Antibiotic Selection and Stewardship with Kate Pocock, PA

You're listening to Streetside, the Street Medicine Institute Student Coalition podcast. Hello, this is Michael Brennan, your guest host today on Streetside. This is the official Street Medicine Institute Student Coalition podcast, and we're so glad you've joined us. Today I have the pleasure of interviewing Kate Polcock from Los Angeles, California. Kate, welcome to the show. Thank you for having me. That's great to have you, and please introduce yourself to the audience. Sure, so as you said, my name is Kate Polcock. I am a physician assistant with USC Street Medicine, so I practice in boilheights. And along with that, I also get a chance to work with the workforce development and education arm of our program. So that gives me an opportunity to do lots of education around the state of California, as well as across the country, and then also do a little bit of research. And in my free time, I'm getting a doctorate in public health and health policy, in healthcare management and leadership, so getting to spend a lot of time bringing all of that framework to the street medicine context and having a ton of fun with it. Wow, that's a lot. Tell me about your educational journey, where did you just start and how did you get to where you are? I started one of those classic cases of folks who really had lots of different journeys, and all of it brought me here today, which is super fun. But I started out getting my undergraduate degree in environmental or science at Berkeley, and really thought I'd spend my entire life modeling climate for NOAA and doing things like that. But through lots of different changes, ended up getting more onto the public health side of things. I went down to Australia to get a PhD in tropical medicine as it relates to vector diseases. And through that process, decided that a clinical degree would really benefit me quite a bit if I wanted to feel like I had a strong context in public health. So dropped out of that, headed over to Duke University, where I got my degree as a physician assistant, and I was really lucky. I got to do an underserved scholarship program while I was there, spending most of my time getting to take care of folks in rural areas around North Carolina. And so that really set the tone for my plans for my career. When I left, I set this uncharted territory of I want to go serve every low-income population around the country so that I can see what's tough, what's tough for my patients, what's tough for me, what's tough about the system. So I did. So I set out locumseeing all around, and it eventually landed me on the Navajo Nation in Arizona, where I fell madly in love with my patient population and my peers and the hospital. And so I settled down there for five years. And then shortly before the COVID-19 pandemic, I moved over to the White Mountain Apache reservation over in Fort Apache and started to take care of folks there. Both in the ER and then got pulled sort of out into the community as we were doing a big COVID response that was much more focused on that sort of community approach. Begin to accidentally do street medicine, like very, very unstructured, which I think is how a lot of folks get into street medicine. And through that, decided, you know, it'd be really fun to see what this looks like in a structured environment. So I called Brett Feldman at USC and I said, hey, can I just come shadow? And he said, yeah, absolutely. So I came out, had the best time ever with the team, and at the end of it, Brett said, so by the way, we kind of have a job, right? So you know, at the time, it was actually a really good decision for me and my family. And so we came on to LA. And now I've been with USC for two years. And it has been the fastest two years ever because it's just been so much fun. So I love your use of the word fun. Yes. That's awesome. Tell us about Los Angeles and homelessness at street medicine. What's it look like? We hear about the huge numbers. But what does it look like from your vantage point? Yeah. I mean, I think that one of the things that a lot of people, especially who are in homelessness services in LA, can feel a very strong sense of being overwhelmed, which is why I think we're really lucky to be in street medicine because what we get is a chance to have a lens that's at the street level and also realize how impactful it is to do all of these programs even on that small micro level. But very much so when you look up and you see just the sheer breadth of the situation where we are, it can sometimes feel like there's a lot more that needs to be done. So I am just really grateful to get to be a part of the community that's doing our best to try to see what we can do. And you know, I think I heard a really great, a really great thing from somebody at this conference, what's what is essentially start with one, it'll turn into 10 and it'll turn into 100. And I think if we can keep that mindset and just remind ourselves how valuable that is, it will take us really far. I would imagine you see a lot of wounds, infections, abscesses in your work. Can you speak to that? Yeah. It's probably one of the top things. I think that we take care of the other really interesting thing about wounds too is it tends to be one of the major things that folks will wave us down for or that we can outreach because it's something we can see. I can't look at you and see your diabetes or see your hypertension, but I can look and say, hey, can I help you with that? And so it really is one of those sort of low barrier ways to connect with a patient. And I love it. I think it's really fantastic. I got really lucky. In my time in the ER for those seven years, what I really did was I asked my nurses to teach me as much as possible about wound care because in clinical, in clinical education, we don't get a ton of wound care in PA school or I've heard a lot from folks in med school and in peace. Well, in peace a little different because the nurses tend to sort of have that background. But I tried my best to learn as much as I possibly could about wound care and I am incredibly grateful that I did because it's really important to understand all of the different bandages we have available, but also what we should not be using, right? Because first and foremost is do no harm. So we have to just really contextualize all of our wound care plans, specifically to street medicine, but also to all of our individual patients. And I think it looks really different than brick and mortar wound care. We're going to talk more about that. But I have to offer a comment first for my own experience in street medicine that the water or the sandwiches or the socks become our calling card, but also the bandages, you know, that that wound that has been there for weeks for the patient and isn't going away that we can we can dress. And sometimes that we do that even off the record. We just, here's the antibiotic treatment and a bandage for your finger and then we build that rapport. And the next time we come around, we can go deeper, further, broader into their health care. Exactly. So what kinds of things are you seeing? You know, so I will speak to sort of that global or that national perspective. We're not seen as much as I was seen as I think the East Coast is seen. And so that is something that hasn't made its way to us because I think, you know, perspective is really important based on where you are in the United States. So I see a little bit of everything. Of course, I see those chronic venous stasis ulcers. Those are something that are really prevalent. We see lots of wound care or of wound issues secondary to folks who have lots of exposure to the elements. So if I have somebody with trench foot that goes untreated, you know, those are some, some of the more common things, also inappropriate shoes that are just giving that chronic friction rub, especially in a diabetic. And now all of a sudden they have this really unhealed wound. We certainly see trauma that has resulted in some wounds that are having a difficult time healing. And then certainly quite a bit of abscesses. And so I definitely see that. And that's, you know, secondary to lots of trauma that can happen to the skin, whether that is from an IV drug user, or whether that's just from somebody who is putting a hand into a recycling bin to pick out a can, and there is now a really big wound that needs a lot of our help. I'm curious. Are you using butterfly ultrasound on the streets for abscesses to check for fluctuation and fluid? Is that something you're doing? So that's a really good question. The answer is yes, no. Yes, we are. But we are still sort of formalizing the ultrasound for all of the folks on our team. What is somebody with any background who had an ultrasound at my hand all the time for seven years? Well, not for seven years, but certainly in the last few years. I have become very accustomed to wanting ultrasound all the time. Also my folks love it, right? Like patients just think it's great that you get to sort of show them, like, hey, this is what a fluid pocket, yeah, this is your fluid pocket. So do I, yes, it's when my medical director is able to, you know, come out with me or hand it to me at times, yeah. Definitely using it. So the standard is in a drainage of an abscesses with an 11 blades kelp or 15 blade and open it up and break up the calculations, the pus pockets inside. And that's what we've learned to do in the emergency room. One of the PAs that I met two years ago, I'm going to mention it by name Joel Hunt from Fort Worth, Texas, encouraged me to use a four millimeter punch biopsy for smaller abscesses because it keeps it open, allows it to drain, and it's been very effective in my practice. Is that something you do? So I'm going to take it one step further. I am, so I think the punch biopsies approach is fantastic. I also think a typical, you know, incision drainage with 11 blade is great, but one of the practices that really was taking off in my ER when I was when I was the partying was loop drains. Have you spent any time with loop drains? - No, don't know what those are. - So yeah, so this is something that the ER world is really starting to get behind. And essentially what it is is it's two small incisions on either side of the abscess and I'll get into a second where you can kind of get yourself in trouble there. But it's two small incisions and you take a small vessel loop drain which are incredibly cheap and super easy and you feed it underneath and you tie it off on top. And so what it does is it gives a little handle for flushing. It also lets folks, it is very easy for them to remove themselves. So if somebody were to just tie it off and pull it, they'll be just fine. And so this is something that we were doing pretty, pretty like universally in our emergency department and having fantastic outcomes. Patient satisfaction was really high with them and decreased rates of needing further intervention was super low. So I got really into it. It has been hard to get my hands on small vessel loops for the street. That's been sort of my smaller issue here and there. And then the other key thing to know and this kind of comes back to the ultrasound is making sure that you don't make your incisions too far that you can't actually feed it underneath. And so one time in the ER I did that and had to ultrasound myself to connect the two sides. So definitely it's not a perfect science but it's one where I've actually had significant, like I say, the patient satisfaction and also just the outcomes have been really helpful. So I haven't found a ton of street medicine folks that are doing it yet but I have found a few, most of them with the ER background. Those are kind of the folks that are interested in it. - I've seen them from the ED. - Yes, yeah. - Seeing them come out back on the street. - Yeah. - I remove them. - Yeah, so I'm trying to sort of really kind of shop this idea around a little bit more and see what other folks think 'cause I really do like it. And then what I'll do is I'll leave folks with a water bottle and I'll just take a 16 gauge poke hole on the top and now they've got a high pressure flush so then they can just pull it up flush and it's really great. - That's appropriate technology. - Yeah, exactly, yeah, no, it's really great. So that is one, but again, back to your question. I think the punch isn't great as well. Yeah, I've seen really good outcomes with those two. - Yeah, I really, it's less painful for the patient as well. So let me ask about your favorite moon care dressings. What do you use? - Yeah, so that's a really fantastic question and I have two off the top of my head that I pretty much talk about with everybody. In terms of, and this isn't addressing, although it can be impregnated into it, but Medihoney is just, I mean, I carry a pouch which has Narcan, I protection and Medihoney. Those are like my three sorta go-to's and you can get bandages impregnated in Medihoney which is really, really nice. So that's probably one of my top favorites. And then also, I do admit that I come from sort of a background where we didn't have a ton of bandages. So I am a huge fan of just your simple, simple things. - Such as ACE wraps. - ACE wraps, I love a good curlics. I think that's something that I'm really happy to sort of give out to folks, although of course, talking about heat and bulk bandages can be really complicated for some folks. But just the non-adherent bandages, I really like the opportunity to leave patients with their own supplies. And so this really comes back to this, like, do no harm concept, right? And so one of the things that I just, I love and appreciate about the patients we get to serve is that they are very willing to share their supplies with others. So I will not leave something like a calcium alginate or something where it could potentially do harm on a different wound. And so I really love the opportunity to just leave these very simple supplies where even if it didn't get to my patient, if it gets diverted to somebody else, it's going to be fine. And so I do like to do that quite a bit, especially if somebody has identified themselves as someone who's excited to sort of do their own wound care, a simple approach is best for that. And so I really like to sort of stick to some of those. And I love it. We have a wound care nurse in California who does a lecture called Wound Care from the Dollar Store. And I just think that's brilliant. It's fantastic. So yeah, so those are some of my favorites. And then of course, I love a good phone. I love a good alginate for all of the reasons, but I think more commonly than not, if I'm reaching into my bag, I'm pulling out Maddie Honey, or I'm just pulling out my simple things. - Yeah, that's great. And you made me think of two things. One is when we do this wound care on the street, I often like to give patients choices, right? So we need to do this for your wound, but we can wrap it with curlex, colban, or an ACE wrap, which do you choose? And just to give some agency and autonomy to folks. And we've also identified people that are the EMTs of the community. They're not EMTs. They're just other unhoused folks, but they take care of everyone else. So I load them up a little bit. Like, oh, here's some extra antibiotic ointment of band-aids. And that leads me to a question. What do you think about antibiotic ointment? You're probably sworn and neosporant. - Yeah, I mean, I think that that is a tricky question, right? Data used to support it, data now is a little bit mixed. We have muperison in our bags, so I'm pretty excited to get to pull things like that. - Some of our listeners may not be clinicians. So what's muperison? - Yeah, so muperison is a topical antibiotic ointment that is prescription, but has really great effects against merseaux, which is one of the reasons why I'm a big fan of getting to pull it out. And so it's also just very similar in its application as what we're talking about, like triple antibiotic ointment. And it comes out in a way that's pretty viscous, so it's not uncomfortable for patients. Super easy for them to administer to themselves. And it also can be, I've never experienced anybody who say it burns or anything like that, like some of some of the other, you know, prescription stuff that we use. And so this is something we recently got on our formulary. So before I was using things like vasotrason pretty readily, and I still use it, like I think that is something that has a lot of value. But I'm also paying attention a lot to the literature that's coming out that is more specific to the etiology of the wound, 'cause we do have lots of folks with burns and things like that. And it's not just from heating sources, it's also from cooking and doing that kind of stuff. So I really like to make sure I understand what caused this wound. And that's gonna probably influence some of my prescribing habits a little bit, or some of what I'm pulling from the bag. - Do you carry silverdeen? - We don't, and I really wish we did. - The literature and the practice coming out of Philadelphia, where they're dealing with a lot of xioazine wounds, is silverdeen rather than, you know, you can use metahoney, but silverdeen is their go-to. - Yeah. - Which, you know, as goes Philadelphia, goes the rest of the country. - Yeah, no, I have to say any opportunity I have to learn from that Philadelphia group that's been doing this xioazine wound care for so long, I'm all ears for them. And I've just been really, really intrigued to hear that that sort of lesses more approach with these xioazine wounds. And I have to be honest, I'm not sure that I've seen one. I can't speak with, you know, definitive nature, but my patients have access. We include xioazine test strips in our harm reduction. And none of my patients have had a positive yet. So I'm, you know, I'm waiting for it. But yeah, no, I definitely think that it's really intriguing. And I suspect when we do start to see xioazine wounds, that we'll put some solvening in for sure. - Yeah, great. Let's talk about antibiotics. You're seeing a patient with a pretty good abscess with surrounding cellulitis, soft tissue infection. What's your approach? What are you doing? - Yeah, so this is a really, really interesting topic. 'Cause I think antibiotic stewardship at that sort of global perspective is gonna be a little different than the perspective that we have. So I know recently there's been lots of shifts to not doing dual therapy, not doing your catholic spectrum and things like that. But I will say I still do that. I think for the folks that we take care of, it's really, really important. Because I have seen non-perulent MRSA and I've seen some things that are a bit atypical. And so if I've got an abscess with surrounding cellulitis, first, you know, if they consent to an IND or anything where I can get rid of some of that post for them, first and foremost, that's what I'm gonna do. And then of course, culture, culture, everything. You know, I think that some folks might think that you can't transfer a culture well or easily, but it is fine, my culture has come back great. And you and I were kind of speaking about it, but I've really been sort of studying some of the culture results of our group altogether. And there has been a lot of polymicrobial cultures with two or more what appeared to be actually pathologic, you know, issues. And so lots of co-infections with MRSA and Group A strap or one of those, you know, one of those kinds of combos. And so I do think about that a lot when I'm prescribing and I don't think that a solo agent necessarily is going to properly address the issues. So yeah, so I'm still doing like a Keflex back drum or a Keflex Doxie. I don't touch clinical mice in very often and it's not 'cause I don't love it, but it's purely because of the GI upset that it impacts folks. So I've pulled it twice now in my time doing street medicine. Once was for a pregnant patient who was going inside and had MRSA infection. And then the other one was for a patient who had just really, really severe cellulitis and wasn't willing to go inside. And I had talked to her and she was willing to sort of accept the GI upset of it. And so, but otherwise I'm a big fan of Keflex back drum. Historically it was Keflex Doxie, but again, I can kind of go into this, but I essentially decided that it was, you know, we really needed some better targeted therapy. So I developed an enhanced antibiotic for our group specifically to skin and soft tissue infections. through that was able to see the doxia cyclan versus MRSA in the patient population that we're serving was just terrible. So it was pretty practice changing for me because really, I thought, you know, catholic soxia was just such a great combo and we know how good doxia is for some other things that we're treating. And so it just felt like a good choice. And now I've had to really kind of reel back that thought process and get back to that sort of catholic spectrum approach. - It's interesting the geographic or regional differences that we're seeing increased back-to-em resistance with the MRSA and where it's sensitive to the doxia and maybe because back-to-em is used. So that's our first line. And I'm curious as well. What doxia do you do on the catholics? - I do do four times a day. It's not great. I think like the key, it's so tricky. First of all, we pull from our bag. And so our bags are sort of preloaded with, you know, with the medications that we already have dosed out. And I will say with that QID, for starters, I had to take catholics myself two weeks ago. It was impossible. I missed doses left and right. I mean, I was 100% like the person that could not adhere to the medications. And so it's a little tricky, though, because I think if we are, if we're sub-treating things, then that's also not great. So if I'm telling you BID, then we're still not doing well. So what I've started to do, I still don't know how much I am committed to this idea, but this is my current practice, is to say four times a day and hope for three or two, because if we can shoot for the moon and get some of those stars, it might be pretty great. But I'm still pretty mixed on this. I could be convinced of some other options. - Okay, so in Rochester, New York, our standard is Augmentin, 875 twice a day, with back-term double strength twice a day, both for 10 days. Do you use Augmentin at all? - I do sometimes. Of course, I use it for any of my animal bites or dental infections. That's gonna be the first one that I pull. But yeah, I would say intermittently, but oftentimes it's after I've gotten a culture result back and I'm making a modification. If I see that it's gonna be a really great choice and I don't have a penicillin allergy in front of me, then I will choose that one. But I can't say that it's the first one that I pull from the bag. But again, I have more data now to look at in terms of our cultural results, and so, if I were to find a trend where it looks like that would be a better option, I would very, very much be willing to try that. 'Cause I think that BID dosing is so much more doable for our folks, but I have a question for you. Augmentin and the GI can still not go great together. What do you find in there? - Well, it can cause the diarrhea, which is a huge downside if you're unhoused and a rough sleeper, but my patients tend to get at least seven days in. - Okay. - So we're still using it, and I'm not hearing a lot of complaints. - Okay. - Thank you for asking me a question. I'm gonna reverse it back to you now. Stewardship of antibiotics. On the street, those of us who's using street medicine are seeing a lot of infections. We're using a lot of antibiotics. Tell me about what does stewardship look like for you? - I think that is exactly something that I'm asking myself that right now, but I think that the best thing that we can do is start to work on targeted prescribing habits, but it has to be founded on data, right? And that's one thing that street medicine is really starting to get behind is first of all collecting data, which has not been something that's always easy for everybody, and then aggregating that data and driving the car that way. 'Cause in LA County, when I first started to explore this topic, I got really excited because our LA General Hospital puts out an antibiogram that is a county-wide antibiogram that has 80% of the hospitals submit data. So it felt really comprehensive and I was like, "Great, this is awesome. "We should be using this to target our prescribing habits." But then when I started to follow that, I realized that it really wasn't working specific to my patient population. So that's where I think my current soap boxes that we really need to start thinking about. How do we make sure that our targeted prescribing is specific to the folks that we're taking care of? And that's gonna be kind of more on that micro level. And so I think for me, antibiotic stewardship is, of course, along the similar lines of don't over-prescribe, don't under-prescribe. But also, how do we really enhance our knowledge of what the pathogens are that are impacting the patients we're serving, and then what do we need to be using against that? From the street level view too, I think it's so much education for our patients on so many different levels. I think it's describing to them why it's so important that they finish these antibiotics, right? I think if you just say that, which is what most pharmacists say, don't forget to finish your antibiotics, then that's not enough, right? Let me explain to you why this is really valuable for you to finish all these antibiotics. Let me describe to you why it's really important that these antibiotics don't go to your friend or anything like that. In fact, let me see your friend instead so that I can get them the correct antibiotics. And then it's also just making sure that you are dropping all the barriers that you possibly can for the folks that you're serving in terms of adhering to those antibiotics. So, will a pillbox help you? Can I help you with that? Is it going to be the case where you're possibly getting displaced here shortly? And so what can I do to help you? I've been known to buy those little passport holders off Amazon and then tuck a pillbox into it. And my patients are like, this is awesome, right? 'Cause it stays under the shirt. It's on them and they're able to kind of, and also it's like, you know, it's right there. So they remember to kind of take their meds. So lots of those sort of little tricks, but also really, really asking my patients, like what's gonna be easy? It's that motivational interview and what's gonna be easy about taking these antibiotics, what's gonna be hard about taking these antibiotics and how can I help you? So I think that that is more of where I'm focusing that antibiotic stewardship concept. - That's beautiful. I love the passport holder with the bill bottle. - It has been a game changer. And also, you know, outside of just antibiotics, but Suboxone and other things, I have had so much good outcomes with using that. And it's super cheap on Amazon cost nothing, so. - Something that we struggle with in my program is the patient that will refuse to go to the emergency room for an infection that really needs IV therapy. What do you do? - Yeah, so first I ask a lot of questions. So what will be tough about going to the ER? Because we know that there's a lot of things, but our patients have so many competing survival priorities. And I need to know which ones are gonna be the ones that are really going to make it difficult for you to go in. So is this gonna be an instance of your very concerned about withdrawing there and you maybe need an advocate? And I can go and advocate on your behalf. Maybe I can see if there is an addiction med team that can consult out of the ED. What can I do to help you there? Is it gonna be your belongings? Is it something that comes down to that? And I was just in a small group of the bunch of folks who talked about identifying some of their local partners who were able to store belongings for people while they went into the hospital. And so just trying to figure out what are your barriers and how can I help you drop those? Also validation, right? Going to the hospital is horrible. It's awful for anybody. And so I never sit there and disinvalidate their distaste or just, you know, their desire to wanna stay where they are. And I think once you can kind of validate then it lets them sort of be seen a little bit better and you can kind of get more to that deeper conversation. And then what I'll do is maybe see if there's a plan later on, right? I know I would love for you to go in right now, but is there a chance maybe you could go tomorrow or the day after because that's gonna be better than nothing. And if all else fails, and actually I was telling everybody, I was taking care of a gentleman who had an external fixator on his leg for a year and a half. And that was when I found him. And so those are gonna be sort of those big, clunky halos that are on people's legs. So by the time I found him at a year and a half, he had just horrible infection that was visible. It took me a month and a half, but I visited with him all the time. My outreach team met with him all the time. And we just kept talking to him and building that trust and coming up with a plan. I also told him I said, look, if this is gonna take a while, what are we working towards and how can I help us get there? So we slowly checked each box to really help him so that he was going to feel like, first of all, he had autonomy. Like he was building the plan himself and he was on board with that. And so by the time we checked all the boxes, I remember looking at him and being like, the boxes are all checked, what do you think? And he was like, okay, I knew when it. And we got it all taken care of. And so it's really persistence and it's really following up and it's really being non-judgmental and gaining trust. And then if all else fails and it looks really bad and you're really concerned, we have Roceffin. I will often times use Roceffin. And I'm not sure if I'm allowed to name other medications on this, but I'm really working on trying to fix-- - Use generic name, generic name. - I'm trying to figure out how we can get deptomycin as an option for-- - Is that Delta Vanson? - Yeah, Delta Vanson, sorry. Yeah, sorry, I didn't give you the generic. But yeah, so that is something I would love to see. I actually got to help with a study at one of our hospitals with that and just had fantastic outcomes for patients and they loved it. So 30-minute infusion and I think we can do this. So I think you and I have had some, yeah. - We're gonna do more questions on that. First, the CFTRA axon, one gram-- - Yes, a grant. I am intramuscular daily for okay, that's what you're doing. Okay, let's let's bring our audience in on in on what we're talking about. When we send someone to the hospital and they need IV antibiotics, they're getting their daily vancomycin for whatever 10 days so they need to be hospitalized during that time. The medication we're talking about Delba Vance and has a half-life of 14.2 days and is a half-hour infusion, IV infusion. So I'm curious where is Los Angeles on developing a protocol and using that? We are being very thoughtful. We're trying to find other folks that might have a protocol and so far I don't think we've come up with with that. You and I have talked about your protocol and I'll turn the tables on you. Well okay, the protocol is to rely on the experts. So we we have a we have a DNP, FNP infectious disease specialist who is very helpful to us and we'll see our patients routinely and we let her order the Delba Vance and then we go to the IV infusion center with our patients to do it. We have not done it on this street. Does she think it's it's doable on this street? Oh she she well let me I was going to respond to the question I thought you were going to ask that she loves Delba Vance. Okay so she it's so useful for our population in terms of the osteomyelitis the you know even the endocarditis so it's it's really a lifesaver. So she's a big fan. I think she is she is in favor of us offering it on the street but those protocols you just when we talk about antibiotic stewardship you don't want to get into a situation where you're like oh everybody needs Delba Vance and you want to save it for for where you want to target your your treatment therapy so that's highly effective and not going to create resistance. So we're working on that. I think that this might be sort of a consensus sort of topic where we might need to really consult with lots and lots of specialists on it especially folks who are using it like you know like the folks that you're working with but but I do think that this is something that is doable but I agree with you we have to be incredibly thoughtful about patient selection for it because you're right it is such an important tool in our toolkit and if we lose that for our patient population it will be really really terrible. Yeah so this edition of our podcast has been more clinically focused than most which is which is great and appropriate and I've really enjoyed our conversation. I'm going to ask you two final questions first of which is if you could give advice to our listenership of something they could do to make the world a better place what would it be? Yeah I think one of the key things and this is really integral to street medicine is to slow down and see people for who they are right so often we are quick to make assumptions we are quick to feel like we absolutely know somebody and we just don't and so whether that is you know taking in nonverbal cues or just asking more questions about people it's it's wonderful for them but it's wonderful for you and then it's wonderful for humanity so see people where they are see people for who they are and that's everyone you know that's our patient population and that's your family that's your friends that's that's everyone thank you for that there's we we tend to go to taxonomy immediately with meeting a new person of where do they fit into my previous experience and to have a fresh fresh eyes fresh look you know to withhold judgment that's that's so vitally important so thank you for for showing that piece of wisdom. The last question is how can folks connect with you and your program and support you and and what can what can people do? Yeah so I mean in terms of connecting to our program we do have a landing page USC street medicine and we actually put on lots of different trainings around California so we are open arms there's no cost to our trainings we want it to be available to absolutely everybody and their CME for the clinical minded folks and so this is something where it's also a community building opportunity and we love to bring people in so open arms no matter where you are in your street medicine journey if you're thinking about it if you're kind of critical of it and you're interested in hearing more like we want to hear from everybody so we are open arms for all of that and then in terms of just supporting us and what we do I think that the thing that comes to the top of my mind is just to be kind to the folks that we get to serve because you know one of the things I think about whenever I come across a new patient is I'm a mom and I'm a new mom and and and I think so often about the delivery room where that person was born and delivery rooms are very big celebration places right these are places where people are so celebratory and somebody looked down at everybody being born and said I wonder who you're going to be right and there was so much hope and there was so much love um and I always try to try to bring exactly that to the person where they are now because I think so oftentimes they haven't been brought that so try that try it on because it's a really really great way to to get to help support the people that we're taking care of that's powerful that's powerful Kate it has been a joy and a pleasure to to talk with you thank you so much for your appearance here on street sign and look forward to staying in communication thanks for having me welcome the opinions expressed in this podcast are those of the individuals included and are not representative of the opinions of a street medicine institute or the street medicine institute student coalition do not use this podcast's medical advice and instead see your own provider for medical care