[SPEAKER_01]: Hello and welcome back to ACRACT.

[SPEAKER_01]: I'm Jed Wolpa and I am really excited to be back doing another master clinician episode and a fantastic one at that.

[SPEAKER_01]: I am really excited to have with me Dr.

Michaela Farber, who is the inaugural Mass General Brigham Chief of the Division of Obstetra, Candice Ziology.

[SPEAKER_01]: She started that role just recently on May 1st of 2025 and she leads both the OB-Annecise divisions at the Brigham and Mass General.

[SPEAKER_01]: She's an associate professor of anesthesia at Harvard Medical School in Boston.

[SPEAKER_01]: And prior to that, she served for three years as OB division chief at Brigham and Women's.

[SPEAKER_01]: She has had quite a career in the first 12 years of her career.

[SPEAKER_01]: She was OB anesthesia fellowship program director at Brigham and Women's.

[SPEAKER_01]: It's the largest program in the country with five fellows per year.

[SPEAKER_01]: And she's very proud of having mentored 56 fellows.

[SPEAKER_01]: And we're going to hear some more about her fellows.

[SPEAKER_01]: But I want to read some of the things that were sent in to nominate her as a master clinician for this series.

[SPEAKER_01]: So, [SPEAKER_01]: Here are some of the things that were presented.

[SPEAKER_01]: Dr.

Farber's clinical expertise is exceptional.

[SPEAKER_01]: Her commitment to improving maternal safety is evident in her research on postpartum hemorrhage, focusing on preparedness, risk assessment, and the far macro kinetics of trans-examigasid therapy.

[SPEAKER_01]: Dr.

Farber has a long-standing interest in educational techniques that serve to enhance patient safety.

[SPEAKER_01]: Dr.

Farber was invited to deliver the Gerard W.

Ostheimer Lecture at the 2022 soap annual meeting and honor that underscores her respected voice in the field.

[SPEAKER_01]: Dr.

Farber's commitment to excellence in reducing maternal morbidity and mortality through sound evidence-based parry part of management has earned her influence in national professional organizations.

[SPEAKER_01]: Dr.

Farber has had a profound impact through mentorship.

[SPEAKER_01]: Over 12 years, this fellowship program director at B.W.H., she has trained in guided 56 fellows, many of whom now hold leadership roles themselves.

[SPEAKER_01]: Her influence on the next generation of obstetric anesthesiologists is widely recognized and deeply appreciated.

[SPEAKER_01]: Dr.

Farber is not only a remarkable clinician, but also a dedicated educator, researcher, and mentor, whose impact on trainees is profound and far-reaching.

[SPEAKER_01]: In the high-pressure environment of labor and delivery, Dr.

Farber sets the standard for excellence with her sharp clinical judgment and unwavering commitment to patient safety.

[SPEAKER_01]: She earns the care teams to respect through both her expertise and the empathy she brings to each decision, whether managing complex cases like postpartum hemorrhage or high risk cesarean deliveries, she leads with poison grace, offering invaluable lessons in clinical leadership.

[SPEAKER_01]: When she speaks the team listens, confident her decisions serve the best interest of patients and staff alike.

[SPEAKER_01]: What truly sets Dr.

Farber apart, however, is her devotion to education.

[SPEAKER_01]: Despite the demanding nature of her role, she consistently makes time to teach, whether breaking down difficult physiological concepts, walking through complex anesthetic decision-making, or encouraging thoughtful questions, especially when things don't go as planned.

[SPEAKER_01]: Dr.

Farber Foster's an environment of learning and growth.

[SPEAKER_01]: her dedication to our development as future anesthesiologists is evident in how she continually advocates for our educational experience while balancing the priority of delivering excellent patient care.

[SPEAKER_01]: Despite her numerous accolades, including the BWH Senior Mentorship Award and the Education Program Leadership Award.

[SPEAKER_01]: Dr.

Farber remains humble, approachable, and deeply supportive of her team, she inspires many to pursue careers in obstetric anesthesiology and exemplifies what it means to be a clinician educator.

[SPEAKER_01]: So that's really something, and those are from multiple both faculty and residents who send those various comments and says a lot about her, and I'm thrilled to have her on the show.

[SPEAKER_01]: Mikayla, welcome to ACRAC.

[SPEAKER_00]: That listen, it's an honor to be here, and I'm just blown away by your introduction.

[SPEAKER_00]: It's a wonderful feeling to have had this impact on so many people over the years.

[SPEAKER_01]: It must be and a real profound impact it has been.

[SPEAKER_01]: So I'm excited to hear some of what you have learned over the years and what you teach and what makes you really stand out as you obviously do in the minds of your colleagues and learners.

[SPEAKER_01]: So one of the things I mentioned up front is that you were a fellowship director for a long time.

[SPEAKER_01]: I know from our interactions that that is a really special time for you.

[SPEAKER_01]: You really cherish that time and as we can see in some of the comments that we're sent in.

[SPEAKER_01]: 56 fellows, that's a huge number of obstetrics and anesthesiology fellows, especially when many programs might have one or two total, and so talk a little bit about that.

[SPEAKER_01]: How did you become a fellowship program director and what did that mean to you?

[SPEAKER_00]: Yeah, absolutely.

[SPEAKER_00]: So I finished up my own training and residency and fellowship at Brigham and Women's in Boston, and after I graduated, I gravitated toward helping future fellows to find their research projects because what I [SPEAKER_00]: It's a short period of time just one year.

[SPEAKER_00]: It's a real challenge to embark on meaningful research in that time.

[SPEAKER_00]: So with that interest, I was kind of nominated to be the Director of Fellowship Research at the Brigham and within the year stepped up into the role as Director of the Fellowship Program.

[SPEAKER_00]: So a huge honor for me, a very exciting step in my career way back then.

[SPEAKER_00]: But it was that kernel of research planning that really [SPEAKER_00]: And it continues to excite me to this day.

[SPEAKER_00]: So working with fellows, identifying with their curiosity is our and what their strengths are.

[SPEAKER_00]: Every single year that can look different from fellow to fellow and from group to group.

[SPEAKER_00]: But OBS is an incredible field where you can really observe clinical challenges, ask a question.

[SPEAKER_00]: And then we have the capacity where I work to design a study that starts to answer the question.

[SPEAKER_00]: And then to really feel like you're truly making a clinical impact and specifically making maternal care better.

[SPEAKER_00]: So, you know, we've even managed to do this within the short course of one year fellowship, sometimes it takes longer, but a lot of times we can manage to do really incredible things in a single year.

[SPEAKER_01]: Yeah, so it is I think that's something that especially people in for example internal medicine or pediatrics right they have these three now sometimes becoming four year fellowships in this huge amount of time so to do a lot especially in research in one year is really impressive and so it sounds like that was something you really prioritized in and how did you I mean say a little more about you know was it um [SPEAKER_01]: through kind of preparing people early, was it selecting people who had some skills and knowledge already?

[SPEAKER_01]: How did you kind of manage to get Fellows geared away so quickly and have, you know, them feel good about what they could produce in just a year?

[SPEAKER_00]: Oh, it's a great question.

[SPEAKER_00]: You know, I think it really relates to the importance of identifying what a fellow is specifically interested in.

[SPEAKER_00]: They will kind of perpetuate their own productivity.

[SPEAKER_00]: If you can take a few minutes or take a few days or weeks up front during their fellowship or even prior to their fellowship and figure out what makes them excited to explore.

[SPEAKER_00]: And sometimes we can do that through talking to fellow candidates before they start.

[SPEAKER_00]: I, as a program director, I spent a whole lot of time exploring [SPEAKER_00]: what their strengths are just based on what they had achieved prior to fellowship.

[SPEAKER_00]: And sometimes people come with a blank slate.

[SPEAKER_00]: And that's equally exciting, because then you can provide them with all sorts of prior research projects that have been achievable within a fellowship.

[SPEAKER_00]: And they can kind of think about, oh, yeah, I'd like to take this previous study in our future direction because I find this really interesting.

[SPEAKER_00]: So across the spectrum of experience, the people are coming to fellowship with, [SPEAKER_00]: You can almost always find something that resonates with them.

[SPEAKER_00]: In fact, I was on call with a fellow recently who just started.

[SPEAKER_00]: And at the beginning of the shift, he said, You know, I'm just really not interested in research.

[SPEAKER_00]: My fellowship is meant to really, you know, refine my clinical acumen and my clinical expertise.

[SPEAKER_00]: And by the end of the shift, he was super excited about doing a retrospective study with me based on something we had seen overnight.

[SPEAKER_00]: So it's just really fun to have that impact on people.

[SPEAKER_01]: that's fabulous.

[SPEAKER_01]: Yeah, I think that's so common that people I see it of course more people coming to residency, but I'm sure it's true fellowship to who come in and that's their thought.

[SPEAKER_01]: They've net the research to them has been this thing maybe that people feel like you have to do if you, you know, maybe if you're going into a really competitive [SPEAKER_01]: field, which didn't used to be anesthesiology, but now is more and more as becoming that, where you kind of, you know, it's like a half-two and it feels burdensome.

[SPEAKER_01]: But I do think there are people out there like you, clearly, who can help people see that it doesn't have to be that way.

[SPEAKER_01]: It can actually be a really neat way to explore something you're passionate about, as you said.

[SPEAKER_00]: Yeah, absolutely.

[SPEAKER_00]: You can demystify it and you can kind of take [SPEAKER_00]: Having mentors around you who have had experience is something I can't emphasize enough for the importance.

[SPEAKER_00]: The reason I'm an obstetric anesthesiologist is my mentorship that I got from people like Lawrence, Son, Bill, Cayman, Bavani, Cadale, Jeannie, Carbwena, you know, the mentorship is pivotal.

[SPEAKER_00]: I think to kind of influencing our future specialists in any field, but OBEA, these are its no exception.

[SPEAKER_01]: Absolutely.

[SPEAKER_01]: So you say I know you like to say that there's never been a more exciting time to be an obstetric anesthesiologist, but at the same time I think some residents feel like, well, I don't need to do a fellowship in obstetric anesthesia.

[SPEAKER_01]: I can go practice OB without unlike, let's say critical care where you can't really be an attending in an ICU without a critical care fellowship.

[SPEAKER_01]: You can at least in private practice.

[SPEAKER_01]: You can absolutely do OB anesthesia without a fellowship.

[SPEAKER_01]: So talk a little about that.

[SPEAKER_01]: Do you need to do one and why?

[SPEAKER_00]: It's a really important question, Jed, and I think, harkening back to when I was thinking about Jane O'Bianna seizure fellowship.

[SPEAKER_00]: I was very interested in cardiac, I was interested in peeds, I was interested in O'Bianna seizure.

[SPEAKER_00]: And multiple people back then said to me, why would you want to do O'Bianna seizure?

[SPEAKER_00]: You know how to do up the drills?

[SPEAKER_00]: You know how to take care of O'Bianna's.

[SPEAKER_00]: And I think to your point in that when you graduate from residency, [SPEAKER_00]: You can practice organic stevia without fellowship training.

[SPEAKER_00]: There's a misunderstanding that you don't need the training.

[SPEAKER_00]: And I think until maternal outcomes are improved in our country, we really should advocate for better training, better refinement.

[SPEAKER_00]: And I'm thrilled that we have 20% of our graduates going into private practice, because I think that's a really clearly defined pathway for enhancing the [SPEAKER_01]: So 20% of your fellowship graduates go into private practice with their fellowship.

[SPEAKER_01]: And I bet that, and you may know this, I'm sure you keep in touch with a lot of them, if not all of them, but I bet you haven't found any of them who say, you know what, man, I wish, what a wasted year, I wish I hadn't done it.

[SPEAKER_01]: I bet not one has said that.

[SPEAKER_00]: No, you're so correct.

[SPEAKER_00]: I think the last time I checked nearly half of our graduates have leadership positions and it was, [SPEAKER_00]: both inside and outside of academics.

[SPEAKER_00]: So I think it, you know, doing the training in a fellowship, you're really strengthens your administrative leadership skills.

[SPEAKER_00]: Your ability to work with a multidisciplinary group of people, especially when complex patients roll through the door.

[SPEAKER_00]: So you're absolutely right.

[SPEAKER_00]: And the OBS community, by the way, is very close knit.

[SPEAKER_00]: So I do get feedback all the time from these graduates and your correct.

[SPEAKER_00]: I've never heard of any regrets about fellowship here.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: And it seems to me, again, from the outside that there's just increasing comorbidities, patients who maybe wouldn't have even survived their congenital heart disease as a kid.

[SPEAKER_01]: Now, we're not only surviving, but they're having children themselves.

[SPEAKER_01]: You've got, you know, the scope of practice of an OBNCologist is wider.

[SPEAKER_01]: You've got sicker patients.

[SPEAKER_01]: It just seems to be like there's more and more need for that specialized training.

[SPEAKER_01]: And this is, this is, this is me just looking in from the outside.

[SPEAKER_00]: Now, you're absolutely right.

[SPEAKER_00]: We've got some really wonderful publications in the last 10 years emphasizing the importance of, for example, the cardiac OB team that emphasizes having an obstetric anesthesiologist on board with cardiologists and maternal fetal medicine specialists to manage patients who have congenital are acquired heart disease.

[SPEAKER_00]: The incidence of placenta a creatus spectrum is really increasing over a short period of time, likely to do with higher rates of sacerian delivery, but other factors as well.

[SPEAKER_00]: So we have these really, really high-risk hemorrhage deliveries that are happening on a more routine basis.

[SPEAKER_00]: So these two topics keep us very engaged in terms of educational strategies to enhance maternal safety and [SPEAKER_00]: She's a better maternal outcomes through better opionist music care.

[SPEAKER_00]: You know, I think also to your point, if you look at opionist music training and patient management, some papers have shown differences in care, just if patients are managed by opionist music fellowship trained physicians, one paper back in 2019 showed that [SPEAKER_00]: If patients were managed by OBE anesthesiologists, there were 40% less likely to receive general anesthesia, for example, for Susarean's delivery.

[SPEAKER_00]: So there are signals out there in the literature that are evolving to suggest that our fellowship training does make a difference and enhance the care that maternal patients receive.

[SPEAKER_01]: Yeah, I believe that absolutely, and you know, I thought of it recently when I was listening, I don't know if you've listened to the most recent season of the retrievals, but you know, what sort of seem very clear and let me be clear.

[SPEAKER_01]: I don't know anything about the actual details of it.

[SPEAKER_01]: Only I only know what they said on the podcast, but you know, is that [SPEAKER_01]: as you would imagine with anything if you do something a lot you're going to be much more comfortable with it and in that case it seemed to be around are you comfortable with when it is in fact in time to say this block isn't working let's go to GA and if you don't do it very often and you just take occasional OB call then maybe you're less comfortable you know with exactly when those subtleties play in.

[SPEAKER_01]: I'm sure the same thing comes from, you know, with a, with a placenta creator, right?

[SPEAKER_01]: You, if you don't do it very often, it's, maybe it'll go well, maybe it won.

[SPEAKER_01]: If you do it all the time, then it seems to me pretty, pretty obvious that then you're going to be better at handling that stuff.

[SPEAKER_01]: So, so that seems clear.

[SPEAKER_01]: I think we know it's clear if you have a surgeon who does, [SPEAKER_01]: brain surgery, heart surgery, abdominal surgery, orthopedic surgery, right?

[SPEAKER_01]: Of course, that doesn't exist, but if it did, there's no way they'd be as good as the individual specialists.

[SPEAKER_01]: And I think the same, why wouldn't it be true for anesthesiology?

[SPEAKER_01]: And so we do have that in many ways, right?

[SPEAKER_01]: We have people who deliver transplants and specialize in that.

[SPEAKER_01]: We have people who do cardiac and specialize in that.

[SPEAKER_01]: And we now have people who specialize in OB anesthesia.

[SPEAKER_01]: And it seems to me very clear that that should produce better outcomes.

[SPEAKER_01]: And it's interesting that at least some data is suggesting that.

[SPEAKER_00]: No, yeah, you're right.

[SPEAKER_00]: And really glad you brought up the retrieval's podcast because it's really sparked a lot of incredible interest and much needed attention to the patient experience.

[SPEAKER_00]: And the fact that a general anesthetic is not always, should not always be considered a negative outcome, right?

[SPEAKER_01]: Right.

[SPEAKER_00]: So I think actually some of the research were conducting this year is centered around that very question.

[SPEAKER_00]: How do we define what constitutes the general anesthetic as an unfeavorable obstetric anesthesia outcome?

[SPEAKER_00]: It's included as a metric in our centers of excellence to have a low rate of general anesthesia.

[SPEAKER_00]: But you certainly, to your point, don't want to avoid these of general anesthesia when it's absolutely indicated.

[SPEAKER_00]: So I'm really fascinated and excited by this, and specifically, I'm really excited and thinking about the patient experience.

[SPEAKER_00]: Post COVID and in this time where we have just, you know, electronics of bounding around us and everything we're doing in anesthesia from the medical record to all of our tools.

[SPEAKER_00]: It's really going to be important to step back and focus more on the patient again, as much as we can.

[SPEAKER_00]: And this specific topic of, you know, the patient's experience during cesarean deliveries is just right for that conversation.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: Absolutely.

[SPEAKER_01]: All right.

[SPEAKER_01]: Let's talk about some of the kind of lessons you've learned and things you've grown to practice yourself.

[SPEAKER_01]: And you like to structure this, I know by kind of the fellows and that you've had in some of the projects they've worked on with you.

[SPEAKER_01]: So let's talk about that.

[SPEAKER_01]: What are some of the things that your 56 plus fellows have taught you?

[SPEAKER_00]: Well, I could talk to you about this for hours, Jed.

[SPEAKER_00]: I mean, I think that as I said before, [SPEAKER_00]: One of my favorite things to do is to spark interest and passion envelopes, especially when they think they're not interested in doing research.

[SPEAKER_00]: And it usually, in almost always, starts with a clinical question that they have.

[SPEAKER_00]: One year, Dr.

Hans Swiggum, who's, I'm proud to say, is now the Division Chief of obstetric anesthesia at the Mayo Clinic in Rochester.

[SPEAKER_00]: And he has been a chair of the Minnesota Society of anesthesiologists.

[SPEAKER_00]: When Hans was a fellow at the Brigham, he was curious about the catheters we used for epidurals, because for OBIC, we used the arrow flex tip catheter.

[SPEAKER_00]: It's a soft catheter to avoid the risk of intra-vascular cannulation, but they're soft and flexible.

[SPEAKER_00]: So for that reason, sometimes they don't thread and it's super frustrating.

[SPEAKER_00]: And you think you're there and you can't get the catheter to thread, and the woman's inactive labor and a lot of pain.

[SPEAKER_00]: So Hans was curious, what is the incidence of this problem and what should we be doing about it to fix it in real time?

[SPEAKER_00]: He followed thousands of epidural placements during his fellowship and surveyed people to find that the incidence is about 5% that these catheters don't thread and they're associated with a higher risk for having a wet tap.

[SPEAKER_00]: So when you get frustrated, when you're trying maneuvers, you have to keep that in mind and try to be cautious.

[SPEAKER_00]: So this was, you know, a really high yield clinical finding that he asked and answered within the course of a short year, he was an overachiever.

[SPEAKER_01]: That sounds like it.

[SPEAKER_01]: Now, did, so what's, is there an answer to that?

[SPEAKER_01]: I mean, do, is there anything, you know, do we need better catheters?

[SPEAKER_01]: Is there a better way to handle the catheters?

[SPEAKER_01]: I, you know, what, what's the takeaway from that study?

[SPEAKER_00]: Well, I think the takeaway back then was that this is something that is not a trivial [SPEAKER_00]: And he found that the best maneuver was to start over and recite the needle instead of trying to twist the needle or advance it slowly in terms of the lowest rate of what type in the highest rate of success.

[SPEAKER_00]: But the takeaway now that I could tell you is that with post-COVID materials shortages we have to be really careful when our kids change and our equipment changes.

[SPEAKER_00]: this in an increased rate of inability to thread a catheter and their too long to perform combined spinal epidural or drug puncture epidural techniques because the hub is longer so we actually had to order longer spinal needles so there's a whole host of things that are happening with material shortages that have to keep us we have to stand our toes to handle and think about the implications for these complications like drill function.

[SPEAKER_01]: interesting.

[SPEAKER_01]: So just had to carry out the, and this, you know, again, I'm maybe speaking about things I don't know enough about, but let's say that you had a, not an emergent sea section, but you know, urgent.

[SPEAKER_01]: And the patient does not have an epidural, so you decide to do a spinal, or let's say you decide to do a CSE, and you get in, you have good loss of resistance, [SPEAKER_01]: You give your spinal dose, but you can't thread the catheter.

[SPEAKER_01]: Would you put the spinal needle back in and give more of a spinal and go with that?

[SPEAKER_01]: How would you, let's say you don't have time to recite and restake and try again.

[SPEAKER_01]: How would you deal with that if that were the issue?

[SPEAKER_00]: It's an excellent question.

[SPEAKER_00]: And for that reason, when I'm doing it from Biden's final epidural in the operating room for the purpose of a longer surgical duration, I'm always going to plan up front to dose [SPEAKER_00]: So if it doesn't thread, then communication is king.

[SPEAKER_00]: And I tell the statistician, look, I don't have an epidural catheter to sustain my anesthetic.

[SPEAKER_00]: And that tells them in so few words that they need to scrub quickly.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: So I think the combination of always doing a long acting spinal for the risk that it might not thread is reasonable.

[SPEAKER_00]: I wouldn't want to wait and try to redo my epidural because then I just get a saddle block.

[SPEAKER_00]: And the worst of both worlds by letting the spinal settle.

[SPEAKER_00]: So you just kind of go with what you can.

[SPEAKER_00]: And if you can't thread the catheter, move forward and communicate and counsel the patient because we're back to that patient experience that you know not wanting to alarm the patient but letting them know what you're thinking in terms of a backup plan, which might involve sedation and it might involve the general anesthetic.

[SPEAKER_01]: Great.

[SPEAKER_01]: So I know you had a fellow who took a look at using music to handle or try to address patient anxiety.

[SPEAKER_01]: Tell me about that and what you learned from that.

[SPEAKER_00]: Oh, this was one of my favorites, Judd, because I'm a music fan.

[SPEAKER_00]: I'm a piano player myself.

[SPEAKER_00]: My favorite of composers, Chopin.

[SPEAKER_00]: But this particular fellow is just a maestro, Dan Dres Malski.

[SPEAKER_00]: He's now the Division Chief of Obianis Thucia at Tufts University and he's the director [SPEAKER_00]: So he's always been a meticulous type and always been a musicficionado.

[SPEAKER_00]: And he wanted to know if playing pre-selected music or self-selected music before a C-section for a patient lowered their anxiety during C-section.

[SPEAKER_00]: So he followed 150 patients having C-sections, somewhere enrolled to listen to this gorgeous Mozart music before surgery, which Frank Baffinck is what I would choose if I was nervous.

[SPEAKER_00]: And other, the second group got to choose their own Pandora music and the third group had no music.

[SPEAKER_00]: And what he found was that anxiety was lowest in the Mozart group compared to the controls.

[SPEAKER_00]: So a simple maneuver, wonderful environmental enhancement in my opinion, is a really easy way to kind of impact how much anxiety patients are feeling.

[SPEAKER_01]: Stay with us, we'll be right back.

[SPEAKER_01]: All right, and we're back and talking about the music study and anxiety.

[SPEAKER_01]: Yeah, you know, I love that both because obviously it's wonderful to hear that about music, but I think just in general, and I see this sometimes in some of our young trainees, is they think that it doesn't really matter what happens from the time you get to the operating room until the time you're asleep.

[SPEAKER_01]: It's kind of like, well, they're going to sleep anyway, you know, they're not going to remember, but it is amazing.

[SPEAKER_01]: I've had, because I always do a very [SPEAKER_01]: almost like, uh, I think of it as almost like a hypnosis or meditation that I kind of talk to patients through as very, I think very commonly as as I'm getting ready with them off to sleep and then as I'm giving them at a kids.

[SPEAKER_01]: And I've had patients who will contact me after to say, you know, that was so.

[SPEAKER_01]: peaceful and calming and it stayed with me.

[SPEAKER_01]: They do remember it and it did make a difference.

[SPEAKER_01]: And there was a breast surgeon at UCSF where I trained.

[SPEAKER_01]: I wish I could remember her name.

[SPEAKER_01]: But she used to let she would ask the patients in their clinic visit before surgery.

[SPEAKER_01]: What song they would like her to sing to them?

[SPEAKER_01]: as they were going off to sleep and then if she didn't know it she would learn it but she knew a lot of songs so she would she would often know it and then she would come the operating room and while we were getting the patient off to sleep she would sing the song to them and it was I mean you could sometimes see the heart rate would come down and as before before the meds went in the heart rate would come down the blood pressure would come down right I mean I think it makes a big difference and it's it's fun that you guys actually demonstrate to that.

[SPEAKER_00]: that is above and beyond and the only thing I can hope for is that she had a good voice she did beautiful beautiful voice yeah yeah unlike I do not say because that would cause a lot of injuries there were windows they would crack exactly how to but I will say Jen to your point I think it's incredibly important what we do prior to our anesthetic instead of just showing up and meeting people with sterile gloves on and saying okay I'm gonna do your spinal now what I do in my own practice every single [SPEAKER_00]: is I'll walk back to the operating room with the patient before sea section.

[SPEAKER_00]: And I'm not doing that because I need to hold their IV.

[SPEAKER_00]: I'm doing that because I want to establish rapport with them and figure out how they communicate and what their priorities seem to be and how nervous they are.

[SPEAKER_00]: And it's so much information you're taking in.

[SPEAKER_00]: It really informs the future steps to the anesthetic you're providing.

[SPEAKER_00]: And I try to teach that to trainees as well because I think it's often overlooked.

[SPEAKER_01]: Totally great.

[SPEAKER_01]: I love that you showed that.

[SPEAKER_01]: All right.

[SPEAKER_01]: So talk to me about what you did with Dr.

Sharon Reo, who of course was on my residence before she was one of your fellows.

[SPEAKER_01]: She's fabulous and what did you do together?

[SPEAKER_00]: Well, first of all, I love that we have this connection through Sharon because she's incredible as you know.

[SPEAKER_00]: Yes.

[SPEAKER_00]: And she was always [SPEAKER_00]: thinking about education, even from an early stage in her training, and really she wanted to identify high-yield publications that our fellows should absolutely read before they graduate.

[SPEAKER_00]: And I think she did that this on the cusp of becoming a fellowship program director herself.

[SPEAKER_00]: She is now our fellowship program director and I have to plug that it's the largest fellowship program in the country and Sharon just does such an exceptional job leading it.

[SPEAKER_00]: But what she did was really interesting, she surveyed the keynotes, speakers from our soap annual meeting, called the Ostheimer Lecture, and did a sequential survey-based survey that was sequential to generate consensus among these experts and our field about what papers they thought were the most important.

[SPEAKER_00]: So they looked at what each other wrote and established consensus.

[SPEAKER_00]: And she came up with the top 22 papers and it remains part of our fellows curriculum to this day.

[SPEAKER_01]: That is awesome.

[SPEAKER_01]: Go Sharon.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: Every speciality should do that.

[SPEAKER_01]: It's not easy.

[SPEAKER_01]: I remember.

[SPEAKER_01]: I think maybe when I was a nice you fellow or maybe right after that, but I thought I was like, oh, this should be easy.

[SPEAKER_01]: And I think I just emailed all of the intensivists here and I said, send me the papers.

[SPEAKER_01]: You think of the seminal papers that like every fellow or resident should know about critical care.

[SPEAKER_01]: And it was very like nobody sent it.

[SPEAKER_01]: You know, it was like, it was not easy.

[SPEAKER_01]: So I'm impressed that the chair and made it happen.

[SPEAKER_00]: Yeah, it's really hard, it's hard to get traction on.

[SPEAKER_00]: And serving the people who took one, I should mention the lecture that we give it, so, probably, us-time-relicture involves this intense year of assessment of the entire calendar years, publications in our specialty, and a distillation of what's the most important based on the expert speakers opinion, essentially, but with their background knowledge, of course.

[SPEAKER_00]: So I think asking those people [SPEAKER_00]: was a really cool way to start and it gave some traction for us to generate this list from.

[SPEAKER_00]: And I also think that we should redo the list because obviously, and they're going to be up and coming papers that we would want to include.

[SPEAKER_00]: So the list will continue to grow.

[SPEAKER_01]: Yep, that's fabulous.

[SPEAKER_01]: There's a group of wonderful educators who do a similar thing each year, they do a kind of best education papers of the year that get to published in the Journal of Education and Perry Operative Medicine.

[SPEAKER_01]: And it's great.

[SPEAKER_01]: It's so useful.

[SPEAKER_01]: And I know at ASA, there's, you know, there's those kind of talks, right?

[SPEAKER_01]: The best papers of the year on this, or that subject, and it's so useful.

[SPEAKER_01]: All right, so what about, I know you've done some work with obstetric hemorrhage prevention or management, tell me a little bit about that, how you manage that and what's some of the projects around that habit.

[SPEAKER_00]: Absolutely, hemorrhage research has really become my passion over the years and [SPEAKER_00]: Really, the mantra I have is that we can always do better.

[SPEAKER_00]: That's my mantra for care in the anesthetic I provide, but specific to hemorrhage.

[SPEAKER_00]: We have to think of it as the leading source of preventable morbidity and mortality in obstetrics.

[SPEAKER_00]: So it's a really effective thing to focus on as an obstetric anesthesiologist if you want to try to make a difference.

[SPEAKER_00]: So one that I was sitting around are lounge between tasks with a fellow [SPEAKER_00]: This consensus bundle from the National Partnership for Maternal Safety had just been published.

[SPEAKER_00]: This was back in 2015.

[SPEAKER_00]: And it's a bundle with 13 elements in it that expert consensus guideline suggested every labor unit should strive to achieve.

[SPEAKER_00]: on their unit for the safest maternal care.

[SPEAKER_00]: This fellow and I decided on a whim on a colonite that we would design a study around this and survey our group of nurses and obstetricians and anesthesiologists at the Brigham to see whether we had these bundle elements in place.

[SPEAKER_00]: And again, we did this Delphi survey study where you do sequential surveys across groups to generate consensus.

[SPEAKER_00]: And we found that nearly 50% of our bundle elements were deficient.

[SPEAKER_00]: And I just love this study because it really demonstrates that even a really high functioning unit like ours has plenty of room for improvement and that study by generating consensus across groups.

[SPEAKER_00]: It was really, it really embraced the OB anesthesia and obstetrics, um, [SPEAKER_00]: so much movement for change and I'm proud to say we've adopted many, many things over the years to reflect improvement in those deficiencies.

[SPEAKER_00]: So it was just a really high yield project we did very easily.

[SPEAKER_01]: Yeah, that's great.

[SPEAKER_01]: Now, this may be an impossible question answer.

[SPEAKER_01]: I'm sure you could and probably do give our long talks on this alone.

[SPEAKER_01]: But if you had to say, like, what are some of the real key elements in terms of hemorrhage management and prevention that you, you know, you have adopted and you would recommend that the places, you know, I'm sure it's all 13 of those, but you know, are there certain ones you find that are harder, that are, you know, important, but maybe not as often done, you know, what would you really highlight from that?

[SPEAKER_00]: Let's start with life-saving ones.

[SPEAKER_00]: having a blood bank that can provide you with blood products within minutes has been life-saving on our unit for me for many, many, many cases of hemorrhage because obstetric hemorrhage is similar to trauma hemorrhage at times.

[SPEAKER_00]: It's very unexpected at times.

[SPEAKER_00]: Even if it's expected, sometimes the severity ramps up and the quite a lot of the [SPEAKER_00]: is insidious and unset and unpredictable.

[SPEAKER_00]: So having a blood bank and having a system of communication with your blood bank that allows you to have units of blood cells released and not necessarily massive transfusion protocol because that actually takes longer to generate all of the products to send, but our blood bank can send us two units of packed red cells during an acute hemorrhage crisis and it allows [SPEAKER_00]: That has saved us so many times.

[SPEAKER_00]: I can't emphasize that enough.

[SPEAKER_00]: And the other thing that was really high yield is having uterotonic agents.

[SPEAKER_00]: So uterotany is the most common cause of postpartum hemorrhage.

[SPEAKER_00]: When we found that some of our second uterotonic agents were too far away at the time of hemorrhage.

[SPEAKER_00]: So simply putting the drugs in proximity to where the surgery is being done.

[SPEAKER_00]: Um, high yields and easy step to take on our unit to make care better.

[SPEAKER_01]: And these are like method jinn and hemabate.

[SPEAKER_00]: Yeah, exactly right.

[SPEAKER_00]: So method jinn and hemabate.

[SPEAKER_00]: Now we have five British and concentrate also in that same area.

[SPEAKER_00]: Um, right outside of our operating room so that they're very easy and very accessible.

[SPEAKER_00]: Um, and you know that the newest evolution of hemorrhage management has been [SPEAKER_00]: TXA, just looking at the pharmacokinetics and pharmacodynamics of it when you give it, because TXA is something that before 2017 wasn't that common in terms of treatment for postpartum hemorrhage, a study back in 2017 called the Woman Trial demonstrated that there was a secondary outcome of lower death from specific to hemorrhage.

[SPEAKER_00]: Again, the second our analysis and in a study that was done in a very low resource environment across the board.

[SPEAKER_00]: So the question became, well, TXA may not be as helpful in our resource environment, but are we doing any harm?

[SPEAKER_00]: And so we looked at the PKPD of the dose recommended now internationally a gram and repeating a gram 30 minutes later if hemorrhage was still ongoing.

[SPEAKER_00]: And we found that the serum levels peak in three minutes after dosing at a very safe level in terms of not being near thrombotic or seizure-related serum levels.

[SPEAKER_00]: So it was a really great study to do because it has clinical relevance to kind of reassure us that even though TXA is not as helpful in our environment where we have all the resources at our fingertips, [SPEAKER_00]: It's not harmful either, and the dose for giving is really effective.

[SPEAKER_01]: I love that because it's, you know, we so often we get these big studies and they show this thing as effective and, you know, we get on board and we start doing it, but then the follow-up questions are maybe just as important, right?

[SPEAKER_01]: So, okay, now we're doing this.

[SPEAKER_01]: Is it working?

[SPEAKER_01]: How do we know it's working?

[SPEAKER_01]: Maybe it worked in this one trial, but is it working for us?

[SPEAKER_01]: Are we causing harm?

[SPEAKER_01]: How do we know, right?

[SPEAKER_01]: So, so this kind of having that curiosity is really important and it sounds like what you, with your fellow, we're able to show [SPEAKER_00]: Yeah, and that was Sebastian Seafert.

[SPEAKER_00]: And he is now the inaugural leader of what's he, the his title, The Senior Division Director for Obianna Seasha at the Brigham.

[SPEAKER_00]: We'll have a senior division director at the Brigham and when at Mass General, Dr.

Emily Naium.

[SPEAKER_00]: So super proud of the work he did, and he continues to just impress me every day with his leadership skills.

[SPEAKER_00]: But to your point, Jed, the harm done is such a great, [SPEAKER_00]: I think when you have these examples in history, within your career, of practice change, talking about the pitfalls of it is really powerful.

[SPEAKER_00]: And one of the things with TXA is accidental spinal injection of TXA.

[SPEAKER_00]: You can consider low resource areas, people drying up drugs who are not actually administering them, the absence of spinal kits that have the look on it, the bupivicane in them already.

[SPEAKER_00]: Um, spinal injection of TXA has been reported a lot in the literature and it's 86% mortality.

[SPEAKER_01]: Wow.

[SPEAKER_00]: So you have somebody having a C-section, um, trying to get a spinal, they have accidental TXA injection, and it's, uh, it's the, the case reports are horrifying.

[SPEAKER_00]: So I like to teach that as a way to remind everybody, um, of the importance of looking at labels for every drug we give, [SPEAKER_00]: And the fact that you can, you can survey most anesthesiologists we've all had a drug error at one point and so it's very humbling to think about and to understand when the stakes are really high and that's the things like spinal dosing.

[SPEAKER_01]: Yeah, absolutely.

[SPEAKER_01]: I did not know about that, but that is a great reminder of, and I tell it, you know, our new residents, I say, I've been doing this a long time.

[SPEAKER_01]: I still read every label.

[SPEAKER_01]: If I'm programming a pump, I look up there.

[SPEAKER_01]: I don't just click the, yes, it's 8 in 250.

[SPEAKER_01]: I look up and I say, is that what it is?

[SPEAKER_01]: When we read this label, what's actually in that bag?

[SPEAKER_01]: Same thing, you know, the blue vial, man, that blue vial is probably [SPEAKER_00]: Yeah.

[SPEAKER_00]: And to come to work every day at your best, you know, getting enough rest, enough balance, enough nutrition, knowing when you're too tired and you need to take a break.

[SPEAKER_00]: All of these things are so central to what we do.

[SPEAKER_01]: Absolutely.

[SPEAKER_01]: By the way, I wanted to make sure we shouted out your fellow who did the work on the maternal safety obstetric hemorrhage bundle, because I don't think we mentioned her name, but that was Anne Maria de Tina?

[SPEAKER_00]: Yes, and I'm sorry.

[SPEAKER_00]: I didn't mention her name.

[SPEAKER_00]: Anne Maria is [SPEAKER_00]: She went on from fellowship to service for Marchief or as Chief of Obianis, Disha at McMaster University and Ontario.

[SPEAKER_00]: And I still see her at the soap meetings most years and she's just had an incredible career thus far in anesthesia since the study.

[SPEAKER_01]: That's awesome.

[SPEAKER_01]: Well, I know you could talk forever, probably at least 56 different times about your fellows and all the work you've done, but this is such a great, I think example of wonderful work done by fellows in just one year and again, it really says a lot about them and you that so many of them have gone on to leadership positions in OB and Esthesia.

[SPEAKER_01]: But let me ask you to kind of sum up some of the most important things that you have learned and that you teach and that you think we should keep in mind as we go for.

[SPEAKER_00]: Well, I really want to end Jed on talking about what really matters, and why, again, I think it's the most exciting time to be on a tetragannic ziologist.

[SPEAKER_00]: And the reason the core reason I think that is that all of this research, all of this effort, all of this enthusiasm and training are future is to provide better care from others and their newborns.

[SPEAKER_00]: And I think now more than ever women deserve this advocacy, they need it more than ever before, because we have the worst maternal outcomes of any industries and industrialized wealthy country.

[SPEAKER_00]: By far, if you look at the statistics, we have diminishing maternal health services nationwide.

[SPEAKER_00]: This has compounded by state's continuing to prove pros, new abortion restrictions.

[SPEAKER_00]: And last but not least, we have [SPEAKER_00]: glaring race-based disparities.

[SPEAKER_00]: We look at the CDC data on maternal mortality ratios.

[SPEAKER_00]: This recent is 2020.

[SPEAKER_00]: The MMR was 55 for 100,000 for black women.

[SPEAKER_00]: And it was 19 for 100,000 for white women.

[SPEAKER_00]: I think these things are just egregious.

[SPEAKER_00]: And to be able to be in a position to try to tackle these problems is incredibly meaningful.

[SPEAKER_00]: I think obstetric anesthesiologists can be activated and inspired with these concepts to be part of the solution.

[SPEAKER_00]: And we're doing this in real time through the Society for Obianicies and Prairie Neatology.

[SPEAKER_00]: Back in 2022, I founded the SOAP State Representative Program, with then President of SOAP Dr.

Klaus Kajer.

[SPEAKER_00]: So I just want to tell you about it really quick.

[SPEAKER_00]: And what this is is an effort through SOAP to identify a SOAP member in every single of our states across the country.

[SPEAKER_00]: And what that SOAP state member does is a representative.

[SPEAKER_00]: Is they look at all of the delivery hospitals in their state and reach out to them.

[SPEAKER_00]: So we're forming a network that's at the state level affiliated with SOAP.

[SPEAKER_00]: And part of that so we can share all of the resources that so it creates, and I'm the Vice Chair for the Education Committee itself, so we're constantly creating tools for open and sociologists.

[SPEAKER_00]: So making sure that people can have access and realize what's out there through so at the state level, we also ask the state reps to identify a mortality review committee member on their state's MMORC.

[SPEAKER_00]: So the group of people who review maternal deaths at the state level, you would be shocked to know that many many states didn't have an anesthesiologist at the table to review maternal deaths.

[SPEAKER_00]: So hammered deaths, cardiac arrest deaths.

[SPEAKER_00]: There's got to be someone with critical care expertise reviewing these deaths to be able to come up with solutions.

[SPEAKER_00]: So we've managed to sign up nearly 10, I think, at this point, over 10, actually, [SPEAKER_00]: MMRC members who before states didn't have an anesthesiologist at the table on that committee.

[SPEAKER_00]: So I'm beyond excited about the SOAP state reps program, and this is just the beginning.

[SPEAKER_00]: And I think we're going to create and identify ways of higher impact throughout the years, just by having the established network and growing the network and what it can do.

[SPEAKER_01]: Yeah, that's fabulous.

[SPEAKER_01]: And we'll put a link to that on the show notes.

[SPEAKER_01]: I also, I know that you've had folks be involved in and it does seem like OBNC is just such a rich opportunity also for global health work, right?

[SPEAKER_01]: I mean, that's something you've had fellows involved in, too.

[SPEAKER_00]: Yeah, it's almost like we don't have enough hours in the day or days of the week or weeks of the month to get all of this work done, but I absolutely, another passion I have is that we increase our global footprint, both at my hospital, but just in general across the country with [SPEAKER_00]: Some of the projects we're working on right now at the Brigham are in Walden, Kejabi, Kenya, Hanway, and Hoay Vietnam.

[SPEAKER_00]: We have collaborators in Mexico City, and also now in Bangkok, Thailand, and in China.

[SPEAKER_00]: So through these collaborations and through these trips that we establish with our fellows from year to year for outreach, what we're doing is we're focusing a bit on the educational infrastructure because that's what our collaborators have expressed the need for is is more education and obiannesthesia, but we're also doing quality improvement projects so identifying how we can help their systems improve.

[SPEAKER_00]: And I have to say that my experience with these places and these colleagues across the world has taught me as much as I think I've taught them.

[SPEAKER_00]: So it's just an incredible, true collaboration in both directions.

[SPEAKER_01]: Fabulous.

[SPEAKER_01]: Well, Michaela, this has been great.

[SPEAKER_01]: Let's turn to the port of the show where we make random recommendations.

[SPEAKER_01]: Do you have something you'd recommend that the audience check out for fun?

[SPEAKER_00]: Oh my gosh.

[SPEAKER_00]: Well, [SPEAKER_00]: I mentioned this before, I'm a music lover, I am a musician myself, but I want to just emphasize that post-COVID, we need to get out there, and we need to create experiences in the public arena.

[SPEAKER_00]: And Boston, I'll put a plug for her as incredible live music venues.

[SPEAKER_00]: And I would recommend that you be yourself a favorite and listen to a couple of bands that are up and coming and established Lord here on, [SPEAKER_00]: as well as the smile, which is a spinoff band of radio head, a band I've appreciated since I was in high school.

[SPEAKER_00]: But both of these bands have played in Boston at small venues in the past couple years.

[SPEAKER_00]: And I think just, you know, listening to the beauty of this new music, exploring new music and getting out there and enjoying it in a public setting.

[SPEAKER_00]: It's post-COVID.

[SPEAKER_00]: It is really enriching for your soul.

[SPEAKER_00]: So don't, don't, don't.

[SPEAKER_00]: Don't deny yourself that.

[SPEAKER_00]: Get out and listen to some music.

[SPEAKER_01]: That's awesome.

[SPEAKER_01]: I love that.

[SPEAKER_01]: Thank you.

[SPEAKER_01]: I'm going to recommend a book that I am about to finish.

[SPEAKER_01]: It's been fabulous.

[SPEAKER_01]: It's called The Correspondent by an author named Virginia Evans.

[SPEAKER_01]: I've never read anything like it.

[SPEAKER_01]: The entire book is a series of letters to and from the main character.

[SPEAKER_01]: And all the story is told kind of through those letters.

[SPEAKER_01]: And it is both really well done and a very kind of heart.

[SPEAKER_01]: heart touching heart felt story but also it has reminded me about you know how wonderful written communication can be and has inspired me actually to start reaching out to some folks who you know don't live near me who I can't get together with regularly but who I would like to be in better contact with and in occasional phone call and to just write some letters or emails in the book it's letters she feels very strongly the main character feels very strongly that letters are better than emails but I think either way and so that's been a great book [SPEAKER_00]: Fantastic.

[SPEAKER_01]: Mikhail, thank you so much for coming on the show.

[SPEAKER_00]: Thank you, Jet.

[SPEAKER_00]: Thanks for having me.

[SPEAKER_01]: All right, hopefully you got as much out of that as I did.

[SPEAKER_01]: That was really fantastic.

[SPEAKER_01]: Let us know what you thought.

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[SPEAKER_01]: Thanks as always to our fantastic acrack crew.

[SPEAKER_01]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao and Rachel Furman are our production assistance and social media managers.

[SPEAKER_01]: Thanks so much for all you do.

[SPEAKER_01]: Our original ACRAG Music is by Dr.

Dennis Quow.

[SPEAKER_01]: You can check out his website at studybusicproject.com.

[SPEAKER_01]: All right, that is it for today.

[SPEAKER_01]: For the ACRAG podcast, I'm Jed Wolpa.

[SPEAKER_01]: Thanks for listening.

[SPEAKER_01]: Remember what you're doing out there every day is really important and valued.