, they have an ignore psychiatrist rehab, a chaplain. Like, it's amazing what they're doing. Yeah, that's, that's really awesome. It's amazing. It really is. Um, and it's like the only one in the country, like the only clinic, like that, yeah, those, those types of multidisciplinary clinics unfortunately are challenging to implement. Yeah, but yeah, definitely. Now, have you lobbied this? Have you, I know you as a resident, you have your own continuity clinic. Have you been accumulating these patient's? I know certain people draw certain kinds of others uh to them for care. So how, how has that affected your, your actual practice? So it's affected it in a few ways. Um Number one, whenever I take care of, of a patient in the ICU, I think my approach is completely different. Number one, I try to pay more attention to the family than I did in the past. And this also took me a while to understand but, you know, when it was about to be like my, my first like anniversary of rebirth, whatever, when you know, when it happened, my mom was a mess like she was like, I just want this day to be over and I'm like, but it's happy like I'm here and just like, no, and I started to notice that, you know, it's not just me, it's affecting other people too. And then I, I had already been in touch with a few co survivors, you know, like wives that their husbands had cardiac arrest or um like Kristen Flannery, I gave CPR to Will, you know, and, and they're like, well, yes, it's pretty bad for us, especially because most of them are the ones that are aware of what's going on and the patient is not so much. So that's one thing I, I talked to the family a lot more, like I pay more attention to them. Then I talked to, to the patient's, even if they're super sedated, intubated, I actually explained to them like what I'm doing, you know, as I'm in the room, I tell them, hey, we're going to where I'm about to check like, your reflexes and I'm sorry, I have to pinch you, but I have to see if you can feel me touching you and maybe the 99% can't hear me, but there's got to be that 1% that might, you know, you, you and I write, I, I was on call in the hospital last week. I, I think I saw at least three or four patient's who we're kind of straddling the line of brain death, right? And, you know, as, as neurologists that, that is just every week uh that you're going to see that and you kind of, you almost build up this protective callus to because it, it is emotional, it right. It's a lot and especially, you know, for our staff who is primarily in the ICU, it's like if you don't find some way to cope, it's uh very mentally taxing. But I think that sometimes we kind of veer too far towards that side and become perhaps more brusque and emotionally detached than we probably should be. You know, I initially, I, I thought I wanted to go more towards that side because the first year it was really, really difficult to deal with, with these kind of consults, you know, when they call you to a neuro prognosticate. Um, or just basically say, hey, this person is like, essentially branded, but it actually went more towards the other side. And I started being a little bit more careful. Well, a lot more careful actually with any sort of like prognosis that I gave. And, um, my practices to wait, don't just, you know, it's 72 hours when we don't have like a devastating brain injury. And the exam is kind of not the best but also not the worst. Um, try not to tell them well, 72 hours and this is bad prognosis because I have seen several cases where it's been like 23 weeks and then the patient, you know, awake and they're talking and their technician is intact and if we had actually given a bad prognosis at 72 hours, they probably would not even be here. Yeah. And there, there were that the new guidelines just came out, like, last week. Have you read them yet? Uh, it's, it's a lot. But, yeah, I have not read through them but, but it essentially boils down to, like, don't be too hasty. Um, but I, I need to dig into them more, more thoroughly myself as well. Yeah, I know. And they definitely touch more on, you know, like multimodal prognostication, which I think is, is great and something that, that we really need to, to improve and kind of how can I say this? Like, not just be okay with the markers that we have right now because not a lot of them are the best. I think it's only like the potentials, right? That we have that are like, yes, pretty good, but not every center doesn't. And, and they're incredibly technically difficult in the ICU. They're so, yeah, they're, the signal is usually bad. It's technically challenging, etcetera, etcetera. I mean, I have never seen one. I've never done one and all I know is from literature that, yeah, it's, it's technically like pretty difficult. So, like, I think that maybe we need to try to find other markers, you know, if possible and, and kind of kind of go from there. But yeah, I definitely started and even telling my attendings like, well, maybe you want to wait, it's, you know, maybe a little bit too soon. At some point. I actually wanted to emulate what such an um Adderall is doing in Columbia with the clinic. And I went to a couple of my attendings like, hey, we have to have this clinic and it's gonna give everything to the survivors and they're like, Sam, like, we need resources where that we need a lot of support. That eternal question. Yes. Where does the money come? From. Yes, I know. I'm like, maybe we can, like, convince some people and they're like, well, there's only, well, back then we only had four intensive ists but they're all so busy that it's hard to have, you know, a clinic dedicated for this and also intensive. It's usually don't like a patient. No. So, yeah, I don't like it but I was, I was able to, um, to, to kind of after like a year and a half of project ideas that we're just not feasible start accu I project. And a few of the of the residents also got involved and they were pretty interested in it. And with the help of my program director, we um we were able to pretty much have the cardiac arrest survivors from our county hospital. Um follow up with neurology like automatically a patient and she's helping me so that the referral goes through immediately, there's no blocking it and then we follow them, our ideas grew up to a year longer if necessary, of course. But um you know, they would have a neurologist seeing them. Um And then there's like specific questions, of course, also that we would ask that they might not even like realize like, oh yes, I'm having memory issues so I can't sleep. So that was like my big win. That's really, that's really excellent. Actually. Now, have you got any preliminary data that you can share or is it still pending analysis? Yeah. No, unfortunately nothing that, that, that we can share. It's, um, it's taken a while to kind of get it to this point. But, but I'm pretty interested to see, you know, and, and one like how they do to, even if like, quality of life improves, um, if these interventions do make a difference, I'm hoping that it will. But, um, but nothing at the stay tuned. Yeah, I'll be looking out for it. Definitely one other question I, I did have, I know that you had said that you're, you're planning on becoming a neuro critical care specialist. Did that happen before? Was that something that developed over the course of your neurology residency or was that something that you went into neurology residency? Kind of thinking? I like the I see you, I want to work there with those people. So I have known that I like the ICU for about nine years. Um Yeah, so when I was, when I was a student, I was in the ICU and back then I just knew that I went to neurology. Um but I, I was in the hospital but I was in ICU and that was the only med student there. There were no residents know fellows, nothing. And one of our patient's comes back from surgery and starts crashing and then we get, you know, rainbow labs and they're looking horrible like shock liver. Um His oxygenation was really, really bad. Um I mean, the hemoglobin wasn't like fives, I think like super pretty, pretty bad and he was, he was there spacing. So like all the fluid that we were giving him was just like leaving the vessels and kind of sticking around in other areas that we don't want him to fluid to be in. And so, you know, the nurses are like, the attending is not answering which never happened by the way, like he's super responsive. So I don't know what, well, I think he was sick. I don't know. But um, he wasn't answering the other attendings in like other icus and the Ed, they were super busy because apparently all the patient's decided to crash that day. So they're like, what do we do? And I was like the best thing that they had that day. So I tell them, well, what if we do this or what if we do that? And we're like, I might as well. So they started to do it and it worked and he got better and he, like, we got him stable. I mean, within like an hour he was definitely stable. Um, like subsequent labs were looking a lot better. And that's the first time that I realized like the ICU I, it was, it was amazing. It was, it really was, you know, like doing stuff and seeing it work right there in front of you. It was, it was great, but I was kind of conflicted because in Mexico we don't have no critical care. Right. So I didn't know how I was going to be able to do neuro and then critical care. I felt that I was going to have to do like a separate internal medicine residency and then do critical care and half my neuro knowledge. So when I got my first job here as a research coordinator and I know I see you. Um, that's when I knew that, but I found out that there was neuro critical care and it's just like, um, like eight years ago or something. So I knew like this is what I'm going into. That's awesome. Yeah. So, have you, I, I assume because your fourth year now, third year, did you already go through the match? So, I'm actually in the middle of interviews. Oh, well, then we'll keep us on the DL I won't ask you where you want to go most. We'll leave that up to the future to decide. I let you know in August where I want to go. Absolutely. That's awesome. That's so great. So, for people who are neurologists, other healthcare workers of different types, what, what are the things that you see that? Because I'm sure there are more than a few things that you see most often that just really drive you crazy about the way people comport themselves where they carry, you know, act in the ICU with patient's. What are the things that you, if you could just get rid of them or change them overnight. What are your, what's the top of your list? The top, my number one is stop joking and laughing in a patient's room. It does not matter that they are on, you know, 50 propofol super sedated and they're intubated. You just never know who might be aware and whoever is aware, they're super scared already. So to hear that the people caring for them, you know, are laughing and joking is it doesn't make you feel good. Uh You know, from when I was aware, I, it's funny because I wasn't scared because I truly, I heard everyone just on the ball, they were really doing their best to, to bring me back and that gives you a comfort that, you know, I'm not alone. I'm not trying my best not to die just all by myself. There's a bunch of other people that know what they're doing and they're helping me. So that's the number one and the number two don't neural prognosticate so early on. Yeah. Do you ever find anyone trying to go before? 72 hours? Yes. Oh, that's a, no, no, isn't it? Oh, yes, it really is. Yeah. You just have to remind them, you know, it's um one not appropriate and two, it's, it's, you could be killing someone if you give a prognosis. Well, bad prognosis before that, that time. Yeah, I, I first came across this phrase when I was in the neuro critical care issue of Continuum from last year. Uh and I really should look up the author to give her credit. Um But actually was, what do you know, Carolina? She's actually one of my mentors. Uh Yep. Yeah. Yeah. She, yeah, she used the phrase uh medical nihilism for this self fulfilling prophecy in neuro prognostication and, and it really is, and it's such an easy trap to fall into, you know, especially with all these people coming in, you know, like opioid overdoses, they were down for an hour, you know, all, you know, everything stacked against them. And so it's very much like, well, that all makes sense, you know, this looks like a very bad picture and it will probably end badly and then, well, you know, we prognosticate as such and family, you know, terminally X debates the person and we'll look at the, they did badly just like I expected they would, right? And everything lines up, all of our expectations are met. So it, it is, it is such a logical trap to fall into uh logical in air quotes. But yeah, how do you, I mean, obviously with your own personal experience, but how do you keep people from, from falling into that, that trap? So it's, um it's, it's been challenging, um you know, particularly when you're talking to people that have done this for like longer than a decade or two. And I, I do understand that my case is not everyone's case and they're stayed out there for a reason. But you, I think you need to think of that 1% that 2% you know, people that maybe don't fall into the norm. And imagine if that person was you or your family members, what if it was your mom, if it was your spouse, you would not want, you know, your own bias to cost their lives. So I just, I, I, I tell, I tell them this honestly, you know, let's give the, the care that we would want for ourselves or for families because these people are not just, you know, a patient there, somebody's daughter, there's somebody's mom, somebody's husband and so treat others how you would want to be treated. Yeah, I think that's, yeah, that's the best we can do. How do you deal with because as you said earlier, right, a lot of our tests for neuro prognostication, you know, MRI has low sensitivity if they have intact cranial nerves, right? Particularly the people, their reflex, the corneal reflex. I mean, those are the two that tend to correlate most as I'm sure a lot of our listeners are aware they're not brain dead, they're not waking up. Testing is normal. Now, what, how do you mentally wrap your head around that? So there was um there was a speaker at H A last year and she, she showed some, some, some data of some cases in Europe I believe that people woke up. Well, physicians waited, I think up to 30 days, um, in some cases and eventually this people woke up. So, because you know of, of the way that our rotations work, I can't unfortunately, like follow them the entire time. But I think the key is, is just hope, I hope that whatever brain injury or other pathologies going on will, will slowly subside and chill and they will be able to wake up. And if, if they don't know, they truly will just not wake up. Um I just hope that the family like has, has the ability to, to accept it and find that those support that they need and the resources that they need in order to, to move from it. Um still pretty difficult but it's, it's help. Yeah, I find those, those patient's like I would mostly put them in a kind of like the minimally conscious state category. Those are, I think the most challenging ones because they're, you know, they're reacting to their environments, but they're, they're not themselves. And it's like some of them, like you said, they will wake up and they probably will improve, but there's still a large percent that, that may not, it may remain in that state. And that's, that's the, that's the really challenging part is you don't know who's who and when, when you take into account external factors like insurance or do they have the means the financial means to keep this person, you know, in an attack or I don't think nursing home would be appropriate place, but let's say an L tech um, or even take them home, like when they don't have that and, and they want to give their, their family member a chance. Like what, what do you do? And like here in our county hospital, uh we recently had a case of something similar, you know, postcard, a grass patient brain injury wasn't devastating enough from what we could see. An imaging, at least eeg was not bad. Just low exam wasn't crazy, horrible, but still just not waking up. And the family had to make a decision because they did not, they were not um citizens of this county of Harris County, so they couldn't get any sort of medical benefits and they didn't have the means. So they had to base their decision solely on. Well, can we afford this? Yeah. Yeah, it's, it's, it's complicated. I don't think that it will find, you know, like the right answer any time soon. No. No, it's definitely a lot of pieces and very complicated. Now, you've also been involved in some advocacy work. Is that correct? Yeah. Tell me a little bit about that. Yes, of course. So, um, so one of the things that I did, um when I, I started realizing that I, I needed some support from others that have gone through the same. I, I looked up some support, you know, group survivor networks, um, here in Texas and I couldn't find any, there's a few for like, youth Kartik rest. But clearly I am not in my teens or early twenties. So I'd like to find like a grown up. So I needed to find something that was more for me. Um, and I couldn't find anything. I talked to, um, Doctor Bentley Barbro who is, um, I think the head of care is here in Texas. And I was like, hey, is there anything here? He said, nope, there's nothing like, but you could start something. I'm like, I think I could. Um, so it created the Texas Credit Rest Survivor Network, um, which is essentially the only, you know, survivors group here in Texas. Um It's, and it's very baby stages. It takes a while to kind of grow it, but we've been able to, you know, reach out to some people help a few others, you know, they're telling the stories. Um, my thing is like providing evidence based information. Um, but in very simple terms because I don't, you know, it's impossible, I think to reach of your entire audience. But if I'm able to help those with low health literacy as well, which I think are the ones that mostly needed. Um, then I've, I've done something good and so I try to keep it just very simple to the point. Um, you know, there's like little meetings you, they have been all over some, um, because COVID, but just even them, like finding someone that they really connect with another survivor that they can talk to and that hopefully they don't, you know, they don't have to go through what I did and like trying to figure out who to talk to, who to connect with. So that's, that's the one thing. And then, um, Bonnabel, a doctor Bella Bella from Penn was the first one to actually reach out to me on Twitter. And he invited me to, to talk at his cardiac arrest, um course that he, he leads um bi annually. And so I started talking about my story and, you know, I, I reached a few people, then I actually reached out to such an auger well, from Columbia after reading his paper on, on PTSD and he took me under his wing Catalina to, they're like, yes, like I can help you and, and threw them, I was able to connect with more survivors, more co survivors who have dedicated truly their lives to, you know, raising awareness and even like the effects of brain injury, there's a friend that had pretty severe brain injury from our critic rest and she is, you look at her and you would never think that today. So thanks to all of them, we have been able to, you know, come up with certain initiatives to really help people and what happens after they leave the hospital. So that's been, that's been pretty cool. That's, that's some amazing, like network building and it's very impressive. It's, it's, it's all thanks to Twitter and I think my credit rest, um, had to bring something good. Well, that's that optimism coming through again. Right, I guess. Yeah. Yes. Uh, any, any final thoughts that you would leave our listeners with about, about cardiac arrests, about the heart and the brain in general? Anything that big take home points. No, no, for sure. So I think the big thing would be and also for our fellow neurologists, be, be careful, be careful with those neuro prognostication consoles. Don't just give a bad prognosis right away, especially if the exam is looking a little bit iffy and you don't have anything for sure. I know it's, it's hard, it's hard to, to say, well, you know, yes, this person could wake up but again, just imagine if it was you or if it was your family member, you know, just give them the chance that you would like to have. And I guess for, for the entire audience, the brain and the heart are definitely connected. Um They are pretty connected and advocate for, for yourself, for your patience, for your family. If this ever happened to, you know, to you or to your loved ones, just advocate to get that support to, you know, maybe see neurology, if you think that there's something going on if you're having memory is um just fight, fight, fight for you. Fight for your care. That's something I always, I always tell my patient sits, bring, bring someone. It's always good to have someone who can fight on your behalf because sometimes it's hard to do it yourself. Exactly. Especially when you're just, I mean, if you're sick. Right. Right. Absolutely. Yeah. No, no, definitely do that. Doctor Samantha Fernandez at Baylor. A amazing story. Thank you so much for sharing all of your experiences and all the work you've been doing. I very much look forward to seeing. I'm sure you'll be a pillar in the neuro critical care community for decades to come. You're so sweet. Thank you so much for, for having me, Michel. It was really great talking to you and um thank you for inviting me. I hope that this can help. You know, the people are two out there. Thank you so much. Thank you everyone for listening. If you enjoyed this podcast, please rate review and share it on Apple Spotify or wherever you get your podcasts and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Drkentris or by email at the Neuro transmitters podcast at gmail dot com. With any questions or show suggestions, we'll see you all next time.