Cardiology In Primary Care With Midge Bowers

Dec 5

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Show notes:

I am excited to introduce you to an absolute gem in the field of healthcare—Midge Bowers, Clinical Professor and Director of the Cardiovascular Specialty at Duke University School of Nursing.

She also actively practices as a nurse practitioner in a Heart Failure Access Clinic, with a unique blend of theoretical knowledge and hands-on experience.

In this jam-packed episode, we covered:

1. Beyond Creatinine Levels:

Assessing kidney function is crucial when it comes to cardiology. Midge emphasizes the importance of looking beyond creatinine levels when assessing kidney function. She sheds light on the significance of glomerular filtration rate (GFR) and its impact on patient care, especially in the context of newer medications like SGLT-2s.

2. Practical Insights into Echocardiograms:

Navigating through the complexities of echocardiogram reports can be daunting. Midge simplifies this process by focusing on practical aspects such as akinesia, hypokinesia, and ejection fraction (EF). Her concrete pearls of wisdom make understanding echo reports more accessible.

3. Demystifying Anticoagulation Choices:

Anticoagulation therapy often presents a dilemma for healthcare practitioners. Midge provides clarity on the decision-making process between Warfarin and Direct Oral Anticoagulants (DOACs). Her insights, drawn from real-world scenarios, empower practitioners to make informed choices.

4. Practical Tips on Adjusting Warfarin Dosages:

Managing Warfarin dosages can be challenging, but Midge breaks it down into actionable steps. It’s an important and common medication, and her guidance on INR interpretation and medication titration are easy and helpful.

5. Prescribing DOACs Safely:

Midge discusses safety measures and risk assessments using tools like CHADS-VASc and HAS-BLED, providing a comprehensive understanding of bleeding risks in anticoagulation therapy. She also covers DOAC prescribing and guidance on reversal agents.

If you liked this post, also check out:

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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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So one of the things I have to say is I'm in my 25th year as an NP and you think,
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oh my gosh, that's such a long time.
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But Liz, I have to tell you, I learn something new every week because cardiology is so dynamic.
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And I think like an FNP.
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I think about the whole person, right?
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All those social determinants of health, I think about prevention.
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So medication, it's really important to me.
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And I'm going to try to add medications to manage the conditions you see in your
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practice.
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Hypertension, AFib, heart failure, it's not just, I'm here for cardiology and
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I don't care.
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I actually do.
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And I think the biggest thing I want folks to get out of this episode is that their
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partners find a cardiology partner, physician, PA, NP, who you're OK like chatting with.
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So I have a really, really delightful interview to share with you.
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I know that I say this all the time, that I love these interviews, but I really,
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really do. This person is a real gem.
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Her name is Midge Bowers.
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She's a cardiology NP, who is an educator and has over 20 years of experience.
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I first met her at the AMP conference where she just gave this talk that was
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phenomenal. She's just an excellent, excellent educator.
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And yeah, I just feel like a kindred spirit.
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So anyway, I want to share with you her bio and then I'll share my interview
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with her. First, the topics that we talked about.
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So first one, the topics that we talked about.
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So we talked about heart failure, we talked about atrial fibrillation and we
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talked about echoes.
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But the main focus was really about medication, titration and like real
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practical applied pieces.
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And so I've done two different interviews, cardiology topics.
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So one was about heart failure, kind of like all about what is guideline
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directed medical therapy. What does that mean?
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So definitely check that out if you're feeling like you want to
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guidance about heart failure.
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We addressed it as a cardiology interview with another nurse practitioner.
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But the focus of this one is really like kind of taking some of those
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things that we talked about and really like, what does that actually look
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like in clinical practice?
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So I think that's one of the reasons that I super love this episode.
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In addition to Midge is just fantastic.
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So yeah, so that's the episode, but let me read you her bio so you can
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know a little bit more about her.
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So Midge Bowers is a DNP, family nurse practitioner, and as well as a
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cardiology practitioner, she talks a little bit about herself in her
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intro, which she currently does, but her pronouns are she, her, hers.
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She's a clinical professor and director of the cardiovascular specialty
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at Duke University School of Nursing and practices as a nurse practitioner
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in a heart failure access clinic.
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Her scholarly work is focused on patients with cardiovascular diseases
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in a professional education and simulation.
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I wish I had her as a professor.
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Honestly, she's amazing.
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As an associate in the American college of cardiology and a certified
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health simulation educator, she is the only nurse practitioner in the
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leadership team of the ACC simulation council.
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She's actively involved in the American association of nurse practitioners
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and recognized as a fellow in AAMP and the American Academy of Nursing.
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She is both extremely impressive on paper and in person.
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She's just fantastic.
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So I really can't wait to share this interview with you.
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Awesome.
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Thank you so much for being here.
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I'm so excited.
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Can you introduce yourself?
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Sure.
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My name is Dr.
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Midge Bowers.
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I'm a family nurse practitioner, a professor at Duke School of Nursing,
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and I work one day a week in a cardiology outpatient practice that
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focuses on caring for patients with heart failure.
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That's awesome.
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That's awesome.
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Thank you so much.
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And you and I talked off recording about how many different
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cardiology topics there are.
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It's just like, so I met you through a conference, through AAMP conference.
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And yeah, I think I'm just really struck.
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I think one of the things that I love about being a family nurse practitioner
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and being in primary care is that we are like jack of all trades, but then
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that comes at the kind of cost of master of none, you know?
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And so I think that I just really appreciate it, especially from your
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talk about cardiology topics is that there's just such a depth to it.
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And there are so many things that one could talk about, right?
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And you and I talked off camera about how I had a heart failure episode
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and I talked with a different cardiology MP, but like, honestly,
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the topics are endless and it is such a big part of primary care.
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And so what we sort of talked about is the focuses on kind of the
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first thing was about medication titration, because that's such a
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huge thing for new nurse practitioners, but also myself experienced
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nurse practitioners, people who are experienced in other
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practices coming to primary care.
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So tell me, where do you want to jump in with that topic?
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Where do you, where do you want to go?
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So one of the things I have to say is I've been in, I'm in my 25th
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year as an MP and you think, Oh my gosh, that's such a long time.
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But Liz, I have to tell you, I learned something new every week
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because cardiology is so dynamic.
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And I think like an FNP, I think about the whole person, right?
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All those social determinants of health, I think about prevention.
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So medication, it's a really important to me.
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And I'm going to try to add medications to manage the
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conditions you see in your practice.
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Hypertension, a fib, heart failure.
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It's not just a, I'm here for cardiology and I don't care.
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I actually do.
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And I think the biggest thing I want folks to get out of this
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episode is that their partners find a cardiology partner,
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physician, PA, NP, who you're okay, like chatting with.
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Recently, I had like messages from a PA in a nursing home who
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was concerned about diareasing.
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So we had, neither of us had time to pick up the phone.
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But we messaged through our electronic health record.
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So I just encourage folks, like this was an offline, the
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patient wasn't followed up Duke.
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I said, if I was seeing a patient like this, right?
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This is how I would manage the situation.
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Totally, totally.
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But that keeps me from my liability.
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I didn't say do this, do this, do this, right?
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Yes.
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But, but ask for that consult peer to peer it.
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And then, because sometimes you can't get in to the
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other reality, right?
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Yes.
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Delay, delay, delay, delay, delay.
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So that's just kind of one contextual thing I wanted to
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put out there.
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Yeah, I love that.
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Because like, so I've talked a little bit, if people have
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been listening to the podcast for a while, they may have
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heard this, but that was one of the pieces of advice that
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I got from one of my mentors when I first started was cold
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calling and I was like, are you serious?
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No way that's going to happen.
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And I literally sat down with somebody and they were like,
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do it right now, just call them.
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And like you said, like, they might not have time to
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have a conversation, but you can leave a detailed message.
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You know, being careful about PHI, but like, what is
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the detailed question that you have?
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And like, is there some sort of way to connect with them?
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Because they really do want to help, right?
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Because like you can talk about the most recent trials
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of all these medications and cardiology.
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Like I can't read that stuff.
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I don't have time for that stuff.
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Right.
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And if it's like a, you know, breaking thing, sure.
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But like not to the depth that you will.
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Right.
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So it's just wonderful to hear that reinforced from
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specialists.
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Oh my gosh.
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Well, I think about the patient that's going for a
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transplant that all of a sudden is coming to my clinic for
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cardiology clearance and they're on these meds.
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And I'm like, I have no idea what this involves and what
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I should stop and what I shouldn't stop.
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And what is, what's their preop risk?
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I have to look that up.
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Right.
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So 25 years into it, you still have to look it up.
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Yeah.
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It was like so fun.
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I love that.
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I mean, I hate it and I love it at the same time.
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Exactly, exactly.
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But you weren't, what I want to value is the
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breadth of an FNP's role.
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Right.
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Just recently, I was doing simulations for adult patients
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on, you know, PEA arrest.
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And these were acute care NPs.
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And then the next day I was doing cardiogenic shock in a
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four month old.
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So in my head, I was like, well, dang, I know how to
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calculate the blood pressure for a four month old, you
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know, just all these things that you build on what you
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know, as a nurse to become an NP and that just further
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invigorates me.
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But back to the question about med titration, I think
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I think the biggest thing people have is fear, fear of
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I'm going to do something horrible, or I'm not like
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I'm going to harm them, but they're going to go
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home.
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Yeah.
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Re-admitted or yeah.
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Right.
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All of this.
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So I have kind of, don't be afraid is the first
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thing because believe it or not, especially in
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the context of things like heart failure, you are
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not going to harm them like, oh, they don't have
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a blood pressure cuff at home or I can't teach
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them how to take their pulse.
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But the bottom line is, if you know the
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pharmacokinetics and dynamics of the meds,
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you're golden.
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So let's just start with beta blockers, right?
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So I was going to say a lot of these, a lot of
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people listening could be students and new
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grads and like experience, like it's a range.
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So feel free to like start at like square
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square one, if you want to write like wherever
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you want to start.
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Yeah.
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So, so I will just say my focus from a
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medication titration standpoint for a patient
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that has heart failure with reduced EF, right?
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Less than or equal to 40% that we used to
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call systolic heart failure is really about
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getting them on their four pillars of therapy.
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Okay.
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And we'll talk a little bit about preserved
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ejection fraction, but the point is
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patients live longer and stay out of the
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hospital if we can get them even on low
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doses of those evidence-based medicines.
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So I tend to think in classes, right?
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So we've got beta blockers, we've got
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the ACE inhibitors, ACE, ARB, ARNI,
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angiotensin, nepolysin inhibitors, and
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then we've got mineralocorticoid receptor
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antagonists, basically our potassium
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sparing diuretics, right?
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And then SGLT2 inhibitors.
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So you look at all of this, how am I
238
00:10:33.910 --> 00:10:35.690
going to get somebody on four medicines
239
00:10:35.690 --> 00:10:37.190
and oh my gosh, how are they going to
240
00:10:37.190 --> 00:10:37.690
afford it?
241
00:10:37.690 --> 00:10:39.970
And that's a lot, but wait a second.
242
00:10:40.450 --> 00:10:42.190
It used to be we'd start one at a
243
00:10:42.190 --> 00:10:43.230
time and go live.
244
00:10:43.590 --> 00:10:46.010
The data shows us that even starting
245
00:10:46.010 --> 00:10:49.430
two or even all four, because average
246
00:10:49.430 --> 00:10:51.950
heart failure hospital stay is four to
247
00:10:51.950 --> 00:10:52.830
seven days.
248
00:10:52.830 --> 00:10:54.670
Well, in that seven days, you can get
249
00:10:54.670 --> 00:10:57.110
those meds, but think about what
250
00:10:57.110 --> 00:10:58.190
you're doing, right?
251
00:10:59.430 --> 00:11:01.130
So example, someone comes in, they
252
00:11:01.130 --> 00:11:02.990
have a history of hypertension and
253
00:11:02.990 --> 00:11:04.930
I'm deciding to start them on an
254
00:11:04.930 --> 00:11:06.750
evidence-based beta blocker, right?
255
00:11:07.030 --> 00:11:09.150
Am I going to pick Carvetilol that
256
00:11:09.150 --> 00:11:11.690
has alpha and beta properties, which
257
00:11:11.690 --> 00:11:13.890
will lower blood pressure, or am I
258
00:11:13.890 --> 00:11:16.150
going to pick the topralol, succinate?
259
00:11:16.470 --> 00:11:17.910
I'm going to pick Carvetilol.
260
00:11:18.070 --> 00:11:20.570
It's twice a day, but now it's
261
00:11:20.570 --> 00:11:21.750
generic, right?
262
00:11:21.750 --> 00:11:23.650
But I can get more bang for my buck.
263
00:11:24.430 --> 00:11:25.570
And fast forward, that's how you
264
00:11:25.570 --> 00:11:26.470
explain it to the patient.
265
00:11:27.270 --> 00:11:27.730
Oh, Ms.
266
00:11:27.930 --> 00:11:29.330
Rohr, I'm going to start you on
267
00:11:29.330 --> 00:11:30.450
a medicine that's going to treat
268
00:11:30.450 --> 00:11:31.930
your heart failure and your high
269
00:11:31.930 --> 00:11:32.610
blood pressure.
270
00:11:33.150 --> 00:11:33.170
Really?
271
00:11:34.090 --> 00:11:34.370
Nice.
272
00:11:34.570 --> 00:11:37.010
I may take away a medicine like a
273
00:11:37.010 --> 00:11:38.490
calcium channel blockers, like
274
00:11:38.490 --> 00:11:39.490
imodipine, right?
275
00:11:39.490 --> 00:11:42.510
So then you've got negotiation and
276
00:11:42.510 --> 00:11:43.490
shared decision-making.
277
00:11:44.230 --> 00:11:45.770
Mitch just took away a medicine,
278
00:11:46.030 --> 00:11:46.070
right?
279
00:11:46.070 --> 00:11:46.530
Totally.
280
00:11:47.590 --> 00:11:49.310
And twice a day, most people can
281
00:11:49.310 --> 00:11:51.190
do, it's the TID ones and the
282
00:11:51.190 --> 00:11:51.510
QID.
283
00:11:51.770 --> 00:11:52.830
I'm like, oh, for gosh sakes,
284
00:11:52.830 --> 00:11:53.630
why do we?
285
00:11:54.450 --> 00:11:56.170
So that's just like one
286
00:11:56.170 --> 00:11:57.370
decision point, right?
287
00:11:58.250 --> 00:12:00.010
Just remember it's metoprolol
288
00:12:00.010 --> 00:12:01.610
succinate, like the long-acting
289
00:12:01.610 --> 00:12:02.750
one we should be using.
290
00:12:03.410 --> 00:12:04.850
And that gets into, so I start
291
00:12:04.850 --> 00:12:06.170
them on an ACE inhibitor and
292
00:12:06.170 --> 00:12:07.110
the blood pressure drops.
293
00:12:07.770 --> 00:12:08.790
Oh my gosh.
294
00:12:08.790 --> 00:12:10.390
But I've had them on a beta
295
00:12:10.390 --> 00:12:10.930
blocker too.
296
00:12:10.990 --> 00:12:11.830
What do I do?
297
00:12:12.250 --> 00:12:13.390
What do you do in that
298
00:12:13.390 --> 00:12:13.930
situation?
299
00:12:14.130 --> 00:12:15.130
Oh man.
300
00:12:18.480 --> 00:12:19.700
I'll give you an easy thing.
301
00:12:19.820 --> 00:12:20.560
Do you ever split your meds?
302
00:12:20.560 --> 00:12:21.860
There's so many options to go.
303
00:12:21.940 --> 00:12:22.240
Go ahead.
304
00:12:22.420 --> 00:12:24.060
But here's an easy peasy one.
305
00:12:24.120 --> 00:12:25.120
This is where I go.
306
00:12:25.400 --> 00:12:26.360
Take one in the morning and
307
00:12:26.360 --> 00:12:26.860
one at night.
308
00:12:26.940 --> 00:12:27.980
They're both once a day.
309
00:12:30.060 --> 00:12:30.620
With carbidolol?
310
00:12:30.720 --> 00:12:31.820
So if it was carbidolol, you
311
00:12:31.820 --> 00:12:31.880
would just...
312
00:12:31.880 --> 00:12:33.040
No, not carbidolol.
313
00:12:33.140 --> 00:12:35.480
So that's, or with carbidolol,
314
00:12:35.540 --> 00:12:37.380
if they're on, say, succubitrol
315
00:12:37.380 --> 00:12:38.680
valsartan, I'm not going to
316
00:12:38.680 --> 00:12:40.320
talk brand names here, but if
317
00:12:40.320 --> 00:12:42.240
they're on like an ACE, ARNI,
318
00:12:42.280 --> 00:12:44.280
or ARB, that's twice a day, I
319
00:12:44.280 --> 00:12:47.280
say, take it at breakfast and
320
00:12:47.280 --> 00:12:48.960
at dinner, and then take your
321
00:12:48.960 --> 00:12:50.800
carbidolol at lunch and at
322
00:12:50.800 --> 00:12:51.160
bedtime.
323
00:12:52.220 --> 00:12:53.180
That's interesting.
324
00:12:53.640 --> 00:12:53.940
Right?
325
00:12:53.940 --> 00:12:54.340
Cool.
326
00:12:54.520 --> 00:12:54.720
Yeah.
327
00:12:54.780 --> 00:12:56.700
We've gotten all the doses in.
328
00:12:57.600 --> 00:12:58.640
Now that's if they're going
329
00:12:58.640 --> 00:12:59.380
to remember that.
330
00:12:59.580 --> 00:13:00.440
We've got to think about what
331
00:13:00.440 --> 00:13:01.780
kind of work they do, or
332
00:13:01.780 --> 00:13:03.300
they can remember to take it.
333
00:13:03.360 --> 00:13:03.840
Totally.
334
00:13:03.840 --> 00:13:05.140
So if they're not going to
335
00:13:05.140 --> 00:13:06.900
remember a twice a day med,
336
00:13:07.720 --> 00:13:09.340
I just put them on once a
337
00:13:09.340 --> 00:13:11.340
day, even for the, you know,
338
00:13:11.340 --> 00:13:13.220
supposedly succubitrol valsartan
339
00:13:13.220 --> 00:13:14.880
has a better efficacy than
340
00:13:14.880 --> 00:13:17.140
maybe gramapro, right?
341
00:13:17.220 --> 00:13:19.380
Like ACE or low sartan.
342
00:13:20.300 --> 00:13:21.780
But if I know they're not
343
00:13:21.780 --> 00:13:22.820
going to take it twice a
344
00:13:22.820 --> 00:13:24.120
day, I'm still, I'm just
345
00:13:24.120 --> 00:13:25.900
going to keep them on the
346
00:13:25.900 --> 00:13:26.620
once a day.
347
00:13:26.760 --> 00:13:27.180
Totally.
348
00:13:27.360 --> 00:13:28.280
And can you say, can you
349
00:13:28.280 --> 00:13:29.080
say a little bit more about
350
00:13:29.080 --> 00:13:30.740
the succubitrol valsartan?
351
00:13:30.900 --> 00:13:31.320
Sure.
352
00:13:31.340 --> 00:13:32.720
So that's, yeah.
353
00:13:32.920 --> 00:13:34.760
So, you know, a brand name,
354
00:13:34.760 --> 00:13:35.900
I'll just say brand name is
355
00:13:35.900 --> 00:13:38.180
Entresto, and it really has
356
00:13:38.180 --> 00:13:40.360
been shown to reduce
357
00:13:41.100 --> 00:13:42.280
hospitalizations, but more
358
00:13:42.280 --> 00:13:43.900
important, the reduction in
359
00:13:43.900 --> 00:13:45.560
symptoms and mortality has
360
00:13:45.560 --> 00:13:46.500
been profound.
361
00:13:47.960 --> 00:13:48.720
So, and this is the
362
00:13:48.720 --> 00:13:49.400
ARNI, correct?
363
00:13:49.560 --> 00:13:50.960
This is an ARNI, right?
364
00:13:50.980 --> 00:13:52.100
So it's inhibiting that
365
00:13:52.100 --> 00:13:54.320
nephrolicin that really is
366
00:13:54.320 --> 00:13:55.900
detrimental in heart failure.
367
00:13:56.480 --> 00:13:56.560
Yeah.
368
00:13:56.560 --> 00:13:58.780
Unfortunately, it's still so
369
00:13:58.780 --> 00:14:00.600
cost prohibitive in some
370
00:14:00.600 --> 00:14:02.680
formularies, but the patient
371
00:14:02.680 --> 00:14:05.100
assistance programs, I'm
372
00:14:05.100 --> 00:14:06.720
fortunate we have APPs in
373
00:14:06.720 --> 00:14:08.340
the hospital, PAs, NMPs,
374
00:14:08.580 --> 00:14:09.580
starting those forms.
375
00:14:09.820 --> 00:14:11.200
Yes, while they're in the
376
00:14:11.200 --> 00:14:11.400
hospital.
377
00:14:11.880 --> 00:14:12.940
outpatient, we're like,
378
00:14:13.200 --> 00:14:14.240
oh, we can follow up,
379
00:14:14.280 --> 00:14:15.260
which is wonderful.
380
00:14:15.900 --> 00:14:16.000
Right.
381
00:14:16.560 --> 00:14:18.020
And that's a big part.
382
00:14:18.680 --> 00:14:20.680
But, but from an initiation
383
00:14:20.680 --> 00:14:22.580
standpoint, I think about,
384
00:14:22.580 --> 00:14:23.680
you know, even if they
385
00:14:23.680 --> 00:14:24.480
started two in the
386
00:14:24.480 --> 00:14:25.580
hospital, so maybe they
387
00:14:25.580 --> 00:14:28.200
started an ARNI and
388
00:14:30.260 --> 00:14:31.740
SGLT2 inhibitor, like
389
00:14:31.740 --> 00:14:32.760
mpagliflozin or
390
00:14:32.760 --> 00:14:34.020
dupagliflozin, another
391
00:14:34.020 --> 00:14:35.780
one shown to reduce
392
00:14:36.380 --> 00:14:36.860
hospitalizations.
393
00:14:37.600 --> 00:14:38.680
You can then, when they
394
00:14:38.680 --> 00:14:40.740
come outpatient, check
395
00:14:40.740 --> 00:14:41.740
labs, right?
396
00:14:41.740 --> 00:14:43.820
And start the potassium
397
00:14:43.820 --> 00:14:45.100
spearing diuretic, the
398
00:14:45.100 --> 00:14:46.240
spironolactone or a
399
00:14:46.240 --> 00:14:47.540
pleurinome, as well as
400
00:14:47.540 --> 00:14:48.920
a beta blocker.
401
00:14:50.040 --> 00:14:51.000
Now I want to back up
402
00:14:51.000 --> 00:14:51.340
a minute.
403
00:14:51.720 --> 00:14:53.060
And so we've talked about
404
00:14:53.060 --> 00:14:54.660
ARNI's and really the
405
00:14:54.660 --> 00:14:54.980
benefit.
406
00:14:55.000 --> 00:14:55.880
So that's your kind of
407
00:14:55.880 --> 00:14:57.240
gold standard, but again,
408
00:14:57.560 --> 00:14:59.000
ACEs and ARBs, if you
409
00:14:59.000 --> 00:15:00.120
can get them on there and
410
00:15:00.120 --> 00:15:01.120
their potassium stays
411
00:15:01.120 --> 00:15:02.620
stable, then you can go
412
00:15:02.620 --> 00:15:03.360
ahead and add that
413
00:15:03.360 --> 00:15:04.240
potassium spearing
414
00:15:04.240 --> 00:15:05.060
diuretic.
415
00:15:06.280 --> 00:15:08.040
But SGLT2 inhibitors,
416
00:15:08.540 --> 00:15:09.540
the cool thing about
417
00:15:09.540 --> 00:15:10.660
them is they
418
00:15:10.660 --> 00:15:12.320
diurese and you can
419
00:15:12.320 --> 00:15:14.020
tell folks that you're
420
00:15:14.020 --> 00:15:15.540
going to be urinating
421
00:15:15.540 --> 00:15:16.660
out sugar or you're
422
00:15:16.660 --> 00:15:17.680
going to pee out sugar.
423
00:15:18.060 --> 00:15:18.840
We might be able to
424
00:15:18.840 --> 00:15:19.640
back off on your
425
00:15:19.640 --> 00:15:20.260
fluid pill.
426
00:15:21.320 --> 00:15:22.760
That's another benefit.
427
00:15:23.120 --> 00:15:24.500
Renal protection, right?
428
00:15:24.780 --> 00:15:25.900
Preserving the kidneys,
429
00:15:26.900 --> 00:15:27.980
ACEs, ARBs, all
430
00:15:27.980 --> 00:15:29.060
protect the kidneys,
431
00:15:29.100 --> 00:15:30.620
even without diabetes.
432
00:15:31.220 --> 00:15:31.960
But gosh, if I can
433
00:15:31.960 --> 00:15:32.700
get you off a
434
00:15:32.700 --> 00:15:34.340
diuretic or a
435
00:15:34.340 --> 00:15:34.940
lower dose,
436
00:15:35.780 --> 00:15:37.240
less, you know, another
437
00:15:37.240 --> 00:15:38.140
win, right?
438
00:15:38.860 --> 00:15:39.060
Right.
439
00:15:39.180 --> 00:15:40.680
Less meds, but less
440
00:15:40.680 --> 00:15:42.720
disruption in lifestyle.
441
00:15:42.860 --> 00:15:43.280
Yep.
442
00:15:43.960 --> 00:15:45.620
Um, so all of that,
443
00:15:45.820 --> 00:15:47.480
I think so often when
444
00:15:47.480 --> 00:15:48.980
I start like, uh,
445
00:15:49.040 --> 00:15:50.240
impagliflozin, for
446
00:15:50.240 --> 00:15:52.420
example, um, I will
447
00:15:52.420 --> 00:15:53.260
cut their diuretic
448
00:15:53.260 --> 00:15:53.980
dose in half.
449
00:15:54.140 --> 00:15:55.240
Now, sometimes people
450
00:15:55.240 --> 00:15:56.460
are like, don't do
451
00:15:56.460 --> 00:15:57.000
that.
452
00:15:57.240 --> 00:15:58.800
Like, remember diuretics
453
00:15:58.800 --> 00:16:00.240
are just palliative.
454
00:16:00.240 --> 00:16:01.280
They're just treating
455
00:16:01.280 --> 00:16:02.180
your symptoms.
456
00:16:02.680 --> 00:16:04.240
So there's no
457
00:16:04.240 --> 00:16:05.100
mortality benefit.
458
00:16:05.100 --> 00:16:06.240
You'd rather be on
459
00:16:06.240 --> 00:16:07.720
this impagliflozin,
460
00:16:07.920 --> 00:16:09.320
dupagliflozin, even now
461
00:16:09.320 --> 00:16:10.980
sotagliflozin, to
462
00:16:10.980 --> 00:16:12.400
help you improve
463
00:16:12.400 --> 00:16:13.100
your mortality.
464
00:16:13.380 --> 00:16:13.820
Yes.
465
00:16:14.120 --> 00:16:14.260
Yep.
466
00:16:14.540 --> 00:16:14.740
Right.
467
00:16:14.940 --> 00:16:15.280
Totally.
468
00:16:15.880 --> 00:16:17.500
Do you know that now,
469
00:16:18.200 --> 00:16:19.700
um, it's still one
470
00:16:19.700 --> 00:16:20.860
in five, the mortality
471
00:16:20.860 --> 00:16:22.720
is 50% at five years
472
00:16:22.720 --> 00:16:23.780
with you have a
473
00:16:23.780 --> 00:16:24.520
diagnosis of heart
474
00:16:24.520 --> 00:16:24.960
failure.
475
00:16:24.960 --> 00:16:25.480
Wow.
476
00:16:25.800 --> 00:16:26.860
It has been that day
477
00:16:26.860 --> 00:16:27.940
since I, way since
478
00:16:27.940 --> 00:16:29.540
I started in 1999.
479
00:16:29.940 --> 00:16:31.040
We have not moved
480
00:16:31.040 --> 00:16:31.980
the needle enough.
481
00:16:32.500 --> 00:16:32.780
Yeah.
482
00:16:33.140 --> 00:16:33.700
Yeah.
483
00:16:33.960 --> 00:16:34.640
Oh man.
484
00:16:35.300 --> 00:16:35.740
Yeah.
485
00:16:36.000 --> 00:16:36.900
So I guess, I
486
00:16:36.900 --> 00:16:37.580
guess in terms of the
487
00:16:37.580 --> 00:16:38.420
titration, I guess I'm
488
00:16:38.420 --> 00:16:39.480
thinking about students
489
00:16:39.480 --> 00:16:40.140
and thinking about new
490
00:16:40.700 --> 00:16:42.180
grads and I'm thinking
491
00:16:42.180 --> 00:16:43.060
about some scenarios.
492
00:16:43.060 --> 00:16:45.760
So I, um, yeah,
493
00:16:45.760 --> 00:16:46.640
like what, I guess,
494
00:16:46.640 --> 00:16:47.480
do you have any idea
495
00:16:47.480 --> 00:16:48.460
of like common scenarios
496
00:16:48.460 --> 00:16:49.260
that you see that
497
00:16:49.260 --> 00:16:50.140
like people are
498
00:16:50.140 --> 00:16:50.740
calling about?
499
00:16:50.780 --> 00:16:51.960
Like, is it, so my
500
00:16:51.960 --> 00:16:52.660
background is in
501
00:16:52.660 --> 00:16:53.180
federally qualified
502
00:16:53.180 --> 00:16:53.800
health centers.
503
00:16:53.800 --> 00:16:55.200
And so it wouldn't
504
00:16:55.200 --> 00:16:56.560
have the most kind
505
00:16:56.560 --> 00:16:57.300
of like novel
506
00:16:57.300 --> 00:16:58.360
medications because of
507
00:16:58.360 --> 00:16:59.420
cost being cost
508
00:16:59.420 --> 00:16:59.860
prohibitive.
509
00:16:59.880 --> 00:17:00.940
And so, and we also
510
00:17:00.940 --> 00:17:01.760
have the situation of
511
00:17:01.760 --> 00:17:02.600
patients who weren't
512
00:17:02.600 --> 00:17:03.600
able to go to
513
00:17:03.600 --> 00:17:04.420
cardiology for a long
514
00:17:04.420 --> 00:17:05.760
time or like, just
515
00:17:05.760 --> 00:17:06.440
missed their appointments
516
00:17:06.440 --> 00:17:07.020
because they ran out
517
00:17:07.020 --> 00:17:07.720
of insurance, like
518
00:17:07.720 --> 00:17:08.400
things like that.
519
00:17:08.599 --> 00:17:09.579
And so, or don't
520
00:17:09.579 --> 00:17:10.760
have transportation.
521
00:17:11.119 --> 00:17:11.520
Yeah.
522
00:17:11.760 --> 00:17:13.660
And so I think totally.
523
00:17:13.880 --> 00:17:14.420
And I feel, so I
524
00:17:14.420 --> 00:17:15.319
feel like the, there's
525
00:17:15.319 --> 00:17:16.160
so many pieces, so
526
00:17:16.160 --> 00:17:16.819
many things we could
527
00:17:16.819 --> 00:17:17.900
touch on with that
528
00:17:17.900 --> 00:17:18.640
scenario, but I guess
529
00:17:18.640 --> 00:17:19.319
when it comes to the
530
00:17:19.319 --> 00:17:21.420
medications, so just
531
00:17:21.420 --> 00:17:22.260
to like, kind of
532
00:17:22.260 --> 00:17:23.200
like ground reorient,
533
00:17:23.240 --> 00:17:24.160
like what our goal
534
00:17:24.160 --> 00:17:24.819
for heart failure
535
00:17:24.819 --> 00:17:25.880
patients is that they're
536
00:17:25.880 --> 00:17:26.640
on those guideline
537
00:17:26.640 --> 00:17:27.740
directed medical
538
00:17:27.740 --> 00:17:28.840
treatments, GDMT,
539
00:17:28.860 --> 00:17:29.340
which is those
540
00:17:29.340 --> 00:17:29.940
classes that you
541
00:17:29.940 --> 00:17:31.140
talked about, um,
542
00:17:31.140 --> 00:17:32.060
which we, I touched
543
00:17:32.060 --> 00:17:32.840
on in the, in that
544
00:17:32.840 --> 00:17:33.380
other heart failure
545
00:17:33.380 --> 00:17:34.520
episode, but like the
546
00:17:34.520 --> 00:17:35.600
goal is to get them
547
00:17:35.600 --> 00:17:36.460
on those medicines
548
00:17:36.460 --> 00:17:38.680
at the goal doses.
549
00:17:39.160 --> 00:17:39.640
Correct.
550
00:17:40.120 --> 00:17:40.660
Based on like
551
00:17:40.660 --> 00:17:41.960
the research studies.
552
00:17:42.660 --> 00:17:43.960
Except that recently
553
00:17:43.960 --> 00:17:45.180
I read and I'm
554
00:17:45.180 --> 00:17:45.840
going to read this
555
00:17:45.840 --> 00:17:46.740
cause I wrote better
556
00:17:46.740 --> 00:17:47.540
to have the patient
557
00:17:47.540 --> 00:17:48.880
on low doses of all
558
00:17:48.880 --> 00:17:50.360
four rather than
559
00:17:50.360 --> 00:17:52.560
fewer meds at the
560
00:17:52.560 --> 00:17:53.360
target dose.
561
00:17:53.500 --> 00:17:54.300
That's so interesting.
562
00:17:54.380 --> 00:17:55.740
So, so the script
563
00:17:55.740 --> 00:17:56.840
has flipped a little.
564
00:17:56.960 --> 00:17:58.240
It used to be sequential
565
00:17:58.240 --> 00:17:59.780
adding, get them to
566
00:17:59.780 --> 00:18:00.920
don't add the next
567
00:18:00.920 --> 00:18:01.540
till you're really
568
00:18:01.540 --> 00:18:02.140
titrated up.
569
00:18:02.300 --> 00:18:03.220
Now it's like, get them
570
00:18:03.220 --> 00:18:04.800
on all four, believe
571
00:18:04.800 --> 00:18:06.200
it or not, titrate
572
00:18:06.200 --> 00:18:08.140
every one to two weeks.
573
00:18:08.440 --> 00:18:08.840
Wow.
574
00:18:09.060 --> 00:18:10.640
Based on really fast.
575
00:18:10.960 --> 00:18:11.320
Wow.
576
00:18:11.320 --> 00:18:12.220
Based on, and we, yeah,
577
00:18:12.220 --> 00:18:12.800
what are you, what are
578
00:18:12.800 --> 00:18:13.320
you looking at
579
00:18:13.320 --> 00:18:13.820
when you're titrated?
580
00:18:13.820 --> 00:18:14.720
Is this outpatient or is
581
00:18:14.720 --> 00:18:15.580
this in this sounds
582
00:18:15.580 --> 00:18:16.340
like it's outpatient?
583
00:18:16.460 --> 00:18:16.720
Okay.
584
00:18:16.960 --> 00:18:17.920
Absolutely outpatient.
585
00:18:18.220 --> 00:18:20.060
And we have, um, like
586
00:18:20.060 --> 00:18:21.340
I might see you in
587
00:18:21.340 --> 00:18:22.820
clinic and bump your,
588
00:18:23.180 --> 00:18:23.920
let's just do beta
589
00:18:23.920 --> 00:18:24.640
blocker, right?
590
00:18:24.740 --> 00:18:24.940
You have bumped
591
00:18:24.940 --> 00:18:26.160
your beta blocker up.
592
00:18:26.200 --> 00:18:26.600
Yeah.
593
00:18:26.760 --> 00:18:28.100
And I might have an
594
00:18:28.100 --> 00:18:29.160
a pharmacist or a
595
00:18:29.160 --> 00:18:29.920
nurse call you in a
596
00:18:29.920 --> 00:18:30.660
week and have you
597
00:18:30.660 --> 00:18:31.460
go up again.
598
00:18:32.600 --> 00:18:32.900
Based on your
599
00:18:32.900 --> 00:18:33.400
blood pressure and
600
00:18:33.400 --> 00:18:34.080
how they're feeling.
601
00:18:34.240 --> 00:18:35.280
If any orthostasis
602
00:18:35.280 --> 00:18:36.040
or dizziness, things
603
00:18:36.040 --> 00:18:36.580
like that.
604
00:18:37.060 --> 00:18:37.700
So symptoms are
605
00:18:37.700 --> 00:18:38.440
often the driver
606
00:18:38.440 --> 00:18:39.460
because I can't tell
607
00:18:39.460 --> 00:18:40.480
you how many times
608
00:18:40.480 --> 00:18:41.480
we get, we are
609
00:18:41.480 --> 00:18:42.620
the ones as providers
610
00:18:42.620 --> 00:18:43.700
that get hung up
611
00:18:43.700 --> 00:18:44.520
on having, well,
612
00:18:44.540 --> 00:18:44.960
what their blood
613
00:18:44.960 --> 00:18:45.560
pressure do, what
614
00:18:45.560 --> 00:18:46.140
their heart rate.
615
00:18:46.340 --> 00:18:46.400
Yep.
616
00:18:46.640 --> 00:18:46.900
Yep.
617
00:18:47.020 --> 00:18:48.340
If they're in your
618
00:18:48.340 --> 00:18:49.520
clinic today with
619
00:18:49.520 --> 00:18:50.780
a resting heart rate
620
00:18:50.780 --> 00:18:52.060
in the eighties and
621
00:18:52.060 --> 00:18:53.300
your goal is to
622
00:18:53.300 --> 00:18:54.360
have a resting heart
623
00:18:54.360 --> 00:18:55.900
rate in the seventies,
624
00:18:55.900 --> 00:18:56.340
right?
625
00:18:56.460 --> 00:18:57.380
Because when they're
626
00:18:57.380 --> 00:18:57.960
active, it's going to
627
00:18:57.960 --> 00:18:58.440
go up.
628
00:18:59.360 --> 00:19:00.380
You can feel free
629
00:19:00.380 --> 00:19:01.280
to start them on
630
00:19:01.280 --> 00:19:02.500
25 on the Topra
631
00:19:02.500 --> 00:19:04.300
call, succinate and
632
00:19:04.300 --> 00:19:06.040
then titrated at that
633
00:19:06.040 --> 00:19:07.900
visit to 50 and
634
00:19:07.900 --> 00:19:08.680
then a phone call
635
00:19:08.680 --> 00:19:10.600
later to a hundred
636
00:19:11.180 --> 00:19:11.920
as long as they're
637
00:19:11.920 --> 00:19:12.760
asymptomatic.
638
00:19:12.820 --> 00:19:13.600
So it's more
639
00:19:13.600 --> 00:19:14.580
important to catch
640
00:19:14.580 --> 00:19:15.640
that orthostatic
641
00:19:15.640 --> 00:19:17.000
hypotension, like
642
00:19:17.520 --> 00:19:18.460
in the South,
643
00:19:18.600 --> 00:19:19.200
we call it
644
00:19:19.200 --> 00:19:19.720
Swimmy headed.
645
00:19:20.100 --> 00:19:20.800
So do you get all
646
00:19:20.800 --> 00:19:21.800
Swimmy headed when
647
00:19:21.800 --> 00:19:23.060
you stand up from
648
00:19:23.060 --> 00:19:23.620
the chair?
649
00:19:23.700 --> 00:19:24.700
Isn't that cute?
650
00:19:24.860 --> 00:19:25.860
It's really
651
00:19:25.860 --> 00:19:26.420
descriptive.
652
00:19:26.680 --> 00:19:26.940
Yeah.
653
00:19:26.940 --> 00:19:27.440
You could say
654
00:19:27.440 --> 00:19:28.320
lightheaded, dizzy,
655
00:19:28.520 --> 00:19:29.040
but really.
656
00:19:29.060 --> 00:19:29.580
Yeah.
657
00:19:29.700 --> 00:19:30.140
Swimmy headed.
658
00:19:30.540 --> 00:19:31.320
Stand up, you
659
00:19:31.320 --> 00:19:32.300
get your head feels
660
00:19:32.500 --> 00:19:33.860
I'm not going to titrate
661
00:19:33.860 --> 00:19:34.480
or I'm going to
662
00:19:34.480 --> 00:19:35.480
split your dose
663
00:19:35.480 --> 00:19:35.880
right.
664
00:19:35.880 --> 00:19:36.580
Morning and night,
665
00:19:36.660 --> 00:19:37.260
you know,
666
00:19:37.280 --> 00:19:37.840
alternate it
667
00:19:37.840 --> 00:19:38.420
with the other
668
00:19:38.420 --> 00:19:39.760
therapies or
669
00:19:39.760 --> 00:19:41.100
de-prescribed that
670
00:19:41.100 --> 00:19:41.920
calcium channel
671
00:19:41.920 --> 00:19:42.740
blocker or
672
00:19:42.740 --> 00:19:43.540
something else
673
00:19:43.540 --> 00:19:44.400
that might make
674
00:19:44.400 --> 00:19:45.560
you dizzy.
675
00:19:46.340 --> 00:19:46.840
But really,
676
00:19:47.040 --> 00:19:47.800
as opposed to
677
00:19:47.800 --> 00:19:49.000
over several months,
678
00:19:49.560 --> 00:19:50.200
the clinical
679
00:19:50.200 --> 00:19:50.980
benefit is to
680
00:19:50.980 --> 00:19:51.480
have you on
681
00:19:51.480 --> 00:19:52.100
all four
682
00:19:52.100 --> 00:19:52.620
medicines,
683
00:19:52.640 --> 00:19:53.500
even within
684
00:19:53.500 --> 00:19:54.720
that first month
685
00:19:54.720 --> 00:19:56.040
with titration
686
00:19:56.040 --> 00:19:57.140
to maximally
687
00:19:57.140 --> 00:19:57.640
tolerated
688
00:19:57.640 --> 00:19:58.180
doses.
689
00:19:59.280 --> 00:19:59.720
Sometimes it's
690
00:19:59.720 --> 00:20:00.540
symptom driven.
691
00:20:00.780 --> 00:20:01.400
Sometimes it's
692
00:20:01.400 --> 00:20:01.880
blood pressure
693
00:20:01.880 --> 00:20:02.360
driven and
694
00:20:02.360 --> 00:20:03.220
a lot of folks do
695
00:20:03.220 --> 00:20:03.840
have a home
696
00:20:03.840 --> 00:20:04.740
blood pressure cuff.
697
00:20:05.040 --> 00:20:05.540
Yeah.
698
00:20:05.680 --> 00:20:06.120
Yeah.
699
00:20:06.380 --> 00:20:07.460
The key for me,
700
00:20:07.460 --> 00:20:08.180
the safety
701
00:20:08.180 --> 00:20:08.660
issue,
702
00:20:08.660 --> 00:20:09.740
and this is my pearl,
703
00:20:10.280 --> 00:20:10.880
is make
704
00:20:10.880 --> 00:20:12.180
sure you check
705
00:20:12.760 --> 00:20:13.540
kidney function
706
00:20:13.540 --> 00:20:14.480
and potassium
707
00:20:14.480 --> 00:20:16.120
a week after
708
00:20:16.120 --> 00:20:16.840
you start
709
00:20:16.840 --> 00:20:18.260
like spironolactone
710
00:20:18.260 --> 00:20:19.340
or clarinone
711
00:20:19.340 --> 00:20:20.260
because that
712
00:20:20.260 --> 00:20:21.100
in combination,
713
00:20:21.280 --> 00:20:21.560
I mean,
714
00:20:21.580 --> 00:20:22.320
it sounds like
715
00:20:22.320 --> 00:20:22.960
best practice,
716
00:20:22.960 --> 00:20:24.140
but I will see
717
00:20:24.140 --> 00:20:25.320
them back in my clinic.
718
00:20:25.380 --> 00:20:26.180
They're two hours
719
00:20:26.180 --> 00:20:26.700
away in their
720
00:20:26.700 --> 00:20:27.260
home clinic.
721
00:20:27.580 --> 00:20:28.600
So what do I do?
722
00:20:29.460 --> 00:20:30.400
I fax an order
723
00:20:30.400 --> 00:20:31.300
or submit an order
724
00:20:31.300 --> 00:20:31.940
to their primary
725
00:20:31.940 --> 00:20:32.620
care provider.
726
00:20:32.940 --> 00:20:33.300
Totally,
727
00:20:33.940 --> 00:20:34.360
And honestly,
728
00:20:34.500 --> 00:20:35.200
like we need,
729
00:20:35.340 --> 00:20:36.060
I feel like I just,
730
00:20:36.180 --> 00:20:37.440
I'm having flashbacks
731
00:20:37.440 --> 00:20:38.160
to being a new grad
732
00:20:38.160 --> 00:20:38.520
and like,
733
00:20:38.700 --> 00:20:39.320
I feel like we need
734
00:20:39.320 --> 00:20:39.900
all the reminders
735
00:20:39.900 --> 00:20:40.920
we can get.
736
00:20:41.600 --> 00:20:42.620
If that's in there,
737
00:20:42.660 --> 00:20:42.820
right?
738
00:20:42.880 --> 00:20:43.140
I'm like,
739
00:20:43.140 --> 00:20:43.440
yeah,
740
00:20:43.440 --> 00:20:44.180
we do want to check
741
00:20:44.180 --> 00:20:44.740
those labs.
742
00:20:44.840 --> 00:20:45.180
Yeah.
743
00:20:45.220 --> 00:20:45.720
And I just,
744
00:20:45.840 --> 00:20:46.300
I do want to,
745
00:20:46.300 --> 00:20:47.040
I do want to pause
746
00:20:47.040 --> 00:20:47.400
and say,
747
00:20:47.440 --> 00:20:47.580
like,
748
00:20:47.580 --> 00:20:48.180
if you're a new
749
00:20:48.180 --> 00:20:48.840
grad listening
750
00:20:48.840 --> 00:20:49.780
and you're like,
751
00:20:49.860 --> 00:20:50.160
wow,
752
00:20:50.160 --> 00:20:50.840
I'm overwhelmed.
753
00:20:50.840 --> 00:20:51.860
Like that is also
754
00:20:51.860 --> 00:20:52.880
normal and fine
755
00:20:52.880 --> 00:20:54.180
because I would actually
756
00:20:54.180 --> 00:20:54.920
recommend you tag
757
00:20:54.920 --> 00:20:55.580
teaming with somebody.
758
00:20:55.640 --> 00:20:56.540
If you have a patient
759
00:20:56.540 --> 00:20:57.220
with heart failure,
760
00:20:57.400 --> 00:20:57.920
needing multiple
761
00:20:57.920 --> 00:20:59.000
medication titrations,
762
00:20:59.000 --> 00:21:00.120
like that's probably not
763
00:21:00.120 --> 00:21:01.220
for a super novice.
764
00:21:01.280 --> 00:21:02.180
Like you can do it,
765
00:21:02.180 --> 00:21:03.440
but like let's run that
766
00:21:03.440 --> 00:21:04.260
by somebody too,
767
00:21:04.340 --> 00:21:05.000
just to like double
768
00:21:05.000 --> 00:21:05.960
check ourselves there.
769
00:21:06.340 --> 00:21:06.700
So.
770
00:21:07.300 --> 00:21:08.260
And I'll be really
771
00:21:08.260 --> 00:21:08.680
transparent.
772
00:21:08.800 --> 00:21:09.400
The guidelines,
773
00:21:09.500 --> 00:21:11.080
like all these updates
774
00:21:11.080 --> 00:21:12.540
and I look for green,
775
00:21:12.540 --> 00:21:13.400
yellow and red.
776
00:21:13.580 --> 00:21:13.880
Yeah.
777
00:21:13.880 --> 00:21:15.380
I actually have at my
778
00:21:15.380 --> 00:21:16.220
work site,
779
00:21:16.400 --> 00:21:18.160
the printed one pager
780
00:21:18.160 --> 00:21:19.220
that says heart
781
00:21:19.220 --> 00:21:20.580
failure with reduced EF.
782
00:21:20.860 --> 00:21:21.540
What's all green?
783
00:21:21.560 --> 00:21:22.840
Should I be thinking about?
784
00:21:23.140 --> 00:21:23.520
Not that I'm going
785
00:21:23.520 --> 00:21:24.360
to do it all today.
786
00:21:24.620 --> 00:21:24.920
Yeah.
787
00:21:25.100 --> 00:21:25.880
What's all,
788
00:21:26.020 --> 00:21:26.660
what's yellow?
789
00:21:26.900 --> 00:21:27.880
What's orange?
790
00:21:27.940 --> 00:21:28.320
Yeah.
791
00:21:28.320 --> 00:21:29.420
Because for half path,
792
00:21:29.680 --> 00:21:30.640
we never had anything
793
00:21:30.640 --> 00:21:31.860
except diuretics.
794
00:21:31.940 --> 00:21:32.880
And now it's like,
795
00:21:32.920 --> 00:21:35.100
Oh, think about SGLT twos.
796
00:21:35.320 --> 00:21:36.200
Well, if I didn't have that
797
00:21:36.200 --> 00:21:36.900
radical little board
798
00:21:36.900 --> 00:21:37.660
next to me.
799
00:21:37.860 --> 00:21:38.080
Totally.
800
00:21:38.220 --> 00:21:38.880
I wouldn't be like,
801
00:21:40.420 --> 00:21:42.260
just treat the comorbidities,
802
00:21:42.340 --> 00:21:43.040
but you know,
803
00:21:43.080 --> 00:21:43.500
on, right?
804
00:21:44.320 --> 00:21:45.040
You know,
805
00:21:45.320 --> 00:21:47.380
so we all need cues
806
00:21:47.380 --> 00:21:48.000
and reminder.
807
00:21:48.460 --> 00:21:49.620
And I mean,
808
00:21:49.840 --> 00:21:51.380
I'm not embarrassed to say
809
00:21:51.380 --> 00:21:52.740
I will go to up to date
810
00:21:52.740 --> 00:21:53.680
in front of the patient.
811
00:21:53.940 --> 00:21:54.960
I heard you in an episode
812
00:21:54.960 --> 00:21:55.780
talking about,
813
00:21:55.840 --> 00:21:56.280
Oh yeah, yeah.
814
00:21:56.440 --> 00:21:57.120
Leaving the room,
815
00:21:57.260 --> 00:21:57.680
go here.
816
00:21:57.680 --> 00:21:59.680
Or go to my clinical guidelines
817
00:21:59.680 --> 00:22:01.380
app and just look at my phone.
818
00:22:01.740 --> 00:22:02.320
We're just checking
819
00:22:02.320 --> 00:22:03.540
a minute to make sure
820
00:22:03.540 --> 00:22:04.900
that I'm not missing anything.
821
00:22:05.400 --> 00:22:06.760
And patients appreciate that.
822
00:22:07.120 --> 00:22:07.340
They do.
823
00:22:07.580 --> 00:22:08.060
They do.
824
00:22:08.140 --> 00:22:08.880
I feel like I had so much
825
00:22:08.880 --> 00:22:09.880
imposter syndrome
826
00:22:09.880 --> 00:22:10.420
as a new grad.
827
00:22:10.500 --> 00:22:11.320
I couldn't handle being
828
00:22:11.320 --> 00:22:12.020
in front of the patient
829
00:22:12.020 --> 00:22:12.360
doing it.
830
00:22:12.460 --> 00:22:13.380
But now, yeah, totally.
831
00:22:13.460 --> 00:22:13.880
Same thing.
832
00:22:14.000 --> 00:22:14.320
I'm just like,
833
00:22:14.320 --> 00:22:15.280
Yeah, we're just just
834
00:22:15.280 --> 00:22:16.140
do some double check-in.
835
00:22:16.680 --> 00:22:17.080
Yeah.
836
00:22:17.280 --> 00:22:18.660
And I'm glad you mentioned
837
00:22:18.660 --> 00:22:19.400
FHA,
838
00:22:20.900 --> 00:22:21.780
federally qualified
839
00:22:21.780 --> 00:22:24.100
health centers, FQHCs.
840
00:22:24.480 --> 00:22:26.220
Because I do think about that
841
00:22:26.220 --> 00:22:27.320
and I keep up to date
842
00:22:27.320 --> 00:22:28.760
what's on their formulary.
843
00:22:28.780 --> 00:22:30.240
So you're going to see,
844
00:22:30.240 --> 00:22:31.740
you know, so-and-so
845
00:22:31.740 --> 00:22:34.040
at the local community
846
00:22:34.960 --> 00:22:35.400
clinic.
847
00:22:36.100 --> 00:22:39.220
OK, I know that these meds
848
00:22:39.220 --> 00:22:40.940
are on that formulary, right?
849
00:22:41.040 --> 00:22:41.680
And I can't,
850
00:22:41.720 --> 00:22:42.780
but I'm going to write a note,
851
00:22:42.840 --> 00:22:44.440
make sure your provider gets it.
852
00:22:44.440 --> 00:22:45.220
They're going to see
853
00:22:45.220 --> 00:22:46.380
what the plan is.
854
00:22:46.560 --> 00:22:47.620
So I try to be as
855
00:22:47.620 --> 00:22:49.100
transparent in my plan,
856
00:22:50.820 --> 00:22:51.980
which I'll give you
857
00:22:51.980 --> 00:22:52.760
my student story.
858
00:22:52.920 --> 00:22:54.420
I have grads that work inpatient
859
00:22:54.420 --> 00:22:55.180
in the hospital.
860
00:22:55.540 --> 00:22:56.840
And all of a sudden
861
00:22:56.840 --> 00:22:58.620
I had a student
862
00:22:59.100 --> 00:23:00.560
dictating their discharge summary
863
00:23:00.560 --> 00:23:02.140
and it would say needs
864
00:23:02.140 --> 00:23:03.160
need to get a basic
865
00:23:03.160 --> 00:23:04.000
metabolic panel,
866
00:23:04.040 --> 00:23:04.980
should titrate this,
867
00:23:05.000 --> 00:23:05.560
should do this.
868
00:23:05.580 --> 00:23:06.380
And they'd say, Dr.
869
00:23:06.500 --> 00:23:07.620
Bowers, I felt terrible
870
00:23:07.620 --> 00:23:09.340
telling you what to do,
871
00:23:09.420 --> 00:23:09.940
knowing you were going
872
00:23:09.940 --> 00:23:10.740
to see them in clinic.
873
00:23:10.980 --> 00:23:12.100
I was like, oh, no,
874
00:23:12.340 --> 00:23:13.620
I would much rather
875
00:23:13.620 --> 00:23:15.240
in a busy clinic.
876
00:23:15.240 --> 00:23:15.560
Yeah.
877
00:23:15.620 --> 00:23:17.140
Have you A, remind me
878
00:23:17.140 --> 00:23:18.740
or B, guide my treatment
879
00:23:18.740 --> 00:23:19.680
so that we're all
880
00:23:19.680 --> 00:23:20.920
part of the same team.
881
00:23:21.000 --> 00:23:21.440
Totally.
882
00:23:21.720 --> 00:23:23.020
So I'm going to say, Liz,
883
00:23:23.360 --> 00:23:25.520
you know, to get follow up labs
884
00:23:25.520 --> 00:23:26.880
at PCP visit
885
00:23:26.880 --> 00:23:27.800
with nurse practitioner
886
00:23:27.800 --> 00:23:29.960
role like that's what I really do.
887
00:23:30.380 --> 00:23:31.020
Yeah, I love it.
888
00:23:31.020 --> 00:23:31.920
I love it when they have a plan.
889
00:23:31.920 --> 00:23:32.460
I'm like, thank you
890
00:23:32.460 --> 00:23:33.320
for telling me what to do
891
00:23:34.520 --> 00:23:35.780
because we're so busy
892
00:23:35.780 --> 00:23:37.160
and so overloaded
893
00:23:37.160 --> 00:23:38.820
that that just kind of guides it.
894
00:23:38.820 --> 00:23:40.820
And it also shows the partnership.
895
00:23:41.340 --> 00:23:42.200
Totally, totally.
896
00:23:42.240 --> 00:23:43.080
And if you think about it,
897
00:23:43.080 --> 00:23:45.040
like at least I do that for myself
898
00:23:45.040 --> 00:23:46.360
when I make my own plan of care,
899
00:23:46.420 --> 00:23:47.860
I'm spelling it out for myself,
900
00:23:47.860 --> 00:23:49.080
but also it's spelling it out
901
00:23:49.080 --> 00:23:49.840
for the next provider.
902
00:23:49.880 --> 00:23:51.000
If I'm not there that day
903
00:23:51.000 --> 00:23:52.360
or or if that person comes in
904
00:23:52.360 --> 00:23:53.460
in between our next follow up,
905
00:23:53.520 --> 00:23:54.140
like they're going to know
906
00:23:54.140 --> 00:23:55.380
what the deal is like they can.
907
00:23:55.380 --> 00:23:56.380
Oh, I can. I'm tracking
908
00:23:56.380 --> 00:23:57.720
based on your HBI and your plan.
909
00:23:57.920 --> 00:23:58.700
Like what the plan?
910
00:23:58.900 --> 00:24:00.140
Yeah, yes, absolutely.
911
00:24:00.540 --> 00:24:02.240
Yeah, I think that's good.
912
00:24:02.680 --> 00:24:04.360
So I know we've covered a lot
913
00:24:04.360 --> 00:24:06.380
on guideline directed medical therapy,
914
00:24:06.420 --> 00:24:08.580
but I think the urgency
915
00:24:08.580 --> 00:24:09.940
to get a little bit
916
00:24:09.940 --> 00:24:12.660
of those four pillars is so important
917
00:24:12.660 --> 00:24:14.140
to reduce mortality,
918
00:24:14.360 --> 00:24:16.200
not just reduce hospitalization.
919
00:24:16.240 --> 00:24:18.020
And if you can help patients say
920
00:24:18.020 --> 00:24:19.240
these medicines,
921
00:24:19.260 --> 00:24:21.340
you may feel yucky when you first start.
922
00:24:21.400 --> 00:24:22.800
And I always tell them that
923
00:24:22.800 --> 00:24:24.540
because you're used to
924
00:24:24.540 --> 00:24:25.500
high blood pressure
925
00:24:25.500 --> 00:24:28.220
or you're used to being so short of breath.
926
00:24:28.520 --> 00:24:30.400
But ultimately, these are going to help
927
00:24:30.400 --> 00:24:31.640
keep you out of the hospital,
928
00:24:32.200 --> 00:24:34.180
feel better and live longer.
929
00:24:34.700 --> 00:24:35.180
Yeah.
930
00:24:35.780 --> 00:24:37.180
Then you buy in.
931
00:24:37.520 --> 00:24:39.220
Right. Yeah, yeah.
932
00:24:39.240 --> 00:24:41.160
And and we do want to talk about
933
00:24:41.160 --> 00:24:43.420
both echoes and anticoagulation.
934
00:24:43.520 --> 00:24:44.100
If we have time,
935
00:24:44.140 --> 00:24:45.220
I'd love to touch on half.
936
00:24:45.940 --> 00:24:47.960
Our I always get half path
937
00:24:47.960 --> 00:24:49.460
preserved as a fraction.
938
00:24:49.540 --> 00:24:50.000
Yeah.
939
00:24:50.140 --> 00:24:52.220
One thing I wanted to just mention
940
00:24:52.220 --> 00:24:53.180
is diuretics.
941
00:24:53.460 --> 00:24:54.260
I was just going to say that.
942
00:24:54.260 --> 00:24:55.360
Can we touch on that first?
943
00:24:55.740 --> 00:24:57.420
Yes, because this is so important.
944
00:24:57.540 --> 00:24:58.400
What I get calls from,
945
00:24:58.460 --> 00:25:00.140
how do you know this call
946
00:25:00.140 --> 00:25:01.080
from the nursing home?
947
00:25:01.420 --> 00:25:04.460
It was, uh, how much diuretic?
948
00:25:04.580 --> 00:25:05.160
What should I do?
949
00:25:05.240 --> 00:25:06.780
Here's an easy formula
950
00:25:06.780 --> 00:25:07.640
for principle.
951
00:25:08.000 --> 00:25:09.860
Pearl, double the diuretic
952
00:25:09.860 --> 00:25:10.940
for two to three days.
953
00:25:11.240 --> 00:25:13.280
If they're not responding to that
954
00:25:13.280 --> 00:25:15.760
at Metola zone or xeroxyl in
955
00:25:15.760 --> 00:25:17.180
two and a half milligrams
956
00:25:17.180 --> 00:25:19.920
30 minutes before their morning dose.
957
00:25:19.920 --> 00:25:21.700
So they're on multi dose.
958
00:25:22.640 --> 00:25:23.540
If that doesn't work,
959
00:25:23.540 --> 00:25:25.400
switch your loop diuretic
960
00:25:25.400 --> 00:25:26.660
because loops, you know,
961
00:25:26.680 --> 00:25:28.800
HCTZ I don't count as a diuretic
962
00:25:28.800 --> 00:25:29.340
and heart failure.
963
00:25:29.480 --> 00:25:30.460
It's really ineffective.
964
00:25:31.220 --> 00:25:32.760
Any of those combo meds,
965
00:25:32.860 --> 00:25:33.420
just, you know,
966
00:25:33.540 --> 00:25:34.900
get them back on a pure medicine
967
00:25:34.900 --> 00:25:35.880
and add a loop.
968
00:25:36.100 --> 00:25:36.500
Exactly.
969
00:25:36.560 --> 00:25:37.900
If they're on furosemide,
970
00:25:37.980 --> 00:25:39.060
switch them to torsemide
971
00:25:39.060 --> 00:25:40.060
because there's something called
972
00:25:40.060 --> 00:25:41.020
diuretic tolerance.
973
00:25:41.320 --> 00:25:42.320
I didn't know about that
974
00:25:42.320 --> 00:25:43.180
for several years.
975
00:25:43.240 --> 00:25:43.720
Yeah.
976
00:25:44.080 --> 00:25:45.720
There's a dose response curve
977
00:25:45.720 --> 00:25:47.860
to diuretics, but it's also
978
00:25:47.860 --> 00:25:49.580
if you switch diuretics,
979
00:25:49.760 --> 00:25:50.320
you may get,
980
00:25:51.340 --> 00:25:52.660
even though it's the same class,
981
00:25:52.660 --> 00:25:53.760
you may get a benefit.
982
00:25:54.220 --> 00:25:55.160
Can you talk a bit about
983
00:25:55.160 --> 00:25:56.200
the dose response curve
984
00:25:56.200 --> 00:25:57.600
for the new people?
985
00:25:58.120 --> 00:25:58.320
Sure.
986
00:25:58.660 --> 00:25:59.660
So from, you know,
987
00:25:59.660 --> 00:26:01.520
we think that each time
988
00:26:01.520 --> 00:26:02.640
you like double a dose,
989
00:26:02.640 --> 00:26:04.240
so you're going from 20 of LASIX
990
00:26:04.240 --> 00:26:05.300
to 40 of LASIX,
991
00:26:05.300 --> 00:26:06.840
you should get a better response,
992
00:26:07.000 --> 00:26:08.660
but there's a ceiling effect.
993
00:26:08.700 --> 00:26:11.500
So you get it up to a certain amount
994
00:26:11.500 --> 00:26:13.520
and I would have to look at the chart
995
00:26:13.520 --> 00:26:15.940
to be honest to see what that amount is.
996
00:26:16.640 --> 00:26:17.320
But you're like,
997
00:26:17.320 --> 00:26:18.380
well, just keep titrating
998
00:26:18.380 --> 00:26:19.620
and keep titrating.
999
00:26:19.980 --> 00:26:22.640
Now, the salient point about this
1000
00:26:22.640 --> 00:26:24.400
is people go, I'm not peeing as much.
1001
00:26:24.420 --> 00:26:25.600
Well, is that because
1002
00:26:25.600 --> 00:26:28.240
their renal function is declining, right?
1003
00:26:28.660 --> 00:26:30.160
Yeah, let's put that in there
1004
00:26:30.160 --> 00:26:31.120
as a little curled up.
1005
00:26:31.120 --> 00:26:31.800
Keep in your mind.
1006
00:26:31.920 --> 00:26:33.300
Don't just focus on the diuretics.
1007
00:26:33.460 --> 00:26:34.300
Think about the kidneys.
1008
00:26:34.580 --> 00:26:35.180
Yes, go ahead.
1009
00:26:36.920 --> 00:26:38.980
And also, you know,
1010
00:26:38.980 --> 00:26:40.560
we tend not to fluid restrict people,
1011
00:26:40.560 --> 00:26:42.380
but if they're not drinking a lot,
1012
00:26:42.500 --> 00:26:44.080
is there anything to pee out?
1013
00:26:44.360 --> 00:26:46.460
Like, you got to think that.
1014
00:26:46.980 --> 00:26:48.900
So for folks with heart failure,
1015
00:26:49.240 --> 00:26:50.280
you can titrate up.
1016
00:26:50.280 --> 00:26:52.100
I mean, I've had patients on
1017
00:26:53.980 --> 00:26:55.760
160 of Lasix twice a day.
1018
00:26:56.020 --> 00:26:57.460
That's 320 in a day.
1019
00:26:57.800 --> 00:26:58.460
That's a lot.
1020
00:26:58.660 --> 00:26:59.360
That's a lot.
1021
00:27:00.840 --> 00:27:03.380
But that's because I do this as a specialty.
1022
00:27:03.740 --> 00:27:05.480
What I'm saying is you're also,
1023
00:27:05.600 --> 00:27:07.020
if it's not effective anymore,
1024
00:27:07.040 --> 00:27:08.900
it could be that they're not absorbing.
1025
00:27:09.380 --> 00:27:10.880
So that's when you really need
1026
00:27:10.880 --> 00:27:12.000
to consult cardiology.
1027
00:27:12.120 --> 00:27:14.620
They just may need a dose of IV Lasix
1028
00:27:14.620 --> 00:27:15.740
to get them over the hump.
1029
00:27:16.020 --> 00:27:16.780
Oh, interesting.
1030
00:27:17.280 --> 00:27:18.020
So I have a question.
1031
00:27:19.120 --> 00:27:20.700
And one of the things I love about
1032
00:27:20.700 --> 00:27:22.300
your teaching is how practical you are.
1033
00:27:22.300 --> 00:27:24.080
So I'm just thinking practically for a moment.
1034
00:27:24.260 --> 00:27:25.820
So if I have a patient in front of me,
1035
00:27:25.920 --> 00:27:27.000
just applied, I mean,
1036
00:27:27.420 --> 00:27:29.280
so if I have a patient in front of me
1037
00:27:29.280 --> 00:27:31.220
and their weight is up,
1038
00:27:34.220 --> 00:27:35.760
you can tell that they have edema
1039
00:27:35.760 --> 00:27:36.980
in their lower extremities,
1040
00:27:37.040 --> 00:27:38.340
but they're not short of breath.
1041
00:27:38.420 --> 00:27:39.400
They're not having any chest pain,
1042
00:27:39.400 --> 00:27:40.020
things like that.
1043
00:27:40.360 --> 00:27:41.320
And it's like,
1044
00:27:41.320 --> 00:27:42.860
oh, well, I did just have a holiday
1045
00:27:42.860 --> 00:27:44.640
and I had a lot of salty food,
1046
00:27:44.740 --> 00:27:45.440
things like that.
1047
00:27:46.280 --> 00:27:48.380
The holiday season is tricky for that.
1048
00:27:50.060 --> 00:27:51.140
That's the kind of situation
1049
00:27:51.140 --> 00:27:52.680
if their blood pressure is stable,
1050
00:27:52.860 --> 00:27:53.400
their heart rate is stable,
1051
00:27:53.500 --> 00:27:54.260
all that stuff is stable.
1052
00:27:54.360 --> 00:27:55.580
That's when I would probably
1053
00:27:55.580 --> 00:27:56.800
want to double that dose
1054
00:27:56.800 --> 00:27:58.020
for two to three days
1055
00:27:58.020 --> 00:27:59.800
and then have them,
1056
00:27:59.840 --> 00:28:01.600
what is that follow-up process look like,
1057
00:28:01.620 --> 00:28:02.460
especially for new grads
1058
00:28:02.460 --> 00:28:05.340
who are paranoid about lab function.
1059
00:28:06.200 --> 00:28:07.860
How recent should their labs have been?
1060
00:28:07.920 --> 00:28:08.780
How do I know if their kidneys
1061
00:28:08.780 --> 00:28:10.260
can handle that for three days?
1062
00:28:10.340 --> 00:28:11.400
Should I check their labs immediately?
1063
00:28:11.460 --> 00:28:12.660
Am I going to put them in renal failure?
1064
00:28:13.520 --> 00:28:15.100
Like, I'm just zooming back to my...
1065
00:28:15.100 --> 00:28:15.880
The angst, I hear it.
1066
00:28:16.400 --> 00:28:18.220
So you just described somebody
1067
00:28:18.220 --> 00:28:19.420
who is warm and wet.
1068
00:28:19.580 --> 00:28:20.860
There's this beautiful cascade
1069
00:28:20.860 --> 00:28:22.820
that talks about warm and wet,
1070
00:28:22.960 --> 00:28:24.120
cold and wet, right?
1071
00:28:24.420 --> 00:28:26.620
But warm and wet, they're perfused.
1072
00:28:26.620 --> 00:28:27.060
Yes.
1073
00:28:27.460 --> 00:28:28.220
Even if they're short,
1074
00:28:28.260 --> 00:28:29.700
they may be short of breath, that's okay,
1075
00:28:29.700 --> 00:28:32.300
but they're hemodynamically stable, right?
1076
00:28:32.360 --> 00:28:34.380
It's not a specific blood pressure number.
1077
00:28:34.740 --> 00:28:36.600
My blood pressure runs in the 90s.
1078
00:28:36.760 --> 00:28:38.440
If mine's in the 80s, that's a problem.
1079
00:28:38.580 --> 00:28:40.220
But if I'm 90 to 100,
1080
00:28:40.500 --> 00:28:42.880
you can still diurese me, morally.
1081
00:28:44.260 --> 00:28:46.120
Oh my God, that's so scary for someone in New York.
1082
00:28:46.380 --> 00:28:47.540
I know, I know.
1083
00:28:47.640 --> 00:28:49.860
But remember, if they're walking around,
1084
00:28:49.860 --> 00:28:52.240
walking, talking, well perfused,
1085
00:28:52.500 --> 00:28:54.360
you feel a distal pulse, right?
1086
00:28:54.400 --> 00:28:57.160
They're not cold and clammy, okay?
1087
00:28:57.660 --> 00:28:58.900
People are walking around
1088
00:28:58.900 --> 00:29:02.040
without their electrolytes checked every single day.
1089
00:29:02.380 --> 00:29:05.380
All we do in primary care, outpatient care,
1090
00:29:05.680 --> 00:29:06.560
is do a snapshot.
1091
00:29:06.920 --> 00:29:07.800
There's a Polaroid picture
1092
00:29:07.800 --> 00:29:09.920
or an iPhone picture of your labs.
1093
00:29:10.120 --> 00:29:10.840
That's today.
1094
00:29:11.780 --> 00:29:14.620
You could eat a whole bunch of, you know,
1095
00:29:14.780 --> 00:29:16.360
I don't know, high potassium foods
1096
00:29:16.360 --> 00:29:17.520
and your potassium go up,
1097
00:29:17.520 --> 00:29:19.240
but your kidneys should adjust.
1098
00:29:19.240 --> 00:29:22.600
So you should feel okay looking at,
1099
00:29:22.860 --> 00:29:24.800
I did labs today, right?
1100
00:29:24.880 --> 00:29:26.540
This is where I know I'm starting.
1101
00:29:26.740 --> 00:29:27.180
Yeah.
1102
00:29:27.560 --> 00:29:29.700
Or I saw them within the past month.
1103
00:29:29.720 --> 00:29:31.860
I wouldn't go like six months worth of labs.
1104
00:29:31.940 --> 00:29:33.000
I might go two months.
1105
00:29:33.000 --> 00:29:34.160
So I saw you two months ago.
1106
00:29:34.280 --> 00:29:36.240
You're now messaging, calling.
1107
00:29:36.760 --> 00:29:37.880
You're fluid overloaded.
1108
00:29:37.940 --> 00:29:39.940
I don't need you to come in for a visit today.
1109
00:29:40.220 --> 00:29:42.480
I'm going to double your 40 LASIX.
1110
00:29:42.480 --> 00:29:44.420
You're going to take it twice a day
1111
00:29:44.420 --> 00:29:46.100
for the next two days and call me back.
1112
00:29:46.340 --> 00:29:47.760
If you're not feeling better,
1113
00:29:47.760 --> 00:29:49.500
I'm going to have you come in the office.
1114
00:29:49.500 --> 00:29:50.720
I'm going to draw labs.
1115
00:29:51.040 --> 00:29:52.100
If you are feeling better,
1116
00:29:52.280 --> 00:29:54.460
I'm going to have you come for a lab only visit.
1117
00:29:54.780 --> 00:29:55.260
Nice.
1118
00:29:55.600 --> 00:29:57.960
I evaluate you over the phone.
1119
00:29:58.160 --> 00:29:59.640
I did an intervention.
1120
00:29:59.820 --> 00:30:01.080
I'm following up.
1121
00:30:01.160 --> 00:30:01.400
Yeah.
1122
00:30:01.400 --> 00:30:03.800
You don't need potassium levels every day.
1123
00:30:03.800 --> 00:30:04.180
Yeah.
1124
00:30:04.180 --> 00:30:06.080
You know, you could look at trends.
1125
00:30:06.360 --> 00:30:08.200
If this is somebody who's followed, right?
1126
00:30:08.200 --> 00:30:11.360
Oh, this person runs about three, three, five, three, six.
1127
00:30:11.660 --> 00:30:14.760
Maybe I'll have them supplement with dietary
1128
00:30:14.760 --> 00:30:17.660
or maybe I need to give them a potassium supplement.
1129
00:30:17.660 --> 00:30:19.860
You know, for a couple of days.
1130
00:30:20.480 --> 00:30:20.540
Yeah.
1131
00:30:20.540 --> 00:30:20.800
Yeah.
1132
00:30:21.040 --> 00:30:24.220
But that's a calming way to say,
1133
00:30:24.820 --> 00:30:27.080
yeah, totally safe.
1134
00:30:27.460 --> 00:30:27.960
Very safe.
1135
00:30:28.000 --> 00:30:29.600
You're not going to drop someone's blood pressure.
1136
00:30:29.640 --> 00:30:33.780
They're not going to pass out really two to three days.
1137
00:30:33.960 --> 00:30:35.180
And how did they respond?
1138
00:30:35.440 --> 00:30:36.560
Because you're right.
1139
00:30:36.700 --> 00:30:38.440
Holiday eating, funeral eating.
1140
00:30:38.600 --> 00:30:41.820
I do all sorts of counseling related to that,
1141
00:30:41.820 --> 00:30:43.660
that trip people up.
1142
00:30:44.300 --> 00:30:44.460
Absolutely.
1143
00:30:44.460 --> 00:30:46.880
And I just, I do want to stress again that like
1144
00:30:47.980 --> 00:30:50.420
if you're just, it doesn't matter how much experience you have,
1145
00:30:50.420 --> 00:30:52.520
if you're uncomfortable, just asking for help.
1146
00:30:52.700 --> 00:30:55.220
Because I mean, I'm asking you these questions being like,
1147
00:30:55.300 --> 00:30:56.280
okay, I'm going to write this down.
1148
00:30:56.300 --> 00:30:57.240
I'm going to bring this back, right?
1149
00:30:57.500 --> 00:31:00.300
I'm writing all this stuff down and I, yeah,
1150
00:31:01.460 --> 00:31:03.020
there's no shame in asking for help.
1151
00:31:03.200 --> 00:31:04.680
And there's no expectation to know it.
1152
00:31:05.180 --> 00:31:05.940
So yeah.
1153
00:31:06.100 --> 00:31:09.400
And I'll just tell you like antibiotics are my nemesis.
1154
00:31:09.520 --> 00:31:14.100
Every time I have a patient that I know they have a complicated UTI
1155
00:31:14.100 --> 00:31:16.460
or I know that they have pneumonia.
1156
00:31:16.460 --> 00:31:18.040
I don't send them for a chest x-ray.
1157
00:31:18.260 --> 00:31:20.860
I actually listen for egopony, but I have to treat.
1158
00:31:20.980 --> 00:31:23.300
And I'm like, oh darn, they're on all these other meds.
1159
00:31:23.420 --> 00:31:27.580
So I have to go look up antibiotics for this treatment
1160
00:31:27.580 --> 00:31:30.260
based on the creatinine, EGFR.
1161
00:31:30.560 --> 00:31:31.680
Like I don't know that.
1162
00:31:32.200 --> 00:31:36.000
So you can do anything for a long time, but you have to be safe.
1163
00:31:36.280 --> 00:31:36.740
Totally.
1164
00:31:37.040 --> 00:31:37.080
Right.
1165
00:31:37.400 --> 00:31:40.340
Do you have any thoughts to add about people with,
1166
00:31:40.340 --> 00:31:43.780
I think people also get really uncomfortable with decreased renal function
1167
00:31:43.780 --> 00:31:45.260
with diuresis.
1168
00:31:45.260 --> 00:31:47.840
Like if you have that kind of combination of heart failure,
1169
00:31:48.120 --> 00:31:50.000
fluid overload and reduced kidney function,
1170
00:31:50.040 --> 00:31:51.900
do you have any like kind of pearls there for people?
1171
00:31:52.220 --> 00:31:54.140
Because I know nephrologists do a ton of like,
1172
00:31:54.140 --> 00:31:56.400
there's always like that argument between like, you know,
1173
00:31:57.620 --> 00:32:00.180
nephrologists and cardiologists of like what we should do or whatever.
1174
00:32:00.400 --> 00:32:02.060
But yeah, do you have any pearls about that?
1175
00:32:03.360 --> 00:32:03.800
Absolutely.
1176
00:32:04.140 --> 00:32:05.640
Because this is something I really,
1177
00:32:05.880 --> 00:32:09.140
I always paid attention to BUN and creatinine, BUN and creatinine.
1178
00:32:09.180 --> 00:32:13.400
And yet with the newer meds, especially like the SGLT2s,
1179
00:32:14.560 --> 00:32:16.760
glomerulofiltration rate, EGFR.
1180
00:32:16.920 --> 00:32:20.860
So I am so biased because most of my patients don't have a normal creatinine.
1181
00:32:22.280 --> 00:32:24.840
But here's the thing, creatinine is that snapshot.
1182
00:32:24.880 --> 00:32:26.500
Again, it fluctuates up and down.
1183
00:32:26.720 --> 00:32:29.240
Your GFR is what you're really impacting.
1184
00:32:29.840 --> 00:32:34.040
And remember that people who are in heart failure with congestion
1185
00:32:34.040 --> 00:32:37.340
often have an elevated creatinine.
1186
00:32:37.340 --> 00:32:40.940
And then you take the fluid off and guess what happens to the creatinine?
1187
00:32:41.020 --> 00:32:42.100
It goes down.
1188
00:32:42.380 --> 00:32:42.800
Cool.
1189
00:32:42.800 --> 00:32:47.300
So like, oh, oh my gosh, I'm seeing a creatinine of 1.9.
1190
00:32:47.300 --> 00:32:48.080
I'm freaking out.
1191
00:32:48.080 --> 00:32:49.420
I don't want to diurese them.
1192
00:32:49.420 --> 00:32:50.540
I'm going to damage their kidneys.
1193
00:32:51.000 --> 00:32:54.020
No, no, no, because they're symptomatic.
1194
00:32:54.120 --> 00:32:57.500
So you look at their GFR, their GFR may be dipped down a little,
1195
00:32:57.500 --> 00:32:59.760
but it's not going to go below 30, right?
1196
00:32:59.760 --> 00:33:01.540
With the creatinine of 1.9.
1197
00:33:01.640 --> 00:33:02.800
I'm going to diurese them.
1198
00:33:02.940 --> 00:33:03.520
And guess what?
1199
00:33:03.840 --> 00:33:05.280
The creatinine comes back 1.2.
1200
00:33:05.320 --> 00:33:08.380
And you're like, oh, they feel better.
1201
00:33:08.820 --> 00:33:10.300
But that freaked me out.
1202
00:33:10.440 --> 00:33:11.180
I couldn't understand.
1203
00:33:11.180 --> 00:33:12.820
I was like, wait, wait.
1204
00:33:13.240 --> 00:33:18.660
So the rule about creatinine is really a 0.3 change.
1205
00:33:20.940 --> 00:33:24.820
Your therapy shouldn't change the creatinine more than 0.3.
1206
00:33:25.020 --> 00:33:26.600
That's when you start getting concerned.
1207
00:33:26.840 --> 00:33:27.880
Cool, cool.
1208
00:33:28.320 --> 00:33:29.880
I love those concrete pearls.
1209
00:33:29.980 --> 00:33:30.520
They're so helpful.
1210
00:33:31.100 --> 00:33:33.440
That is like one of my, oh, what did I do?
1211
00:33:33.520 --> 00:33:34.340
And look at trends.
1212
00:33:34.660 --> 00:33:37.500
Like just in your other episode, you mentioned like BNP.
1213
00:33:37.820 --> 00:33:39.580
We don't treat BNP.
1214
00:33:39.640 --> 00:33:40.640
We treat trends.
1215
00:33:40.640 --> 00:33:44.680
We look at creatinine trends.
1216
00:33:44.920 --> 00:33:46.740
What's baseline for that person?
1217
00:33:47.860 --> 00:33:49.920
And remember, they're going to look at their labs and go,
1218
00:33:50.100 --> 00:33:51.800
it says I'm in moderate kidney failure.
1219
00:33:52.180 --> 00:33:55.540
Yes, because you've had heart failure for a while.
1220
00:33:56.660 --> 00:33:58.940
And we're continuously monitoring it.
1221
00:33:58.960 --> 00:34:00.000
And we're supporting it.
1222
00:34:00.000 --> 00:34:00.940
Do I need dialysis?
1223
00:34:01.280 --> 00:34:03.000
You don't need dialysis.
1224
00:34:03.320 --> 00:34:05.640
But they read those interpretations.
1225
00:34:05.760 --> 00:34:08.280
And you're now getting panic calls.
1226
00:34:08.280 --> 00:34:11.380
So just relax.
1227
00:34:11.420 --> 00:34:13.800
But I think that's probably one of those other things
1228
00:34:13.800 --> 00:34:14.659
that took me a while.
1229
00:34:14.980 --> 00:34:16.520
What's your filtration rate?
1230
00:34:16.580 --> 00:34:18.440
Let's look at how your kidneys are really
1231
00:34:18.440 --> 00:34:20.480
filtering the toxins in your body.
1232
00:34:20.560 --> 00:34:22.800
And then it helps us both understand.
1233
00:34:23.820 --> 00:34:24.659
Definitely, definitely.
1234
00:34:25.179 --> 00:34:26.500
So here's the thing about echoes.
1235
00:34:26.719 --> 00:34:29.340
I think your previous Cardiology NP speaker
1236
00:34:29.340 --> 00:34:31.460
did a great job of talking about like
1237
00:34:31.460 --> 00:34:33.100
which diagnostic test to order.
1238
00:34:33.380 --> 00:34:36.139
But just in case folks haven't seen that episode,
1239
00:34:36.400 --> 00:34:37.980
I think a couple of things to remember.
1240
00:34:38.280 --> 00:34:41.020
First is, why am I getting this test, right?
1241
00:34:41.159 --> 00:34:43.920
I always go, you have to know why you're getting it.
1242
00:34:43.960 --> 00:34:45.719
So for simple things like,
1243
00:34:46.060 --> 00:34:47.699
I look at the structure of the heart,
1244
00:34:47.880 --> 00:34:50.120
the valves and the ejection fraction,
1245
00:34:50.239 --> 00:34:52.560
the function of the left ventricle, right?
1246
00:34:52.900 --> 00:34:53.699
That's simple.
1247
00:34:54.480 --> 00:34:57.620
Do I have a patient with known valve disease
1248
00:34:57.620 --> 00:35:01.180
that I want to look at progression over time, right?
1249
00:35:02.140 --> 00:35:04.080
As far as ejection fraction goes,
1250
00:35:04.080 --> 00:35:07.760
you also want to have patience on adequate therapy
1251
00:35:07.760 --> 00:35:09.140
for at least three months.
1252
00:35:09.480 --> 00:35:10.980
So patients sometimes get a little eager.
1253
00:35:11.140 --> 00:35:12.140
You started me on the medicine.
1254
00:35:12.320 --> 00:35:13.400
Is my ejection fraction better?
1255
00:35:13.480 --> 00:35:14.280
Is it better? Is it better?
1256
00:35:14.300 --> 00:35:17.080
And you're like, whoa, it takes a couple months.
1257
00:35:17.620 --> 00:35:19.380
Three months is the magic number.
1258
00:35:19.740 --> 00:35:22.180
Don't do anything until they've been
1259
00:35:22.180 --> 00:35:23.920
on good therapies for three months.
1260
00:35:24.500 --> 00:35:29.960
The other thing is looking at the left ventricle.
1261
00:35:29.980 --> 00:35:33.500
And you see words like achinetic, hypocontractile,
1262
00:35:33.740 --> 00:35:34.780
and a dyskinetic.
1263
00:35:34.980 --> 00:35:37.120
I'm like, what do all these things mean, right?
1264
00:35:37.120 --> 00:35:39.500
Well, achinetic is pretty easy.
1265
00:35:40.120 --> 00:35:42.520
A absence of kinetic movement.
1266
00:35:42.900 --> 00:35:43.660
So no movement.
1267
00:35:44.160 --> 00:35:46.400
So if I see an echo report
1268
00:35:46.400 --> 00:35:49.040
that says the inferior wall is achinetic,
1269
00:35:49.340 --> 00:35:50.340
do you know what I know?
1270
00:35:50.680 --> 00:35:52.980
A person probably had an inferior MI
1271
00:35:52.980 --> 00:35:54.220
because it's dead.
1272
00:35:54.640 --> 00:35:55.780
It's not moving.
1273
00:35:56.320 --> 00:35:57.520
We're not going to fix that.
1274
00:35:57.760 --> 00:35:58.540
It's gone.
1275
00:35:59.200 --> 00:36:02.060
Versus hypokinetic or hypocontractile,
1276
00:36:02.080 --> 00:36:03.300
depending on how your echo.
1277
00:36:03.700 --> 00:36:06.020
That means there's options to improve that area,
1278
00:36:06.020 --> 00:36:07.560
especially if it's in a region.
1279
00:36:08.120 --> 00:36:11.760
So maybe this is a person who has no coronary disease
1280
00:36:11.760 --> 00:36:14.300
and might need angioplasty,
1281
00:36:14.440 --> 00:36:16.100
might need bypass surgery.
1282
00:36:16.360 --> 00:36:17.920
It's not for you to decide,
1283
00:36:18.160 --> 00:36:20.080
but looking at an echo report,
1284
00:36:20.100 --> 00:36:22.000
I always say, what's the quality of it?
1285
00:36:22.380 --> 00:36:24.320
They say poor, moderate,
1286
00:36:24.520 --> 00:36:25.680
nobody ever says excellent.
1287
00:36:25.900 --> 00:36:27.400
And then you go down
1288
00:36:27.400 --> 00:36:29.420
and you look at left ventricle wall motion.
1289
00:36:29.620 --> 00:36:30.880
There's about six different,
1290
00:36:31.620 --> 00:36:33.760
does it say global hypocontractility?
1291
00:36:33.760 --> 00:36:38.120
More than likely it's an etiology that's not ischemic,
1292
00:36:38.380 --> 00:36:39.360
not reversible.
1293
00:36:39.820 --> 00:36:41.100
So from a virus,
1294
00:36:41.700 --> 00:36:43.080
from chemotherapy,
1295
00:36:43.840 --> 00:36:45.340
from peripartum.
1296
00:36:46.000 --> 00:36:49.120
So global hypocontractility or hypokinesis,
1297
00:36:50.360 --> 00:36:52.060
you hope to improve the function,
1298
00:36:52.360 --> 00:36:55.160
but that's less likely an ischemic origin.
1299
00:36:55.700 --> 00:36:57.200
Then you look at the ejection fraction.
1300
00:36:58.080 --> 00:36:59.880
Is it less than or equal to 40?
1301
00:37:00.120 --> 00:37:01.940
Is it that 41 to 49?
1302
00:37:02.260 --> 00:37:03.560
Or is it 50 and over?
1303
00:37:03.560 --> 00:37:06.560
And that kind of gives you your three buckets of treatment.
1304
00:37:07.860 --> 00:37:09.000
And then the last thing I look at,
1305
00:37:09.020 --> 00:37:10.200
what is their interpretation?
1306
00:37:10.540 --> 00:37:11.680
Is this their second echo,
1307
00:37:11.820 --> 00:37:12.840
their 14th echo?
1308
00:37:12.980 --> 00:37:14.620
Is it worse, better, or the same?
1309
00:37:15.740 --> 00:37:17.640
Now, there's a special group that I think,
1310
00:37:18.040 --> 00:37:20.640
you see tons of patients in AFib, right?
1311
00:37:21.700 --> 00:37:24.320
And it could be paroxysmal, chronic, bless you.
1312
00:37:24.460 --> 00:37:25.960
It's more pervasive than ever.
1313
00:37:26.460 --> 00:37:27.720
One of the things that I learned
1314
00:37:27.720 --> 00:37:29.560
from an electrophysiologist is
1315
00:37:29.560 --> 00:37:31.060
if you're getting an echo
1316
00:37:31.060 --> 00:37:33.420
and you think, oh, well, my patient's in AFib,
1317
00:37:33.420 --> 00:37:35.440
they're going to go for a cardioversion.
1318
00:37:35.740 --> 00:37:38.400
If their left atrium is dilated,
1319
00:37:38.640 --> 00:37:39.940
and I'm not going to give you numbers
1320
00:37:39.940 --> 00:37:40.840
because it doesn't matter.
1321
00:37:40.860 --> 00:37:43.280
Just look if it says severely enlarged,
1322
00:37:43.300 --> 00:37:44.480
nail or woman,
1323
00:37:44.760 --> 00:37:46.220
you are not going to cardiovert.
1324
00:37:46.300 --> 00:37:47.600
And here's how I describe it.
1325
00:37:47.740 --> 00:37:49.520
That atrium is so dilated,
1326
00:37:49.620 --> 00:37:51.360
the electrical system's distorted.
1327
00:37:51.880 --> 00:37:54.960
There's no way a shock is going to make it better.
1328
00:37:56.440 --> 00:37:59.280
So that's when they might need an ablation.
1329
00:37:59.360 --> 00:38:00.900
They might need meds titrated.
1330
00:38:00.900 --> 00:38:03.240
But that's another kind of pearl of,
1331
00:38:04.200 --> 00:38:06.860
oh, this patient's stable in their AFib,
1332
00:38:06.900 --> 00:38:09.040
but I'm going to look what their atrial size is
1333
00:38:09.040 --> 00:38:13.440
in case they're thinking about cardioversion, right?
1334
00:38:14.480 --> 00:38:16.820
So that was one of those, huh?
1335
00:38:16.940 --> 00:38:18.040
It's just not effective.
1336
00:38:18.280 --> 00:38:19.620
Yeah. Oh, I love that.
1337
00:38:20.260 --> 00:38:20.520
Cool.
1338
00:38:20.660 --> 00:38:23.560
So that's really like the main things of an echo
1339
00:38:23.560 --> 00:38:26.200
is don't get mired in the details.
1340
00:38:26.540 --> 00:38:28.420
Again, you're comparing a prior echo.
1341
00:38:28.580 --> 00:38:30.760
You're looking for improvement on therapy.
1342
00:38:30.900 --> 00:38:34.320
Because maybe they'll need a defibrillator or a pacemaker.
1343
00:38:35.120 --> 00:38:37.500
The last thing I know you wanted to talk about
1344
00:38:37.500 --> 00:38:38.840
was anticoagulation.
1345
00:38:39.380 --> 00:38:40.580
Yeah, absolutely.
1346
00:38:40.800 --> 00:38:43.340
I mean, there's so many questions.
1347
00:38:44.460 --> 00:38:46.640
Yeah, so, well, the context for this question was
1348
00:38:48.760 --> 00:38:50.120
people, I think that, I guess,
1349
00:38:50.760 --> 00:38:52.280
I also like to give examples
1350
00:38:52.280 --> 00:38:54.920
because it really normalizes the imposter syndrome
1351
00:38:54.920 --> 00:38:56.520
for new grads of like, you're not alone.
1352
00:38:56.840 --> 00:38:58.280
We all feel this way or felt this way.
1353
00:38:58.940 --> 00:39:01.220
But yeah, I think there's a lot of discomfort around.
1354
00:39:01.460 --> 00:39:03.220
So I've had a lot of students, for example,
1355
00:39:04.200 --> 00:39:06.620
that they will hear in a regular heartbeat,
1356
00:39:06.700 --> 00:39:11.540
they will do an EKG and they'll be like hands shaking,
1357
00:39:11.560 --> 00:39:13.040
like, is this, what is this?
1358
00:39:13.100 --> 00:39:14.360
And I'm like, well, what do you think it is?
1359
00:39:14.380 --> 00:39:15.300
And I'm like, I think it's AFib.
1360
00:39:15.380 --> 00:39:16.420
I'm like, well, it is AFib.
1361
00:39:16.500 --> 00:39:18.140
And they're like, okay, so I just like refer it.
1362
00:39:18.140 --> 00:39:18.740
Like, what should I do?
1363
00:39:18.760 --> 00:39:20.520
And it's like, oh, no, no, like, what else should I do?
1364
00:39:20.540 --> 00:39:22.480
I'm like, no, no, that's like your diagnosis.
1365
00:39:22.600 --> 00:39:23.760
Like you made a diagnosis.
1366
00:39:24.280 --> 00:39:26.680
Like, congratulations, AFib, you made a diagnosis.
1367
00:39:26.780 --> 00:39:26.980
Great.
1368
00:39:26.980 --> 00:39:28.760
So what are you going to do about that?
1369
00:39:29.180 --> 00:39:32.740
And so, and I think that there's like a panic moment there
1370
00:39:32.740 --> 00:39:34.100
of like a new diagnosis.
1371
00:39:34.240 --> 00:39:37.300
And then there's also the people who are on things already.
1372
00:39:38.060 --> 00:39:40.960
And I know like, I guess the variables to think about are,
1373
00:39:42.080 --> 00:39:43.540
and I've touched on this a little bit,
1374
00:39:43.640 --> 00:39:45.500
but I feel like professors and different perspectives
1375
00:39:45.500 --> 00:39:46.300
are always so helpful.
1376
00:39:46.460 --> 00:39:47.940
But like, what are your kind of steps
1377
00:39:47.940 --> 00:39:49.840
when it comes to either a new diagnosis
1378
00:39:49.840 --> 00:39:53.740
or somebody who is already on medications?
1379
00:39:53.800 --> 00:39:56.460
And like, we're thinking about the treatment options of like,
1380
00:39:56.460 --> 00:39:58.420
we can kind of just keep it to the two main categories,
1381
00:39:58.420 --> 00:39:59.520
unless you want to add more things,
1382
00:39:59.540 --> 00:40:02.600
but the DOACs and then Warfarin basically
1383
00:40:02.600 --> 00:40:05.160
are the two kind of main categories, at least that I see.
1384
00:40:06.000 --> 00:40:07.700
Yeah, so what are your thoughts about that?
1385
00:40:07.880 --> 00:40:11.680
Okay, so I have some easy confidence building tools
1386
00:40:11.680 --> 00:40:13.320
for folks, right?
1387
00:40:13.660 --> 00:40:16.380
Because this was my panic area.
1388
00:40:17.240 --> 00:40:17.500
Oh, totally.
1389
00:40:17.620 --> 00:40:18.840
No, and I'm giving an example
1390
00:40:18.840 --> 00:40:20.720
because I also did that as a new grad, yes.
1391
00:40:21.320 --> 00:40:25.000
Yes, so DOACs weren't invented when I started as an NP.
1392
00:40:25.140 --> 00:40:26.180
So that is one thing.
1393
00:40:26.180 --> 00:40:30.100
My first week of everybody left, I was on call
1394
00:40:30.100 --> 00:40:32.060
and I was needing to manage Warfarin
1395
00:40:32.060 --> 00:40:35.520
in about a million people, and I panicked.
1396
00:40:35.780 --> 00:40:38.420
And luckily, I had a pharmacist who was a pharmacy fellow,
1397
00:40:38.440 --> 00:40:40.520
so I had a local resource.
1398
00:40:40.960 --> 00:40:42.760
And I ran everything by the attending
1399
00:40:42.760 --> 00:40:44.540
to the point that he finally said,
1400
00:40:44.560 --> 00:40:45.840
Mitch, would you stop calling me?
1401
00:40:45.860 --> 00:40:47.420
You're giving me all the right answers.
1402
00:40:47.440 --> 00:40:48.640
And I went, okay.
1403
00:40:49.760 --> 00:40:52.600
So I now use this as a teaching tool in my class.
1404
00:40:52.600 --> 00:40:53.580
We do an on-call sim.
1405
00:40:54.180 --> 00:40:57.820
Say, so I'm going to start with Warfarin first, okay?
1406
00:40:58.180 --> 00:41:02.260
And Warfarin, it's not just about this one dose.
1407
00:41:02.420 --> 00:41:03.780
Again, if you look at lab results,
1408
00:41:03.800 --> 00:41:05.840
there are always a snapshot in time.
1409
00:41:06.100 --> 00:41:07.180
What you need to look at
1410
00:41:07.180 --> 00:41:10.200
is the patient's total weekly dose, right?
1411
00:41:10.360 --> 00:41:11.600
If you're making adjustments.
1412
00:41:11.960 --> 00:41:13.640
And people say, but I have a nomogram
1413
00:41:13.640 --> 00:41:15.820
or I have a chart or the pharmacist does this.
1414
00:41:15.820 --> 00:41:18.040
And I'm like, you could be in the grocery store
1415
00:41:18.040 --> 00:41:19.640
picking up children from ballet,
1416
00:41:19.860 --> 00:41:21.160
getting the dog from the groomer.
1417
00:41:21.320 --> 00:41:22.900
You have to know how to do this.
1418
00:41:24.200 --> 00:41:26.780
So let's just pick a fib as an example.
1419
00:41:26.940 --> 00:41:29.120
Your INR range is two to three.
1420
00:41:29.820 --> 00:41:32.700
And say the person only wants to be on Warfarin.
1421
00:41:32.780 --> 00:41:33.740
They trust Warfarin.
1422
00:41:33.800 --> 00:41:35.720
They don't want to be on these other meds.
1423
00:41:36.000 --> 00:41:37.800
So you get an INR.
1424
00:41:38.020 --> 00:41:40.540
That's 1.5, right?
1425
00:41:41.140 --> 00:41:43.860
You're going to look at what's the reason, right?
1426
00:41:43.860 --> 00:41:45.020
If they've been taking their med,
1427
00:41:45.160 --> 00:41:46.460
haven't missed any doses.
1428
00:41:47.360 --> 00:41:48.340
You go through the Ds,
1429
00:41:48.420 --> 00:41:49.820
has there been a change in diet?
1430
00:41:49.980 --> 00:41:51.180
Are there any new drugs?
1431
00:41:51.180 --> 00:41:53.260
And have they been drinking alcohol?
1432
00:41:53.620 --> 00:41:57.100
Those are kind of my quick little nice diet,
1433
00:41:57.420 --> 00:42:02.240
drugs, drinking, and drugs also refer to substances, right?
1434
00:42:02.920 --> 00:42:04.620
And no missed doses.
1435
00:42:04.960 --> 00:42:09.240
So now I say, wow, you are on five milligrams every day.
1436
00:42:09.560 --> 00:42:11.660
Five times seven is 35.
1437
00:42:11.760 --> 00:42:14.600
That's 35 milligrams total weekly dose.
1438
00:42:16.060 --> 00:42:16.600
What did I say?
1439
00:42:16.600 --> 00:42:20.240
They're on 1.6 and I need to get them to two, right?
1440
00:42:20.890 --> 00:42:25.520
I want to increase that total weekly dose by 10 to 15%.
1441
00:42:27.740 --> 00:42:30.080
You can go up to 20 if it was really low,
1442
00:42:30.100 --> 00:42:33.900
but that's a safe way to do it, right?
1443
00:42:33.980 --> 00:42:35.820
Today they're 1.6.
1444
00:42:37.620 --> 00:42:40.560
10% of their total weekly dose is 3.5.
1445
00:42:41.220 --> 00:42:43.300
I have to keep the math simple.
1446
00:42:45.220 --> 00:42:48.980
Even if we said, okay, 15, maybe I'm going up four milligrams.
1447
00:42:48.980 --> 00:42:50.920
Well, I look at what size tablets
1448
00:42:50.920 --> 00:42:52.940
do they have at home too, right?
1449
00:42:53.300 --> 00:42:55.800
I don't want such a rookie mistake that I would make yet.
1450
00:42:56.660 --> 00:42:59.120
Tell me the strength of your tablet.
1451
00:42:59.680 --> 00:43:03.600
If I say, I want to increase you to get you back
1452
00:43:03.600 --> 00:43:04.760
to your therapeutic range.
1453
00:43:05.060 --> 00:43:06.420
I'm going to have you take,
1454
00:43:08.640 --> 00:43:10.100
break your five milligram tablet
1455
00:43:10.100 --> 00:43:12.800
and take an extra two and a half tonight, Monday,
1456
00:43:13.380 --> 00:43:16.160
and take another two and a half tomorrow night, right?
1457
00:43:16.160 --> 00:43:17.780
That's five milligrams, Midge.
1458
00:43:17.920 --> 00:43:18.960
You went up like 20%.
1459
00:43:19.680 --> 00:43:21.260
Then have them check on Friday.
1460
00:43:22.720 --> 00:43:25.320
There's lots of ways, but the easiest,
1461
00:43:25.560 --> 00:43:29.840
remember it's their total weekly dose 10 to 15% up,
1462
00:43:30.080 --> 00:43:36.220
10 to 15% down, and then check an INR several days later.
1463
00:43:36.560 --> 00:43:40.500
Like I say within, because Warfarin has a longer half
1464
00:43:40.500 --> 00:43:42.000
life than the DOACs, right?
1465
00:43:42.000 --> 00:43:43.320
So you don't want to check it tomorrow
1466
00:43:43.320 --> 00:43:44.760
like you do in the hospital.
1467
00:43:45.400 --> 00:43:50.380
Three to four days later, safe formulaic plan,
1468
00:43:51.360 --> 00:43:57.820
diet, drugs, drinking, misdoses, 10 to 15% up or down.
1469
00:43:58.280 --> 00:43:58.700
That's so great.
1470
00:43:58.760 --> 00:44:01.740
Just no mechanical valves are 2.5 to 3.5.
1471
00:44:01.780 --> 00:44:03.640
So you've got to know your ranges, right?
1472
00:44:04.740 --> 00:44:06.200
Yes, the reason for their anticoagulation.
1473
00:44:06.360 --> 00:44:07.960
Yeah, exactly, exactly.
1474
00:44:08.020 --> 00:44:09.440
But that's like the simple way.
1475
00:44:09.460 --> 00:44:10.660
And then as far as the DOACs,
1476
00:44:10.700 --> 00:44:13.220
my biggest message on these DOACs are
1477
00:44:14.020 --> 00:44:16.920
we are so under treating our older adults.
1478
00:44:17.140 --> 00:44:21.420
We are so worried about falls and a head bleed.
1479
00:44:21.740 --> 00:44:22.140
Guess what?
1480
00:44:22.560 --> 00:44:27.040
I think it's worse to have a head bleed
1481
00:44:27.040 --> 00:44:29.980
and not be able to, you've just,
1482
00:44:30.700 --> 00:44:33.120
it's worse to have a stroke, excuse me, than a head bleed.
1483
00:44:33.360 --> 00:44:34.880
So here's some safe tools.
1484
00:44:35.300 --> 00:44:37.300
You use the Chad's Vast Score,
1485
00:44:37.620 --> 00:44:39.160
little calculator on everything.
1486
00:44:39.600 --> 00:44:42.640
Have you ever heard of the HazBled, H-A-S, right?
1487
00:44:42.640 --> 00:44:44.320
Yeah, but people might not have, so go.
1488
00:44:44.740 --> 00:44:47.380
Right, so HazBled Score looks at your risk for bleeding.
1489
00:44:47.860 --> 00:44:49.800
So if I'm saying, oh my goodness,
1490
00:44:49.840 --> 00:44:50.900
I don't know what to do.
1491
00:44:51.400 --> 00:44:53.900
Chad's Vast gives you formulas for,
1492
00:44:54.160 --> 00:44:54.980
do they have heart failure?
1493
00:44:55.020 --> 00:44:55.860
How old are they?
1494
00:44:55.900 --> 00:44:57.140
Are they a man or a woman?
1495
00:44:57.200 --> 00:44:58.920
Do they have vascular disease, right?
1496
00:44:59.060 --> 00:44:59.940
Have they had a stroke?
1497
00:45:00.260 --> 00:45:01.220
What's your stroke risk?
1498
00:45:01.940 --> 00:45:04.960
HazBled looks at hypertension, liver function,
1499
00:45:05.180 --> 00:45:08.460
bleeding history, history of labile INRs,
1500
00:45:08.500 --> 00:45:11.200
my bleeding risk, and then you balance them out.
1501
00:45:11.920 --> 00:45:14.300
And that's how you make a good,
1502
00:45:14.300 --> 00:45:16.080
evidence-based clinical decision.
1503
00:45:16.400 --> 00:45:16.940
And guess what?
1504
00:45:17.180 --> 00:45:18.440
I put it in my notes.
1505
00:45:18.520 --> 00:45:20.140
Yeah, totally.
1506
00:45:20.540 --> 00:45:22.620
If I say Chad's Vast equals this,
1507
00:45:22.860 --> 00:45:23.820
HazBled equals this,
1508
00:45:25.080 --> 00:45:25.560
anticoagulate.
1509
00:45:26.060 --> 00:45:28.360
I just learned, and I'm looking at this,
1510
00:45:28.500 --> 00:45:30.420
it's called the SPARC tool, S-P-A-R-C.
1511
00:45:30.420 --> 00:45:32.040
Oh yeah, yeah, yeah, you told me about that.
1512
00:45:32.220 --> 00:45:33.220
I haven't looked at it yet.
1513
00:45:33.600 --> 00:45:34.180
Yeah, go ahead.
1514
00:45:34.540 --> 00:45:37.900
All it does is combine the Chad's Vast and the HazBled.
1515
00:45:38.160 --> 00:45:40.540
I'm like, if they added in,
1516
00:45:40.540 --> 00:45:42.800
are they on NSAIDs or antiplatelets?
1517
00:45:42.940 --> 00:45:44.920
So that's important.
1518
00:45:45.560 --> 00:45:48.960
But again, if we use evidence-based tools
1519
00:45:48.960 --> 00:45:54.040
that are usually available either online or in an app,
1520
00:45:54.940 --> 00:45:56.820
and document that in our note,
1521
00:45:57.640 --> 00:46:01.980
then if the 92-year-old tripped and fell
1522
00:46:01.980 --> 00:46:05.880
and hit their head, that's not on you.
1523
00:46:05.980 --> 00:46:07.300
You've given good evidence
1524
00:46:07.300 --> 00:46:10.340
because their risk of stroke was 58%.
1525
00:46:11.440 --> 00:46:13.220
Yeah, and you've had the conversation
1526
00:46:13.220 --> 00:46:14.580
with the patient as well.
1527
00:46:14.700 --> 00:46:15.920
And you've had shared decision-making.
1528
00:46:16.040 --> 00:46:17.580
Right, it's all about that,
1529
00:46:17.580 --> 00:46:19.220
of what do you want to do?
1530
00:46:19.640 --> 00:46:21.600
So that's pretty much my passion.
1531
00:46:21.920 --> 00:46:23.320
There are reversal agents.
1532
00:46:23.380 --> 00:46:25.200
I haven't had to use any of them for these.
1533
00:46:25.360 --> 00:46:29.100
Several of like a Pixaban and Dabigatran and a Doxaban.
1534
00:46:30.000 --> 00:46:31.680
There are reversal agents for them now,
1535
00:46:31.680 --> 00:46:33.180
which is also a benefit.
1536
00:46:33.520 --> 00:46:35.060
So if you're concerned,
1537
00:46:35.820 --> 00:46:38.640
you and I aren't measuring Factor Xa levels
1538
00:46:38.640 --> 00:46:40.180
as a routine practice.
1539
00:46:41.060 --> 00:46:43.180
I don't want the folks who may work
1540
00:46:43.180 --> 00:46:44.880
at an academic health center
1541
00:46:44.880 --> 00:46:46.720
and then their brand new NP is going,
1542
00:46:47.000 --> 00:46:49.520
I'd like a Factor Xa level and I'd like this and this.
1543
00:46:49.920 --> 00:46:50.400
Like, whoa, whoa, whoa.
1544
00:46:50.440 --> 00:46:51.800
No, no, no.
1545
00:46:51.800 --> 00:46:53.460
No, no, no, no, no.
1546
00:46:53.460 --> 00:46:57.060
Cost stewardship and really what does the patient need?
1547
00:46:57.100 --> 00:46:59.300
And I think for your listeners, Liz,
1548
00:46:59.600 --> 00:47:03.420
I think that's it is you're going to overorder
1549
00:47:03.420 --> 00:47:06.240
as a brand new provider.
1550
00:47:06.240 --> 00:47:08.500
You're going to overorder if you're uncomfortable.
1551
00:47:08.800 --> 00:47:11.280
But as you increase your confidence
1552
00:47:11.280 --> 00:47:13.820
and I would say get a buddy on board,
1553
00:47:13.840 --> 00:47:15.780
whether they're physically with you in the clinic
1554
00:47:15.780 --> 00:47:17.380
or they're just a phone call away,
1555
00:47:18.120 --> 00:47:20.060
that's going to increase your confidence.
1556
00:47:21.740 --> 00:47:23.120
Well, can I ask briefly?
1557
00:47:23.320 --> 00:47:25.340
So I actually feel way more confident with Warfarin
1558
00:47:25.340 --> 00:47:26.400
than I do with the Dox
1559
00:47:26.400 --> 00:47:29.040
just because that's how I came into practice was
1560
00:47:29.040 --> 00:47:32.140
that's all we had because it was just too expensive.
1561
00:47:32.140 --> 00:47:34.040
So I'm very comfortable with that.
1562
00:47:34.160 --> 00:47:37.440
And I know, excuse me, the mentees I've worked with
1563
00:47:37.440 --> 00:47:39.220
kind of like across the country, it's so different,
1564
00:47:39.400 --> 00:47:40.800
whatever their comfort level is because they're like,
1565
00:47:40.800 --> 00:47:42.960
oh my gosh, I've never even seen Warfarin before.
1566
00:47:43.020 --> 00:47:44.840
And it's like, oh, no, no, that's literally all I do.
1567
00:47:45.320 --> 00:47:46.620
So if you had somebody, for example,
1568
00:47:47.720 --> 00:47:50.320
and it's so hard because I'm not in the school setting
1569
00:47:50.320 --> 00:47:52.400
right now of like, what are they kind of covering?
1570
00:47:52.420 --> 00:47:54.440
And I think it's different depending on the school,
1571
00:47:54.700 --> 00:47:57.720
but like, yeah, I guess they could be covering this
1572
00:47:57.720 --> 00:47:58.320
already in school.
1573
00:47:58.520 --> 00:48:01.180
But if I'm thinking also of the people who are switching
1574
00:48:01.180 --> 00:48:03.440
into practice who've been out of school for a while,
1575
00:48:03.660 --> 00:48:05.360
like if you're doing like DOEX 101,
1576
00:48:06.740 --> 00:48:10.560
like what are your pearls of practice that you have of like,
1577
00:48:10.840 --> 00:48:12.520
so for example, if you have Warfarin,
1578
00:48:12.620 --> 00:48:15.440
you have to monitor the INRs,
1579
00:48:15.440 --> 00:48:17.680
it's kind of annoying for people.
1580
00:48:17.980 --> 00:48:19.920
And so, yeah, like what is your decision making
1581
00:48:19.920 --> 00:48:21.460
between Warfarin and DOEX?
1582
00:48:21.520 --> 00:48:23.640
And then like, what are some pearls of practice
1583
00:48:23.640 --> 00:48:27.160
that you have just kind of briefly about the DOEX choices
1584
00:48:27.160 --> 00:48:28.960
and management of those?
1585
00:48:29.620 --> 00:48:31.560
So that's a really good question
1586
00:48:31.560 --> 00:48:34.600
because I tend to not have folks on,
1587
00:48:34.600 --> 00:48:37.240
I'm not usually initiating the anti-guagulation
1588
00:48:37.240 --> 00:48:39.740
unless they come to clinic in AFib and then I am.
1589
00:48:40.260 --> 00:48:41.880
So I don't initiate for AFib,
1590
00:48:41.900 --> 00:48:43.900
I don't initiate anybody on Warfarin
1591
00:48:43.900 --> 00:48:45.940
because the DOEX are more affordable now.
1592
00:48:46.080 --> 00:48:48.740
So that's one thing and on more formularies.
1593
00:48:50.260 --> 00:48:52.020
From a Warfarin perspective,
1594
00:48:52.280 --> 00:48:54.320
I manage folks who have valve disease
1595
00:48:54.320 --> 00:48:58.200
and that's really mechanical valve specifically
1596
00:48:58.200 --> 00:49:00.620
where I'm managing Warfarin.
1597
00:49:01.040 --> 00:49:02.860
Or someone, I had somebody recently
1598
00:49:02.860 --> 00:49:05.100
who has Factor V Leiden disease
1599
00:49:05.100 --> 00:49:09.320
and they have DVTs and PEs ad nauseum.
1600
00:49:09.920 --> 00:49:12.300
So they're just on chronic Warfarin therapy
1601
00:49:12.300 --> 00:49:14.800
and they actually do their own home INRs.
1602
00:49:14.800 --> 00:49:15.460
That's awesome.
1603
00:49:15.820 --> 00:49:16.840
Which is wonderful.
1604
00:49:17.140 --> 00:49:20.180
And this particular individual is only 38 years old.
1605
00:49:20.260 --> 00:49:21.720
I had a patient like that, yeah.
1606
00:49:21.960 --> 00:49:22.840
She didn't do self-titration
1607
00:49:22.840 --> 00:49:25.260
but she was really young with Factor, yeah, Factor V Leiden.
1608
00:49:25.260 --> 00:49:27.680
So that situation.
1609
00:49:28.340 --> 00:49:31.200
What I've found and part of it is just by choice,
1610
00:49:31.380 --> 00:49:35.020
a Pixaban is very safe to use.
1611
00:49:35.300 --> 00:49:38.140
I've had less like GI bleeds or adverse events
1612
00:49:38.140 --> 00:49:40.780
as opposed to maybe Dabigatran again.
1613
00:49:40.780 --> 00:49:42.520
And then it's what I'm comfortable with.
1614
00:49:42.780 --> 00:49:44.660
It's like anything, right?
1615
00:49:44.660 --> 00:49:47.200
I know my anti-hypertensives I'm comfortable with.
1616
00:49:48.740 --> 00:49:51.920
My SGLT2s, I would prescribe one or the other
1617
00:49:51.920 --> 00:49:54.940
based on my comfort of what I've seen, right?
1618
00:49:55.260 --> 00:49:58.000
The thing about a Pixaban is if renal function,
1619
00:49:58.020 --> 00:49:59.480
if kidney function declines,
1620
00:49:59.540 --> 00:50:03.020
you have to go from that five twice a day down to 2.5
1621
00:50:03.020 --> 00:50:04.560
if they need a couple of categories.
1622
00:50:04.880 --> 00:50:08.480
So I would encourage folks to pick one
1623
00:50:08.480 --> 00:50:10.760
that's available on your formulary
1624
00:50:10.760 --> 00:50:14.220
or the formulary of wherever your region,
1625
00:50:14.440 --> 00:50:16.500
because we also know some medicines are regional
1626
00:50:16.500 --> 00:50:19.020
and the bright new shiny object
1627
00:50:19.020 --> 00:50:20.760
is not always the best choice.
1628
00:50:20.980 --> 00:50:23.160
Get to know that medicine,
1629
00:50:23.160 --> 00:50:25.460
see how your patients tolerate it.
1630
00:50:26.160 --> 00:50:27.720
Because I'm often at the mercy
1631
00:50:27.720 --> 00:50:29.580
of what they've started in the hospital, right?
1632
00:50:29.580 --> 00:50:31.300
I see someone in a hospital follow-up
1633
00:50:31.300 --> 00:50:34.500
and I'm not going to switch the Dabigatran to a Pixaban
1634
00:50:34.500 --> 00:50:35.520
just because of my comfort.
1635
00:50:35.520 --> 00:50:36.100
Just because you like it.
1636
00:50:36.100 --> 00:50:37.620
You're on this, right, you know?
1637
00:50:38.100 --> 00:50:39.080
But that's it.
1638
00:50:39.300 --> 00:50:41.380
And just do the same instructions for,
1639
00:50:42.200 --> 00:50:44.340
you know, I think our opportunity,
1640
00:50:44.380 --> 00:50:47.760
even though I would say don't unbecome a nurse
1641
00:50:47.760 --> 00:50:49.100
when I become a nurse practitioner,
1642
00:50:49.380 --> 00:50:50.640
still the name is there.
1643
00:50:50.980 --> 00:50:52.800
So talking about all the bleeding,
1644
00:50:52.800 --> 00:50:54.620
I ask every single patient
1645
00:50:54.620 --> 00:50:56.420
whether they're on a blood thinner or not
1646
00:50:57.040 --> 00:50:59.220
about do you cough up blood, vomit blood,
1647
00:50:59.220 --> 00:51:00.400
or see blood in the toilet?
1648
00:51:00.700 --> 00:51:02.700
I have diagnosed cancer twice
1649
00:51:02.700 --> 00:51:04.620
by asking just those questions.
1650
00:51:06.440 --> 00:51:08.860
So really bleeding on a medicine,
1651
00:51:08.940 --> 00:51:09.700
not on a medicine.
1652
00:51:09.960 --> 00:51:10.500
It's easy.
1653
00:51:10.620 --> 00:51:11.740
You don't have to say,
1654
00:51:12.040 --> 00:51:12.700
do you help him up?
1655
00:51:13.000 --> 00:51:13.780
Just says, do you help him out?
1656
00:51:14.420 --> 00:51:16.520
No, cough up blood, vomit blood,
1657
00:51:16.540 --> 00:51:17.540
or see blood in the toilet.
1658
00:51:17.640 --> 00:51:20.560
That gives you a lot of info.
1659
00:51:20.860 --> 00:51:21.980
And then, oh my gosh,
1660
00:51:21.980 --> 00:51:23.560
they're on a DOAC.
1661
00:51:23.900 --> 00:51:25.340
What am I going to do, right?
1662
00:51:25.700 --> 00:51:28.880
And then sometimes it's the things like
1663
00:51:28.880 --> 00:51:31.420
I get asked for dental extractions.
1664
00:51:31.600 --> 00:51:33.020
How long should I stop it?
1665
00:51:33.260 --> 00:51:34.840
I get asked for colonoscopies.
1666
00:51:34.900 --> 00:51:36.160
How long should I stop it?
1667
00:51:37.000 --> 00:51:38.440
No, just remember,
1668
00:51:38.840 --> 00:51:41.060
most DOACs are very short-lived.
1669
00:51:41.340 --> 00:51:44.500
You know, they're dosed twice a day.
1670
00:51:44.720 --> 00:51:46.220
So that's how you can tell.
1671
00:51:46.280 --> 00:51:47.900
They have a shorter half-life.
1672
00:51:48.360 --> 00:51:50.380
So usually two days before a procedure,
1673
00:51:50.440 --> 00:51:51.360
if they're stopped,
1674
00:51:51.360 --> 00:51:54.900
yes, their stroke risk is higher in that little window,
1675
00:51:54.900 --> 00:51:56.940
but they need the procedure, right?
1676
00:51:56.940 --> 00:51:59.080
And you don't need to hemorrhage from a colonoscopy
1677
00:51:59.080 --> 00:52:00.320
or a dental extraction.
1678
00:52:01.200 --> 00:52:02.540
But I still look it up.
1679
00:52:02.720 --> 00:52:03.940
Like, I question myself.
1680
00:52:04.060 --> 00:52:05.080
Totally, totally.
1681
00:52:05.860 --> 00:52:07.840
And then if it's a big surgical procedure,
1682
00:52:07.960 --> 00:52:09.400
I'm like, well, geez, I don't know,
1683
00:52:09.400 --> 00:52:10.940
but are they going to hypernize them
1684
00:52:10.940 --> 00:52:11.960
so they're controlled?
1685
00:52:12.280 --> 00:52:16.280
But they want you to make that decision.
1686
00:52:16.560 --> 00:52:19.460
So don't hesitate to look it up.
1687
00:52:20.140 --> 00:52:21.040
Definitely, definitely.
1688
00:52:21.040 --> 00:52:23.620
Oh my gosh, this is so much fun.
1689
00:52:23.800 --> 00:52:26.700
And I just want to talk to you for hours.
1690
00:52:27.420 --> 00:52:29.460
But I do want to be respectful of your time.
1691
00:52:30.240 --> 00:52:31.000
Thank you so much.
1692
00:52:31.000 --> 00:52:32.740
This is such an honor to have you on here
1693
00:52:32.740 --> 00:52:34.160
and you're such an awesome lecturer.
1694
00:52:34.440 --> 00:52:36.800
Are there other conferences you're speaking at
1695
00:52:36.800 --> 00:52:39.840
or is there any other place people can learn from you?
1696
00:52:40.240 --> 00:52:42.160
Well, skin, bones, hearts, and private parts.
1697
00:52:42.440 --> 00:52:43.960
Next year, three different times,
1698
00:52:44.140 --> 00:52:45.620
I'll be doing the cardiology day.
1699
00:52:45.780 --> 00:52:46.400
What is that?
1700
00:52:46.640 --> 00:52:48.040
I've not heard of that conference.
1701
00:52:48.180 --> 00:52:49.460
Oh my God, that's hilarious.
1702
00:52:49.460 --> 00:52:54.260
It's for, Chuck Dillehy is the founder of this company
1703
00:52:54.260 --> 00:52:58.200
and he asks physician assistants and nurse practitioners
1704
00:52:58.200 --> 00:53:00.800
to talk to primary care audiences
1705
00:53:00.800 --> 00:53:05.000
and it's called Skin, Bones, Hearts, and Private Parts
1706
00:53:05.000 --> 00:53:08.740
because for a week you go to say Pensacola Beach
1707
00:53:08.740 --> 00:53:11.660
or Virginia Beach and you get a day of dermatology,
1708
00:53:11.920 --> 00:53:16.520
orthopedics, cardiology, bones, hearts,
1709
00:53:17.500 --> 00:53:18.300
and private parts.
1710
00:53:18.300 --> 00:53:21.840
So four days, G-Y-N-G-U thing.
1711
00:53:21.860 --> 00:53:23.940
So it's a great way for continuing education
1712
00:53:23.940 --> 00:53:26.240
but it's really geared toward it.
1713
00:53:26.240 --> 00:53:29.240
So I'm covering topics like lipid management,
1714
00:53:29.640 --> 00:53:31.520
what not to miss in primary care
1715
00:53:31.520 --> 00:53:34.060
like aneurysms or accutum eyes,
1716
00:53:34.620 --> 00:53:36.220
how to do a good telehealth visit,
1717
00:53:36.640 --> 00:53:38.120
a cardiac telehealth visit, right?
1718
00:53:38.120 --> 00:53:38.960
Yeah, perfect.
1719
00:53:39.700 --> 00:53:40.500
Go through that.
1720
00:53:40.880 --> 00:53:44.140
So I think those are some things coming up in 24.
1721
00:53:44.500 --> 00:53:46.940
I've worked with this company in different regions
1722
00:53:46.940 --> 00:53:49.500
but I just think, you know, reach out to me.
1723
00:53:49.520 --> 00:53:50.580
Feel free to share.
1724
00:53:50.860 --> 00:53:53.040
It's margaret.bowers at duke.edu.
1725
00:53:53.220 --> 00:53:55.440
Oh my gosh, get ready for the influx.
1726
00:53:55.580 --> 00:53:56.400
I'm okay.
1727
00:53:56.400 --> 00:53:58.120
I have students all over the country
1728
00:53:58.120 --> 00:54:00.860
and I think regional practices is the other thing
1729
00:54:00.860 --> 00:54:02.100
we have to respect.
1730
00:54:02.440 --> 00:54:05.480
And remember, we are all in this together
1731
00:54:05.480 --> 00:54:08.040
to care for our patients and their loved ones, right?
1732
00:54:08.160 --> 00:54:09.220
Yeah, definitely.
1733
00:54:09.600 --> 00:54:10.540
That's why we do it.
1734
00:54:10.760 --> 00:54:12.260
This was so much fun, Liz.
1735
00:54:12.500 --> 00:54:13.780
I really can't thank you.
1736
00:54:13.960 --> 00:54:16.440
I got to be real with someone and chat.
1737
00:54:16.980 --> 00:54:18.660
About what I love to do.
1738
00:54:18.800 --> 00:54:20.460
Well, you are welcome back any time,
1739
00:54:20.800 --> 00:54:22.900
any topic you want to get on the soapbox for
1740
00:54:22.900 --> 00:54:23.600
of like, priority.
1741
00:54:25.620 --> 00:54:26.600
That's what I say.
1742
00:54:26.660 --> 00:54:29.620
I was a critical care CNS, became an FNP
1743
00:54:29.620 --> 00:54:31.420
and I love blending both worlds.
1744
00:54:32.060 --> 00:54:33.680
Well, thank you so much.
1745
00:54:34.400 --> 00:54:36.080
That's our episode for today.
1746
00:54:36.200 --> 00:54:37.960
Thank you so much for listening.
1747
00:54:38.380 --> 00:54:40.700
Make sure you subscribe, leave a review
1748
00:54:40.700 --> 00:54:42.580
and tell all your NP friends.
1749
00:54:42.980 --> 00:54:45.540
So together we can help as many nurse practitioners
1750
00:54:45.540 --> 00:54:48.300
as possible give the best care to their patients.
1751
00:54:48.780 --> 00:54:50.200
If you haven't gotten your copy
1752
00:54:50.200 --> 00:54:52.740
of the ultimate resource guide for the new NP,
1753
00:54:53.200 --> 00:54:56.300
head over to realworldnp.com slash guide.
1754
00:54:56.740 --> 00:54:58.560
You'll get these episodes sent straight
1755
00:54:58.560 --> 00:55:01.340
to your inbox every week with notes from me,
1756
00:55:01.720 --> 00:55:03.420
patient stories and extra bonuses
1757
00:55:03.420 --> 00:55:05.580
I really just don't share anywhere else.
1758
00:55:05.980 --> 00:55:07.520
Thank you so much again for listening.
1759
00:55:07.680 --> 00:55:08.920
Take care and talk soon.

Podcast

Liz Rohr