S3 E10: "Our conversation with Admir Hadzic (Part 2)"

Previously on block it like it's hot. What I think most of our listeners will not know, and, Ahmed, don't even know if you know this. When when Admir talks about he and Jerry taking a taxi up to Columbia University and going to the morgue and doing these experiments, they were residents. They were, like, full time anesthesia residents Is that right? Doing this is before, like, work hours were a thing. 

So they're already working a hundred and twenty hours a week in nineteen nineties in New York City and then leaving their shifts, going and working all night long to figure out, okay. That's this fascial plane. That's that fascial plane and that sort of thing. So amazing. Right? 

Once I graduated anesthesiology anesthesiology residency, I became actually a cardiac anesthesiologist. So I did TEEs at the time and cardiac anesthesia. But then Jerry convinced me that the right thing to do was to go into regional anesthesia because as opposed to cardiac, there just so much new to discover and contribute to the field. You know, back in the day when we were working so hard to try to redefine regional anesthesia techniques, we came up with an idea that maybe we could, put together a departmental website that would teach the techniques that we were publishing at the time. Now this was back in 1993. 

One of our T shirts for fun says, Nysaura free since 1993. So we went to our department, and we talked to the department heads. And, you know, we told them about our idea of teaching regional anesthesia and publishing our research as well on on website, and we've been ridiculed. We were laughed out of the room. We were told, look. 

Who wants to read about medicine on the Internet? Stay tuned for this exciting conclusion to our two part interview with Admir Hadzik. I'm Amit Power. I'm Jeff Gadson. And this is Block it like it's hot. 

Well, listen. I what it Admir, you have been at the forefront of different iterations of innovation in regional anesthesia, and I want to I wanna ask you having seen all that you have. What what are you excited about next in regional anesthesia? Do you know, I think what I'm seeing in regional anesthesia, it's it's just an incredible, I think, groundswell of, do you know activity? There's a lot more people, younger people that are just so ultrasound savvy. 

This is the video gaming generations that are incredibly, you know, skilled in, you know, sonogramming and and blocking just about anything that moves. And then what I think, you know, we have acquired is just an incredible, you know, technology, ultrasound, that's becoming increasingly more available, available, smaller. You know, there's AIPs that has been integrated into it. I don't know how that plays into it. But okay. 

But it's, also not just about technology and the scale of regional anesthesia that grows. There's also a lot of excitement about community. You know, the rise of regional anesthesia of society, and I have to say, especially Ezra, the European Society of Regional Anesthesia, has been incredibly, important. Ezra has done an amazing job, I think, connecting clinicians across continents, especially here on this side of the Atlantic. And it's created really a great sense of global collaboration and belonging, you know, that I really, really appreciate. 

So I'm really excited to see how that continues to grow as as the critical mass of practitioners of regional anesthesia grows. I'm hoping that the collective wisdom will prevail to establish some standards as opposed to, you know, everybody practices the way they see things. One of the biggest failures of societies that that almost questions their existence, if you will, is their failure to establish any standards. They can't agree upon themselves. Do you know when when general anesthesia societies have introduced ASA monitoring standards, it wasn't a grand groundbreaking development. 

It's not that they really had evidence based information to go by enforcing pulse oximetry that's never been proven to save lives or improve outcome or end tidal c o two monitoring, but comes to regional anesthesia, every time a new tool comes up, we are ready to throw away everything that we've learned. So I'm hoping, you know, that that will change, and we will establish some kind of standard so we can all speak the same language. Because if he had that, you know, Amity wouldn't be asking me which of these blocks you do, which of these blocks you believe or not believe. It's got nothing to do with believing or disbelieving. It's got to do whether something really works for a certain indication Yeah. 

Or it doesn't. And I think comes to regional anesthesia, that's really where I'm really super excited about. I also am excited very much about, do you know how we utilize Yeah. The incredible power of the AI, the ability to to synthesize the massive amounts of information and bring it closer to the clinician. Do you know? 

So one of the things that we have done, you know, quite a few months ago, we've developed a program, a module that's called MOPCA, which is the medical AI powered knowledge assistant that we incorporate now in our elearning, system and our NoBlock app where you can, you know, type a few essential, you know, questions about a case. A 75 year old for colectomy with hypertension and, you know, hypothyroidism. And then, basically, the the system goes through back end where Nysaurus content is and supplements it with the source that we specified and provides some guidance at the very least for discussion on how to proceed with the case. I think, as we get better, in in in harnessing that potential of AI, and particularly, if you are able to provide the content in the back end that's that is, peer reviewed and vetted, I think we are really encroaching and put some incredible developments. As an example, we all know that, it's challenging to do the, preoperative evaluations because they're costly. 

They take time and effort and whatever. But I believe with the good content and individual protocols that could be fed into the back end in an AI model such as MAPCA that I just talked about. It's an an in anesthesia assistant. You can actually devise complete preoperative, you know, procedure evaluation and what patient needs to do using AI, which would save a lot of time. Yeah. 

You know, a lot of money. We do know that preoperative evaluation doesn't really pay, but aside from the important presence of the anesthesiologist in the Operating Room, etcetera. So those are things that I'm super excited about. That is that is an amazing idea. I mean, we we pay a full time anesthesiologist, and I think four or five nurse practitioners to staff our pre op clinic, generate notes, you know, make these decisions that we have enough data now. 

Right? We have enough Yep. Algorithmic data. If you have this, you're gonna need this test. That is super exciting. 

Does your thing, the the MoCA, ever come up with cancel case? Well, I guess, you know, you know, I I tell my resident they come in or they'll they'll, you know, scared about the next case that's coming up at some kind of a DNR or something. And and they so he was like, doctor Hadzik, you know, we had done a next case. I don't even listen to it. I said, cancel. 

And then but but I'm you know? But what we do have those ethical dilemmas. One of them is is what do you do when you have somebody who is inoperable, basically, due to medical condition, has a hip fracture? They got a couple weeks to live. You know, it's a really, difficult ethical dilemma. 

What do you do with these people? You put them to sleep or given spinal for hip fracture, whether they'll live or not, and the whole surgery and whatever is is only for maybe two weeks or three weeks worth of life. And then we have devised these protocols, using neuroablation techniques or, here, they call it alcoholization. That's a European. I said, look. 

I'd like to get alcoholized too. Sometimes that term. But but the the, the phenol alcohol box, and and they, they really help a lot. But so, you know, I think we need to be reasonable as to, you know, who we can operate on or not. The times have come that seems like whoever has a problem, you must do an operation, but may not be the best outcome always. 

Listen. I would say that's I mean, it sounds to me like you created a chat GPT, but just for regional anesthesia, or you can put these complex problems into it, and it and it uses the source of the content or use it as a source of the content you created, which is which is fabulous. So thank you for doing that. I look forward to seeing where that's going in the future. Now we talk a lot about, doing these techniques, and we all love regional anesthesia. 

But at the end of the day, we're not performing regional anesthesia on ourselves unless your name is Jeff Gadsden because he does it all the time. We've got to perform these blocks on patients. So how do you approach your patients when it comes to education and communication regarding regional anesthesia, especially when they're nervous or anxious about being awake for surgery? What's your strategy? How do know, we love you. 

We know that you're passionate. How do you convey that to your patients? What are your tips? Alcoholization. The alcoholization. 

Yes. Well, you know, I think Jeff can tell you as much about that as as I can. Jeff and I, we used to work in in a, you know, Spanish Harlem facility, Saint Luke's, where we had a lot of Latin American patients. These people are, they are very pain insensitive. And, you know, if you ask them whether they wanted to go to sleep or needle in the neck, you know what the answer would be. 

So we always had to tell them that they're going first to sleep and then going to get a nerve block, that will help them with the pain. And we delivered back at Saint Luke's. We did a lot of midazolam, alfentanil kind of techniques. And everywhere I went, you know, there's always these people who don't do a lot of blocks, but they claim the patients don't need anything before the block. And I I, you know, I don't believe that the patients come in to enjoy needling. 

I think they come for an operation, and and we are just a a necessary evil. We need to provide an anesthetic so that operation can happen, but they don't have to endure that. When I started building the last center here that I, that I built in in Belgium, what was quite obvious that in a community, everybody knew that you really, if you can possibly avoid getting a nerve block, you should tell your anesthesiologist not to because they never gave anything for premedication to these patients. And then you can imagine you're there being stuck with a needle. Somebody's teaching an assistant, and you hear, stop. 

Stop. You know, you'll hit the artery. No. Pull back. I mean, these are really distressing moments for patients. 

There's no two ways about it. I'll tell you an anecdote. It's kinda funny. At Saint Luke's in New York City, there was a a our and Jeff will recognize some of the some of the names. But the chairman of the orthopedic program was a guy by name George Eunice. 

Yeah. Yeah. Yeah. Of course. Brings big back memories. 

Right, Jeff? So George Eunice, one time, it was a funny it was a funny guy. This would be this would be, George Eunice's typical orthopedic surgeons back in the day description of a patient, like a premedical condition. Hey, Admir. She's, I tell you, she's a she's a she's crazy, but she's healthy as a horse. 

But, anyway, in in this in this particular situation, he wanted me to be a personal anesthesiologist to the woman who was a chief perioperative nurse at Yale. And so it took quite some maneuvering until I was available. You know, like, nobody else could do what I, you know, could do, but, you know, she made it a point. She wanted me to be there, to make sure that she gets an anesthetic properly. Oof. 

No pressure. Eventually, after about six months of timing and waiting, she comes in, and I meet her casually in the, you know, in in the Holland area. And I introduced myself, and she's got tears in her eyes. Just thank you, doctor Hadzig, for being here. You know, I would not have this operation had it not been for you as my anesthesiologist. 

And I said, but don't worry. This is what we do all the time. We're going to do an interscaling block, and she freezes. No. Just no. 

Doctor Hadzig, this is exactly what I wanted you. I don't want blocks. I want them to go to sleep. So so okay. Something went wrong over here. 

Of course, George Junis didn't talk to her about what I do for a living, and I don't know how she got this information, you know, about me being a only journalist. But then she explains me how in her practice at that hospital, she heard so many screams and people, you know, moaning as the blocks are being placed in awake patients that she was praying to lord that she if she ever had to have that shoulder operation, that she never had to receive a block. And, again, speaks volumes about patients don't come for your block. They come for surgery. Make it easier. 

And I think premedication goes a long way. Currently, we use a couple of milligrams, one or two milligrams of midazolam and five milligrams of ketamine s, for in everybody. And that really goes a long way making sure that these patients have a good experience. Our surgeons also do not negotiate with patients. I mean, patients are always told that for whatever operation they're having, there's a list what block they're going for the operation. 

So they come in already prepared. We actually rarely have that situation. And when we do, honestly, we do not try to to change that unless there's a strong medical reason. Not everybody needs to get blocked. Remember, if somebody doesn't get a block and is pain in the recovery room, I mean, it gives you an opportunity actually to reestablish the value, to demonstrate before and after. 

So Yeah. That's funny. I can I can picture that? The awake thing, I just don't get it. Don't know why you'd want that. 

Well, I'm I'm just gonna derail for a second because you know that power don't like gawa. And I know a lot of you guys do general anesthesia without airway, but this recipe, a little bit of madaz, a little bit of ketamine sounds okay. That doesn't sound crazy, but I've heard a variation of different kind of, sedative cocktails that have been used to insert a block, which sound like a gen like a general anesthetic without an airway. And I think the other thing I I mentioned to you, Jeff, depending upon which institution you're working in The UK, sometimes the aim is to get the patient to walk out of the OR and go directly to the ambulatory or to the discharge area. So if you've somebody kind of a little bit too zonked, then that flow has changed. 

But that doesn't mean we shouldn't give the patient the best experience for them. So listen. I'm I have changed my practice. When I started Regent Anesthesia, it was all about wouldn't it be so cool if we could do this without anything and just under a block, and we think we're great. But, actually, it's not me having the surgery. 

It's not my experience. It's all about the patients. So I appreciate your insights, Admir. That's that's really lovely. Well, you know, people who don't do a lot of regional anesthesia, they think you go you do a block, and that's all you need to do. 

Then, you know, there's nothing else. But they don't I actually think that every anesthetic has four components. Right? Anesthesia, analgesia, amnesia, and hypnosis. And some people definitely do need all of these components even though you took care most of it with your nerve block. 

You can't do amnesia and hypnosis with the nerve block. And so, this is extremely important. Likewise, if you block the left hand, but patient's moving with the rest of the body, you know, that doesn't really help surgeons intraoperatively. But if you sedate them, they know it it does. So Yeah. 

You know, folks who do a lot of regional anesthesia, they do not need to talk about the subject all that much because they know that the block isn't just a block. But it's a it's a intraoperative management management that determines the block's success more than, actually a block, if you will. And as opposed to an IV anesthetic where, you know, your anesthetic injected into the bloodstream always goes to the receptor sites where they work, you can't. It's impossible for you to, you know, assure a 100% that your local anesthetic will also occupy all the sodium channels. It's impossible. 

Therefore, the management intraoperatively, perioperative management, sedation before, sedation were necessary intraoperatively, and that's that. Yep. Exactly. Admir, I spent a I spent a lot of time in New York watching you and helping you at some point write textbooks, and you have published at least four textbooks that I know of, probably probably more. But and I and I I I love looking through textbooks. 

But are they are they still a resource that we need? Our textbook is dead. It's paper. I think so. Yeah. 

You think so? I think so. Here's here's the do you know when was the last time you saw somebody with a textbook in the operating room? Do you know? I don't think you've seen this. 

I have not seen a textbook in the anesthesia department for the last ten years at all. If you look at the reviews of the standard textbooks as we used to know them, Miller's and Barrage's, I don't think the Barrage even exist anymore. Do you know it takes, and and clinicians and folks who write textbooks, they're just so busy. It takes them three to five years to put out put one out. In the meantime, with the, rate that a new medical knowledge is generated, they outdated already at the time of publication. 

And if you look at how the current generations of students study, they don't I mean, I haven't seen one anesthesia resident bringing in computer or laptop to work in a long time. All they got is their smartphone. So, basically, you've got a generational change, and the consumers of you know, that have completely transitioned to mobile, you know, methods of of learning. And I you know, we sell textbooks, and we write textbooks. And there's a a group of folks who like to have that old school feel with the paper in hand, you know, in front of you, and I'm one of them. 

But it is inevitable inevitable that the, the tide is against the textbooks and towards more condensed, easy to access medical information in as convenient format as possible, and that's not the textbook. When I realized that I'd got old was I was trying to I remember back in the day, was trying to to to draw a diagram on a piece of paper of a slice through the supraclavicular brachial plexus to try and demonstrate what the, the learner was doing wrong and, why eight ball corner pocket may be something we wanna do. And and and the the resident said to me, sorry, doctor Parr, can I just show you something? I'm gonna open up their iPad and got one of these virtual anatomy apps. I started moving this three d thing around, and it blew my mind. 

I was thinking, how can I not know about this? So people don't use textbooks. People sometimes don't even use pen and paper. It's living in this virtual world. But it so it's not even that that they're reading Miller or Barish on their phone. 

They're just not using those resources at all anymore. It's just more dine it it's more dynamic. Okay. But but, Jeff, you you you you definitely remember both you and and and Ahmed. You guys are, you know, not old, but you're you're you guys are at the forefront of education out there. 

But you definitely do remember the times when you went to library to copy some pages to have to to to to read. Right? Remember the times when you studied for your anesthesiology. Oh, and you and you and you and you were looking for that one journal, and you were just hoping that they had that issue of that journal, and someone hadn't, taken it out and never returned it. You're like, yes. 

It's there. I can photocopy this now. Yes. Yes. And then then Internet came. 

Right? And the Internet now, you went to various websites. You went through, like, 10 different websites to get information that you have so you don't have go to the library. But today, with AI, it comes up in one app. Do you know what I mean? 

Okay. Yeah. Maybe not maybe not all information in that, AI module depending on how it's built and what the back end is. That's why in in with Nessora's approach to AI, we use the content that is Nessora's content Yeah. To feed the module first before it goes to other sources that we specify. 

But, even even though there may be mistakes, you know, most people think, actually, that the textbooks what they used to think is that the textbooks were like golden information, undisputable. And very few people realize, actually, that textbooks are not peer reviewed at all. You can write whatever you want to. If you want whatever you want to. Do you know? 

So, and and therefore That's true. There's nobody once you decide you wanna publish it, that's that's that. Wait. I think the other thing that's fascinating about AI, it's I I'm learning a lot more. I mean, Jeff told me that I could make a a family meal plan for a family of four or five using these things, and I and I was blown away by that. 

But but it's the quality of the prompt that you put in, and that that's something I'm I'm learning. So I would I would doing a lecture with I get I would pro condemnate against Mark Vander Velde at Barra about whether we need journals or not anymore. I just thought, let me see. I put into an AI prompt. I said, oh, using, the following resources, can you evaluate the evidence over the last five years about the regional anesthesia techniques for total hip arthroplasty and tabulate the results in a table, with morphing dose versus block. 

But two seconds, this table came up, and actually, it was pretty good. So I think, you know, why would I then go to a separate journal or go to a textbook to read about technique when I can extract this information at the at at the end of my fingertips. So I think this is a very interesting time we're living in right now. Yeah. Totally. 

Well, listen. I'm talking about evidence and publishing evidence. I was umming and ahhing about whether or not I was gonna ask this question, but, hey, you know, we like a bit of controversy on this podcast, so I'm gonna go for it. So I have enjoyed watching the updates and discussion points that you put out on your YouTube channel. Always think of what's he gonna be talking about this time, but there was one that appeared to generate quite a lot of controversy. 

I wanna take a moment to ask you about it. It relates to the whole spinal versus general anesthesia for fractured neck or femur. Why did you feel so passionately about the whole topic and that whole the whole debate? And what do you think the message should be now for regional anesthesia practitioners when it comes to selecting the right mode of anesthesia for this patient cohort? You know, what Mark Newman did with those studies that were published in the New England Journal of Medicine and Annals of Internal Medicine and Anesthesiology, it was not that you're right because anybody who is regional anesthesiologist knows that spinal anesthesia can save lives. 

You get these old people that are so diseased, pretzeled, immobile. If you put these people to sleep, they never come back. So Mark knew we know that from the these previous studies that have clearly demonstrated in a retrospective fashion that people who received regional anesthetics that did better than those that received general anesthesia. And Mark Newman himself has published one of those studies on a large scale, and then he now devises a prospective trial to kinda prove that. Now you would think prospective trials will be more powerful and better, but in fact, they are not because in prospective studies, you know, you have limitations that I can, refer to in in a little bit that bias the studies completely. 

Why did Mark Newman do this? Because he received $10,000,000 grant by the, by the foundation that focuses on on on patients' interest in in medicine. And, basically, in order for him to do this study, he had to ask specific questions, outcome questions that will be appealing to patients. You and I know that the use of spinal anesthetic or any anesthetic, creates a difference, immediately perioperatively, but not six months down the road. But in order for him to secure $10,000,000 grant, he had to ask questions that the laypeople, the patients can understand. 

So, therefore, the questions were whether you receive a spinal or a general. Are you you be more likely to, you know, live or die six months after or being able to independently walk six months later? If we were to die you know, devise a study, those are not the outcome variables that you and I would consider to be, you know, relevant to the anesthetic outcome. But that's what he used. And this gets really, wild because then every participating patient pays a thousand bucks to the institution that enrolls them. 

Right. So now Uh-huh. Here we go. You know, Jeff is is a director of of research, regional anesthesia research at Duke, and now he's getting a call from his resident in the middle of the night. Hey. 

Doctor Guts, then we got another one of those suckers. And then, he's got a hip hip fracture. So, but there's nobody who knows how to do spinal tonight. And Jeff, I could imagine, you know, maybe not Jeff, but Amit perhaps, he would say, hey. Buck is a buck. 

We tried. And if it works if if you get the spinal, that's great. If not, we just shuffle them to general anesthesia. And that's why in these studies, fifteen percent of patients, they couldn't get spinal. They had to have them converted to GA. 

So now think about this a little bit. People were are not skilled, let me back that up. That's not a correct way to say it. But, occasional regionalists, you know, who is confronted with a spinal that is particularly the one in a difficult patient, you know, he or she, the usually thinking like this. I only have a one chance to make this work. 

Let me give him a little bit more. And this is exactly how spinal anesthesia becomes dangerous because the folks who know how to do a spinal, they know how to do a low dose spinal Mhmm. And get away with all of the other hemodynamic effects, which we know today are, deleterious to the patient's outcome. Okay. So that particular study, when it got published in the, in the New England Journal of Medicine, found no difference. 

Obviously, spinal anesthesia was not practiced properly. It there was not even a protocol for spinal anesthesia, so you could have done whatever you wanted to. In fact, you could have put patients to sleep before putting the spinal in. You could have given hundred milligrams of ketamine just to position him for spinal, and then you're in the delirium after. It's incredible how the New Journal of Medicine published this. 

But, look, the study was, you know, supported by 10,000,000, you know, dollars, and New England Journal of Medicine knew that if they ran this study, it will be an instinct to the readership, and and the foundation will will, you know, make sure that it hits all the news news outlets, which it did. It's it's crazy to me that that I I feel like that methodological aberrancy doesn't come through in a lot of the discussion. Right? Like, that many patients in the treatment cohort did not get a spinal or, you know, were ended up in this intention to treat oh, we'll just do a GA instead or the or the spinal failed. And, like, how how can you rely on results like that if it's just garbage, complete garbage data? 

Totally. Listen. The important thing is it's important to have discussions about it because if you just read the headlines and don't delve below that Yes. That's when you can practice bad medicine. But the danger is, and this is, again, keeping on that controversial theme, I don't think regional anesthetists would change their practice based upon this data because we know what we're gonna do and we're gonna tailor our anesthetic to our patient. 

But the worrying thing is if all comers, all those occasional practitioners will say, well, hey. I don't need to call in a specialist for this because there's no difference. So it doesn't matter. Exactly. I'll just offer what I want. 

And that's where I think the the nuance and the importance of discussion. Look, this is a pragmatic trial. It was done on a large scale in multiple centers. And on the surface of it, it looks very good. And I think, you know, we have to appreciate how much effort goes into research. 

And, yes, there are big sums of money involved, but there's a lot of effort, a lot of coordination. So I take my hat off to anyone who who's out there doing research. But the important phase is the post publication phase. If a study gets published, you cannot just believe what it says black and white. You have to look into the nuance. 

So, yes, it generated a lot of discussion, and and not everybody was open to discussion. And that's one of the the you know, you have to accept. If you put something out there in the public arena, people are gonna talk about it, and you have to be able to have those open discussions. So I think this is an important platform. Yeah. 

What really upset me, actually, was I was really disappointed is because clearly a paper like this, okay, may not change your practice because you know. But at the same time, it will change, you know, prac practice and and demeanor of your surgeons. Why are you pushing for spinal when there's no difference? Exactly. Physicians may also be instructing the patients when they're asking about, but what should I choose for my for my, for anesthesia? 

It just doesn't matter because the the the the paper in Neuron Journal Medicine found that there's no difference. And I'll expand on this in a little bit. But here's the thing. What really surprised me, and I was disappointed by, Regional Anesthesia Society, and this is where I acted a bit emotionally, and that is that there was an editorial in regional anesthesia pain medicine, the flagship journal of regional anesthesia, in which the editorial concludes, well, there's many things in medicine we don't know, but now we do know that there's no difference between a spinal and a general anesthesia. And he says, so now when I talk to my patients, I tell them, look. 

There's no difference between one or the other, so, you can choose whichever. And at the same time, man, these people do not understand what is one anesthetic, what is another. And most of these patients that will be the greatest beneficiaries of spinal anesthesia are not with it to begin with. Do you know? And it was I was disappointed by this. 

I I felt that the regional anesthesia and pain medicine, I still stand by as a flagship journal of the specialty, should have really introduced or shed some more, you know, reasonable light into this. Now check this out. Here's how far that goes. The news outlet that picked this up, there was a a guy by name Gupta who is an internist and who writes a column for for patients based on the information from the New England Journal of Medicine. That information went worldwide, to everybody. 

Now the patients know that there's no difference. And Mark Newman is now setting up another grant in which he wants to set up an educational website to educate patients and health care consumers and givers that there's no difference in choosing the anesthetic for hip fracture patients. And that grant was $3,000,000. Wow. There you go. 

And and check this out. And then there are follow-up. Another slice of the sausage of this of this one single study was a publication in the, Annals of Internal Medicine where, that concluded it's also a study. Right? They concluded that the spinal anesthesia results in more pain. 

The delta in pain was, like, a point three on a VSKR of zero to 10. So, like, sir, how much pain do you have now? I have zero point three five now. And then anesthesiology publishes a pay paper based on that study, but now it's an outcome after a year. Right? 

So Yeah. Right. General versus spinal anesthesia outcome after one year. What's next? You know, effects on the offsprings? 

Yeah. The DNA changes? Yeah. And someone's gonna read that headline. That's gonna be just the headline. 

Right? No one no one's gonna go and see that point three. Yeah. Yeah. Yeah. 

For sure. The why I saw I was so emotional and powerful in this, I felt that our specialty was endangered. You know? Because if if this is what spinal anesthetic is perceived as not being valuable in these these difficult cases, which we know, it is, then you know it will affect also, the training in spinal anesthesia in which the training programs may deemphasize the training in regional because there's no evidence. Yeah. 

Yeah. Do you know? And and the worst case for this is, like, if you look at the retrospective data, you know that patient who was a candidate for spinal because general was was too dangerous would not have been randomized to, a GA. Whereas here, they randomized all comers. Yeah. 

Exactly. So there's just so many elements, but I think this will be way over the top, and beyond the scope of of of the podcast, I think. We'll have a we'll have a separate episode just on just on spinal versus general. Well, no. Thank you. 

That that summarize that that summarize everything. Right? Hey. Listen. I wanna switch gears here literally and talk a little bit about your one of what what seems like one of your newest passions, which is fast cars, man. 

Tell us all about your, your new hobby. Do you know, when I was a kid, growing up in the in the seventies, you know, my dad was a a mechanic and a toolmaker. So I spent a lot of time in the shop with my dad. That's where I learned a lot of skills that eventually, you know, translated into my manual dexterity and a love for procedures in medicine, etcetera. But I, you know, I had my first car when I was 17 years of age. 

I was modifying cars with them. We we we were hot rodding them. And, you know, even when I was a medical student, I spent a lot of time, you know, in a pit underneath the car, you know, fixing stuff up. So the smell of gasoline and oil on my hands has have really never left me. And time allowing, there were times when I just didn't have, you know, enough time to dedicate to motorsport. 

Right? So being a medical student, I had to, you know, cut back a little bit later on fighting for survival in the in the internal medicine residency and anesthesia residency, career, and such. But I will I would ever, so often return back to my love for motorsports. And then I've you know, as I move to perhaps my last destination here in in Europe, of course, you know, Europe is close to Modena, to Italy, and all of these hot rodded cars. And and the so, one day, my I here in you know, I when I arrived at Belgium, I built my own community. 

So I have a you know, my music community where we talk music, play music, jam, whatever. Then I have my fitness community where we, you know, talk fitness, health, longevity, you know, hit the gym and etcetera. And then I have my car community. You know? And the car community are the diehard, you know, folks. 

Remember, Belgium is a very traditional when it comes to there's a lot of rich tradition when it comes to motorsports here. Franco Charms is here as one of the Formula ones. Some of the surgeons that I'm working with, they are doctors at the Formula one events. You know, some of my students as well work there. And then, one of my car buddies, he he, invites me to join him on a ride, and he he he makes me drive his Honda s 2,000. 

And for those who know, they know. For those who don't, Honda s 2,000 is a small unsuspecting two liter car that was made by a famous Japanese Honda engineer, to be his last project before retirement. And he made a car that became a surgical scalpel on the road that revs up to 9,000 RPMs. The moment I heard that sound, I was possessed. You know? 

And ever since I kept, you know, pursuing my passion for cars and acquiring a collection that I that I always wanted but never had time to have. And my wife, Catherine, she goes, but why do you need all these cars now? And I still have some cars in New York that I'm that I'm just waiting for the old timer status so I can actually, you know, import them without paying huge, import tax. So she said, well, why do you need all all these cars now? And my simple question, my simple answer to her question is, because y'all don't have time. 

Do you know? You just don't have time. Many of the cars that I bought are from the very folks who just can't drive them anymore, and they sell them, you know, with a tear in the eye. And the time has just a very, you know, uncanny ability to slip away from you. Do you know? 

You just can't buy yourself a luxury, you know, to postpone things that you love to do that make you a person that you are until a certain time because many things can happen in the meantime that may prevent you from experiencing that experience. So now, you know, when I go to work, you know, then I fire up every day different beast and and makes me come alive. And it's like, I'm about 85 kilometers from home to work, and it's wonderful. I also with the car community that I have And it takes you twelve seconds in a car. Exactly. 

Exactly. Why don't I drive responsibly? But and then we do regular rally rides in Luxembourg. And in fact, this is super cool, man. I'm teaching a a workshop this weekend in in Taiwan. 

And Philippe Gauthier, professor doctor, monsieur Philippe Gauthier, is coming with me from Brussels. So we we we're flying to to to Taiwan, and I return back on, Monday, June 2. And when I return, I shower. And two hours later, I go with my buddies, you know, to more than a six hour rally drive over Stelvio Pad, Switzerland. And while we were in the Wow. 

Yeah, man. And while so the we are a friend of a friend of mine, Eddie, from New Jersey is coming. He'll be driving my Honda NSX. Andy will be driving his Honda NSX. These are two red fury beasts, and I'm taking my, Ferrari Testarossa to this ride. 

Holy moly. This sounds crazy. And we have a video crew. We have a video crew coming with us to document all of this. Check this out. 

And as I was planning this trip with with Andy, Andy is a as a master planner, I received a, I received an invitation. Please, if you can join us to this orthopedic anesthesia meeting in Milan on June 4, I said, I can do that. Now we'll pay for your trip and and your flight. I said, I'll be flying, but you don't have to pay for my flight. So I can imagine what happens when I pull up in front of the conference venue in the Testarossa and with these other guys that flanking me. 

I was saying That's what I kind of expect from now. You set the standard. Everyone's gonna expect you to arrive like that. But it Right. But they there you there you have it. 

It's it just, I I think it's really interesting how the world has gone all electric, and I can, definitely see the the the conveniences of electric, you know, cars and transportation and such. But, you know, I think people are realizing. I see my, you know, colleagues when they see me, one of these, you know, beasts. They they they kinda lust for the sound and the connection. And and, do you know, most people think that this is some kind of a super, unreasonably expensive, do you know, hobby? 

And, frankly, if I look at the, you know, part the the cars that my colleagues park in a parking lot, I probably drive the cheapest cars even with these exotics. And moreover, do you know when I decide to sell them, if I do, do know they will be selling their, you know, electric cars at the zero residual value because nobody Yeah. Yeah. Yeah. Nobody needs an old battery and old electronics. 

Whereas the cars that I drive, I don't consider them all that much as cars as pieces of art. Yeah. I imagine if you sell your Testarossa, it'll it'll hold its value. But, you know, you talk about that that that visceral sense of hearing that engine rev up, you know, to, like, 9,000 r p m. I feel the same way when I get into my 2017 Chrysler minivan. 

It's it's just awesome. Wow. Listen. What, what an incredible, incredible story and journey this whole podcast has been. I think, Jeff, I started with the first question. 

So can I have the last question too? Yeah, man. Have at it. Okay. Listen. 

How on earth did you get into the brewing of beer, and how can I get some? I need to know about the beer. Okay. Well well, look. Everybody makes mistakes. 

So so since I started coming more often to Belgium when I was dating my my wife, Catherine, now, you know, I learned that that beer is a national treasure in in Belgium. As a little kid, I grew up with my dad distilling, you know, plum brandy, pear brandy. And so as a little kid, we always tried a little, but I acquired a I acquired a taste. A taste for plum brandy. I acquired a taste and a respect, you know, for alcohol. 

So I have never been drunk that I remember of at all. But, you know, I I do respect alcohol. So as I started working, you know, in Belgium, I met this incredible person. His name is Carlo Tack. He's one of the, you know, technicians, orderly people that that just move equipment between operating rooms or whatever. 

And he talked to me. He says, look. Doctor, he says, do you like Belgian beer? And I said, what are you talking about? I love Belgian beer. 

He says, I make my own beer. And so I you know, when people in America tell you something like this, you're always thinking they, you know, brew their beer in the bathroom in in two in two small but he brings me, an incredibly beautiful bottle with glasses. And and when I tried that beer, I was blown away. It was the best thing that I've ever tasted. And he says, look. 

I see you. You get all of these people from across the world that come you know, your your colleagues, your business partners, your your students, your family, your friends, your musicians, and what you always get them something. It's usually a chocolate or a beer in Belgium. Why don't you make your own beer? And I and then he he, he introduced me to somebody who helped me make the first beer. 

It's not a home project. And then eventually got into investing into a brewery and and, and so develop a range of these beers. They're they're they're they all have their own story. Actually, there there's a recipe, or I'm sorry. It's a prescription with the visual analog score. 

And, so you just need to in order to choose one of the, you know, recipes that I make, all you need to do is you choose the level of pain that you're having, and they'll tell you what to drink. So if you if you have a lot of pain Mhmm. That will be a painkiller. If you that will be 10 out of 10. If you have, like, a eight, nine out of 10, that could that could be a nerve block, which is a 10% triple, hop to triple. 

And then it goes down to pacemaker, which is 4.4%. Wow. And, if you don't have any pain, you qualify for placebo. Placebo. One one a day takes the alcohol away. 

And then so we even had a definite we even had a definition of what these the you know, how you define a lot of pain, a little pain. So little pain would be a in a problem with the dog or, you know, lost your keys. And the worst pain would be, you know, wife and a, you know, a mother-in-law and etcetera. So it it really turns into a great story. But truth to be told, you know, it it's really for a medical profession, and these are some of these designs. 

For a medical medical professional, it's Wow. So that so that's the nerve block. Right? And that's the, that's a painkiller. For all my for all my friends, I basically and and our participants, our our instructors at workshops, we we ship them beer from from Belgium, and it comes with a custom and things. 

And for those who can't wait, there's, doctorblues.com. But the the the truth of the matter is I cannot really make alcohol any longer. I will need to go back. It's just not an excuse today. No amount of alcohol improves health. 

That's what Lancet says. I I tend to agree. So Yeah. That's the end of the story. But everybody makes mistake. 

I wish I didn't. Because once you make a good beer, you need to make a greater quantity because it's wanted, and you to maintain a quality, you need quantity. And once you have a quantity done, now you need a warehouse. Once you have a warehouse, now you need people on the ground. You need a forklift. 

You need, you know, the sales operation. It's a you know, all I'm saying is not all of the not all of the decisions that I made were were always good. Understood. Understood. It is it is incredible beer. 

It is the official beer of our regional divisions, quarterly meetings. So, you've got, some co branding opportunities there. I will put the I put the link in the in the description. Can people buy it online? Like, if we if our listeners want to get some, I mean If you go to doctorbluesdoctorblues.com Yeah. 

And just you know, there's actually a gift bag that has a selection of all four of them. Pacemaker, super pills takes away all of your other pills. The the nerve block will keep you comfortably numb, numb and and a a pain killer. One a day takes all the pains away. So that it comes in a in a in a package in a in a custom box. 

You need. Admir, thank you so much for your for being here today, for your for being so generous with your time, and for sharing all Thank you for having me. All your stories, and it's been amazing chatting with you. It it really has. I think this is gonna be either one bumper episode or two episodes. 

We've we've got so much out of it. It's been really fun, peeling back the layers and allowing people to to to get inside and see what, what being in your world is like. And thank you so much for your time, Adam. Likewise. Keep doing what you're doing, guys. 

It's it's great. Congratulations on your success as well. Fantastic. Well, we really appreciate that. Thanks, buddy. 

Thanks so much for being here. So folks, please do like and subscribe to our podcast from your usual podcast provider, and please also give us a rating. Leave a comment. Let us know what you think, and what you want us, to talk about next. So, Jeff, where can they follow us? 

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