S3:E8 "Blocks, Books, Blues, Beer and Belgium: Our chat with Admir Hadzic (Part I)"

Clear. Stay tuned to find out how one cardiac arrest was the inspiration for the first of several career resets for this episode's special guest. I'm Jeff Gadson. Have you got a bit of the blues? Well, I can barely contain my excitement when it comes to our next guest. 

So sit back, fasten your seat belt, and rev those engines. I'm Amit Power. And this is Block it like it's hot. Right. Jeff, are you ready to do our our special very high-tech, clapper board? 

Yeah. Yeah. Sounds good. Okay. Yeah. 

Three, two, one. But you didn't clap. I clapped. Didn't clap. Okay. 

I I'm I'm a I'm a delicate clapper. Okay. I didn't see anything happening. Jeff, you know, it's a little sad that we've gone back to our old style of recording for this podcast. Don't you think? 

I know. Because the last time we were doing this, we were in person in this glass box thingy. That's right. We had our RA party in The USA. Right? 

That was my that was Miley Cyrus. Our guest is just taking the headphones off because, like, the windows were cracking in the background. I'm so sorry about that, man. May was it too early for singing? Was it necessary to wear the Miley Cyrus bikini while you sang that? 

Well, I thought the wrecking ball was a little bit too much, but but yeah. Listen. It it was it was so much fun to see you in person, first of all, man. To be in person in that glass box and chat to each other, that was great fun. Right? 

Yeah. Yeah. Amazing. And the weird thing was, like, I'm so used to looking like I'm doing right now, I'm looking at it's I mean, he's a good looking guy, but it's a small guy in a small box on my computer. But this time, I had to remember to look at your actual face, which was crazy. 

And then we got the hug. The hug, the in person hug, man. Yeah. Yeah. In person. 

Yeah. Versus virtual hugs. You big softy. It was a great catching up with you. And, and and talking with you, I just heard just hang hanging out and then meeting all our friends with some great updates and and, insights and stuff. 

We even got a few wow moments. Right? Well, holy. Though, I cannot wait for you to release some of those. There's a few I can I I can I've got goosebumps now when you're talking about this? 

There's some of those little reveals that are gonna come out in future episodes. They literally made us go, wow. That was that was a lot. Well, what have you been up to, man? Well, you know, I'd love to say I chilled, after, our little visit at Azra, but I'd be lying because, you know, I flew back. 

I had one day off, and then I worked today, and then I headed to Leeds whilst I was finishing my talk for the RE UK twenty five meeting, which was wonderful. I know someone else who finishes their talks in the front row of the audience right before he's about to walk up on stage. Well, maybe talk more about that later. He or she. We haven't we haven't we don't know who we're referring to yet. 

He he or she. Well, that sounds I I saw that RA UK stuff on social media. It looked like a great meeting. An amazing faculty, some even from Azra. And is it true there was some sunshine in Leeds? 

Yes. Believe it or not, in the North Of England in Leeds, it was sunny, and this was Matt Haslam's first, meeting as president. And along with Toby Ashkin, Maria Pass Sebastian, Jenny Ferry, and the rest of the RE UK team, they put on a fabulous meeting with many internationally renowned names in regional anesthesia. And for the first time ever, a majority female faculty too. And, the Bruce Scott lecture was professor Nula Lucas MBE who did a great job. 

And you know what? She's convinced me that we need to have an obstetric anesthesia episode. So something we need to think about there. And but there's one thing that came out, you know. Our RA, and poker's guru, Rosie Hogg, she told me she doesn't listen to our podcast because she can't stand the jokes. 

Well, that just I mean, that just goes to show you what good judgment Rosie has. What I'm hearing, Rosie, is you wanna hear more singing. Got it. Thank you. Well, noted. 

Wally, listen, man. You must be exhausted after that, all that travel. Yeah. I was. You know, on the train on the way back, I was, I was sitting next to somebody rather chatty. 

You know that horrible thing when you kinda just wanna sleep? This person was talking to me the whole time. I'm usually that I'm that guy. But the person I was speaking to The chatty guy. You're the chatty guy. 

Well, this person I was speaking to, they were actually a zookeeper. And they were busy telling me that nowadays, if you wanna open a zoo, gotta you have at least four pandas, two grizzlies, three black, three brown, and one polar bear. Apparently, that's the bare minimum. No idea where you're going with that. Good. 

That was good. That was good. Okay. Silence. Okay. 

Well, listen. Since since that time, what what have you been up to? That that's my story. What have you been up to? Less exciting. 

We our kids are finishing up school and Uh-huh. You know, our two oldest have summer jobs. They said they started their summer jobs. With Duke, Duke is lifeguarding at the pool, which is just down the street from us. And so you can walk walk there and back. 

And then Reef is tending bar, the snack bar snack bar at the at the same pool. So Okay. I was gonna say, holy moly. You guys have got a relaxed, like, age range there. Okay. 

Yeah. No. It's, it's I mean, can you imagine a better summer job? Like, just hanging out at a pool filled with, like, your your peers and kids and splashing around. This reminds me Beverly Hills nine zero two one o. 

Isn't that what they used to do then? Like, I've just got these memories of watching that, and that's what that's what kids did, hanging out in the summer club, and that's where the kids were. You had that haircut, didn't you? You were the Yeah. I did. 

What the which one? The yeah. The Dylan or the Brendan? Dylan. Luke Perry. 

Luke Perry. Yeah. Yeah. Yeah. Yeah. 

I I was more of the older one. Kinda guy. Yeah. Yeah. Exactly. 

Got it. Right. What was so what was your best summer job? Oh, okay. Well, I had two summer jobs. 

One of them, I worked at a fashion store back in the day. It was called Topman. And I was I was famously I had the same haircut. Please please say they sell top hats. No top hats. 

It was just basically, like, young male and female fashion. The the female shop was top shop and the male men was top hat. And I had the same haircut as the mannequin in the window. I had, like, a bob length haircut, and so people used to come in and just to see if I was like the mannequin in there. So so I did I did top that was one job. 

And the other job, I was a silver spoon waiter in the summer holidays, summer vacation, and that's how I saved up money to buy my first ever mobile phone. So those are the two best jobs I had. Wow. Yeah. Those sound those sound good. 

I was I had a variety of summer jobs. I was I was a camp counselor, which is great for a number of years. But before that, I I was a gas station attendant, pumped some gas. Did you really? I yeah. 

Yeah. Yeah. Yeah. Do you have the mullet when you were doing that? Right? 

Because I know you had a mullet. Oh, the Were you rocking the mullet? Of course. It was it was it was 1985. I mean Okay. 

Right. I was a sandwich artist briefly at Subway. Artist. A sandwich artist. Well, that's that's that was the that's the job description. 

That's the job description. Sam I was fired though for for I couldn't cut the tomatoes had to be cut a certain way, and I just wasn't wasn't getting it. Are you making this up, or is this right? No. No. 

I swear to god, I was a sandwich artist for for a short time. But the best job I ever had Right. As a summer in summertime, I I decided to, like, just put this advertisement up in the local town that I was living in saying it's in high school. Saying, like, I'm available to do any kind of work you want. And so I got some odd requests from people, like, to help them out around their house. 

But one guy said, right. I got a field full of rocks that need I need the rocks out of the field. Is this a joke? Is this a joke? No. 

It's not this is not a joke. This is for real. But the so I did this I did this job. I didn't do it for very long, but now I've got the street cred to say to my kids, oh, you don't like, you know, having to do your homework? Things could be worse. 

You could be picking rocks out of a field. But I'm a bit bummed this week because I do you do you use an e calendar, or do you use, like, a paper calendar still? Yeah. I'm all I'm all electronic, which my wife, Catherine, hates. I'm all about e calendars. 

Yeah. Yeah. Yeah. Yeah. No. 

I I'm a paper guy. Paper paper and pen paper and pencil still. But I'm bummed because someone, like, vandalized my calendar, at work. Oh, no. Yeah. 

It, they they ripped they ripped out the pages for, like, this current month. Right. I'm dismayed. Oh, no. Jeff, I you know, that's very good. 

I'm actually that was that guys, I'm so sorry if the laugh is a little bit over the top, but that was actually very funny. Thank you, Jeff. Alright, buddy. So what are we gonna talk about today? We got our guests waiting in the wings here. 

I can see Well, he or she, are are are waiting, and they're and they're they're being very patient. But, Jeff, you know, there are moments in one's life when you experience those kind of hinging moments. Well, if you told me fifteen years ago that I would be in a podcast with you and the person that we're about to introduce, I wouldn't believe you. This person has become synonymous with regional anesthesia worldwide. They're a professor, a clinician, a researcher, a musician, and a brewer of beer. 

I wonder who that is. In addition to being a book author, a sports car enthusiast, an entrepreneur, and the founder of nisora.com, he's also one of my best friends. It gives me the greatest pleasure to welcome Admir Hadzik to Block It Like It's Hot. Admir, welcome. Welcome, Admir. 

Thank you, guys. Thank you for a wonderful introduction. You guys are way fun. I really congratulate you on the stuff that you're doing. You guys are, just awesome. 

Thank you for having me. Oh, thanks, man. It's so good to have you here, finally. Absolutely. For sure. 

This is something that Jeff and I have been hoping aspirationally would happen, and we're really, really grateful that you finally joined us. I can't wait to get started. Jeff, can I please, please have the first question? Yeah. Yeah. 

Go ahead. Okay. So, Admit, when I look back to when I first started in regional anesthesia, you were an inspiration to me. And I followed all the work that you did right in the early days of Nysaura, and I'm pretty sure I remember the first time I met you and being pretty starstruck. I admire, I I assure you there is a question here somewhere. 

Yeah. Yeah. Sorry. Sorry. Sorry. 

I was getting carried away. Okay. Look. Finch me. Right. 

So there this is the question. The question is, can you share with us a little bit about your journey into regional anesthesia? Who were your early role models, and how did you become interested in regional anesthesia? We'd be fascinated to know. Okay. 

Well, Dino, we all take certain journeys. There's a a wonderful song about making a a turn in the right moment. There's always two paths you can go, and we all end up going certain paths you never ex you'd expected. As an example, funny enough, my original vision really wasn't to study anesthesiology at all. I was set to an internal medicine cardiology, actually, to be specific, if you will. 

And I was completely drawn to electrophysiology. So as a kid, I was completely obsessed with electronics. I was building audio amplifiers, speakers, stereo equipment. Right. And, honestly, I still do it. 

This all this stuff to this day. So that's why I'm an an audiophile. But I figured, why not blend my love for circuitry with medicine and become an electrophysiologist? But then Woah. I know. 

But then one night when I was on call at St. Joseph's Hospital in Paterson, New Jersey, this is where I studied internal medicine, I led the team of young internists, residents that is to, resuscitation floor. There was somebody who just had a cardiac cath, and, the patient corded in the middle of the night. And I remember we went there to the room, and the patient was blue, dying. You know, there was no heartbeat or whatever. 

They were at that time, we didn't have electronic monitors. We only had, like, a rhythm strip that was printing out the the rhythm. And we, internal residents, me as a chief, we were arguing over what the rhythm was. It was difficult to decide while the patient was dying. The respiratory therapist was kind of just blowing this patient's cheeks. 

There was no air exchange. Patient was completely blue. The nurses did not have an IV access either, so we couldn't really do anything. At a point of time, when we were arguing about a rhythm, there was a, voice loud voice in the hallway. And, there was somebody who was saying, excuses. 

Excuses. And there were two anesthesiologists, a senior one and a resident. And they come into the bed of the table. Right? So and they ask, like, two questions. 

You guys have an IV? No. You guys have an airway? We go, no. So then the senior anesthesiologist led the junior anesthesiologist, you know, to intubate, and then the color of the patient started changing with chest compressors. 

The next thing, you know, they popped in a central line, and this all happened with the, you know, speed of light. And, you know, they pushed in a few medications, and the the rhythm came back. The patient, you know, regained heart rate and and all that stuff and the blood pressure. And then they looked at us in the full room, and they said, do you guys need anything else? And we would I just said, look. 

No. We okay. And they said, we gotta go back to the Operator Room. Let us know if you need something else. And then as they left, I realized that we continued arguing what the rhythm is now. 

Do you know what mean? And I was starstruck. You know? I went through the night, like, in some kind of a I don't even know, hallucinations. Then as I was driving back home next day, I said, I wanna be like these guys, man. 

I wanna be a lifesaver. And that was it. I quit in telemedicine. I, you know, tore down my contract for cardiology electrophysiology, and then I went to New York City to Saint Luke's where I became an anesthesiologist. Now there, getting closer to the heart of your question, I met this incredible guy Uh-huh. 

Jerry Voloka. Jerry was a a little older than me, and then he was Polish originally. And he, was already ICU trained, and he had some skills with regional anesthesia. And he kinda liked me. The two of us started publishing abstract, and we were kind of competitive. 

You know? It was a competition between the two of us as I came from internal medicine, so I I was, you know, quite a bit advanced with the medical knowledge compared to the other, you know, residents at the time. And he was already a graduated anesthesiologist and intensivist with some experience in regional. And Jerry and I made friends eventually, and he says, look. There's just so much stuff to do here in regional anesthesia. 

If you can see all of these books and these books that are written about regional anesthesia, they basically describe blocks based from the Netter's Atlas. You know, these people say, look. Here's the artery. You see the nerve is right next to it, so here's how you do the block. You introduce a needle next to the artery, and that was it. 

But that never worked. And then we took that then to an at the mill up at Columbia University. We worked endless, you know, hours, nights and weekends, dissecting cadavers, and eventually introduced that term regional or functional regional anesthesia anatomy, which became a nidus for creation of all of these a bit more anatomy related or functional anatomy related techniques that we use today. Uh-huh. And, especially, Jerry was, you know, so driven to discover what else can be done to regional anesthesia to make it more, you know, exacting, reproducible, etcetera, and the the, the concept of tissue sheets that never really were, back then much talked about. 

It is Jerry Walker that introduced that into the into the language of regional anesthesia. So there you have once I graduated anesthesiology residency, I became actually a cardiac anesthesiologist. So I did TEEs at the time and cardiac anesthesia. Yeah. And then I did six months of transthoracic, echocardiography in a in a transthoracic lab because I wanted to become now a perioperative anesthesiologist, and I did do a lot of TTEs perioperatively determining whether the patients, you know, were fit for surgery or whether they needed whatever additional monitoring, etcetera. 

But then Jerry convinced me that the right thing to do was to go into regional anesthesia because as opposed to cardiac, there was just so much new to discover and contribute to the field. Right. And there you have it. We went full blown into regional. So that's how I became regional anesthesiologist. 

That's an amazing story. And what I think most of our listeners will not know, and, Ahmed, I 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 to to figure out, okay. That's this fascial plane, that's that fascial plane, and that sort of thing. So amazing. Right? That is absolutely amazing. 

I'm I don't think I could do that now, let alone when I was a resident back in the day. So that's truly, truly impressive. Now those are those are crazy times. I remember many nights. Do you know? 

We would go back from Columbia Lab, 50 cadavers all exposed, and, you know, there were nights when Jerry wouldn't make it home. He would sleep on Garden State Parkway for a little bit and just turn right back to the hospital for another shift. Wow. I I had to say it was really intense. It was a huge dedication back in the day. 

That's how you get it done. For sure. I'm a bit confused because you started talking about The States, but you're not in The States now. Right? So you've done a little bit of traveling to finally end up where you are now. 

Just tell us very briefly about that story, Jeff, to jump in, but I had to ask the question. Yeah. I mean, you know, it sometimes it feels like I lived, you know, 10 different lives, really. But I think but I think it's really important for everyone to, learn, you know, when to pivot, meaning to change things. I was born in Yugoslavia back in the old country when Yugoslavia was an amazing country, composed of, you know, Slovenia, Croatia, Serbia, etcetera. 

It was an amazing environment to grow up with, but, you know, I had fire in my belly. I just could not settle. You know, I was, yearning for more education and opportunities in a different place to prove myself, and then I went to United States, as as I just talked about. I landed in New Jersey and then New York. I studied in telemedicine, became a board certified internist, and then board certified anesthesiologist. 

And then I was there for about twenty five years driven by passion about creating. You know? And then there was a huge community that I built on different sides, whether that be in medicine or research or music, or, you know, electronics. It was a very, full life. And then, eventually, I met, a love of my life who is also an an anesthesiologist, Catherine Wandepitte, a Belgian anesthesiologist. 

So once we started having, you know, babies, decide to live together That happened fast. I had to make yet another decision. Where do I, you know, pivot now? And I made some really amazing decisions. But let me tell you something about, you know, making these decisions and executing them. 

It's like, imagine if you now you work a living in UK, but imagine your whole life is on a big board. Right? So it's all written up, and there's no space anymore on that board to put more stuff. That's your family. That is your work. 

That's your meeting, your commitments, whatever it is. And if somebody gave you an opportunity to take a sponge and wipe that board clean as we can start writing from the scratch. That's how we felt three times when I did this. So when I when I moved from New York, from United States to Europe, to Belgium, it was like think of it. It is like moving to another continent, another job, another country. 

As you said that, I started getting shivers because I was thinking, I how on earth do you do that? You know, with another life, with another wife. New kids. But it is it is truly inspiring when you're given, you know, carte blanche to ride your life just the way you want to one more time. To me, it made, you know, I met incredible new people and experiences. 

Those are great decisions, I think. That's an amazing perspective because I think a lot of us, you know, get momentum and inertia in a certain trajectory in life. And the maturity that you have at age 40 or 50 where you got to wipe that thing clean and say, with intention, this is how I wanna live my life. These are the next things we're gonna do. You don't have that at age 18. 

Like, you're like, oh, I'm just gonna I guess I have to go to college and I guess I have to go to medical school and then I'm do this and this and this. And so what a cool what a cool way to say with intentionality, hey, here's my next here's my next chapter. I'm gonna write it the way that I wanna write it. Yeah. It's easy it's easy to fall into the groove and become complacent. 

Do you know, if you think about when you see these, you know, I can use one example. If you don't have something to look for when you wake up and plow that, you know, first step out of the bed, you know, then you're really missing out something huge. Some of my trainees, they come into work huffing and puffing, you know, on a daily basis. I always tell them, don't look, you know, back and don't live in thirds. And they don't understand what I mean when I say don't live in thirds. 

What I mean by don't live in thirds is most people, live so that their life is somehow organized in these three thirds. One third is sleep. There's nothing you can do about it. Everybody needs to sleep. One third is your freaking work. 

Because once you are done with your freaking work, we can you know, you can go back home from your freaking work and live your life. What we don't actually realize, none of us, is, you know, when you go back to home, to live your life after your freaking work, you need to invest some time to drive back home or commute back to home. And from from your life, you need to go to work, so it's also some time. You need to prepare for work. When you come back home to live your life, there may be a sick kid or a child or in laws or a parent. 

Registered. The roof needs to be fixed. The bills needs to be paid. And, you know, if with a little bit of wisdom, you can easily realize that the only protected time in your life you have is your work. So if you can actually live your life that is fixed so that, you know, when you go to work, that's your life. 

You really gain so much, you know, of your life. And so all of these pivots that I've done, they were not done based on just the multiple factors. I it's a basically simple equation. No matter where you work and live, you will have to sleep, you'll have your private life, and you'll have your work. But if you transform your work into your life, it's easy to switch places. 

Yeah. Wow. That's that's a I had not thought about that equation that way. I have I am guilty of thinking of things in thirds. Mhmm. 

Work Did I? Life, sleep. I often wonder if you even take time for sleep, Admir, sometimes. It it doesn't look like it. Actually, I do. 

Most people most people ask me that question, and and I'm guilty for, you know, alluring them into thinking that I don't sleep because when people ask me, where do you have time to do all the stuff that you do? And I'll always tell them, like, you know, a day has twenty four hours or twenty five if you wake up an hour earlier. But, but I do I do I do sleep. My sleep usually about six hours. And, I mean, then that's you know, everybody's different. 

Yeah. But even if you sleep a lot longer, let's say it. So we have pretty much the same amount of time to do stuff we wanna do. We'll be right back after this word from our sponsor. Before we talk any further, we wanted to interrupt with an important conversation topic just for our US audiences sponsored by the folks over at Pacira, the makers of EXPAREL bupivacaine liposome injectable suspension. 

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No pain, guardian of the pack you. Honestly, not far off. The no pain act is a game changer here in The US, especially for folks like us who care about reducing reliance on opioids after surgery. Sounds important, but fill me in. Something about expanded access? 

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Okay. Now I'm listening. So we both used EXPAREL and consulted for PERSURA two. Solid data, long acting, patients do well, but our hospital used to have to eat that cost. Sure. 

I believed in it, but it wasn't exactly budget friendly. Ouch. So what changed? Well, now we get reimbursed for all outpatient use in Medicare patients, and private payers are jumping on board too. There's even a j code that makes it simple to bill. 

That actually sounds efficient. Are we allowed to say that about health care? Miracles do happen. And more importantly, it lets us do the right thing for patients. We've always known multimodal opioid sparing analgesia is better, but now we can offer it without putting our hospitals in the red. 

Right. Less opioids, more options, and less financial friction. What's not to love? We're calling it precision pain management omit. The superhero cape is optional. 

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Some of the most common adverse reactions reported in adults and pediatric populations include nausea, vomiting, constipation, pyrexia, and anemia. Monitor cardiovascular status, neurological status, and vital signs during and after injection of EXPAREL. And now back to our show. I wanna change gears a little bit and talk about Nysaura. So if you ask anybody where to go to get regional anesthesia education, the first word out of their mouth is Nysaura. 

For sure. And that is around I remember in '2 when I graduated residency, you know, at Saint Luke's Roosevelt and went to Australia for my first job, within the first week, I was with some trainee and I said, oh, you you know, let's let's do a block for this case. And he goes, oh, yeah, mate. That's a great idea. What was was he from India? 

What? What? Come on, man. This is one of the accents I can I can do? Sorry. 

Sorry. Go ahead. He's not my typical Indian Irish combo guy. And he pulls up the he goes, but but first, I wanna show you this this website. This is where I get all my information from. 

It's called Mysore. Have you heard of it? And, I was just sort of, like, nodding in the background. Yeah. I I think this looks looks a little familiar. 

So we're laughing. We're laughing because of the accent, Jeff. You have to realize the story is amazing, but we're laughing because of the accent. Anyway, worldwide global phenomenon now, the go to resource in the field. So how on earth did this start? 

Where where does one start to do something like this? Do you know, if you ever wonder why why it's so successful, I think it's a it's a, you know, consistency of of leadership and a vision. I think that's really what it comes down to. It was unwavering. But I talked about how Jerry and I worked back doctor Jerry Walker, of course. 

We we also, nicknamed the the popliteal sheath, as a as a walker sheath, in memory of of of Jerry. But, 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, anesthesiology 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 gas free since 9093 as a Pretty good. Yeah. 

But, so we went to our department, and we talked to the department heads. And, you know, we told them about idea of teaching regional anesthesia and publishing our research as well on on website, and we were ridiculed. We were laughed out of the room. We were told, look. Who wants to read about medicine on the Internet? 

You know, they said, fast forward thirty years now. Can you imagine? So we had that vision thirty years ago. And then, you know, NYSORA has always been a labor of love, really. It never was a commercial, organization. 

And in fact, we had two or three meetings annually. We channel all of those funds, if you made any money into our departmental research back in the day. And, it's only about five years ago that I decided to scale NYSORA. I just kind of felt with the preponderance and and popping up all of these open access journals, I I felt the academic field was getting really dissolved. And I didn't wanna get into the trap of working for all of these enterprises that are controlled and manipulated and milked by these publishing companies. 

And then I decided to scale NYSORA. That's how, about five years ago, decided you know, NYSORA decided to grow, to build a community, around itself, and to open a and I saw a press, which is a publishing entity. I used to publish books for publishers like McGraw Hill, whatever whoever would raise a hand, it was something that you did as a as a as an honor and to contribute the knowledge. But the publishers will basically take your knowledge. They did not go anymore to any medical meetings to promote your books. 

Do you know the libraries closed? The bookstores closed? They never advertised, any books, and they basically would turn back to you when they would ask you, so what are you doing to promote your books? And my answer to them was, what are you doing to promote my books? And it's only then, really, that about five years ago that I started to to change it completely around. 

So NYSORA, fast forward today, is an organization with 40 full timers, actually. So it is really immense organization. The website right now is about 12,000,000 readers annually. Yeah. The black app has the 200,000 downloads at about 15,000 users. 

It's it's immense, really. The the newsletter distribution is 230,000 people. But this is really, this, this really all come with a, you know, substantial efforts. Do you know what mean? Well, 40 people that we have in the organization, we have a full scientific group. 

They're all here with me, on the Belgian side because we have several offices. In Belgium, we have a scientific office, and we have a video editing office. In London, you guys know Pat McCourney. She runs our, you know, live programs as well as she's a general manager. In Serbia, we have the publishing group that publishes our books, typesets them, etcetera. 

In Sarajevo, we have IT group. We have a complete, you know, service in house that publishes our apps and maintains websites, develops all of this cool stuff that we do now with AI. And that's another thing I would love to say a word of or two eventually if if the time allows. But, again, NESORA is a really large organization today. And, again, the when people when people ask me, how is that possible? 

And, again, it's really it's a the labor of love and consistency of leadership, you know, with a vision Uh-huh. That leads to an outcome like this. It's an incredible success story what you've done, as you know. And I'm I'm interested in, like, your your you talk about consistency of leadership. Like, how do you run that enterprise? 

You've got teams in four different countries. You've got you've got design teams. You've got production teams. You've got but when I open my inbox and I see a new video from you, like, I don't know, three times a week or twice a week, you are in the video. So you're not just you're not just in a room directing people. 

You're you're the Or is it an AI? It might be an AI admire. It might not be him. Maybe it's a virtual it's a virtual admire. Oh my god. 

It's hologram. So what is your take take us through a day in running NYSORA. Okay. So look. I'm primarily a clinician. 

So, you know, most people who either read my publications or see me lecture places and whatever, they think I don't do actually anything clinically. But those who venture to visit us during our boot camps here in in Genkina, our clinical practice in in Belgium where I'm at right now, also have a clinical privileges at in Long Island as well. But primarily, primarily, I'm here, in in Belgium where my family is. And then whoever comes here, they actually see that I am primarily a clinician. But how do you get to do so many things? 

You know, it is you just can't be a micromanager. Do you know? I I think you really there's always a question as to how do you how you hire your employees. And whether you hire somebody who's really so well trained and pick the best people that are best trained and hire them to do the stuff, or you select people who are the best people. You train them the way you you want them to work. 

That's the model that I go after. Once, our team members are trained, they're really fully capable of executing much of this stuff by themselves. As an example, it comes to the newsletter, which we have, like, a twice a twice a week now. All these newsletters are created using our chatbots that we've developed in full transparency. We identify literature. 

We have our, you know, journal clubs meetings with our scientific team members. In NYSERDA, we have four biomedically trained people with masters of education. They're all Belgians, and they sit with me. They're, so we go through journal clubs. We select the literature and then use the technology to help us extract, you know, clinically valuable and easy to read material that we serve to our community. 

And that, Jeff, has really, helped us grow substantially because as opposed to featuring the next meeting or whatever is coming up, we actually, for the long time now, have been only serving the, the content that's valuable to to clinician. So that's really, in in a in a in a nutshell. I can tell you one other thing is five years ago when I decided to scale NYSORA, I also, had to put on that board all the stuff that I did back in the day. And what I realized is that, you know, traveling and lecturing through universities and various conferences, workshops Uh-huh. You know, society meetings, what have you, took so much of my time that I was not actually able to grow any sort of or be at home. 

Look. If you're not at home, stuff doesn't get done. It's period. Also, I remember the days when I would, you know, review for 10 anesthesiology journals. You know? 

And then all the time, they went into reviewing the papers all of that effort if you can repurpose into growing something like your own enterprise or your own Yeah. Publishing company or whatever it is. That's a lot of time, and it's a lot of focus that, definitely shows over time. I always tell everyone that, you know, to be successful, you need to do something well and do it for a long time. And whether that's a shoe store or a deli or whatever it is, it will be successful. 

You know? You become known for doing something well. So that's how. Listen. I this is fascinating. 

That would explain, Jeff, why admin might be seen in the front row of a lecture theater quickly putting the finishing touches to his presentation because he's so been so busy doing other things. Speaking of conferences, I do remember one of the early times I met you back at Ezra World, which was in New York in 2018, and you got up on stage in an Irish bar and played with a band. I mean, what instruments do you play, and what's your favorite type of music? I I I know from some of your nicknames or your x handle that I roughly know, but but give us a bit of a an insight into the musical side. You know, the passions that I have today is passions that I have really carried all my life. 

Even even with the with the music and the cars and and whatever. And that is when I was a kid, when I was in high school, I played, you know, bass guitar, and I played, drums. I was a DJ back in the day. So has always been a part of what I did. But when I, you know, went to United States, I got into studying jazz and blues. 

And that, for me, changed everything. So I play a a bass guitar in a in a in a blues rock band. Blues is a foundation of pretty much all in modern music. And and at some point in time, I even opened a commercial recording studio in New Jersey just just chasing my passion. And that's when I started connecting with some amazing musicians locally. 

One thing led to another, then I formed my own band, the Big Apple Blues. We recorded a few albums that actually did pretty well. And through that journey, I met this incredible person, who I don't you know, his name is Hugh Pool. He's a he's a New York hall of famer, rock musician, guitar player, an incredible, powerful vocalist. Good guy. 

Yeah. Yeah. And he invited me to to, join his he, he had a situation in which he was invited to play someplace on a tour, and then he couldn't get a bass player. You know, he heard me play bass somewhere, but not that I was an amazing bass player, but okay. You don't need to be an incredible musician. 

You just have to have a ear and a passion for that kind of music. So I said yes, and I toured with Hugh, I think, all continents, pretty much. And I tell you, the journey of music has taught me so much. It it, teaches you how to communicate to people. It teaches you, you know, how to interface people. 

You know, given a lecture, as you know, is a part information that you're sharing, but also is a part show, how you captivated people. And then, so yeah. So I'm a bass player, and the rock blues is what I play. So to this day, I still tour at least once a year, and I still have a recording studio in in Brooklyn. So anytime Really? 

Wow. It's a analog recording studio that I'm so much proud of. I have a lot of equipment there. Hugh Pool is still there, And all the people that I played with, I still meet with them whenever I'm back. Amazing. 

Amazing story, Jeff. I now that I know that Admir's got a recording studio, we gotta get into it, man. That's got to be aspirational. That's easy. There you go. 

I think it's I think it's for more like professionals, not like, you know, hacks like you and me. Oh, come on. Come on, Jeff. I I saw your YouTube videos. Come on. 

They're awesome. Come on. Or you or maybe just maybe just for a photoshoot. Just the photoshoot. I've been in the audience for many of those performances. 

It's it's a good vibe, man. It's a good, fun, powerful vibe. Admiral, you talked about being a clinician first, and I have seen you run a regional anesthesia service in New York, and I've seen you run one in Belgium. And I think it'd be fair to say that we all have similar pressures and constraints and and sort of a shared set of things that help influence how we run re regional anesthesia, but some things would be different from country to country. But what are the keys to making it work? 

And when I say make it work, I mean, like, consistency and and and delivering a good product and getting surgical buy in and making, you know, the operation run so it's it's efficient and those sorts of things. If you were giving advice to someone who is starting a regional service, what are your top tips for there? Well, do you know I I think I would say this. First, you have to create value in regional anesthesia service. If you do not create value, don't have a chance of succeeding. 

And how do you create a value that's, that may vary from situation to situation? But, I'm happy to share one very simple technique that can help. As an example, lots of folks who learn regional anesthesia, they come back home from various workshops, and they wanna implement, some of what they learned in the workshop. The way they do that, as an example, they take a patient with a total knee replacement and pop in a a doctor canal catheter. And in the process of doing that, you and I know that sometimes that can take up to twenty minutes or even longer. 

The catheter sometimes can accidentally fall out. And then you gotta talk to surgeons how they position the the tourniquet so the catheter doesn't get affected, etcetera, etcetera. And, eventually, that patient gets to the recovery room, with possible even some operating room delays because, you know, sometimes you don't get to the catheter right on time, and it's a lot of stress on you, on your nurses, and everybody as you're trying to complete the procedure in time, meaning the catheter. So now you're in the Recovery Room. And what's the percentage of the patients that will have pain after there is you know, they come to the Recovery Room with your catheter? 

The answer is hundred percent. So now you have a situation in which you pissed off everybody on the way, and now you're in the now you're in the Recovery Room, and now you're pissing off nurses who not only need to take care of your catheter, but now they also need to take care of the IVPCA. And everybody's saying, why are we doing this? These never work. So how about you how about if you change that? 

So if you didn't do any blocks, just put him to sleep like everybody else does. I think ninety percent of our colleagues would just put patients to sleep and deal with it later. Right? And then in the recovery room when the patient is in pain, do you know then you go in when you call to troubleshoot the situation. They're taking twenty milligrams plus morphine, etcetera, and you pop in a femoral block as an example or a doctor canal or whatever you do. 

And now you have a before and after. So now they become believers. Now they see what the value is. So as you do this a few times for several different indications, could be a shoulder, could be a foot, now all of a sudden, are approached by somebody who says, well, Emmett, you know, but why don't you do this in everybody? And now you're creating value. 

Right. And now you have bought yourself the creed to go back and say, well, we're gonna do this preoperatively, and everybody is a is a protocol. The second thing that comes in the way oftentimes is and in the places where I help set up regional anesthesia, you know, practice, like, for instance, Belgium here, you know, you came in and you saw And these binders were menus that individual doctors who do regional anesthesia use when they do walks. So when I'm there to do regional anesthesia Right. You know, the nurses know that I hate, the needle that Amit uses, and I will not use the same technique that Jeff Gustin does. 

Everybody does. Because I have, you know, better techniques than either one of these idiots do. So they have to set up things the way I want them. And I don't use, you know, like Jeff Gudson does. I use only, etcetera. 

So what I'm talking about is complete absence of standards. So unless you establish standards in your own institution with your colleagues, then I can tell you, it's very difficult to create value. I always say jokingly, if I was an orthopedic surgeon, I would never let my anesthesiologist do blocks. Why? Because when Emmett is there, I know that blocks will work. 

But when Jeff is there, he puts everybody to sleep. That's fair. And when Admir is there, he doesn't do really blocks like Emmett. He does does them differently. So what do tell to my patient? 

If my patient if my patient has a pain in the recovery room or some kind of a problem, I need to call an anesthesiologist to find out what they did. This should never be the case. So Mhmm. You know, you have to have standards. Listen. 

Even if it is difficult to establish standards in a group, you should establish your own standards that you repeat and you become reproducible. You know, I I love that because we quite often just look at things from our own perspective. Right? I wanna go I'm gonna go and do my things for this surgeon. I get cheesed off why he doesn't want me to do that, and that's because the guy that was covering the OR last week did something completely different, or somebody else did the same thing that I did but took twenty five minutes to do it, and then it the block didn't work. 

So from a surgical perspective, they must be thinking what on earth is going on with my patients. So I sometimes struggle to get my colleagues to all agree that standardizing the anesthetic is a good idea because people have their own thoughts. So how do you convince your colleagues? How do you get your colleagues on board? So you talked about how you might convince the surgeons or the PACU staff or the nursing staff. 

How do we get everybody to sing from the same hymn sheet? How do we get everyone to to kinda say, well, let's go with plan anesthetic a for this type of case? One of the one of the problems is a preface to your to to the answer. One of the problems is, you know, most anesthesiologists, most of our colleagues, consider regional anesthesia as fun, as something different to do. For me, for us in our service, it's not fun. 

That's what we do for a living. And then so so, you know, to establish service, it cannot be one person. Then you get these people that do incredible things. The other day, I was I was corresponding with somebody who does thoracic spinals, right, and a continuous thoracic spinals. And and he's she they swear by that. 

Okay. You know? But you and I know you can't establish that service because, you know, there's just not enough, you know, people that would do that or have skills to do that. So you're gonna have to say, alright. So we're gonna create a team, and we're to devise a number of, techniques for specific indications and adhere to one technique, one local anesthetic, etcetera, and stick to it. 

And then, you know, when you approach a patient who has a risk fracture, you know, you know in our practice, they're going to get an axillary block. And the nurses are ready for with everything. They will never ask you. Hey, Amit. What do you want for this risk fracture? 

Well, if I was Jeff, I'd say a raptor. Exactly. So, you see, everybody has their own biases. But, you know, but service, cannot be Jeff Gudson or Amit Para or Admir Hazzic. Service is more people that provide service twenty four seven. 

And so how do you get everybody to to get there? That comes to the, you know, people management. There's four kinds of people. First, the type of people they're called mother Theresos. This is your family. 

These are people that are unconditionally yours. Do you know you come back home no matter do you know how nasty you were there yesterday? They, you know, they love you again today. And then you have mercenaries, group number two. Mercenaries are people that are yours for as long as you pay them. 

So surgeons, as long as you don't delay cases, don't cancel cases, put their names in the abstract, Ahmed is the best guy ever. The first day that he, you know, cancels a case, you're an a hole. Right? And so what you need to do, you need to pay them back, pay them again in order to you just need to know what you need to do with them to be yours. And then you have the hostages, group number three. 

Hostages are people who basically have to do what you tell them to do. In some places, this could be residents or nurses. So, you know, you don't have to worry about them except that you need to know that maybe today they don't have an option, but tomorrow they might. Right. The final group of patients of of sorry, of people in your team that you really have to recognize because this will be the determining group, how you approach them. 

It will determine your success in making the service. They're called terrorists. Right? And the terrorists have never been constrained by any army or governments or police. They're just completely unpredictable. 

And here's the thing. We tend to spend about 90% of our time convincing a few terrorists, neglecting everybody else. So in building a team, you have to understand this, that the people who don't agree with you, you will never change. Let them be. And work with the family, with the with the hostages, and with the, mercenaries to create a service and let these other people, you know, be. 

And, you know, eventually, they might help or or join or leave because they feel isolated. So in in determining the team, you have to have a mission the the service. You have to have a mission and the goal. Here's what we wanna accomplish, and these are our three, you know, main things we want to accomplish. Don't change everything all at once. 

You know? Change one thing at a time, make it a success, get a creed that you can actually make things better, and then keep on introducing new things that make a difference. And, in my case, in in this practice, the latest over here in Belgium, we started doing spinal anesthetics outside of the Operating Room. And once the surgeons figure out how that saves them time, both, you know, before the surgery and after, there was no way you could go back. And then that gives us you know, gave us creed to go ahead and, you know, do other things like that. 

We never ask surgeons whether we can do a block. Do you know? They are expecting you to because they know they're saving time. Yeah. Yeah. 

Yeah. That's fine. As you're saying this, I can I'm picturing people on yep. I know that mother mother Teresa. I know that terrorist. 

I know. This I mean, it's a really fascinating insight. In fact, I remember you talking back in back in Brighton in 2018, I think when you gave your Bruce Scott lecture talking about developing teams and getting them on board and turnovers. Just before we hit the joke break, we know that you're passionate about reviewing evidence, evaluating evidence, and applying it to clinical practice. So now in this era, when you open up a journal every day and there's a new block that's been described or being invented, how do you decide whether it's something that you will incorporate into your clinical practice or it's something worthwhile teaching, your audience? 

How do you go about making those decisions? Do you know, we have a very rigid protocol in which here's how we go by. Look. If the block works for surgery, then it has to work for analgesia as well. If there's no surgical indication you can use a block for, you and have to agree that that block or technique cannot be as powerful. 

Do you know? So that's one way we go about it. Uh-huh. There are times when there are no blocks that are powerful, and you have to adhere to some of these weaker analgesic or fascial technique injections. It is what it is. 

But I think if you, put on the board 90% of your indications and select which ones are going to give you the most bang for the buck, this is what you should, you know, go after. And as far as all of these techniques, variations, me too, etcetera, we have three principles in in our service. The principle number one is the definition of a nerve block. The nerve block is an injection of a local anesthetic in the space that contains a nerve. Now how you approach that space is up to you. 

You see, if you simplify things like that, it makes it different. The second principle that we teach everybody who comes through our service is the pressure principle. And what that means, really, maybe you might need a little bit of pressure on a to do so to get images that you want, but once you get them, you need to let that pressure go. Otherwise, the principle number one will not work, meaning you cannot actually spread local anesthetic in the tissue plane that you are trying to. And it's one of the most common problems with facial plane blocks. 

People are so stressed to get it into the proper plane that they apply so much pressure into that they never actually get the spread that they're supposed to get. And finally, that standardization that I talked about. Our nurses have basically a sheet of paper like this, and assistance as well. And then, basically, it says wrist fracture, dead block. You know, whatever. 

You know, bunionectomy, dead block. And it's and it spells down the number of cc's you give, and and that really, helps a great deal. It makes nurses extremely happy when they know what the next case, will they will need for. That makes a lot of sense. Because sometimes when I look at these blocks coming out, I'm thinking, god. 

Can I justify doing that, or does it really work? But that makes a lot of sense. I admit, I think that's that set us up really nicely now to just have a little bit of a chill now. We're gonna enter the joke break. Okay. 

And and Is it time for the beer? Yeah. Now it's time for the beer. Yeah. Yeah. 

Now it's time Yeah. Well, I listen. I I, you know, it was Mother's Day here recently. Is it Mother's Day in in The UK as well? It's a different day. 

Right? Bro, for some reason, I don't know why being British, we've gotta do things differently. The whole world has, like, international Mother's Day, but not in The UK. It's like Brexit. I don't know. 

Like, not at all? Yeah. Yeah. No. We do have it, but on our own day. 

We have, like, a Oh, okay. We have, like, a British Mother's Day, but because I'm kind of I've got a bit of Indian in me, and I was born in Thailand, I don't know which day to celebrate it. I celebrate my mom every day. Oh, it's a good answer. You just you dodged that bullet, and that's good, man. 

Well, listen. I I I I failed on Mother's Day. I I my Oh, no. Cory came to me, and she was really upset that I didn't buy her flowers. [pause...] I didn't even know she sold flowers. 

Oh, Jeff. Oh, Alright. That's my that's my contribution. Is that you, done? Do you know what, guys? 

I'm gonna say, my friends around here think I'm a little bit weird, because I'm constantly eating baked ham and pineapple sandwiches. But what can I say? That's Hawaiiai roll. Hawaii roll. Listen. 

On on the subject of pizza, what's the world's saddest kind of pizza? Saddest. No. A pepper lonely. Pepper lonely. 

Well, listen. I'll admit laugh, so I'm gonna take that as a win. Okay? Even if Jen just if Jen just groaned. Admit He's very polite. 

Gonna join this party? Have you got something for us? Well, okay. Do you know there's been a couple there's been a couple of times, couple of occasions when these surgeons are kind of, you know, looking at us. Anesthesia. 

So you peek over the drape. This is some of these newcomers are trying to make friends with us. And they go, it's a good anesthesia, doctor. Really good anesthesia. I said, look. 

Doctor you know, a good surgeon deserves a good anesthesiologist. Anesthesiologist. And then they go, oh, thank you. Thank you, doctor Hanzig. But a bad surgeon needs water. 

And that's and that's how it chills them down. Funny entry. Oh, man. That's good. And that's the end of part one. 

But wait. There is lots more Admir to share, so make sure you listen to the next episode where we get into AI, best practice for hip fracture, and why beer may be the best medicine. And in the meantime, do us a solid and block it like it's hot.