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#095 - Dr. Nathan Sundgren MD PhD

Nathan Sundgren The Incubator Podcast

Hello Friends 👋

This week we have a fun interview with the fantastic Dr. Nathan Sundgren. We covered a lot of interesting topics including the current state and future of neonatal resuscitation and the tools available to educators for teaching strategies that can translate into better outcomes for neonates in the delivery room. We highly recommend you give Nathan a follow on Twitter as he frequently posts excellent articles in the field of neonatal resuscitation. We will link to his content right below.

Have a good Sunday!



The transcript of today's episode can be found below 👇

Ben 0:54

Welcome. Hello, everybody. Welcome back to another episode of the incubator. It's Sunday, we have a very, very cool interview lined up for you Daphna, how are you?

Daphna 1:08

I'm doing really well. I was really excited about this interview. You know, we've been we've been following this doc on social media, and I love his resources. So we're very excited to have him on.

Ben 1:23

Yeah, I mean, Nathan is somebody that we met, both you and me through social media. And he posts basically a lot of stuff related to neonatal resuscitation. And and he's a great follow. I mean, he's exemplifying how when you pick a lane on social media, you can really make a difference. And I'm pretty much following Him so that I can keep up to date with what's going on. In neonatal resuscitation, we'll get through his bio in a second. Do we have any housekeeping stuff that needs to be addressed before we roll out the interview? Roll out the carpet for the interview,

Daphna 2:01

roll out the carpet, I think we wanted to talk about a save the date again.

Ben 2:06

Yeah, the Delphi innovation neonatal innovation conference is scheduled for March 27, march 28, march 29, it will be we're hoping with will be something different. Where we can start thinking just not just the goal is not to encroach on other medical conferences, and create a forum where people can share preliminary data, the goal is to have a forum where we can all come together and think about things a bit differently. And that's going to be quite neat, we can actually announce that the conference will be closed by an independent event that we're putting together, that's going to be a TEDx conference. And so that's sort of some of the stuff that we were talking about earlier this year about doing things with Ted. And so we'll have a TEDx conference, to close out to close out that that that those few days. So it promises to be a lot of fun. It's located in a very cool spot down here on the Nova Southeastern campus. There's like robots greeting you at the Innovation Center and it's like, my daughter took a selfie the other day pepper is the name of the robot that will greet you at the entrance of the innovation center. And so my daughter was like, What can I do with the robot I'm like, you can take a selfie. So there's like a selfie mode and like the robot will actually extend its arm and be like, posing for the picture is very cool.

Daphna 3:32

I like it when pepper dances

Ben 3:33

Yeah, she dances. And

Daphna 3:38

at the weather will be wonderful down here in Fort Lauderdale. For sure.

Ben 3:43

That's so that's that we have week of neonatology review Podcast coming up tomorrow. Definite pick the topic of abdominal wall defects. And that's going to be fun. Because this even though you may, you may know which one is the invalidity and which ones against releases. That's not the hard part. But like all the management or the the embryology and the long term aspects, that's gonna make a lot of big difference. So,

Daphna 4:14

yeah, super high yield. And actually, you know, for people who haven't been doing board review podcast with us, you know, I always feel like, okay, we were doing the same routine, but we're, every single week is a little bit different. It's been really cool how that has worked itself out. So I'm excited about this one.

Ben 4:35

Yeah, this is gonna be a fun one. And I think that's really it. We want to be thankful for everybody who submitted applications on the new neural network for the end to grants. We will let you know, you will have an opportunity to participate in the review process. We'll let you know about that very soon. And we'll announce the winners of those As in a few weeks now, talking about winners. Stay tuned for a nice little collaboration. So as as you may know, we are good friends with everybody at the EB Neo. What are we going to add EBL evidence based neonatology, whether it is from some of the founders Stefan Johansson, to Brian King to Ravi Patel, to all the all the gang. And this year, we are partnering up with them for their article of the year campaign. So you won't hear us over and over like we're bringing the EB Neo, they're they're agreeing to come on the podcast, and present some of these contenders. And you'll get a chance to vote and then they'll come back and tell you who won. So it's just super cool that we get to, to use our platform for them to do their thing. I'm a big fan of that campaign. And like, like I've said before, even Neil has really paved the way for us to do what we're doing here. So that's exciting.

Daphna 6:03

Yeah, it's, it's really kind of it's like the podcast, like came full circle, right? Like, what they what they started out doing, you know, many years before us is is really trying to make the evidence accessible, right. And so we're just doing it in a little bit of a different way. So it's going to be super fun to partner with.

Ben 6:27

Absolutely. So I think I think that covers it. Yeah. All right. So then let's talk about Nathan a little bit. Nathan Sandgren is a neonatologist. He is working at Texas Children's Hospital, and Baylor and the Baylor College of Medicine. He is an associate professor in pediatrics in the section of neonatal perinatal medicine. He is the Associate Medical Director of the pavilion for women neonatal intensive care unit. He's the Medical Director of the neonatal resuscitation education program. He is the medical lead of the small baby program. He is the CO lead of the institute simulation program and a member of several quality improvement program at Texas Children's Hospital and Baylor College of Medicine. He obtained his medical degree from Oregon Health Sciences University that his residency and fellowship at University of Texas Southwestern Medical School and like we've said before, he is a neonatal resuscitation guru, and he has done a lot of cool stuff that we're going to talk on this podcast. So stay tuned. And without further ado, please join us in welcoming Dr. Nathan Sandgren. Dr. Nathan sanguine, thank you so much for being on the show with us today.

Unknown Speaker 7:48

Well, so great to be here. Thank you guys for inviting me

Ben 7:52

with as we commonly do, right Dafna with our neonatologist colleague out, we always like to find out exactly what what were the factors that led you to pursue a career in the field of neonatology?

Speaker 3 8:05

Oh gosh, well, I guess for me, neonatology was a nice mix of intensive care, ICU sort of it's something I was always drawn to, you know, as I was going through medical school I was when I tell people like how do you find what track you want to go on when there's medical students thing like I think every little bit kind of tells you I already knew I love kids. I'd been involved with Kid activities and through my church and things growing up that was that was sort of a given to me, pediatrics, and then it was well what and pediatrics and you know, you go to the clinic and you realize, oh my god, I'm so bored. You know, the 20th runny nose, so I needed ICU care. I needed ICU care, but you know, nothing but ICU care is pretty hard. So I think neonatology. For me, it was a nice mix of, of the intensive care work and follow up and routine care that I liked. And one of the highest critical things for me was no follow up clinic like I do not want to be in clinic. And neonatology was great for that. And for me, that was partly because I was going to pursue basic sciences and I needed a lab and I needed a way not to be in clinic, you know, once a week or something like that. So it'll fit really well for me. And it's, it's a it's been fantastic and just a great place to be.

Ben 9:27

And you spent the bulk of your career in Texas, is that correct?

Speaker 3 9:32

I did medical training in Oregon and undergrad in Oregon and Portland, Oregon area. And then yes, I've been in residency fellowship faculty all in Texas.

Ben 9:43

It's interesting, because I mean, right now, no more but I love to move around, especially during training and my wife and I just like traveled all around. I'm curious too, as to what are the reasons that prompted you to say yeah, I want to continue in the same area. The same institution for that long. And versus the opportunity, because I'm sure you, you had the opportunity to go somewhere else and explore other ways of doing things, other locations and stuff like that.

Speaker 3 10:12

Well, when I first went into training for med school, the primary goal was to do as an MD PhD, I wanted again, basic training, I wanted to fast track residency. And so I didn't want to move twice. I didn't want to go to residency for two years, and then up and move again. And even though I was a single and that I could have done that, I just thought, No, I just want to be in the same place. So going to Dallas UT Southwestern, they actually allowed the fast tracking not every, not every institution can do that. I don't think it's an option anymore. But it was then I was able to fast track the residency goes straight into fellowship to me that made sense to do that in one place. And then I would have stayed there. And it was just a set of circumstances and a lot of things that just didn't, didn't allow me to stay on as faculty there. And then moving to the opportunity was ripe in Texas Children's in Houston. And then here now for I think I just finished my tenure, I'm think it's 10 and a half years anniversary of being at Texas Children's. Congratulations. Yeah,

Daphna 11:12

I'm the I'm the opposite. As of Ben, I feel like if you're at a place and you're happy than why. And I mean, it's obvious that you were drawn to really be intensive aspects of of neonatology, given your interest in sim and resuscitation and procedures. So how did how did you figure out that that's what you wanted to kind of study?

Speaker 3 11:40

Well, I think it only takes being one month on with Mayra Wycoff in Parkland Hospital, and, and you're sold right your soul. This is like the most fantastic thing in the world. I mean, I was an intern at UT Southwestern. And back then the interns were the one that covered the meconium deliveries. And of course, back then, right where we're hoping we're hoping for the floppy baby. So we can intubate and suction. And I think we weren't supposed to be there. But I think the the, the more full resuscitation team was on the way, but here I am as an intern, the baby's out. And it's floppy. And it's like, Whoa, I gotta do this, right. So intubate suction the baby, just as the other teams coming in, they're like, well, good job, you already did it. And I think those sorts of experiences, and then you move up into the actual sort of more full resuscitation team and you're, I'm a second year resident, I don't know anything, I've had one block under my belt as an intern. And being a part of that team was so seamless, I always, it just felt like, like, you felt like a puppet. Like they just grabbed your hands and put it in the right spot. Like you're doing this right now. And you just follow their lead and these fantastic group of nurses and respiratory therapists and all these people just lead you through it so that you felt like you are a great team lead, even though there was there like their hand was behind your back moving you and making you do the right things. And I just thought this is so fantastic team and it's sort of easy to think that's how every team operates. And then you go in other places and you find out that's that team took got there because of a lot of training and a lot of practice and a lot of work. But just the excitement of the delivery room, just the you know, just what a great moment to be a part of anyways, right? Somebody's brand new life starting and it's it's amazing to be a part of that. And I think from a from an intellectual side just always been fascinated my my basic science was always trying to be wrapped into the fetal origins of adult disease and the dough had theories and those and then just that setting the baby up right at birth, doing the right things then has just a lifetime of impact. I mean, where are the time and place? Are you going to intervene in medicine that just impact somebody for the next 8090 years of their life? And I just think Man, that's such a great place to be a part of and so there's just no, there's there's no greater place to be when it comes to medicine in my mind.

Ben 14:07

You're speaking my language there chaos theory. Right is the is the crux of neonatology. I wanted to I got familiar with your work through Twitter, I think this is the fact that we are recording this episode is it is a testament to how valuable the engagement of the community on Twitter can be. My first impression of you on Twitter was, boy, this man reads a lot of papers. And, and I want to to know, you seem what I really appreciate about the content you post on Twitter is that obviously it's very focused. So you look at neonatal resuscitation, you're looking at simulation in relation to neonatal resuscitation. And for the trainees and the young faculty listening to us, how do you manage IGE to keep up with the evidence when you have picked a narrow segment of the field. And again, and you're not following like you're not, you're not just posting articles that are coming out in a single journal. Like, it seems like anytime a paper comes out, and it's related to resuscitation, you're aware of it, you read it, and you're posting about it. How do you keep up with the evidence in a single area of the field without, without being overwhelmed or without missing any evidence coming?

Speaker 3 15:28

Well, I guess for one thing is is a lot of that was very intentional. And when, when I went over to more clinical, and I said, What am I going to do with my life, I mean, as a ray is a very tough experience to change over from my dream of, you know, Carl, one funded lab and now I'm going to be just a neonatologist. That's a horrible thing to say, but in my mind, that's sort of what I was going to be now. And, and what what am I going to do with that, and, you know, I had a, I went to a meeting where they talked about social media and how to use that and how that could be beneficial. And so I purposely decided, then, that I was going to use my Twitter account, which had just remained, you know, dead for years hadn't looked at it, that I was going to purposely use it. And I chose the most narrow field I could think of, because it was what interested me number one, right, it's what interests me. But I also, I mean, I always think about if you are really trying to design yourself some sort of empire of followers, that was like the worst strategy ever, I pick the most narrow and narrow fields, like, there's got to be 10 people out there interested like me in this field. And so you know, when I get to max numbers, it's gonna be something infinitesimally small still. But by focusing on that area and saying, This is what I'm going to do, what I so how do I keep up with the papers? Number one, Twitter itself is a great way that people at EB Neo and people like yourself are posting about articles, that's an, that's an incredible, easy way, it just feeds to me, I don't have to go searching for it. But then there obviously has to be another component if you're really wanting to dig down and search for it. And, you know, at some point early on in this journey, I made a recurring search weekly on PubMed that I've just have automatically feeds in my email on every Monday. And I put in a few key words and a few key names. I want to know anything George smells or puts out there. So he's in my search list, right? Because he's publishing the best stuff. And so by putting in a few key words, I get a list of 1520 papers. Every week that I can scroll through, read the abstracts enough, find out oh, that one actually interests me, or that one actually fits in my area of what I'm trying to, you know, forward on and talk about with people. And, and then I read those papers sometime during the week. And then my goal is to kind of just at least once a week, tweet out of paper, like just, if I can just do that. I feel like that's a small enough goal. I don't feel like I'm stressing myself out. I don't want to be endlessly scrolling Twitter, I don't want to be slave to it constant distraction of who's, what's the next like, or what's the next share? I don't, I don't want to care about that stuff. But I do want to, I want to weekly add something. And that's it's a small goal, but in doing so, you know, is the vast majority of people on Twitter, don't ever post anything. And there's a craving for content for somebody to say something and that, you know, it's not uncommon to put out something on Twitter and get one or two more followers just for putting out something out there. And that's, that's partly because people are craving that. So if you want to be one of those people who says, I'm going to add something, you're probably naturally going to be able to get followers I don't have any magic secret sauce to it and probably better ways to do it. But that's that's just been my strategy once a week, put out a paper I've got an automatic search. Sometimes it gets me a journal article before EB Neo sometimes he'd be news already put it out there and then okay, fine. No big deal. Right. And, but, and, but it just I think it's allowed me to find a few niche articles that pick me up today.

Ben 19:19

Okay, this is very in the in the mud type of question, but that's okay. You're saying something that Michael narvi, who is also very active on Twitter mentioned to us, right, the idea of like, Hey, you can actually save a search on PubMed. And every week you get an email saying, Here's what popped up with the search terms that you've used. And actually, people got back to us saying, Well, I put like neonatal, and I get, like 1000 articles that have that term. So I'm just curious, can you share with us like, what are some of the terms you've used to tell you your search?

Speaker 3 19:52

Yeah, I wouldn't mind that at all. I think I knew exactly what's not here. The secret sauce Yeah,

Ben 19:59

and And I've even tried it myself, you put, like, while you're searching, you put like preterm NICU, and you get like all the animal studies or the clinicals. And it's like, this is actually not helpful. But there's a very good balance to strike right between too much and too little. And I think for people like you who have figured it out, I guess I'm curious to hear what some how many keywords and what are they so that people can maybe reproduce that.

Speaker 3 20:25

So I really only have three, right, neonatal resuscitation is one of them. Now that again, because I'm going for narrow market, yes, I want to know about the latest PPD treatment, I absolutely care about HIV and cooling and those things, but I'm not focused on that in terms of what I'm trying to learn about and keep the most up to date about and send that along to other people. So neonatal resuscitation probably alone, narrows it down. And then the others are or terms which should have anything exploded, make it larger, but two people who I think are the most amazing neonatal scientist, and that Stuart Hooper and George smalls are, and they are part of my list. So the anything they publish, I don't care what it is, I want to know about it. Now for Dr. Hooper. It's going to be mostly animal studies. But for me, that's, that's really exciting. I want to know, the animal studies, I want to try to think about what does that going to mean in real patient care to know the animal study. So there's probably a few other people I could put in that that would be amazing to get, but I also kind of get through them by following them on Twitter or things like that. So I think that for me that those three search terms is pulls up a pretty good, pretty good listing of, and as you say, I think one time I got something like, some studying armadillos or something, I mean, you get some weird stuff show up now. And then and you're like, Oh, that's cute, but but not so much that you can't scroll through that and figure out the papers you actually want to talk about.

Ben 21:52

And if it happens once in a while, it's bearable, but it's when the search becomes just too polluted with with too many articles. So yeah, yeah.

Speaker 3 22:01

Yeah, I think it's the narrowness is the is maybe the key, right? Like, because because, and that's the other thing. I mean, if you really, you know, the quote, unquote, keep up with the literature is, it's a task on its own. And I would say the benefit of my goal of once we put it up, it is forced me to look at that list. I mean, I think I set up that list weeks before ever, you know, maybe years before I ever used it, because who has time to read all those papers, but like, I feel under the gun sometime around Wednesday, Thursday, like, oh, my gosh, I gotta read through that list. I gotta get to it.

Ben 22:34

That's the podcast. That's the whole reason. It's like, we did this podcast so that we would finally have to sit down and read those damn papers. Because when you finish fellowship, you're like, oh, yeah, I'm gonna, I'm gonna keep up with the evidence. On a sunny Saturday afternoon, I will I will sit on my couch and just read papers. And as you all

Daphna 22:51

know, that's something we we had, we were lamenting together that we both had set these individual goals of how many journals we wanted to review or how many papers we wanted to review a week or a month, and then the time was just passing and passing.

Unknown Speaker 23:06

Couldn't get it? Yeah, absolutely.

Daphna 23:09

I think you bring up an interesting point, especially for people who are early in their career is that, like, it's impossible to know everything new that's happening. And so a few things. I actually really liked that you are talking about picking a narrow focus. I think some people think like, what if I pick something that's too small, but nothing's too small. And the second thing is that I think one of the reasons we love being on Twitter, and we're hoping more of our listeners will join us on Twitter and engage in social media is because, you know, if everybody has their area of expertise, and we're sharing, you know, that's how we grow the community, and we educate the community, because it's impossible to know everything.

Speaker 3 23:55

Absolutely. I mean, I depend on I will say, from a workplace experience, right? I just offloaded parts of my brain. I don't I don't think about nutrition. I mean, I will tell families, that is your only ticket out of the NICU is good nutrition. Time and growth is the only cure we have in the NICU, everything else is just stabilizing the baby till that happens, right?

Ben 24:17

I say that. So.

Speaker 3 24:18

So nutrition is of huge value. But I've got doctors like Amy hair and Raleigh Premkumar, who worked with me who if I can just offload that part of my brain just what's what's our current? What's our current guidelines? Just tell me what to do. I know you guys are up to date with it. And I know that, and I don't know, I don't I've been fortunate to work in places, you know, in big institutions where you have all that expertise in multiple levels. So I don't I don't worry about trying to keep up with every detail. It'd be nice. But here's my narrow focus, right that I'm going to be sure I'm up to date on so that they can come to me, when I'm annoying them questions about nutrition, they can turn right around and say yeah, but I've got this question about last night I was in the delivery room. What do you think of this situation? And, and so that, I guess to me staying in a narrow field, but having great colleagues you can turn to it really makes that doable. I don't know what I would do if I was that sort of, I don't know that anybody practice solo practitioner in neonatology. But if I was at small group and those things, it'd be a little bit harder, right? It'd be a little bit harder to keep up and you, but I think platforms like this, like the podcast, like Twitter, I think could definitely help with that. Because again, that stuff's being fed to you, you're not having to go out and search for it.

Ben 25:32

Yeah, that's, that's the goal. And I think what you're describing with the with the narrow focus is exactly what we were concerned about. We said, well, how many people are going to benefit and then you say, Alright, maybe if 20 People get to benefit from this, it's worth it. And then anything on top of that is gravy. And then I think in your case, many people are benefiting from from the work that you're doing. Because again, it's like, it's like you said, I don't think in our group, we have people with various interests, but we don't really have somebody that really is dedicated to resuscitation and sim, and so I offload that to you. And I just follow you on Twitter. And I think you can do that and have even if there is somebody who's interested, you can have like a multidisciplinary group of people that you consult here and there. And, and Twitter is a great is a great place to do that.

Daphna 26:20

Well, and you're not just putting out an article, right? Like you're really engaging with the community on those papers that you're putting out, but also papers that other people are putting out, which I think really just elevates the conversation, which which I think I'm hopeful that everybody can be a part of, but at least, you know, come join us as a as a lurker. Yeah, and hear about it?

Speaker 3 26:47

Well, there's so many great content out there, and people deserve to be recognized. And I don't know that. I don't know how much. You know, I just went through the promotion process. And how much did any social media factor in that? Probably very little right. And I've heard that on Twitter, too. How much does this really count towards your academic career? Do you do people sort of counted in there? I don't know. I think I would say whether it counted to them or not. It led to all the it led to so many opportunities that led me to have the portfolio that could get me a promotion. So it doesn't matter to me whether they actually noticed it per se or not. Because it because it it helped me do the things that that led to that. So I I think there's a lot to be gained from it. And and, but, but I think it is it is amazing. When you see somebody tweeting about your paper, you're like, oh, wow, I did. That took me some time. And that was great work

Daphna 27:44

to reach somebody. I'd love to hear more. You. You alluded to it early on, but you did have this kind of transition from you know, the, what you hear about in academia r1 grant funding basic science, to changing to a really a shift in your career. And I'd love to hear more about that.

Speaker 3 28:09

Yeah, well, it was it was sort of foisted upon me, right, I used but I'll take, I'll take blame as much as I can. I know, when changing institutions. Number one, there's just some realities about you, when you're, when you're doing basic science research, you've got some momentum, you've got a project you've got to track. And so when you change institutions, you probably either need to totally shift focus, re get a whole new set of mentors really change what you're doing. And that's going to take several years to build in. And if you've got the support for that great, which, which I would have, I would have had the support for that. Or what I tried to do is bring my project to, to a new institution continue to have mentor support from my from my past institution and how to a good mentor team here, but it wasn't a good fit. And, and I just couldn't make it work. I couldn't make the project move forward is very hard, very slow process. And it just it just became obvious that the things weren't going to work for me. And it wasn't gonna lead to an AR one funded and and again, that's when I surveyed the landscape and say, Okay, what is it I like to do clinically? What is it that I can bring? I've always enjoyed teaching, I've always loved working with learners, how can I engage in that and and just looking around where the opportunities were. And the NRP program became one of those it needed sort of a new lead, who would take on the course and teach it we've got something like 700 learners every year we're putting through our interview program just aren't just internally we don't take external learners and a huge number of people. And and there was things about it first, I'm actually even became involved in the training of the NRP program. I obviously taken NRP to be a I was an instructor through through fellowship got the instructor status. But first time actually being there and actually teaching in a class setting was sort of eye opening, like, wow, there's some there's some room for improvement here. And so seeing, just taking that opportunity saying yes to that I took another opportunity. They were a quality improvement group called the golden hour team was wanting to get launched. And I said, I'll do it, I'll raise my hand, I knew nothing about quality improvement work. Nothing in quality improvement work is so strange when you first do it when you're a basic scientist who's like, you have to control factors XYZ, and you only manipulate this data and then you go into quality improvement. It's like, well, we'll do this and see what happens. And then we'll try this and we'll see what happens. And that was very different thinking that was challenging. But we took on a few projects and ended up with at least three papers out of that work. That got me in trenched, with the with the the nurses, the RTS, the doctors that did a lot of our resuscitation NRP program, just looking around seeing what could I do. And that led to really the string of events that led to the first videos on my YouTube channel, which led to everything else.

Ben 31:15

This episode is proudly sponsored by Reckitt to me Johnson recognized Johnson is dedicated to the research and development of nutrition products that help support baby development at every stage, including an extensive and female portfolio for premature and low birth weight infants learn more at HCP dot meet I wanted to go back then to this to this focus on resuscitation because I think you are putting out a lot of papers and you're thinking proactively about how could we improve the resuscitation the immediate post natal resuscitation? And I want to be a bit of devil's advocate and say, Well, what is there to improve? I mean, I feel like we're doing pretty good. You look at the statistics. And it's like how many babies do need resuscitation very few. Even the NRP says maybe like 10% of babies will need some form of resuscitation. And then when you're talking about something beyond like suctioning and a bit of oxygen, it's like maybe 1%. So in your opinion, where is the great frontier, when it comes to resuscitation? What really gets you excited in terms of the potential for this area to improve or change?

Speaker 3 32:24

Well, I love the NRP program, and I love the simplicity of the the algorithm. And I think there probably isn't a lot of, you know, major changes coming down the pike, right, maybe maybe we're going to learn something about some compression ratios that can do a little bit better, maybe sustained inflation, with compressions as being studied. Maybe that's going to come along and be something amazing. But as you said, that's such a small percentage of babies who even need that? I would say so some of the frontiers that I see is despite that, right, despite how simple organize despite the incredible focus on on ventilation in RP, I can go into the SIM center anytime put a group together, and somebody's going to start compressions, the moment they see a low heart rate before they've ever established ventilations, that the chest is like a magnet to people's thumbs when they see a heart rate below 60. And they just cannot help themselves. And I am sitting there seething every time saying ventilation, ventilation ventilation, so So I don't think we're ever going to run out of needing to teach it. Right. Okay, so that I think some of the frontiers of the human factors, right, that's where I kind of got interested in the human factor stuff. It's like, okay, that's one thing to say, Do this one minute later, do this. 30 seconds later do this. But can you actually physically accomplish it mean something as simple as NRP used to say you add 20 seconds to an intubation attempt? And then there's studies out there that the average person takes 40 seconds? Well, that was impossible. Why would you? Why would you put a recommendation on there that really was an impossibility. And so now it says 30 seconds will yay. But in an era of less and less intubations, and fewer and fewer competency in that? Are we even going to be able to accomplish that? And is that really the goal? Or do we need to bring in something like LMA are those things? So I think there's there's physical limitations of people. And so that breeds into is there technology that can add to that, you know, is there technology can take over that your hand is not good enough to get four to six mils per kilo tidal volumes every single time? Why don't we have some automated system that can do that? Why can't we get that going? You're you're not able to pay attention to everything. What about a recorder roll? That's the current study that we just finished up? What about them being able to really keep you on track more? So the human factors are one and then the second I would say is everybody's everybody, you know, this comes up at every meeting, right? Pals versus in RP. What do we do in the nick You know, we've got this complicated Nikki like ours where I'm at, you know, we've got six month old babies with heart disease, and maybe maybe Pals is the right way to go. But where's there enough overlap where we need to train? And that's that's the impetus for the NRP. Advanced, it's like, Okay, what about the situations where maybe it's not exactly in Dibbler? delivery room? But where is it that we need? We still need the focus on ventilation for most of our neonates. But how do we incorporate that with recognizing that there can be other underlying problems? And how do we know about it? How do we learn about it? Maybe without training everybody to pals, maybe there's something in between we could be doing for that. And so that comes up all the time. And I think I think there's areas to delve into that. I don't know that we'll ever answer that conundrum. You know, at some point, we, we need to understand the underlying physiology, what's going on and treat those conditions and but in a stressful moment, that's hard to do. That's, that's, for me, that's always been one of the biggest advantages of any program, whether it's NRP pals BLS. It's the, in that intense moment, when your brain goes to mush. Everybody's going to be following the same playbook, right? And that keeps a team together. And maybe kind of what quality improvement teaches you maybe even doing not the best thing. But all doing it together is better than doing the exact right thing. But everybody else scattered and not doing the same thing. So a program like NRP takes all these scattered thoughts and put you on the same playbook. Even if at that moment, the baby be better served by 15 to two compression ratios. Maybe that's okay, if we're all on the same page, doing three to one better than if somebody started jumping and doing 15 to two and the respiratory therapist is still trying to get three to one ventilations. And the team leads yelling about bringing me the paddles, maybe that's just not going to be as good.

Ben 36:55

Hold on, you mentioned something called NRP events.

Speaker 3 36:59

Yeah, it's my name for I've always kind of given this idea that you know, sometimes called NRP 401, like college course, right at the senior level or graduate level NRP. So, to me when you come to my NRP course, that you have to do every two years, that's NRP, one on one. That's basic, and I know now in our piece got their advanced in their essential learners. And we're all trying to sort of figure out how to how to set that class up well. But if your day to day actually in the delivery room, I'm sorry, you can't be one on one level anymore. You've got to be NRP advanced, you've got to be NRP 401, you've got to be something beyond just basic nrps. Because at least where I train the where I work, the we have a fetal center, right? We have we have everything we're nationally capturing babies coming here for incredibly rare conditions. And so basic NRP just may not be enough at times in the delivery room. So you better be ready, you better be ready for that. Oh, we weren't expecting this. And so that's sort of the ongoing training that I think needs to happen that I think inside do simulation simulations, ongoing education needs to fill that gap. Because once every two years is not enough.

Ben 38:11

I wanted to ask one more thing. Since we're talking about resuscitation. I think you're right, I think there's probably a need for the NRP to create a program that would bridge the gap between an RP and pals, because I do think like you said, when you have a six month old that's in your unit that is on fentanyl or morphine, if they stopped breathing, you should probably consider Narcan. And, and then maybe maybe you should think more towards pass pills. So I think there's definitely a need for a hybrid when it comes to the NICU. And going back to resuscitation. I appreciate your your thoughts. And so then if we feel like we can improve on the human factor, and that, yeah, there may not be a dramatic review revolution coming down the pipe in the coming years or year or two. What do you think I wanted to get your take on the Apgar score because I think it's one of these things that has lingered around, or like, since the 1950s. It's barely evidence based. We're still using it religiously. And it's like the most archaic thing. And I'm not. I'm not saying it's bad, but I'm saying. I mean, when you think about it, like how advanced you're talking about, hey, could we get like ventilators at the bedside? Could we do like all these advanced techniques? And yet, we eyeball like, yeah, that's a six out of nine or six out of 10. And what what are your thoughts on that? Do you think that the Apgar score is here to stay? Because it's now like the dogma or do you think there's something more advanced that I mean people have looked at that I know but is there something better coming or us than just the usual nine and nine that we give everybody?

Speaker 3 39:41

A Well, mine's eight and nine. That's my standard. I always feel like maybe those don't deserve a nine first so. So I think I dragged down our app or our women Apgar score because I'm always giving them a it's I feel very much the same way about that guy. Do you feel like it? It's sort of archaic. I know people have tried the What is it the the extended Apgar where we give a little bit more context at least what were you giving at that time? CPAP versus intubation. So it's one thing to say you're spontaneously breathing on CPAP than it is to say you're spontaneously breathing on room air, right? So how do you capture that in that score? But there's no real standardization on how to do that. Do you take off one for CPAP? Do you do not on the respiratory section? I don't even know what reflux irritability is. That's why I can never score that I have no concept what it is I just make it up every time. And I think for those reasons, I wish there was something else but the things seem to be holding on to one or the OBS live and die by it right? Like you they want to know those Apgar scores and they leave the room and I think there's some medical legal stuff there that makes it for them pretty high likelihood. But then I gotta say every now and then a paper comes out where you just I'm just shocked at how predicted the Apgar still can be. I think Stephen Johansens work over in Sweden, he he had a big, you know, big database. Apgar score was predictive, it's like, Are you kidding me? Surely my Apgar scores aren't predictive because everybody's getting an eight nine from me. But, but somebody's it is. And I'm sort of shocked by that. But yet it is. And so and we still have that is easy data. And so like when I worked with my OB colleagues, and we did the paper where we looked at core gas values, trying to be predictive of Apgar scores, well, Apgar scores were what we used, even though we all sort of felt like maybe that's not the best short term outcome to use. It's readily available, it is predictive in these other larger databases. And so it's something to use, so I'm sort of double minded about it. I don't, I feel like I'm personally not doing a great job of giving an accurate score. But I think it's because some things are so nebulous is what to do with it. You know, what does it mean to have a reflex heritability of one versus two if you're a crying baby, but you're just slightly low tone? What does that mean? And how do you count for a 24 weekers tone versus a term baby's tone? What's it? Do I give a to for the 24 weaker because they were crying and doing well, even though that's nowhere near what a term babies to tone is? I don't think we have a good concept for how to adjust for all those things. And so we just sort of probably all just give scores, somewhat at random. I'm very ambivalent

Ben 42:23

towards the Apgar score. I feel like sometimes you get called to a C section or delivery and you expect disasters, and the baby comes out crying, but it's not perfect. Maybe they're breathing not effectively. But you're so happy that it's not the catastrophic, finding that you're like, sure nine, nine, this is fantastic. I'm so happy. Yeah, yeah. And yet, I also think like we said on the podcast last week, is that we try to overfit so much. It's like, oh, can 10 minutes Apgar score predict the retirement age? You know, it's like, it's like, hours for a break. It's like, it's not really meant to predict things this long. So yeah, I appreciate your feedback. And I'm sorry, I've hugged the mic.

Daphna 43:00

No, no, I want to make sure actually, the fact that you brought up our obstetric colleagues, we definitely want to talk more about that since we are so much in overlap, especially in the delivery room. But I My question is one more question specifically about resuscitation? And, you know, as our guidelines are, maybe changing in the next few iterations is like, you know, when does resuscitation really end? Like, I feel like we have a good definition about like, a code, when are we done with the code? But when does resuscitation really end? Especially as we have much smaller babies, much more medically complex babies, congenital anomalies, cardiac problems, you know, sometimes you feel like, the resuscitation is really like the first 12 hours. So given your expertise, I'm curious to what you think about that. And how can we standardize? You know, we're out of the delivery room, but we're still not out of the woods yet. So how do we standardize that?

Speaker 3 43:57

I think that's where I would say the golden hour concept really speaks to that right? And, and, and people that write about the golden hour will tell you, it's not a it's not a physical 60 minute hour, we're talking about, we're talking about those first critical steps you're going to do and the order you're going to do them in and that you're going to keep consistent on because again, maybe even choosing the slightly not best thing is still better if we probably all practice that together at our institution and agree upon it and go for it. Right. So the golden hour is a way to address that and to have some standardization around timing of things. That being said, that's going to be so hard to standardize from one institution to another I where I trained it was a pack them up and go. I mean, you stabilize the reputation and get in the NICU and all the golden hour work was really done in the NICU. And then I came to been working at Texas Children's we just have a culture where a lot more of that is done in the delivery room, or almost the first whole hour actually happens with the mom in the room at the bedside. Right in that Every room a lot of our time is spent there in the stabilization process because like you say, the first first few minutes is really the resuscitation, probably. And then hopefully right then you've got a spontaneously breathing baby on CPAP. And now you've got all those other things you got to worry about, you got a temperature regulation, glucose control, getting getting umbilical access, if they're small enough or PIB axis or whatever, whatever route you're gonna go. And I think so each hospitals kind of got to decide, where's the best place to do that? And how can we best accomplish that and have sort of a set of guidelines of this do the things we need to get done and accomplish and having a goal of, you know, top down in the incubator humidity on by, by such and such time from admission? Or whatever it is? Thank you. I don't know if that fully answers your question. I don't know.

Daphna 45:53

For sure, for sure. Go ahead, Ben. Sorry. No, I didn't ask about obstetrics,

Ben 45:59

collaborate. No, I wanted to ask about simulation. So that's why I was wanting to know if you weren't OB, then go ahead. But I want to go into

Daphna 46:05

No, I think we were just talking about this, Ben and I in our in our own unit about how much you know how, how we feel it's so important to have some anticipatory knowledge about the situation, right. And, you know, NRP really only asks us only has this ask a few questions, right when we walk in the delivery room. But could we prepare ourselves better by having better collaboration with our obstetrics colleagues, better identification of what the baby might need better set up ahead of time, which is not tech me is technically maybe out of the scope of NRP.

Speaker 3 46:47

Yeah, but it's so important. It's funny. And I think what, when I first arrived at Texas Children's, they were just moving into a new hospital for the deliveries, and they were going from separate room out of the room resuscitation to in room resuscitations. And that was it was so it was a big deal. Everybody was concerned, how are we going to do this? It's going to be so different. But I trained it institution where we always did it in the room. So to me, it was like well done, it's easy to do, you just do it. Yeah. And, and so coming there, it was interesting, that was sort of the first barrier was how to do that. But partly because of that culture, that when I took on that Qi work, as I told you, from the golden hour, the first thing we noticed is what used to happen when they were resuscitating in a separate room, there was a little sheet of paper that just sat on the bed. And it gave a great list of information, all the GS and peas, and the GPS status and all this great information of handoff from the OB team to us. But nobody ever spoke to the OB because we were outside the room, you know, somebody went in there and grabbed the baby and ran out. So now we're in the room. And so the need for the paper somewhere got lost somewhere that that practice changed where the paper wasn't there anymore. But nobody was still talking to each other. And it was just it was it was oddly silent, that we would go in and very little information would come from the OBS. And so. So the first step in our QI project was just to get a system where we could get more information up front. And we thought, well, the pager system is one of those where at least while we're on the way, we've got at least one bit of information, right, just right there on the page where it tells me I'm coming from a conium. Or I'm coming because of choreo or something like that, at least puts me in a little bit of right mindset, or 26 weeks ago at least got some pretty good information if I knew the gestational age. And that was all before the interview came out with their four questions. And that was a really difficult project. Because when you get start digging into systems and how we work Oh, my word there is there's so many things that that you can't imagine are going to be barriers to something that sounded so simple. I would say the next level of conversation that really up the game, though, is delayed cord clamping. When we really decided to start pushing that from the NIO side, when when a couple of us really became convinced that this data looks good. Why aren't we doing this and started asking and just going straight to the obstetrician and asking. That opened up amazing doors. I couldn't believe how easy that was when we finally started talking the information and some of that becomes familiarity. I've worked with them enough long enough. Now I do enough delivery service blocks that I'm there. And they know me and recognize me and that helps. And I know some of our younger colleagues, it's still a bit of a struggle when they don't know the obstetricians that well. So I think for me, it's been it's been a lot easier to really just go up to him say, hey, something's not jiving or what I tell my fellows is the question you need to ask it every delivery room is why now, like those four questions are great, but it's easy to be lulled into, okay, I repeat C section 37 weeks, that's why we're here. Okay, but something about that you go Ding ding ding something's wrong with that. 37 We don't schedule repeat sections at 37 weeks we wait to 39 Thanks. Why today? Why am I here today? Why not tomorrow? Why not two weeks from now? That question usually opens up the Oh, I forgot to tell you. A mom's diabetic baby hasn't been growing has reverse and diastolic flow. Oh, that's why we're delivering it. 37 weeks, not 39 weeks. So that question I think is the most valuable. It's not on the four questions, but that's what I want to ask every time why today, you know, that gets that. Okay. Why am I in a C section versus vaginal delivery? vaginal delivery mom came in and labor. Okay. You know, nobody caused that it happened. All right. Now, I understand why today at 36 weeks, because she came in and labor. So I think that's an important addition to the question. And and that was one of the surveys. We did one of the studies we did we did with the Dr. Suresh and I, Dr. Gautham. We, we just surveyed the country who does the communication in the delivery room? And it was a very mixed smattering. Right. Some of that was the charge and or some it was the OB nurse the l&d Nurse, very few it was the obstetrician themselves, mostly relying on the nurses to relay that sort of for question type information. But is that appropriate? I would say and delayed cord clamping, it's absolutely not, it has to be Dr doctrine that you have to really be on the same page that we're doing this, and we're going to be watching for the recess. If the kid needs resuscitation early, we're gonna have to ask you to stop. If you're seeing some problems with the mom, you're gonna have to let me know and clamped early. Right. So that has to be a discussion between the two of them.

Ben 51:32

I really like the idea of just having this shared decision making with the obese because I think this is the outlet to us being more productive together. But this is a Nathan this hour is flying by. And I'm very afraid we're not going to get to talk about certain things that I wanted to talk about. And simulation is one thing that I wanted to pick your brain on. Because I'm a big fan of Formula One. And Formula One drivers swear by the simulator, right? I mean, they they the practice, just for people to understand is that they practice races on the simulator to an extent that they know they build muscle memory, or the entire track. So they know exactly. We are on hand when they should turn right how much and they can do this from memory. And this is how much simulations they go through. I think this is fascinating. And I think we we want to try to be more oriented towards simulation. But then I think what gets lost in the shuffle is that our mannequin, and the things that we use are terrible when it comes to procedure, right? I mean, if you want to try an IV on a mannequin, I mean, the veins are like, huge, they're bulging, it's really hard to miss. But then there's this other aspect of simulation where it's teamwork and the flow of, of information role assignment. Can you talk a little bit about how do we use simulation in each context? Or for teamwork versus for procedures? Because I think I think sometimes to get confounded.

Speaker 3 52:53

Yeah, no, wow, that's excellent, because I did something I struggled with. So I had said, when I took over the NRP training program, the first thing I went around and watched the procedural training, and I thought this, this is just not right, right, these people, these people need to go through this. And they need to drill them and drill them until they get things right. And they need to, and they need to get the intubation on the first try. And they need to be doing compressions. Exactly right. And it was all technical related that I saw as needing improvement. And then as I kept teaching more and more in that class, what I realized is, especially at that one on one level, that NRP introductory class that everybody's got to take you and includes the labor and delivery nurse, it includes the Mother Baby Unit nurse that includes some midwives and includes includes this gamut of people who are on the NICU nurse, but I'm in level two, I'm a NICU foreigners, but I never go to deliveries. And such a huge variety of learners, that what I learned is over and over again, as much as I wanted to have sort of a, a drill them, you know, drill and drill and drill them kind of get that muscle memory in them and how to do a resuscitation. I realized for most of the people that come to our one on one level in RP class, the team based training is probably more important. That's my current feeling on that because at one point we really when we designed the changes around MRP class that I eventually got around to the publishing about what we did, which the videos were a part of the when we got to that one of the goals was eventually to change over to a type of debriefing called rapid cycle deliberate practice. So our CDP training we have some local experts here Texas Children's that have taught that for pals especially. And we thought that's going to be the drill on get them to do it exactly right. That's going to be the really the most beneficial. But I I've come to feel like for so many of our learners the sitting back and reflecting the more traditional debriefing is probably more powerful because it allows them to really think through the actions of teamworks How many times have I been at the end and their take home point was, I need to learn to speak up. Think Gosh, that valuable no matter where you're at. So whether you go to the delivery room or not, yes, you need to learn that. And if my class helped you realize you need to speak up. Well, thank God. So I've come to feel like that's where that belongs. And so then where am I going to get the drill them? Right? When I get people in simulation, one of my favorites is to is to have them use the green anesthesia bag and say, show me how you can bag this baby. And everyone's Oh, I love this bag. This is my favorite so good. I rarely see somebody technically competent at that bag. It's incredibly rare. And neither am I. I'm horrible at it. And I admit it. But I mean, I've practiced so much. Now I actually think I'm pretty decent at it at this moment. But really, in order to maintain peak gig keep a good mass seal while getting the right rate, the right amount of flow. It's an incredibly difficult device. So I need you to practice that more than more than a, you know, once every two years. I jokingly say I can imagine what would happen if a baby's if before you could clock in for the day, you had to bag a mannequin perfectly for two minutes, right? Just imagine if everybody showed up to work, nobody would ever get out. That's the problem, we'd have the line out the door, maybe maybe you just don't get to go to break till you till you've effectively bagged in that maybe just one minute, right? If you could keep the mannequin in proper title volume range with adequate peep, for one minute, you get to go on your break. And you do that once a week or something, just imagine that sort of that repeated the idea, right? There's the repeated practice that we need to have. So that if you're now in the actual scenario, you've got a perfect mass seal, you've got the right feel you're giving the baby Good tidal volumes.

Ben 56:36

I did that I was part of this study with Dr. Deepak Jain at the University of Miami where he actually made us bag mannequins, and had like, monitor to measure tidal volumes and pressure, and you would not see the waveform and then he would show you the waveform after you were done. And you're like, Oh, my God. And then you realize that the new puff, gets you basically that consistent 20 centimeters of water tip and that's that's really the frequency is off. It's just it's a mess. It's, it's so frustrating. Because you think you walk into these things. I was like, I do a good job. I'm like a third year fellow. I'm the king of the castle here. Yeah, that's that waveform. Jeez.

Speaker 3 57:16

Yeah, you know, those sorts of things. If we brought those either into the into code situations, do we have respiratory function monitors, which should be just a standard part of some of these equipment so that we can at least see that see the percent leak, see those things, but but then the more equipment you add one of the things we added on to the end of our study, and we did eye tracking glasses, because we wanted to see, okay, that's great. We have this great software and this great recording system. But does anybody even look at it? Right? How can they? How do you actually incorporate that into your, your, as a team lead? How do you incorporate that into all you're trying to take in? And we haven't analyzed that at all yet, but we we will be looking into that shortly?

Daphna 57:58

Yeah, when you talk about how, how much repetition, we really need to create, like Ben said, this muscle memory. I'm curious at a place like yours where, you know, simulation, and I'm sure my codes are like a very common thing that you guys are doing. What does that schedule look like? Like? How much if you could design an optimal sim schedule? Like how much is enough? Like, what's the minimum necessary that to do? And is it possible?

Speaker 3 58:32

I think the data would say, you know, are learning from any course like NRP is pretty much disappeared by four to six months later, right? Whatever, whatever, whatever knowledge you took from that, and technical skills, I don't know, technical skills is probably different. But there's a there's a there's, there's learning theory that when you get to sort of mastery level, it's maybe you need shorter bursts of reminders, right. So if you're somebody who's I've intubated, you know, hundreds of babies now, and I can give those away to every fellow and train them through it, but but maybe just once every couple of months, there's a baby comes on that nobody can get. So I have to step up and do it. And maybe that's just enough refresher for me, right, that I'm gonna do. Okay, so maybe in simulations the same way. So currently, I don't know the right answer, or the currently we do try to do our insight to simulations about once a week. But if you think about that, who, when we've got hundreds and hundreds and hundreds of nurses on our NICU, how frequently will any one individual come back to that simulation? It's probably they can get away with once or twice a year, they're probably going to be, you know, randomly picked to come into our simulation. And so, that may not be enough. I think if I could truly build it in, at least, you know, every four to, I guess four to six months, it got to be bare minimum, that you're coming back for those refreshers for those reminders to that and that's assuming you reach mastery in the First place, right? You know, from an intubation standpoint, we know you need, you know, what do you need, like 1520, successful intubations to really reach sort of mastery level? How many of our learners actually get that? So you're going to have to supplement it with something like simulation.

Ben 1:00:15

We're going to go over time, I've accepted dynamic, no, it's okay. We're not going to make it within 60 minutes. But I have two questions. Number one, what when you draft a scenario for a mock code, what is the ingredient to a great scenario for the people who are designing these mock codes? And then the personal question is, which one is your favorite?

Speaker 3 1:00:34

Oh, well, I don't know, we're still I feel like we're still pretty new at insight to simulation only because we've just we had to pandemic set us back. Right. And that was, and we were we were very hyper focused on a study through recently. And so we had unplanned extubation was our most common and the reason we chose that was because that's a real life scenario that hits you on the floor, you know, that gets everybody right, whether you're, you're working in the delivery room or not, and recognizing it and going through the steps and making sure it isn't done. Well. I guess what I find every time most fascinating really, though, is the teamwork issue. So I don't think you need a very elaborate scenario, to build those out of there. What I pay attention to is, you know, when the person called out for the medication dose, what exactly did they say? And how did the the person drawing up respond? And just the amazing, you know, learning that comes from that when you ask them, like you asked for high high dose? What did that mean? Like, I don't know what high doses? Did you want to give that a number? And learning like that, but then again, recognize, but then when you get feedback, like well, it's on the sheet and it says high dose right here? Like, okay, I give you credit is right there. It does say high dose, maybe, maybe you're fine. Right. So I, I think that human factors i i appreciate, I think the one from a learning standpoint, the one I really love running the most is PA because I do think that is just as a personal thing, having seen that in the NICU and missed and not recognized. And just the devastating answer to that. I just, I feel like from a learning standpoint, it is so great for them to understand what it means to have a heart rate that looks good on the ECG, but it's actually meaningless, right, it is zero and you need to move forward with. I don't care what it is at this point. NRP pals something this kid needs compressions now. And I think that's for me a good one to learn because I think it's very eye opening to people.

Ben 1:02:43

I want to give credit to one of my picky attendings at Mount Sinai when I was a resident who used to always introduce in the mock codes like a human element of mishap. So you would say, All right, let's, let's get a let's get a glucose on this patient, like, shoot like the thing broke. And then your residence and you're like, that's not in the that's not in the in the script. Like it's supposed to be working? Yeah. And it's about like thinking on the fly. And doctors, like I always did these things. And it was great, because it made you realize that yeah, these are supposed to be simulations of real life scenario. And I remember one of them, the glucometer broke, and the nurse in the scenario walked out to go get another one. I was like, Wait, where'd she go? And, and that was that was devastating. But you're mentioning the PA, which I think is a great transition to your beyond advanced videos where you actually are on YouTube, you are publishing videos on topics you've covered already a couple of episodes, including PA, you've covered the thingy for the meconium aspiration tool, you've covered CPAP meds during resuscitation, the videos are great. If you if people haven't had a chance to watch them, we'll link them in the on our website and in the show notes. But can you tell us a little bit about what prompted you to to put this this content out there? Well, I

Speaker 3 1:04:00

think I think one of it was relief that I didn't have to update my NRP videos to eighth edition. I feel like seventh eighth edition was fortunately, not big enough changes for me that I had to totally redo the video because the live action is, is really hard videos to do. cartoon characters tend to do what I tell them to do. It's a little easier to work with. So one of them was then okay, well then, I love this concept that they now have essentials and advanced and I'm like, but again, in my mind, we've got to go beyond that we've got to do beat something beyond advanced for those everyday situations, whether it's in the NICU or in the delivery room. And these are just things that I've taught for years and I've learned over and over again in scenarios that you you find learners all the time that these are areas that are difficult to sort of process in the NRP algorithm. And I just came up a list of I think four or five that I thought would be good areas to cover. And I just started fleshing it out and putting on impetus This was probably back September, October last year where I was really putting my mind to, and I kind of wanted to have a set of them down at the same time as opposed to putting one out and then two months to get to the next one, I wanted to really have them just ready to roll. I've maybe got one or two more ideas left in me, I think I say in the video, give me some ideas posted. I really I'm like out of ideas. But it's not that there isn't more things to discuss in the algorithm, but I think but the goal is to teach something a little bit elevated from just the straightforward algorithm. What are these little nuances in there that we can learn from? And, and I guess, you know, at some point, it's a little bit of hubris, but just thinking that, that I understand this well enough that I'm willing to put it out there. It doesn't make me any better expert than many people working around this country and neonatology. But, but I'm willing to stand up and say, Well, I'll try to I'll try to teach to others. Because for me, that's the biggest compliment I you know, the best compliment I've had through all of this was when Michael narvi, as you mentioned him earlier, tweeted back one of my when I introduced my lease a video on Lisa, I'm a less invasive surfactin administration. He said, he's not only to say this was a great video, that's a great compliment, right. But he said, we're going to use this video now to teach everybody here about why we are going to use Lisa. And that is the goal. That is the whole entire goal of my channel, right? I want people using these things. I spent a lot of time on it. I'm actually using it when I teach different classes. Like why should I say stuff for 20 minutes when I can show a six minute video that covers it pretty darn well. I would love for people to use that right. And I know places that are using it. I just I guess this story stuck out to me. It was one of the weirdest moments and all this making these YouTube videos and things was I was out of delivery. I think it was a straight for delivery, the baby was doing well. And there was turned out to be the aunt of the baby the mom's sister in the room, and she just walks up to me, it's somewhere in the middle, you know, and everything's been going well, she has I knew exactly who you were when you walk in the room. What and I didn't even I was too am, of course at some point. And I'm like, I barely heard her. And I'm like, Excuse me. So I knew exactly who you were when you walked in the room. She happened to be a NICU nurse at another local hospital. She's like our NRP director makes us watch every one of your videos. And before. That's like that is so weird, right? Why in the world? Would anybody know about me? But that was that was one of those weird moments. But that's exactly why I made them right? Use them at your local hospital, use them, see if you can incorporate them into the learning. Think about flipped classrooms, send it out ahead of time say watch this before you show up tomorrow. And we'll we'll answer your questions about it. I think there's some opportunities there. And and that's the point of it. Right? The point is to help educate people, whether it's on these be beyond advanced concepts or just straightforward in RP, get, you know, how do you incorporate delayed cord clamping? How do you get that stuff? And well, these are things that have just come up as I've learned about it as I'm like, well, I need to teach this to people, can I wrap a video into that that other people might be able to use?

Daphna 1:08:08

I think you've given us some great ways to use the videos on like a systemic level. But say for an individual learner who just you know, is following the channel picking up the the videos, what do you think is the best way for people to like cement? The learning that you're putting out?

Speaker 3 1:08:30

Well, I think at some point, you've got to actually practice it right? I think, you know, we talked about the Formula One racers, I think that's a great analogy that been brought up the you know, they're simulating it their finger, but at some point, they got to actually get out there and drive the car. And I think I think you can't take away the need still for those, especially technical skills continuing to go. But visualization is a huge part of it, right? Really, so much of what we got feedback, when we started introducing the videos at the beginning of each technical training session in our ERP class was, I could finally see what it was supposed to look like, right? It's one thing to read the algorithm, it's another reason to see it, oh, that's how the people actually should interact. That's how it should look. And that visualization helps them so much that when they go now as a team and actually do it, they have a shared concept of how that should look. And I think that's powerful for the learner. You know, it's, it's, you know, it's Google themselves and YouTube, and you get in there some of their content creators stuff, they'll tell you that, you know, when they talk about how memories retained, you know, so much, you know, picture's worth 1000 words, right? Videos are worth so much more than that. And the way they can really tap into a part of our brain that really helps us memorize things or see things were a snapshot in our mind of how things are supposed to look. So I think it's a powerful, powerful tool. It's not everything, but it's it's a powerful tool for learning and so I don't mind putting in there and then and then take away a lecture for To me it just the ogham watch that instead, I think it can work that way. But then you have it should leave more room in those sessions to be more interactive, it should lead room to be now for that individual. Hey, what are the parts that you didn't understand? Or what do you need extra work on?

Ben 1:10:15

Yeah, and the videos are actually very realistic in the sense like, I mean, I use your the one time we did Lisa, right? At our previous institution was because, yeah, watch the videos like that we're gonna do this. And I think sometimes the American Heart Association, you know how they have these videos, and they're so polished, and they're actors who've never been in any stressful situation before. And you're like, that's not real.

Daphna 1:10:38

Yeah, didn't even look stressed on the right. Like, it's not realistic at all.

Speaker 3 1:10:43

I love the people that made those videos. You know, when we first made the three main NRP videos, we started incorporating museum art class and said these are these are great, I need to get these out there. And I went to I think it was IPSs conference several years ago, and there was people there in the NRP. They were the developers of the app, like, hey, we want content on this. And like, Hey, I'm willing to let you guys put my videos on the NRP app, and it just just went went nowhere. plunk. And in a similar way, you know, my impetus on like, Well, nobody's gonna just watch something I put out there, who am I right? Nobody knows anything about me. I'll get it on our hospitals website, on YouTube site, right? And they're like, Sure, we'll put it on there. And then I found out, they put it on there. I'm like this so happy. But they made it unlisted, right. So you can actually search for it and find it. That's actually the videos we use in training in our class, right? They don't, they don't know any better. They don't know whether this guy is selling junk or not. So they don't want to put it on, I get it. But on the other hand, was sort of like, oh, that's what pushed me to make my own channel, I'm like, alright, well, you're not gonna make it public on your channel. I'll make it public on my channel. And, and, and then just seeing that that has gotten good responses. And I do know other NRP programs that are using it and actually using it to train their learners still using those videos. So I think it's, it has been valuable to people. And at some point, NRP is going to change the algorithm enough, I'm gonna have to redo them. And we'll see what that looks like. But, but I definitely think that's the way to teach it. So committed to keeping those up to date.

Ben 1:12:13

That's good. Awesome.

Daphna 1:12:15

I have one more question, then I'll let Ben finish out the show. We, you know, for places that are not doing a lot of Sim or mock resuscitations, and things like that, and maybe they're, you know, weary about doing it like, right, quote, unquote, what is your kind of, I guess, best suggestion for getting started? And I guess to follow up on that, like, obviously, we're trying to make things. We're trying to video things, we're trying to make things as much fidelity as possible, but say you don't have access to any of those things. How can any hospital do better?

Speaker 3 1:12:57

So first of all, I would say I'm a huge fan of low fidelity simulation, I think, I think the steady support that you get as just as much anxiety provoking cortisol rise in a person as you do with high fidelity simulation and the learning, especially on team based learning, you're gonna get just as good a learning on a low fidelity, high fidelity. So number one, never ever, ever used that as an excuse, right? Get out there with your low fidelity mannequins and start doing it. So that's the first thing you just got to you got to do it, you've got to decide and get the commitment that you're going to do it, really to make it run you need people who have protective time. I mean, are we struggle with that still, I think I'm there almost every week running the insight to simulations, we're taking a bit of a pause right now where we kind of retool some things, but the, you need that dedicated person and I don't really have protected time for it, but I'm going to do it, I'm going to make sure it happens you need that sort of level of commitment. And that's hard to get I know, but But recognize if it's important, it should be it should be given to an educator or something like that, that can have that amount of protected time to do that. And then I would say that you do have to pay attention to psychological safety. That's that's an important thing. It's so easy in sim. And I've had some really bad episodes where I've unknowingly right and and not on purpose really hurt some people in simulation and just just emotionally never, ever our intention. But wow, things that came up that I didn't believe would have that. So it's probably going to happen, you're going to be ready to deal with that, you know, apologized correctly, move on with it and continue to learn from that, but, but some level of knowing how to debrief those sort of sticky, hard emotional situations of psychological safety is really important. But some of that you can't train enough for you're gonna have to learn as you go. Sort of where to navigate some of those those really high emotion situations. And so I don't know, I think I would start by saying low fidelity is just as good as iPad Elodie, so don't don't let that you know I need the $80,000 mannequin stop you from starting right get get something low fidelity and start doing it.

Ben 1:15:11

My last question for you Nathan is I was fortunate enough to be trained as a resident in the era of intubation from a conium. And I got hundreds of intubation, I used to enjoy going to the delivery room and every time in the courtroom and floppy baby came out, like that was my chance to practice repeated intubation if that was needed. And then now I feel like as fellows, there's much less opportunity to practice specific procedures. I am wondering how can we make sure that trainees acquire the necessary skills to be comfortable and confident and independent in their, in their practice? Considering that our field is shifting?

Speaker 3 1:15:52

Yeah, I think that's the big question for a lot of people, right. And so there's other people have written written statements like this one not too long ago, that basically said one thing to do is maybe focus on the people who really need it. Like, unfortunately, it's probably unrealistic at this point in neonatology to train every resident on how to do good and get them to competency on neonatal intubation. So maybe we just have to admit that the general pediatrician is not going to be trained on this and take that off the competency list, I'm actually would be a proponent of that. Instead, for them focus on LMA use, right that's not going to get them that small preterm babies, but l amaze should be able to take a place a lot of that when NRP, elevated LMA to sort of equal status with endotracheal term tubes and firms in terms of the alternate airway and Mr. SOPA. When they did that, they sort of opened the gateway in my mind to say this is an adequate way to do it. We should be training on this more. So then you could focus on even whether they're in residence or in fellowship training them but that that still doesn't get to your problem. Like you said, Ben, I mean, already had a few intubations under my belt as a resident so going into fellowship I started not it, not it blank never doing it, I started at least at some level of on my way towards competency. And that's where of course we're struggling so many players struggling because you fellas are now coming in with fewer and fewer intubations and you're starting at a different level. And now some guy says, Well, you know what, we don't need to intubate them all let's just do Lisa. And now I've had trainees who I'm trying to help learn Lisa who've really never done intubate tracheal intubation enough and and Lisa's takes a lot of the same skills it's it's a different set of skills to it's what I tell them when I'm trying to teach them least I say, it's just like any other intubation you ever done number one, number two, it's unlike any other intubation you've ever done. Because it's just a different set of skills and so but now I'm I'm working with people who don't really have that competency to translate from 80 tube intubation to Elisa catheter placement. And so I think simulation takes a part of that you've got to think that's got to be part of it. But as you mentioned earlier, the mannequins are all nice and floppy and their mouths are wide open, secretions are nowhere to be found. That's right. And you know, how many times to people spend on suctioning you know, that 30 seconds NRP gives you 30 sec 3029 seconds of is spent suctioning you know, and how are you going to get that last second? How are you going to get the ET tube in? I think it's a daunting task. And I think really the way forward, I would echo something I heard Henry Lee say, we need brand new technology. We need something that whether it's some version of video laryngoscopy or something that actually fits our micro preemies don't get me some device that's giant made for term babies. Give me something made for a micro preemies that just helps guide the tube in forming, right something, something that we haven't even thought of that has to come along in some ways and just take the place of the current endotracheal intubation process that that will put an EEG tube in the airway in the correct spot,

Ben 1:18:58

like the crosshair of a fighter jet. You know, when they lock in and be like, you're locked in. Yeah, you

Speaker 3 1:19:02

just throw it across the room, right? Just like a paper airplane that just goes in. Right. You got something something news got to come along.

Ben 1:19:09

All right. That's fair. That's fair. If you're listening out there, get it. Get it out there.

Speaker 3 1:19:14

Yeah, whoever's got it in their mind created. Yeah, yeah.

Daphna 1:19:17


Ben 1:19:19

yeah, Nathan, this was this was tremendous. We went over time it was

Daphna 1:19:22

we have more things we could ask for sure.

Ben 1:19:25

I still had some some questions on my hands. But that was amazing. And for anybody listening, if you haven't checked out the beyond advanced videos, you should. They're very thorough there. They're gonna reach a very wide audience because I think if you are a seasoned neonatologist, you will learn tremendously from them as well. The PA one was excellent. I liked the thing. The little thing about the meconium aspiration was a lot of fun. And yeah, thank you for your time. Nathan, this was this was tremendous.

Unknown Speaker 1:19:52

Thank you guys so much. Been a pleasure to be on here.

Daphna 1:19:54

Our pleasure. Have a good one.


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