Hello and welcome to everyday oral surgery, this is your host, Dr. Grant Stukey. I am an oral and mixed facial surgeon practicing in Denver, Colorado. The goal of this podcast is to connect, learn, and inspire. In this podcast, you'll be hearing from Ole Miss surgeons all over the globe discussing ways to improve the practice of oral and mixed facial surgery. Most information shared in this podcast will be based on personal experience and opinions, so please supplement what you learn here with approved research studies. If you are a regular follower of the podcast, please go to our website everydayoralsurger.com and register to receive newsletters and find links to our social media accounts. Most importantly, if you'd like to be interviewed on the podcast or know someone who you'd like to hear from or if there's a topic you'd like to hear about, please email me at
[email protected]. Without further ado, please enjoy today's episode. All right, welcome to another episode. Today I'm with Dr. Steve Yoon. He is an anesthesiologist practicing in Southern California. Steve, thanks for joining us on the podcast. Great, thank you. Yeah, could we start by just having you give us just a little bit of background on your training and your current practice setup? Sure. I'm a board-certified physician anesthesiologist. I trained at the USC School of Medicine and then also did my postgraduate training in the anesthesia at the UCLA Medical Center. Like most physicians, I started off my career as a hospital-based anesthesiologist. But for the last 15 years, I have been doing primarily sedation in anesthesia for dentists and oral surgeons throughout the Southern California area. As part of that, I've also become an expert consultant for the Down Board of California. I'm a medical advisory board member for docs, education, and health first. And also recently became a member of the board of counselors at the UCLA School of Dentistry. So even though I'm a physician, I have a great respect and a lot of connections with the dental community. Yeah, that's awesome. So great that you're involved in doing so much so in Southern California. Well, good. We wanted to talk a little bit about anesthesia and how it relates to oral surgery. And specifically about, you know, you had mentioned to me prior of this discussion on some of the more dangerous drugs that can be used or things that we should be aware of as practicing, you know, OMS/anesthesiologists. Can you talk to us a little bit about that? Yeah, so as part of my career, I, you know, review probably 30 to 40 cases involving malpractice or issues and negligence, either as an expert witness or as an expert for the Down Board of California. And over the years, I've noticed a really disturbing pattern with regards to some of these adverse events and tragic consequences. And so the question that I would pose to your audiences, what would you consider to be the most dangerous sedative in oral surgery sedation? What would you consider to be the most dangerous sedative? Now, before I answer that question, I want to be very clear. You know, as a physician anesthesiologist, I want to emphasize again that I have incredible respect for oral surgeons and their training. Really, your especially is quite unique in all the different things that you do. And most particularly in how much anesthesia training you have. Personally, for me, I really enjoy working with oral surgeons because it's like working with a second anesthesiologist. So I'm one of those few physicians who believes in the safety of the single operator anesthesia model. I think for the vast majority of cases that you're doing in your office, you do not need a services of someone such as myself, a separate physician anesthesiologist, in order to provide sedation safely for your patients. That being said, though, I think we have a moral and professional duty to highlight deficiencies or possible problems when they occur. And so what I want to do today is answer that question. What is the most dangerous sedative in oral service sedation? By reviewing a couple of the cases that I have analyzed. And again, this is not meant to be a plenky criticism of all oral surgeons. But I think we have a lot to learn from these types of cases. So let me give you the first example. And that's a 59-year-old male insulin-dependent diabetic, stiff and peripheral vascular disease. In fact, he had a below knee amputation. And he's on continuous peritoneal dialysis. In addition to that, he has hypertension and moderate obesity. He comes to your office for full mouth extractions. So what would you do in terms of your analysis and preparation for this patient? I can tell you that many of the oral surgeons I work with here in Southern California. And I think this is true for many across the country would argue that this kind of patient who is a significant severe ASA3, right? Type 1 diabetes, continual dialysis, probably should be done either in the hospital setting or this is one of those times where you want to hire another anesthesiologist such as myself to help you with the sedation. In this particular case, the oral surgeon decided to proceed by himself and gave 5 milligrams of a dazzling and 100 micrograms of fentanyl. Now, I think for many patients, especially young healthy teenagers for third molars, that's a very reasonable sedation regimen. But I think I would guess that many in your audience would also argue that for this particular patient, 5 milligrams of a dazzling, 100 micrograms of fentanyl is a little bit generous. Regardless, this is an oral surgeon who's had years of experience, probably over 25 years of experience. He proceeded with the procedure. Everything seemed to be going well until after the extraction of the four maxillary teeth, the patient started becoming agitated. How many times have we seen this in our practice where we start off with our sedation? Everything is going smoothly for the first 10 minutes and then you get to more difficult part of the procedure or you do something more stimulating and the patient becomes agitated. What then do you do? You may give a little bit more fentanyl, you may give a little bit more medazlam. But oftentimes, I think the sort of reaction is to give a sedative to help rescue a population. And too often, I think that sedive is kind of mean. And that's what was done in this case. The patient was becoming agitated. You've already given 5 milligrams of a dazzling, 100 milligrams of fentanyl. Perhaps you're thinking, I don't want to give any more of those two sedatives. So I'll give a rescue sedive i.e. ketamine. And so in this particular case, the milligrams of ketamine was given, which I think many of you in the audience would also find to be a little bit overly generous, especially for a severe ASA3 patient. And unfortunately, after giving the ketamine, it led to respiratory arrest, cardiac arrest, and hospitalization. Now, when I present this case, many of the doctors in the audience will tell me, okay, Steve, yeah, that's a very interesting case, but that doesn't apply to most of us as oral surgeons because most of us are much more judicious when that had given such large amounts of sedatives. Or we wouldn't have even done the case in the first place. We would have either referred it to a hospital or referred it to the services of another anesthesiologist to help us. And I understand that. And I realize that this is perhaps more of an extreme example, but I use it to highlight the fact that this idea, this common training or teaching that ketamine is a relatively safe sedive because it doesn't depress the respiration, but can really help smooth out a difficult sedation. Maybe is something that we need to rethink and reconsider. Now, again, I totally grant the premise that this oral surgeon, in particular, was perhaps a little bit cavalier. And as disturbing as this case may be, it really doesn't bother me as much as the other cases I see, in which smart, well-trained, well-intentioned doctors make mistakes and do the wrong thing. Okay, that's really where I want to focus on today, because I'm going to assume that most of the doctors in your audience, just by virtue of the fact that they're taking valuable time to listen to your podcast, are really trying hard to improve their skills, improve their knowledge base, improve their understanding. And so my goal here today is how do we stop good doctors making bad mistakes? Okay, case in point, let me go to case number two, it's a 37-year-old male, five foot, eight, 210 pounds, so moderately obese, who had previous spinal neck fusion with instrumentation. The patient told the oral surgeon that he had some TMJ issues that oftentimes his job pops or clicks when opening and haven't stuck open before, but he comes to your office with left lower molar pain. He has an infected tooth. And so you proposed the extraction of all third molars. Okay, now this particular oral surgeon was very well trained, very well-intentioned, very judicious and careful. So he did a thorough airway examination. In fact, he actually measured the range of motion of the neck, laterally and vertically to make sure that there was enough range of motion for him to feel comfortable in sitting in this patient. In fact, there was some mild, you know, maybe 10 to 20 degrees limitation in terms of the range of motion, but on his exam, it was more than adequate to help him provide jaw thrust or a head tilt. He also looked at the jaw opening and tested the jaw opening with a small bite block and found that there was no issues whatsoever in putting the bite block in. And so he determined after this thorough exam that there was enough mobility for him to support the airway during the procedure. Patient was classified as a maln poddie to an ASA category of two. Now, how would you proceed with the sedation for this patient who potentially may be a difficult airway because of his neck surgery and his limited mouth opening? Well, again, this oral surgeon, I think, was very well-intentioned and had a reasonable philosophy. That is, he decided we're going to use very light to moderate sedation rather than general anesthesia. In particular, he said, I want to purposely avoid an opioid such as fentanyl because of its tendency to depress respiration. And as he stayed in his own words, this patient was not going to get an opioid in my hands. This surgeon was so concerned about safety, so concerned about this patient's airway that he decided he was not going to give the patient an opioid. Instead, he chose ketamine because, quote, it's short-acting for light to moderate sedation and does not depress respiration. So for this procedure, what would you do for the sedation? In this case, the surgeon gave midazlam 4 milligrams and then ketamine 20 milligrams. I think most of you would agree that this is a very reasonable force of sedation. I mean, the dosages are reasonable and relatively small. 4 milligrams of midazlam and 20 milligrams of canine. I personally have no problems with those kinds of dosages for the vast majority of patients. But in this particular case, what happened? They gave the local anesthetic with epinephrine injected six carpules, proceed with the surgery, nine minutes later, the patient started becoming agitated. Then the patient started exhibiting signs of respiratory distress. The surgeon tried several physical maneuvers to open the airway, including pulling the ton out oral airway, bag mass ventilation. He even tried the place in LMA. All of those efforts for whatever reason were unsuccessful. During the course of that four minutes where the patient was having respiratory distress, the pulse examiner went as low as 26% with no end-title carbon dioxide reading. Now, after this, there were a number of mistakes made, including the failure to use a paralytic such as sexual colon. But regardless, the end point of this story is that they lost the airway and the patient ended up dying from hypoxic encephalopathy. Again, from a very small dose of medazlam and ketamine. Now, let me go through my last case, which is the case of Caleb Sears. This is the death of a young six-year-old boy in northern California that has changed the way we think and talk about the regulations for pediatric station in oral surgery offices. Okay, again, a healthy six-year-old boy who came to an oral surgeon who, again, was well-trained, had an outstanding reputation in the community had been practiced for some 15 to 20 years without any major incidents or disciplinary actions. This oral surgeon was able to start an IV on the six-year-old boy, which I'm quite frankly impressed. I mean, how hard is it to start IVs? On small children, but he was able to do it with 50% nitrous oxide. So the IV is in, and he gives small doses of medazlam, fentanyl, and two doses of proper fall for a routine procedure, right? The extraction of a palatal supernumerary tooth. So medazlam, fentanyl, two small doses of proper fall, perfectly reasonable sedation regimen. However, what happens after the first five to seven minutes, there's agitation. Patient starts moving, patient starts bucking, there's airway restriction noted. So what does this surgeon do? You go ahead and do all the things that you've been taught to do, right? Triple air and maneuver, reposition the airway. You start the surgery, things can relatively stable, but you give another dose of local anesthetic, and now the patient becomes severely agitated again. So what do you do? You have a young six-year-old boy, you've already given a medazlam, are you giving fentanyl? You decide that you don't want to give any more proper fall. How can you rescue this difficult case? So in this particular case, again, a small dose, 12.5 milligrams of ketamine was given. After the ketamine was given, the patient developed further respiratory distress. Wrath sounds became absent. Bag mass ventilation was attempted, but again, in these kinds of cases, what typically happens is Murphy's Law applies. The animal beg broke. They tried to call for the sexual colline. They couldn't find the sexual colline because the receptionist was the one that was asked to get it. She looked in the refrigerator, couldn't find it, you know, tragic error. The sexual colline was actually on the cart right next to the surgeon, but no one realized it. So sexual colline wasn't given until it was way too late. By that time, the patient was in severe respiratory distress, and they even tried to do a crack-otheraidomy in a small child, which I think most of you will appreciate is a very, very difficult maneuver, and that was unsuccessful. Again, ultimately, Caleb Sears died two days later. Again, this death has had profound implications for us in California because it led to Caleb's Law and all these other regulations that have now restricted the use of pediatric states in oral surgery offices. So with those cases in mind, I would pose to you the question again, what is the most dangerous sedative in oral surgery sedation? And obviously, I'm pointing my finger at ketamine. I think ketamine is a wonderful sedative when used properly. However, I think all too often we think of ketamine as being a safe respiratory drug, right, because it causes bronchodilation. It doesn't depress the respiratory rate, and as a result, it's a great sedative, especially as a rescue sedative, to help smooth out those more difficult cases to allow us to finish the procedure. But I think we need to rethink and reconsider some of the effects of ketamine. Let me give you, for example, a small study that was published some 27 years ago in the anesthesia literature that looked at male volunteers and the oxygen consumption when receiving either fentanyl alone or fentanyl with ketamine. Now, as you would expect when you look at those two groups, the fentanyl group had more respiratory depression and a decrease in ventilation and alveolar relation compared to the ketamine group. However, when you looked at the endpoints of oxygen saturation and arterial oxygen pressure, both treatments that is fentanyl and fentanyl with ketamine decrease the oxygen saturation similarly. In other words, ketamine seems to attenuate the respiratory depression with opioids, but does so without preventing a decrease in blood oxygenation, right? So all too often we focus on the respiratory rate, we focus on the left side of the equation, but we forget about the right side of the equation, right? Oxygen saturation also depends not just on our respiratory rate and how much oxygen we are being delivered, but how much oxygen we're consuming. And one of the interesting things about this study is that they emphasize the point that ketamine, because it is a sympathetic, mimetic, increases oxygen consumption and it's this increase in oxygen consumption with ketamine that appears in the gate, the effect or the attenuation effect on the respiratory rate. So if you're using ketamine because you think it's a respiratory safe drug, that's really only part true. Yes, it may not decrease the respiratory rate as much as other sedatives, but it's not going to really help us in terms of oxygen saturation because it increases significantly oxygen consumption by the body. So a very small but very interesting study that I think points out some of the problems with ketamine. There was another very interesting study, this was published in the British Journal of anesthesia back in 2024, that looked at the association of ketamine used during procedural sedation with oxygen desaturation and healthcare utilization. So this study, which is done in the US, looked at over 234,000 patients who received ketamine as part of their procedural sedation, and then looked at the endpoints of oxygen desaturation and hospital emissions or discharge their nursing home. And obviously this is a very complicated study because of its large size and because of all the confounding variables involved. I mean think about all the different drugs and sedatives and cold morbidities with over 234,000 patients. But during the last sophisticated statistical analysis, they found that ketamine was independently associated with a dose-dependent increase in the risk of oxygen desaturation, which they define as being less than 90% for two minutes. And it increased odds of discharge to a nursing home. So ketamine was independently associated with a dose-dependent increase in the risk of oxygen desaturation and the increased odds of discharge to a nursing home. Now this is not saying that ketamine causes these things, I mean this is really just a correlation study. But again, I think it really made me pause and think, you know, what am I using ketamine for? And what do I think chemists' properties are? And how much do I really understand about the use of ketamine? As I research this issue more thoroughly, as I see case after case after case of these tragic outcomes in which severe ASA3 patients, you know, usually who were severely obese, coming for a routine oral surgery procedure, the surgeon decides, you know, I'm going to just give light sedation, starts off with good intentions. But then the surgery becomes difficult, the patient becomes agitated. I think we tend to lose our broader vision and we become tunnel vision and we focus just on the problem in front of us. And so, oh, you know what? Maybe just out of frustration, maybe just out of habit. Let's just go ahead and give a little bit of ketamine, try to smooth out the rest of the case. I can't tell you how many cases I have on my desk where I've seen that end up in disaster. And the more I try to understand ketamine, the more I realize it's really a drug that was so many unknown factors, with so many unknown factors, where the more I study ketamine, the less I know. And so I'd like the editorial title that came with this British Journal of anesthesia article. The title is "Rethinking ketamine as a panacea." "Rethinking ketamine as a panacea" adverse effects on the oxygenation and postoperative outcomes. So again, I want to make it clear, I use ketamine regularly. I think it is a wonderful sedative one used properly, especially as a preemptive analgesic. My goal here today is just to help your audience reconsider and rethink of ketamine as being that wonderful rescue sedative, especially in the more compromised severe ASA3 patients. One other interesting note, something that we have all seen, but none of us have ever read. And that is the drug's manufacturer instructions that comes with every box of ketamine. And to me, it's amazing that this has not been more widely homil gated or more widely recognized. But if you look at the drug manufacturers instructions that again comes with every box of ketamine, you will find in the small print the warning, quote, "Because pharyngeal and laryngeal reflexes are usually active, kettler or ketamine should not be used alone in surgery." Again, let me emphasize that again, should not be used alone in surgery or diagnostic procedures of the pharynx, larynx, or bronchial tree. Mechanical stimulation of the pharynx should be avoided whenever possible if ketamine is used alone. Now, what's happening when you're using ketamine as a rescue sedative? You know, you've given them a dazzling, you've given the fentanyl, you've given the proper fall, maybe 10 minutes before, the peak effect of those drugs has dissipated. And now you're trying to rescue a difficult case with a small dose of ketamine, which normally, you know, would work in the vast majority of patients. But when you're doing that, you in effect, in my opinion, are using ketamine alone, right? Because those other sedatives have not dissipated, their peak effects have dissipated. And so now you're trying to rescue a difficult case by using a small dose of ketamine alone while you are operating and stimulating the oral pharynx. And, you know, it begs the question, why would the manufacturer make this specific warning and then not promulgated so that we're all more aware of it? Now, what do the manufacturers know that we don't? You know, I find it very interesting, sort of confounding that this has not been more widely disseminated. So again, I want to emphasize, ketamine is a wonderful sedative and it will work and you will get away with using it for the vast majority of your patients, even if you do use it as a rescue sedive. But for those severe ASA3 patients, either difficult airway or severe obesity or severe comorbidities, I would urge your audience to reconsider the idea that ketamine may be a pansea rescue sedive for those more difficult cases. Because remember again, ketamine increases oxygen consumption. It seems to have intrinsic effects that may precipitate the rinjal or bronchial spasm. And then of course, even when you're using small doses of ketamine, as reasonable as that may be, there is no reversal agent. There is no reversal agent for ketamine. And so once you give it, we're stuck with it and we are stuck with dealing with its consequences. So, so with those things in mind, I would argue that the most dangerous sedive in oral surgery sedation is the sort of habitual use of a rescue dose of ketamine in severely compromised ASA3 patients, in which we have not really considered the consequences and the conditions of that particular case. So, chemine itself is not a bad drug, is not a dangerous sedive in and of itself. But the way that we use it, especially because we've been taught over and over again that it's a wonderful agent, because it doesn't depress the respiratory rate, it doesn't help cause bronchial deletion. I think these things need to be reconsidered, especially when we're dealing with more difficult patients. Bring up a lot of great points. I think, well, one, I use ketamine as well on a daily basis. And I think a lot of us think more of ketamine from the standpoint of stressing the cardiovascular system and the heart because it increases blood pressure. And I think this brings up a good point that we probably don't give as much credence or focus on the fact that ketamine can make the area more reactive. There's more secretions, that type of thing. And I really like this point you bring up of using ketamine, quote unquote, "alone." And maybe we don't consider it being alone, but you're right. If you use it as a rescue drug several minutes after the initial drugs have been given, it is kind of like you're using it alone. And we probably don't consider some of the consequences there without pairing it with another drug that can help with those reactive airways. I often use this tennis analogy because I like to play tennis. Where do you not want to be in tennis? You don't want to be in no man's land. In other words, in tennis, you either want to stand the baseline and hit your ground strokes, or you want to be more aggressive and come to the net so you can hit a volley and put the ball away. But you don't want to stand in that middle area of the court because then you're really vulnerable to the opponent making all these passing shots. So similarly, for me in sedation, the two safest spots in sedation are either one where I'm in control as the anesthesiologist or sedationist of the airway and the patient. Or the patient is awake and in control of their airway and their airway reflexes. But when we try to go halfway, when we try to go into this gray zone where the patient is really not in control of their own airway and we're not in control of their airway. And we're trying to provide what we think is a safer solution by providing a light dose of ketamine. We end up being in no man's land, the area where we do not want to be where the patient is most vulnerable. So I think, yeah, there is some wisdom to that idea that if we have a difficult case, one, just stop and let the patient wake up. A lot of times, after the initial injection of local anesthesia, that's the worst part for many of these patients. So wake the patient up, talk to them, use your tachysthesia, use our non-pharmacologic techniques to guide them through the rest of the procedure, but at least then they're awake and control their own reflexes. Or what I typically do as an anesthesiologist, because I'm comfortable giving heavier doses as I do is I'll take more control of the airway and give either more propyl fall or maybe even propyl fall combined with ketamine. But I want to deepen the patient, take the patient back to the baseline of the test court and depress their airway reflexes enough so that we can continue with the surgery safely. But the idea of going halfway, because we think it's safer, oftentimes I think puts us in the very bad position of no man's land. Yeah, a really good point to bring up. I appreciate you sharing those cases because I think cases like that always help us more to drive the point home and think about how these drugs are used and what's going on. So super helpful point there. Real quick, just to follow up, you mentioned Caleb's Law. How does that affect the practice of anesthesia in California? Yeah, so with Caleb's Law and SB, and actually the subsequent, it's called SB501, what's now required in order to provide my deep sedation or general anesthesia for a child under the age of seven is you have to provide documentation that you've done 20 cases, 20 such cases in the last two years. So 20 pediatric cases in the last two years. Much to my surprise, many of the oral students I work with have had a very difficult time coming up with that volume of cases. Moreover, the paperwork is archaic in terms of the application to apply for the pediatric sedation permit. It's very cumbersome. It's all paper-based. You have to pull out 20 records, print them off, you know, collate them, and then submit it down board. And you know, you're a busy oral surgeon. You have so many other things that you have to worry about. And so most of the oral students that I work with have said, you know what Steve, it's just not worth it. It's too much of a hassle, too much stress. So many of the oral students that I work with, I would say the vast majority have given up altogether and given up their pediatric sedation privileges, which I think really is unfortunate. Because what that means is that they have to call and CZL just such as myself. And you know, again, I love working with oral surgeons. I love coming with you and helping you with your cases. But to be honest with you, there is no way we can meet the demand. You know, as you know, there's a shortage of physician and dentist and CZL just throughout the country. And there's no way we can provide sedation for all these pediatric patients in oral surgery offices. So what does that mean? Either the oral surgeon is just using oral sedation and nitrogen oxide, you know, which oftentimes as we know is not a really great sedive. And so a lot of these kids are being probably traumatized by their procedure or they're having the wait, you know, six months to a year and a half to get the procedure done in the hospital or a medical facility. So I think it really has decreased access to care for a lot of, you know, very relatively simple procedures that can and should be done in the oral surgery office, you know, under the single operator anesthesia model. So yeah, it's had a tremendous impact on us. And for me, personally as anesthesiologists, it means I'm being called in more often for these short, relatively straightforward cases. And again, you know, we're grateful for the business. We're happy to help, but really, it's not an efficient use of everyone's resources, right, to bring in the separate anesthesiologists for, you know, a simple extraction. So I think it's really unfortunate in that respect. And when these surgeons give up the pediatric designation, do you know the age limit on that? Like is that 12 and under or what is it? No, in California, it's seven and under. Seven under, okay. Right. And then the kids still obviously provide sedation and they do, you know, for older kids, teenagers for third-molers, as long as they're pals certified. Yeah, all the oral students are really good with in terms of keeping up with their ACLS and pals certification. So fortunately, it doesn't affect that aspect. But for kids under the age of seven, yeah, it has had a tremendous impact. Gosh, yeah. Well, again, I think great topic, you know, always important for us, you know, as the oral surgeons to be understanding the drugs we're using, to think about all these scenarios, and, you know, practicing the safest anesthesia techniques we can. So I really appreciate you sharing your thoughts on this in those cases. Any other comments you had? Sure, let me just put in the plug. One of the things that we like to do is discuss a lot of these cases in more detail. And so let me put in the plug or advertisement for our next conference, which will be in Park City, Utah, next February, snow and sedation. So along with Harvard, medical school professor, Dr. Kira Mason, we talk about all these different aspects of oral surgery and dental sedation and not just the M&M cases, but all sorts of other techniques and strategies we can use to safely provide sedation in the dental community. And again, that's next February in Park City. And our website, if you're interested in more information, is simply www.snowandsedation.com, all one word, snowandsedation.com. And so we would love to see you guys out there on the slopes. It's a great way to have some fun, but also learn a lot of great material as well. Awesome. Terrific. Well, thank you. That sounds like a great resource as well. Great. No, thank you. Yeah, I appreciate you real quick. We end every podcast with some rapid fire questions. So my first question for you is, what's the best book you've read in the past year? Yeah, that's a great question because I love books that are very important to me. And so I'll pick a fiction and a nonfiction book. The fiction book is James by Percival Everett. This is a retelling of the Huck Finn story from the perspective of James, you know, the slave. And just an amazing, outstanding book that I really enjoyed. I think, you know, what I remember about novels or fiction is the quote that if you really want to understand the truths about the human condition, read a novel. And this book, James, really highlighted that point for me. The best nonfiction book that comes in my mind recently are two. One is Challenger by, I believe, Higabatham. It goes over the Space Shuttle Challenger disaster. And it has so many lessons and parallels for us in oral surgery sedation, you know, the same types of mistakes or lapses and critical thinking that led to the Space Shuttle Challenger disaster are many of the same mistakes I see made in these tragic oral recidation cases. So that is a great read. The other one is Nexus by the Israeli historian Yvall Harari Nexus. All of his books are amazing and great. I recommend any of them and clean sapiens. But the latest book Nexus is a wonderful analysis of just how AI and future technology is going to affect us as a civilization and really just insightful in grossing read. So the other question is, what non anesthesia thing do you do in your life that helps you with your daily anesthesia skills? Yeah. So again, I'm a huge fan of being in the mountains and playing in the snow. I love snowboarding. And that's one of the reasons why we started this snow and sedation conference. And snowboarding and other physical activities that I do and enjoy like surfing really have helped me relax. But also keeps me and disconnects me from technology, right? It keeps me away from my cell phone, keeps me away from my laptop and really helps me to think and sort of even meditate on some of these issues or problems I face clinically. So for me, snowboarding and surfing are huge in my life in terms of just not only helping my physical health, but also helping me gain mental clarity when I think about these issues. That's awesome. I usually ask the oral surgeons what their favorite furseps is, but what's your favorite tool on your anesthesia kit? Yeah, that's a great question. And this brings up a really good point. I think we're at the point now where every oral surgery office should have a video laryngeoscope. And so that is my favorite tool of video laryngeoscope. It has, I could not practice anesthesia without it because there are too many times where I have a difficult airway or maybe it's not even that difficult, but because it's hard to place the position, the patient in the proper position in the oral surgery chair, right? It's not a hospital table. It makes airway manipulation more difficult. So that has been a game changer, has been the video laryngeoscope. And there's a number of studies now that have demonstrated that for more novice users, and I'm not saying that oral surgeons are novices, but you'll learn intubation during your residency, when you do your anesthesia rotations with us, but how many oral surgeons never really intubate after they finish their training. And then all of sudden there is an ASA3 patient who's severely obese and you're being called to do an emergency intubation. I mean too often that results in a disaster. So there have been a number of really well-designed studies that have demonstrated that in those types of situations, the video laryngeoscope is superior because it's easier and provides more likelihood of first intubation success. And the price point on many of these video laryngeoscopes has come down tremendously. Maybe not so much after all this tariffs, but for example, I was able to get a very high quality video laryngeoscope from China for $499, which is incredibly cheap. So I would urge the doctors in the audience to start thinking about getting a video laryngeoscope as your emergency airway, your go-to emergency airway device, if you do need to do intubation in your office setting. Nice. Yeah, we've had a few other guests bring that up as well. And I think it sounds like pretty affordable and probably a really smart purchase for most OMS docs. Exactly. Yeah, you have a favorite TV show or movie you've seen recently. Oh wow, I don't watch that much TV, but I can't say for sure that I can recommend it because I haven't seen the whole series yet, but the series Dope Thief. Dope Thief on Apple TV. As an anesthesiologist, I find anything about opioids or the opioid epidemic or illegal substances to be of interest, right? And Dope Thief sort of plays out those themes in a really realistic, engrossing way. And so so far, I think I'm only halfway through the show, but so far has been the really, really enjoyable and also insightful watch. So that's the show I'd recommend. Nice. And last question is, what is your favorite quote? Oh, illegitimus non-carporundum. And the Latin is probably incorrect in its grammar, but roughly it translates as don't let the bastards get you down. So no matter what happens, you know, make lemonade out of lemons, but don't let the naysayers and the negative people in your life get you down. Great quote. Awesome. Well, thank you. That's all I have for you Steve, and I really appreciate you doing this. This has been awesome. Great. Thank you very much. Cool. And if you're okay with it, I'll put your contact information in our show notes in case listeners want to reach out and further ask questions about this topic. Yeah, absolutely. Okay. Thank you so much. Have a good day. Okay. Great. Thank you. Bye. Thank you so much for listening to this episode of Everyday Orals for Dream. More information on these podcasts, please visit everydayoralsforgery.com. I love feedback and would be very grateful if you would reach out to me via my email, Grants2KGmail.com, and let me know what you thought of this episode. Or you can text me at 720-441-6059. Additionally, if you have any topics you'd like to hear about or if you'd like to be a guest on the podcast, please, please email or text me. I found many of my interviews through people who have been contacting me and have been listening and have gotten so many great ideas for more podcasts, and that's what helps keep keep the podcast rolling. So really appreciate making that extra effort and helping me out with feedback and knowing what to do next on the podcast. Thank you so much.
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