We’re rapidly learning that COVID-19 doesn’t behave like typical ARDS or viral pneumonia.

Dr. Scott Weingart is an ER/Critical Care doc in New York and the host of the EMCrit podcast. He shares his insights into the changing management of coronavirus critical illness.

We discuss which patients need ventilators and which do better without, the insane amount of COVID quackery found on social media, issues around aggressiveness of care and end-of-life, clotting and COVID, acid-base physiology in these patients, and much more.

– Hey, everybody, it’s Dr. Z. Oh my gosh, today, I’m super excited because a long-time friend of mine, and a super, superhero in the medical podcasting world, Dr. Scott Weingart, who’s the director and superstar of Emergency Critical Care at Stony Brook in New York. Long Island, right, Scott?

– Yeah, yep, unfortunately.

– Has come from on high where he has been teaching for millennia, we met back like in 2011 and became fast friends ’cause we were like the only two people on the Internet in medicine in those days, with like Rob Orman and some other people.

– Yep.

– And we met and immediately, I was like, this guy is a genius communicator, and knows everything about emergency critical care which we’ll talk about, especially now since he’s on the front lines of COVID. Scott, welcome to the show, I’ll stop blathering.

– Oh no, it’s great to be here, thank you so much. I’ve been waiting for the invite. Each day, I look at my mailbox, nothing, nothing.

– Okay, let’s be,

– I leave bereft.

– Let’s be brutally honest here, all right. I’ve been waiting for the “EMCrit” invite since I started doing this, and you know why you don’t invite me, because I’m not smart enough. I’m neither– I’m not an emergency physician. I’m not a critical care physician. I’m just a lowly hospitalist, Scott, and you won’t come down from on high to talk to me.

– Uh-huh, uh-huh.

– But now’s our chance, we finally get to connect. You know, it’s interesting, because what immediately made me think of you is when COVID was really blowing up and Cameron Kyle-Sidell did his piece about, you know, does this look like high altitude pulmonary edema, what’s going on? This is not a typical ventilator-demanding situation. I thought, okay, I need to talk to Scott about this because this is confusing and intriguing to me. So start us off, like what’s going on with that?

– Yeah, you know, you remember from your time in the hospitals that if you had a patient breathing 55 times a minute with a saturation of 60%, in general, we would stick a tube down those patients, right? There may be some intermittent playing around with a BiPAP machine, but in general, those patients got intubated, and we had built over years in medicine, every single person, they’d be trained as a pup to recognize that, and understand, oh, patient sick, stick tube in, and so we built in these reflexes, but COVID’s different, man, COVID’s a different world.

– This was shocking to me because like, if I didn’t intubate someone that looked like that, I was gonna get my ass handed to me on a platter in the morning on rounds, like wait, what did you do? Like do you understand what hypoxemia does to, you know, human organs, and this and that, and I’m like, actually, I don’t, because I don’t read, but apart from that, I get what you’re saying. All right, next time, I’ll intubate quickly, but you’re saying it’s different now, and Cameron was talking about this as well, and others have said this, what’s different? Is it a lung compliance issue? Is it that it’s not a ventilatory problem, it’s pure hypoxemia, what’s going on, what are you seeing?

– Okay, so when you really break it down, what our reflexes were built on was the fact that, and most people, they did this subconsciously. They didn’t even make these, like, you know, iterative connections, but wow, if I see a patient satting 60, and breathing 50, what my brain tells me based on my gestalt experience is that this patient’s lungs must be garbage, and they must be breathing so quickly because they could barely get in any tidal volume ’cause their lungs are so bad, and if I don’t take over, they’re gonna tire out and crap out, and have a cardiac arrest, but COVID’s different. Now you mentioned the compliance, and how we could put fancy scientific, you know, descriptions on all of this, but what it comes down to is that even though their saturation, it’s the measure of oxygen in their blood, is so low, they could go on like that for days, and stay at this really scary place, but they don’t seem to tire out, which is radically different than other lung diseases.

– And are you seeing that they’re breathing, they are breathing, like at 40 and 50, like they’re really, rapid, shallow breathing?

– No, no, no, the rapid yes, but not shallow, and this is the key thing, is they seem to be tachypneic, you know, which is the fancy medical term for breathing quickly, but they don’t seem to be doing these dog-panting breaths, which are a sign of a patient at the end of their rope, ready to fall of the cliff if we could add some more, you know, mixed metaphors in there, and, you know, these patients, they seem to be tachypneic because their pleura may be inflamed, or they just have a nidus in the respiratory center of their brain to breathe more quickly, but it does not seem to be indicative of them not being capable of managing the load, and in fact, these patients will stay, you know, breathing, at high respiratory rates and have no problem, and this has lead us to dub them happy hypoxemics. Not me, I didn’t come up with this term, and in fact, it’s kind of a crappy term, it’s really putting a spin on this you don’t really want, but that is the one that came out, and it means, it’s somewhat relevant because they’re happy in the sense that when you look at ’em by numbers, oh my God, satting 80%, breathing 30 times a minute, that’s unhappy, and then you talk to them, and they’re like no, I’m cool, when are you sending me home? And you’re like I’m not sending you home, but that is what the happiness is trying to get across, is that they are not the standard patient, at 80% sat, breathing 30, where they are begging you to do something. Doc, I can’t manage this, help me. That’s what their face is telling you, that’s what their body language is telling you, and these patients are not.

– You know, and it’s interesting because that term, happy hypoxemic, was in a Reuters piece that actually quoted you as part of the piece, and I’d read it the other day about this idea that maybe, the question is, and there’s a lot to discuss here because I have so many questions, because first of all, you’re seeing a lot of COVID patients there, right?

– We saw a ton, we, I think have plateaued in the New York City and the suburban areas of New York City, but that’s because of the social distancing, and the question will be when they open up, ’cause eventually they’re gonna have to, what happens?

– Yeah, yeah, and you know what, actually, let’s explore that for a second and get back to the hypoxemia thing because it’s interesting, because it seems to me, there’s two possibilities. The social distancing is working and that’s why we’re seeing plateauing, and not a fulfilling of the worst predictions of this, or, and it’s not an or, it’s an and/or, and/or this, the reproductive number of this virus is innately lower than we thought, or it’s more susceptible to minor changes in social behavior, or it’s less fatal than we thought, or, or, or, or, and so either we’re seeing a case fatality or infection fatality rate that’s less than we thought, or the social distancing working, I think it’s a combination of both, and until we tease it out, we won’t know the best way to start reintroducing, you know, quote unquote, normal life.

– You know, I could speak to a little bit of that, from the New York experience, and you know, so I have my own experience, I speak to almost all of the hospitals, ED, critical care folks, we’re all in like a little cadre, a little cabal.

– I prefer the term coven myself.

– Yes, yes that is appropriate with our little cauldron in front of us, and then we also have a publication from the Northwell system, and they have so many hospitals that it might be at a fairly good representation, and that was just published somewhere in the JAMA set of journals and all of them say the same thing, which is the case fatality, the mortality of this disease is astronomical for the sick patients. Now when you take it overall, and you look at all-comers, you know, patients who don’t even have symptoms, yeah, it might be a lot less than the the most scary numbers out there, but it’s just one of the worst things I’ve seen for patients who actually hit the hospital. So from that perspective, it is a high mortality, higher than I think that we thought initially.

– Okay, so this is important, it’s an important distinction. For the patients who come to the hospital, who are sick, they are the sickest, it’s a crazy terrible thing, and this is something I’ve heard across the board and experienced, when they’re sick, they’re sick, and so the question is let’s then wrap it back into these sick patients, so you’re seeing them, it seems to me like you might have to make a distinction, right, so you have an elderly, let’s say it’s an 80-year-old, are they ever going to be a happy hypoxemic where they’re breathing at 50 and able to tolerate it, and still mentating, I mean having clear thinking, and that sort of thing, or are you only seeing that phenomenon in younger patients?

– You know, now that you make me think about it, it’s less common in the elderly, but it does happen. We do have, you know, 80-year-olds who are chugging away with lower sats, but the weird thing is that this, at least in the New York City strain, and New York in general, strain of this disease, we’ve seen a lot of sick patients in the younger categories. In fact, most of the really sick patients I’m seeing are like 45, 55 years old and that, that’s petrifying,

– Yeah, because we’re in that age group .

– Yeah, exactly right.

– That’s why

– And you do not wanna be treating yourself, that is always rough goes. You know, the propaganda out there is, you know, it’s jus knocking off old people, it’s gonna solve social security, you know, horrible things being bandied around.

– The boomer doomer, yeah.

– Yeah, exactly, we’re getting the revenge. No, at least in New York, that is not the case. We are seeing younger people getting super sick.

– Yeah, are these younger people having comorbidities, diabetes, hypertension, even undiagnosed, or are they just well people?

– Well you know, cognitively, what we do is we search for reasons they’re not us, so where we’re looking, you know, oh, they’re hypertensive. No, I mean some of them have something, but there’s a bunch that have nothing. We have noticed ethnic lines and I think this goes along with why Italy and Spain maybe were so hard hit, is there may be some form of genetic component that makes a worse presentation in certain subtypes.

– That seems to make a lot of sense, and one of the theories I’ve heard on this, there’s quite a few, but one of the pieces of thinking is that certain ethnic subtypes, mine included, Middle Eastern, so I happen to have factor V Leiden and prothrombin 20210A mutations, heterozygous for both, so I’m a high clotting risk, I’ve never had clotting, but the theory is with the hypercoagulable state, the hyper clotting state that this virus seems to predispose to, those people are at greater risk for microthrombi, other problems that then manifest as severe illness in the hospital. Is that anything that you’ve been able to see in your emergency medicine experience or is it just a theory still?

– Clotting has been a huge portion of this disease and these patients, we are prophylaxing all of them at a level we would not normally do for patients at the risk level. That would be denoted just by, you know, basically, if you come into the hospital, we’re at least giving you prophylaxis against clotting, and as you get sicker, we up the stakes on that pretty significantly. This is definitely a disease where clotting is part of the pathophysiology, which makes it even scarier because you have a patient, you got through their entire course of being on the ventilator, which is such a win in the first place, and then they have a massive pulmonary embolism, not fun.

– Not good, and things were hearing anecdotally from the front lines are large vessel clots, so big carotid vessel clots, big strokes in young people, and in fact, young people having stroke is a primary presentation sometimes, and then having, whether it’s microthrombotic lung disease, whether it’s cardiac disease from thrombus, which is again, this is unusual, like infections can lead to things like that, disseminated intravascular coagulation, but this is something that seems a little bit unusual and unique to COVID.

– Oh, it’s definitely different than anything we’ve seen before in terms of just the propensity to clot.

– Are you amazed at how quickly our understanding has progressed in like three months since this thing was pretty much described, I mean.

– I’m amazed we don’t have any true understanding of the pathophysiology of this disease, at all by this time, and, you know, I’m sure you’re getting the same thing. Everyday, I get hundreds of crackpot theories, and you know, it’s just vetting them would be my entire life, so at this point if it’s not published, and I don’t know your name, goes right in the trash.

– You know, it’s funny, okay, so let’s talk about this for a second because this is inside baseball for people that do this, you and me, and by the way, “EMCrit,” your podcast is one of the greatest tools, let me just talk to the Z-Pack for a second. If you do not subscribe to “EMCrit” and you are in medicine or not in medicine, shame on you, it is the greatest thing ever. Scott has been a mentor to me, it was Scott actually, I gotta say this, Scott, I’m gonna kiss your ass for a second ’cause you deserve it

– Oh God.

– So I was losing my voice, I remember I’d come to Essentials of Emergency Medicine to come do a performance or something, and I’m like, Scott, man, my voice is just jacked, and he’s like, dog, you need to do these vocal things, these warm-ups, these lessons, talk to an ENT, do something like that and it’ll change your life and it did and I actually was able to sing the kind of later parodies that we did because I listened to Scott Weingart about preserving and protecting

– Wow.

– Treating my voice like a tool, so thank you, Scott. So I trust you implicitly for everything. Now speaking of that, you and I both get thousands of these crackpot, and sometimes it’s from the crackpots themselves

– Yeah, yeah.

– You know, like a chiropractor, in like Laguna Beach, is like, bro, if you take zinc and you smoke vitamin C, I’m telling you, I’ve seen 100%, 100% non-mortality in my patients that don’t have COVID, and you’re like okay, listen, so a ton of my fans send me stuff that can you debunk this? No, I can’t, here’s a simple algorithm. If it’s a naturopath or a chiropractor probably already, just stop, if it’s a doctor, okay, if they’re in Florida, stop again How do you actually think about, you know, talking to people about debunking this stuff? I’m joking kind of, but that is my heuristic,

– Yeah, it’s pretty close though.

– That is my heuristic.

– It’s not that far off.

– Exactly.

– Yeah. I think you gotta stop debunking, and start only bunking, which means, you know, it’s hard because the unfortunate thing is that crackpots have gotten savvier, they’ve learned to speak real language, they’ve learned to how to add references and vet everything and if I just showed you something like and you just perused it very briefly, it looks real, you know, they’ve gotten very good, the fools just keep getting smarter and smarter, it’s a real problem.

– You nailed it, it’s the science words. So there was the guy who wrote that article on heme dissociation

– Yeah, yeah, yeah, yeah.

– Yeah, okay, not a doctor, all right, the whole thing sounds scientifically valid, well, the three-plus heme dissociates, and there’s electron flow, and you see, look at the gunk in the lungs. I solved it, bro, like bro, you’re not a doctor, and what you’re saying actually to a doctor makes no sense at all, so what’s going on, but the average public including like, nurses and respiratory therapists and residents can’t debunk this.

– That was the one that was I think the tipping point where I’m like I just spent, you know, eight minutes, reading this like pile of offal,

– Me too.

– And I’m like I just gotta stop doing it because you know that time could’ve been used for something more valuable, and it just sucked me in because at its base, when until you actually look at the words, how they connect with each other, it seems legit.

– You know the best part of that article, I got to the end ’cause I was like you, I was like okay, let me see what’s up here because enough people have sent me this, now I got to the end, and he has a line oh, and by the way, don’t trust the Chinese data, because Chinese are asshoe and he spells it A-S-S-H-O-E, and I’m like okay, so this is like the final nail in the coffin of credibility for this guy. It’s like I’m not sure JAMA would ever allow that statement in, I think it would not meet peer review.

– Yeah, that probably would’ve been peer reviewed out, but you know, see there’s a new thing going on, I don’t know if you’ve noticed this, but people are not waiting for their articles to go through peer review and be released pre-print to put ’em out there.

– I’ve seen this

– So we’re really hosed now, because of all of these cutting edge research pieces are being released on these sites with a proviso up top saying this has not gone through peer review, well then, why the is it being published on a site? And so now, you know, if they get smart to that, they’re going to start making fake sites that have the same headers and now you’re really hosed.

– You know, and that actually translates into actual damage to patients because they’re doing the same thing with rushing through antibody testing and other things that aren’t properly validated because they made the mistake of going too slow on the original test and now they’re making the opposite mistake of well, okay, now this is an emergency, let’s just let everything happen. Well, let’s see a false positive is a disaster, a false negative is a disaster, so we better be really careful but you’re right. Even that Stanford seroprevalence study that I did a video on, I said this is not peer-reviewed, guys, they put this out here and then you get the cult of social media peer-review which is a shit show, so.

– Oh yeah.

– Yeah, right.

– Even that’s been dirtied up. You know, for a while, we were pretty clean on lay public entering into the Twitter medical conversations and for better or for worse, I mean Twitter is a cesspool

– Yes, I agree. But for better or for worse, it was the place you could get, you know, some real feedback on cutting-edge research. You have to filter out, you know, the people who are somewhat sketchy, but the lay public are now there and now all the crackpots have infiltrated medical Twitter, so even that can’t be used.

– Dude, medical Twitter, like you see this guy, Dr. Shiva.

– Yeah.

– Okay, so I can’t talk much more because he’s highly litigious, so he sues anyone who talks negatively about him, he’s done this historically, but let’s just say I had a phone call with him a couple years back, yeah, don’t believe anything this guy says, all right, Don’t believe, just really, really, so speaking of people we should believe, Scott, back to the hypoxemia thing.

– Yeah.

– Yeah, yeah, yeah, because this is interesting. Do we talked about, you know, is it older people who can’t tolerate, et cetera. Walk me through what it’s like when you see someone who is comfortable with an O2-sat of 70, speaking in full sentences, not tired out, how do you manage them emergently?

– Okay, well, if you will allow me to pull back a little,

– Please.

– I think it’s super interesting to put two patients out there because the difference between them is striking once you start dealing with these patients but until you’ve actually been in the midst of a high COVID prevalence ED, it’s only gonna be this very vague idea of how weird it is to have two very distinct patient presentations, so let’s say in bed one, you get this patient, they come in, their sat is 79% on the non-rebreather the paramedics have put them on and they put ’em in the room and they’re breathing a 32 times a minute and you go talk to the patient and they are fully lucid and they are totally capable of giving you a story and you’re like, well, that’s weird, you know, you should be collapsing with a sat like that. You get their history, they tell you everything, and you realize, okay, well, maybe I don’t have to intubate this patient right away? Let’s try some stuff and what we’ve been trying if they’re already on a non-rebreather mask which provides about, you know, 60, 70% FiO2 is we could augment that further, we could stick a nasal cannula underneath, and that knocks the saturation of the FiO2, the provision of oxygen those devices provide up to near 100% and some of the patients, that’s enough. So let’s say we did that, this guy shoots up to 85. Okay, first major paradigm shift, we would never tolerate 85 in the past.

– Yeah

– 85’s still bad, that’s not enough, you gotta intubate him or you gotta do something more. Now 85, we call that money, that is good, we’re happy with that, so we markedly degraded our goals for these patients’ oxygen carrying capacity in their blood, so 85 is great, 80, I’ll take it, I won’t take it forever, but I’ll take it for a while, so this guy, 85, he’s still talking to me, he’s looking at his phone, he’s sitting in there in bed. The other thing we’ll try that’s very different is we’ll try moving their position, from sitting up in bed to maybe flipping onto their belly, something we did in patients on machines to help them breathe in the ICU, we’d do that all the time in really bad lung disease, we were never doing it on awake patients. For whatever reason in this disease, those shifts of position radically change what’s going on with this patient, so go ahead.

– So yeah, you’re proning awake, non-intubated patients which is fascinating, right?

– And very different than anything we’ve done, but when you think about it, it’s just what they do at night in bed, it’s nothing, it’s nothing. You walk into the room and say all right, time to flip, and you know, they do it on their own, which is very different when the patient has a tube in, it’s like a seven-person job

– Yeah.

– And it’s like scary, and it’s like oh my God, you know, every move has to be calibrated. When it’s an awake patient, like all right, time to make the donuts, all right, flip to your left side, flip to your right side, so it’s easy and it’s had real results, at least on numbers Patients go, they drop to 77, you say okay, time to flip onto your belly again, and boom, they’re back up to 90

– And it’s like a rotisserie chicken, right, because if you stay on one side too long, you’re going to get collapse of those alveoli, VQ mismatch shunting, by flipping regularly, you’re actually allowing parts of lung to intermittently open up and profuse and ventilate, correct?

– Yeah, so it’s funny, on the intubated patients before COVID, we would take them and we put them on their belly for like 16 hours because there was just a geographic distribution of badness, with COVID, things are happening on a smaller level, and so just flipping them one way and leaving them there forever doesn’t seem to be as effective for us as moving them consistently, like you said the rotisserie chicken, or you know. my friend Dave calls this the pig roast because you know, every so often to go out there to the barbecue, you just change the position of the pig, which is a horrible, you know, analogy for patients. We don’t mean it that way. Please if you’re listening and you’re lay public, we’re not equating patients to pigs, let just put that out there.

– Also, you just triggered every single vegan in my audience, which is one vegan.

– But the image is right. So that’s what we do on this patient and then, we were told initially, on patients like this, that you can put on a nasal cannula up until six liters, and then you have to intubate them, and all across the country, we were doing this and the reason why was they were scared of aerosol generation to the staff, and it’s understandable to be afraid, I mean this is like the first disease aside from Ebola, where on a large scale, you not only had to worry about your patient, you had to worry about the providers around you and yourself, so I understand where it came from but I think it was wrong, and they ruled out that the intermediary steps that we used to be able to do, things like non-invasive, you know, putting a mask on the patient’s face and giving them a continuous positive airway pressure, or high-flow nasal cannula which does the same thing. Now there’s been some recent studies saying it’s safe. So we would certainly, before intubating this first patient we’re talking about, try some other things, and we’ve gotten a bunch of patients through without having intubate by using things like high-flow nasal cannula just like a couple tubs in your nose that go with super rapid oxygen flow.

– How many liters per minute are those high flows?

– Sometimes up to 60 or 80

– Wow.

– So, it seems scary, it seems like a jet engine, but it’s actually super comfortable, because the gas is humidified and warmed, it feels great, it feels better than a mask around your face which is really claustrophobic.

– Scott, okay, you and I both know that there’s a lot of physicians out there struggling with furloughing their staff, they’re not doing elective procedures, they’re going out of business. I just had the greatest business idea ever talking to you, which is high-flow oxygen bars. So you bring people, you go I’m a doctor, and you sit ’em up and you give them like 60 liters of jet engine O2 and they come out, you know, with free radical damage, and you know, other terrible side effects What do you think, are you in?

– Well I’m just hearing in the back of my mind, Z, that you might be on rough times and you’ve taken the Vegas opportunity to come into people’s rooms and give them a bag of IV fluids and so, are you okay, dude? Should we set up a Patreon donation schedule for you?

– I mean I’m not saying that all my speaking engagements have been canceled, Scott, but all my speaking engagements have been canceled. So yeah, I remember I did a piece on medical management of COVID early on and I was sort of repeating some of this early guidance which was just go, you know, if it looks like they need BiPAP, you should probably just be intubating ’cause you don’t want it aerosolizing, now we’re changing that, how are you preventing aerosolization in those patients on high-flow, non-invasive masks and things like that?

– Yeah, it’s funny, so high flow scared me more than then the the CPAP or the BiPAP initially because it just seems like you’re putting the worst possible situation of blowing an enormous amount of gas at incredibly high rates into the nose and it just spews out the mouth. All the studies that say it’s safe all put a surgical mask over the patient, and seemingly, even though it seems scary, that’s enough to stop all the aerosol particles, those surgical masks just catch ’em all, and it’s just reinvigorated to the patient to breathe their own crap, and so, that’s how that was made safe and there’s been a few studies. One was manufacturer-supported, so obviously, you know, grain of salt, but there’s been some independent ones, seems safe. The BiPAP, all the studies out there that said this is dangerous, where all with standard non-evasive machines that have an open port to the environment, you remember from the hospital days, right, they would get air forced in and there would be a hole, and it would just be spewing all around the world. What we realized early on, and really intuitive that this was why all the studies said it was unsafe is that if you could filter their exhalation before it hits the environment, that that’s an entirely different situation, and then there is one trial that finally looked at that and it seems very safe, the only lack of safety with non-invasive is if there’s a circuit disconnect, like it accidentally got disconnected, but while it’s on, remarkably safe, probably safer than the non-rebreather mask.

– Great to know, and I’m relating to that then because you mentioned you throw a surgical mask on them and it cuts down that aerosolization. What’s your take on surgical masks versus N95 in the hospital setting?

– Okay, so this is just anecdotal

– Yes.

– Impressions because I don’t have

– So sorry

– The data to show this. Not peer-reviewed, is that what we’re doing now, are we going down that way

– No, not even the least, un-peer-reviewed, for the, you know, program of my colleagues. We, early on at my imaginary hospital Janus General, went to mandatory N95s for any, you know, area of the ED. It didn’t matter if you’re in a patient’s room or not, and our staff infection rate has been, I think for the docs zero, and for the nursing staff very close to it, so I gotta say, if you’re in a COVID-rich environment, think it’s gotta be N95, and I think if you’re in the rest of the hospital hallways, then a surgical mask is fine, and at Janus General, anywhere in the hospital, you gotta be at least in a surgical mask, but I think places like ICUs or ED, it’s not when you go in the patient’s rooms, it’s anywhere, my take, N95.

– Yeah, gotcha, okay so that’s the Scott anecdote on that, and you know Janus General sounds like a hospital on a soap opera, like you know Dr. Migos works at Janus General, he’s trying to take over the staff so he can run his weather machine to control to control the weather. So okay, back to this. Now are you finding, Scott, that you are actually having to intubate patient two? So we talked about patient one, the person who’s actually, yeah, what about patient two?

– So let’s talk about patient two. So patient one was the happy hypoxemic. We’re stuck with that term whether we like it or not. Patient two comes in, they’re also satting 79% on a non-rebreather and they might even be talking to you but they look crappy, they look like they’re not having a fun time, that they are not happy, and if you got initial Labs back before you felt the need to intubate this patient, all of their inflammatory markers are through the roof and this is a patient in fulminant cytokine storm. Their bodies’ own immune system is reacting in a bad way more so even than the viremia, than the virus going on, is their body’s reaction has been really up-regulated and these patients if you don’t intubate ’em now, are gonna have a rapid decompensation very soon, and so we’ve taken these patients who are not happy hypoxemics and we would intubate these patients relatively early

– Right, and once you do so with cytokine storm, or, you know, is the clinical pattern that you’re seeing the sort of sepsis-like syndrome with hypotension, multi-organ failure, that sort of cytokine effect?

– Yeah, but it’s worse, you know, this is like the worst septic patient you’ve ever seen.

– Oh God.

– The fulminant ones, the ones that this happens up early on because most of these patients who go into cytokine storm, it’s, you know, five, six days into their ICU course, but the ones that come in at time zero are super sick and they could go from talking to you at arrival to unfortunately in cardiac arrest after being on four pressors and insane vent settings, and you still had sats at 40%, you could not ventilate him. and then they code, there’s nothing you could do on those patients, there’s nothing we have to offer at the time of cardiac arrest, and so these fulminant patients are really demoralizing and a bunch of the ones I’ve seen have been young, and they do not do well. If they are that inflammatory, that bad off at arrival, that has been a fairly dismal picture.

– So you said a lot of these guys have been young, do you think it’s the young that are having the more aggressive cytokine storms because they have such an intact immune system?

– Yeah, I mean this is all postulating out of my ass, but yeah I agree with that

– Yeah, that’s my favorite.

– It’s like why are the young, super young people, you know, the kids doing okay? Well, okay, maybe they don’t haven’t developed all of these antibodies to hit the, you know, things and the old people, maybe the reason we’re not seeing these fulminant old people is because their immune system has revved down, but I don’t know. I am not the kind of person you wanna talk to. I am a frontline, stick tubes and holes-type of guy.

– Scott is the kind of guy who will wear a North Face sweater vest with spandex, right? Right after para-snorkeling in Belize. he’ll come into the ER and just put tube in hole, and yet also is like the smartest and most thoughtful and compassionate person that I know. So all that being said, it’s interesting ’cause this actually brings me to a thing that I think we must discuss and we can circle back to patient two but I think patient two is an example of this. You’re seeing people in extremis in the emergency department, you’re very good at saving lives, but then the question always becomes at what cost to their life quality, and in the setting of COVID, it’s really shined, shone a spotlight on this idea of why aren’t we having these end-of-life conversations before a pandemic happens and we’re dying on ventilators alone without our family? Is this something that you’ve acutely experience because when I would work ER shifts, it would happen all the time. Why am I doing this to this person? They never had the conversation, and then it turns out they didn’t want any of it, so what’s your thinking on this?

– Yeah, well, this is a big part of what I do from an educational perspective, teaching the residents, and from EMCrit Education Project, as you know, our motto is Maximally Aggressive Care, which puts people in mind of those rock climbers and you know, apes that like to stick lines in people, but that’s not what it means. It’ss maximally aggressive curative care, but it’s also maximally aggressive palliative care, and that’s the key, that’s what makes that okay. Otherwise you hear that, and you’re like, you know, meet Dick, you know, and so we really try to get across that the idea is to do everything as well as possible for the patient, but you have to decide your course as whether curative care or palliative care is the way this patient wants to go, or the way we think as health care providers, things should go and I think that’s what I wanna put a pin in and talk to you about in a sec, Z, because that’s the big change that COVID actually enacted in many places, but just in general even before this, we were ultra aggressive about having end-of-life discussions with our patients and we would have, you know, have stage four cancer patients whose oncologist had never had the conversation about end-of-life goals because they were in a different mindset, they were just trying to do everything to cure the cancer and I understand that. I want my oncologist to cure my cancer. You know, I don’t wanna go down that road if it happened, but I also would love some conversation, whether it be by that actual person, or maybe they could have some staff to do it so that they don’t have to have a mixed mindset, but a lot of times it’s not done, and they’d come to the emergency department, and we’d have a 95-year-old patient who had no activities of daily living, and no one had ever asked do you wanna be intubated or not? So we’ve aggressively tried to make that different at my place, but things are different in COVID. Things are like nothing we’ve ever seen before because we’ve never been in a circumstance where there’s no ICU beds and no ventilators available in hospitals. That’s a new one and it’s led to a sea change, a paradigm shift in the United States way of dealing with palliative care at many places.

– Yeah, and you know, we’ve done some shows on this and I talked to Wes Ely, do you know Wes?

– Yeah, just by name, but yeah.

– Yeah, yeah, great guy and he talks about that as well and also like keep maintaining our dignity and our mind coherence in ICU settings when people are, you know, over-sedated and not, you know, when people are, you know, over-sedated and not, you know, So this thing to me is so crucial, because there’s so many opportunities out of this tragedy. It’s a disaster, right, a total clusterfuck on every level, but we have some bright spots. One is that we may emerge a new way to pay physicians for what they do which is not fee-for-service because they’re going out of business now and you see how vulnerable that is. We ought to be paying people, doctors, to do the right thing for patients, keep them well, keep them out of hospitals, that sort of thing, but the second thing is having conversations with those that we love, picking a decision maker and saying this is what I want out of my care and my life, right?

– Well, yes, 100%, but this is where COVID’s wrinkle is different and this is controversial as you’ll see

– Oh, bring it.

– So I hope you don’t mind some emails.

– This is why I want you on the show.

– In every other developed nation that I can think of, you know, on the top of my head. Canada, Great Britain, Australia, New Zealand, most of Europe. It never gets to the point of finding out patient’s wishes about end-of-life care for any individual piece of care until the physicians and care team have evaluated whether this is a reasonable care to provide and that’s something very different in the United States. In the United States, and as an individual state in New York, things are even more dire. It’s always been that the physicians feeling of whether the therapy is appropriate or not, never enters in beyond just being able to express your opinion in the conversation, but by all the things of medicine, you should never even be asking the opinion of a patient or family if it’s an inappropriate treatment to begin with. Now that’s super controversial until you realize it’s being done all the time, just not in areas where people have as much exposure. So for instance, if your surgeon looks at a patient with a mesenteric ischemia and says they’re 95, they have 10 comorbidities and I have an almost certain, but not certain, but almost certain feeling that they’re not going to do well with the operation, they don’t even offer it as an option, they’ve always been able to say no, I don’t deem that this is a good option. The nephrologists say this is not a good candidate for dialysis, as someone who does ECMO, we always have said, this patient’s 77, and they have hypertension, and you know. some other stuff. We’re not going to even offer it as an option, but in terms of putting a tube in a 95-year-old patient with no activities of daily living in a nursing home? Yeah, you could you can express your feelings to the family but if they say put the tube in, you gotta put the tube in. That’s stopped with COVID. This is the first time where we will take the family wishes in as part of our decision-making, but if it’s not a treatment that is appropriate and that patient I just gave you, that 95-year-old nursing home patient with no ADLs due to severe dementia, that’s not appropriate to intubate that patient, regardless of family wishes. Intubation, ICU care was never meant for that patient. It’s not it doesn’t get to the point where the family gets to overrule you. It has to stop before that, like every other civilized country in the United, in the entire world.

– This is the internet equivalent of a slow clap because it’s actually a slow clap. So the fact that that is controversial is one of the most disgusting things to me because we do this, Scott, you and I do this for a living. It’s kind of like until you’ve seen a 95-year-old with no activities of daily living in a nursing home, intubated, suffering and tortured until they inevitably die or if they survive, they are so messed up, whereas the surgeon can say oh, I’m not gonna operate on that patient because it’s a terrible idea and the outcomes will be poor, and actually I’m gonna get dinged for having poor outcomes, even operating on this patient, this oughta be across the board. Now, of course people will push back and say but that’s paternalism and I knew my grandpa, they told me that about my grandpa, but then he survived and he’s playing golf, right, but the thing is you also have to realize that we’re in a resource-constrained environment so you cannot throw a nuclear bomb at every single patient hoping that they’re one of the .5% that might actually survive.

– Yeah and I wanna make it clear. At Janus General, at all the hospitals I’ve dealt with, it wouldn’t be the patient who could go back to playing golf. That is a whole separate issue. When things become so scarce, and luckily we didn’t have to run into this ’cause we got so many ventilators, but let’s say we got to that point. There is a ventilator allocation policy at many hospitals that would put the 85-year-old versus the 45-year-old and have an ethics committee decide and I think that’s appropriate, but what we’re talking about is a slightly different thing that comes before that which is where there’s no chance that patient’s gonna go back to playing golf. We would never take a 90-year-old who is with their grandchildren every day, taking, you know, mile-long walks and say we’re just not gonna tube you. That’s not it, that might happen but that’s happening beyond the individual set of doctors taking care of them. That’s at a much higher level with all sorts of people weighing in. What we’re talking about is a patient I can never get better, a patient who has been, you know, chronically vent-bound with no mental status due to severe traumatic brain injury for five years with no signs of anything more than a vegetative state. That should never enter into the discussion of ventilator allocation.

– You know I love your analogy of the surgeon because imagine, okay, you have a family who’s in denial or there some other psychopathology going on where they’re like no, Mom needs to live, but she’s 95, on a feeding tube, nonverbal for years with bed sores in a nursing home, you want us to tube her? Yes, we need you to do everything, right, because of whatever’s going on, but would they go to a surgeon, and say no, I need you to take her to the OR right now for that mesenteric ischemia and the surgeon can just say uh, no, that’s not

– Right.

– How this works, that’s not how any of this works, right, so there does need to be that discussion, and it also means we need to have open communication, right, and we need to set expectations. Right now, it’s like the expectations of patients is oh, I see it on TV, people getting tubed all the time. I watch “Grey’s Anatomy,” I watch, you know, “House.” Stuff happens, in “House,” like the one guy can do every single medical specialty how come you can’t, Scott?

– Of course.

– Well, why do you have call ID? I thought you were ID, what’s going on?

– It’s craziness, but I think that is one good that will come of this, is to set the precedent that inappropriate care should actually be dealt with prior to families being able to decide.

– Yeah, I’m with you, and again, we’ll be accused of being paternalistic and playing God and all that. Go ahead and accuse us, dude. I’ve been accused of much worse. I’ve been accused of playing Satan, which is not a stretch. So back to the ECMO thing, you mentioned that you do ECMO. Tell me about ECMO in the setting of these patients.

– It’s rough, okay, so ECMO is very good at one system of disease states, so you have really bad lungs, like with the H1N1 flu, we were putting patients on ECMO all the time because we just had to get them through the pulmonary side of things, or if you have a bad operation on your heart and your heart’s just not working and you gotta bridge them to something, then it will handle the heart really nicely. ECMO’s not that great at handling multi-system failure because it does not work as well there. Now the problem we have seen is most of the really bad respiratory failure in COVID comes along with a nice little additional baggage of every organ system in your body going downhill, so where it plays is if you had a patient with isolated horrible respiratory failure, it definitely’ll help, if you had a patient with post-COVID myocarditis, or myocardiopathy or any of the horrible devastating heart failure after they’ve gotten through the respiratory course, then venoarterial ECMO might be the win, we’ve had a hard time taking these multi-system organ failures that also include horrible lungs and getting them through, and it’s also enormous resource utilization, so we’ve been super selected in the cases at Janus General where we could do an ECMO.

– So when you see, you know, dozens of elderly patients in Italy proned on ventilators in these units, in the earlier days of this, what was going through your head? Do you think that those people were inappropriately ventilated because you hear all this anecdotal reports now of, you know, high mortalities in patients who are sick enough to be ventilated. How do you see that now from through the lens of your own experience?

– I don’t wanna make any negative comments. I mean they had it rough, so I don’t wanna, you know, comment in a negative light at anything, I would just say they were where we were at the beginning and we were intubating everyone, beyond a modicum of minimal action provision and beyond which Italy is one of the exceptions of the European states where it comes to palliative care. They’re very much a a country that feels everything should be done regardless of, you know, other issues. At least that’s my outsider’s impression but I got that outsider’s impression talking to a whole bunch of people. You know that is the country that is very much like the United States in Europe, so they might not have had much choice in the matter, so if they were using the paradigm of early intubation and they can’t make these inappropriate care decisions, then that’s exactly what you didn’t wind up with.

– I’ll never forget I saw a news piece where an Italian critical care doc came out and just was tears in the saying I don’t understand it. All these patients on the ventilators are dying, they’re all dying and then they show these patients and they are an ancient old people face down. It’s not necessarily the experience you’re having with young people. This is a very different experience in in Italy.

– Well the weird thing that at all of us have noticed, Z, is you can take a patient that looked great, they might be that happy hypoxemic patient that was making it through but then they finally hit whatever your number is on saturation even though they were still happy, so let’s just starting hovering around 76, and they’re like I can’t do it anymore, and you intubate them, a lot of them have gotten radically worse immediately after the intubation. Now all the doubters say oh, well that’s just selection by the time they got sick enough to need the tube. I don’t know, man, I think I’m seeing something as a signal that my other buddies are seeing as well, which is the tube and mechanical ventilator itself may actually start this cycle of bad inflammation and multi-system failure, that something’s going on.

– And you are not alone. That’s what a lot of people are speculating, and again, like you said, let’s be very careful and tease out the selection bias, so if you’re sick enough to need a tube, you’re probably decompensating on an arc that would correlate, it’s kinda like the people who say oh, you know what, my kid got autistic right after the vaccines, it was the vaccines, but in this case, there’s enough physiological plausibility that there’s something we’re doing with ventilation that’s either triggering an immune inflammatory cascade, worsening lung dynamics, worsening cardio dynamics, in a situation where we already know the cardiac dynamics are crucial because there’s something that this virus is doing.

– Yeah, the reason we can say it is because they seem to stay in one system when they’re not intubated, it’s just their lungs, and then all of a sudden, once we intubate, their kidneys are failing, and they need to be on vasopressors, and so, you know, we’re seeing something.

– How much, you know, and I speculate this because you know, you and me have talked about meditation and things like that and I’ve done shows on the nature of consciousness and that gets really heady and stupid, but it makes me wonder that when you intubate someone who was not mentally that off, in other words, they were reasonably okay mentally when you intubated them, and suddenly they are unable to speak, breathe on their own, these things, doing these things in a synchronization that isn’t quite their own, even though they’re sedated, there’s something there. that is causing a cortisol release or a stress response that’s contributing, not cause of necessarily, but contributing to the overall multisystem collapse, but I’m just curious your intuition on that.

– It sounds right, I mean I’d love to see some proof. We notice a phenomenon all the time in emergency medicine where a patient will have been compensating for whatever length of their hospital transport, and then literally the moment they’re get put in the hospital bed, in our emergency department, they crap out and go into cardiac arrest and we see this so commonly that those patients must mentally have been holding on. I just need to get the hospital. I just need to go to the hospital, and then once they get to us, their brain just says ah, I’m there and that,

– That’s it.

– They should’ve waited a little while. They should’ve said I’m gonna hold out until the doctor says you’re out of harm’s way because we see it all the time and maybe the patients have been holding out to avoid, you know, things getting worse and then once we tell ’em you’re going to get tubed, that same release says all right, well, now I don’t have to worry I’ll let them do the work.

– You know it’s funny, the Reuters article that cited you from yesterday actually was talking about a case of a doctor who got COVID and was talking about that experience where he was getting more and more hypoxemic, but they were, he was in a facility in Europe where they don’t do a lot of that, they were like no we’re going avoid ventilation at all cost and he got to a point where he was like you guys need to do something, I am crapping out like this is bad, but they were like suck it the hell up and he’s like all right and he got through it, and never got intubated and got home in decent shape, and so you do wonder about this a little bit, and again, this is purest in the pure X-Files speculation component of it.

– I will say all of my buddies in the ED critical care world will do anything humanly possible to avoid getting put on the ventilator if we did come down with COVID.

– Yeah, yeah.

– We would work with every trick in the book.

– Yeah.

– To try to make it through without, and by that

– Would you cheat on your blood gas test?

– Hold it over a candle? I don’t think you’re allowed to do that.

– You’re like see, the blood gas is great. Man, I know I’m with you, I was talking to my wife about this and I told her, like here are my wishes ’cause she’s she’s working right now at Stanford, it’s one of the hotspots, you know, I’m not privileged there, I have privileges in Las Vegas, and so with the travel ban and everything, I’m like you know what, I’m just gonna do this thing and expose myself naturally to COVID through my wife and so the wife, by the way, she just got, they just did nasopharyngeal swab and antibody testing ’cause they’re offering it for Stanford employees now. She said that they push so hard on that NP swab that she was convinced she had a CSF leak after the procedure.

– The proper way to do it is you take a small mallet, and you keep.

– She said they put it in and it was uncomfortable and she’s like yeah that’s not comfortable, then the woman goes no, I don’t think we put it in far enough and she started to tear up and like she said she needed a moment afterwards to recompose herself before she could go back to work but the point is, I told her, I’m like, listen ’cause I’m at high risk because I have these clotting disorders, I’m Middle Eastern, I’m 47 as of yesterday, so I’m an old comorbidity-strewn individual, that’s the only comorbidity I have, and I said I will not go on a ventilator, you will do everything possible if it involves taking a fan and just blowing it on me so I feel better, I don’t care, cheat on the blood gas, I don’t know. So back to the blood gas test. So what in the happy hypoxemics, quote unquote, what are you seeing on their blood gases, I’m curious?

– Yeah so for the most part the oxygen saturation and PaO2 correlate with the the hand saturation with the understanding that below 90 or 85%, it’s not as accurate, those pulse oximeters that go on the finger but they correlate. We’re not seeing radical differences between PaO2 and sat which would imply there’s something going on with the hemoglobin. So many people have postulated this, Oh, it’s a right shift, it’s a left shift, it’s a right shift, we don’t see it. The other interesting thing is the carbon dioxide is usually quite low, they are blowing off, so these are not the rapid shallow breathing, these are rapid big breaths, when that carbon dioxide starts rising, that’s a sign the patient’s no longer compensating, and if you show me a normal carbon dioxide on a happy hypoxemic, they ain’t so happy anymore.

– That makes perfect sense because they’re decompensating ’cause decompensation is blowing off CO2 and but their pH adjusts because they’re buffering and they’re, you know, the Henderson-Hasselbalch equation

– Yeah, they leave ’em for days, then their pH starts moving to normal.

– Exactly, exactly, what kind of pH would worry you enough and again, I hate to talk about numbers as a absolute, right, in a patient that you’re a little concerned about, what PH threshold would make you say you know what, it’s time to think about doing intubation here?

– Well, you know, the pH is a less helpful measure ’cause it blends in both respiratory and metabolic, so if you had a patient with a low CO2 and their pH is low then that makes me think there’s an inflammatory component, and we sent lactates on all these patients, but if you haven’t at that point, send it, and if you see a lactate through the roof, it might be the cue that there’s some other inflammatory stuff going on ’cause they all seem to come in packs, their ferritin, their D-dimer, their lactate, in these inflammatory patients, they all are super high like higher than anything you’ve seen and that’s a mark that this is not the happy hypoxemic even if that this moment they look relatively well.

– Yeah, yeah, yeah, so you know, as we’re approaching an hour here, you’re there doing the stuff on the front lines, you’re a smart person who works on this and it’s your life’s calling, and I’ve heard you talk about this with a kind of passion that you rarely hear physicians talk about their trade, you know it’s really interesting, ’cause most of us are kind of cynical, and we’re like yeah, you know, it’s just a bunch of old people, Scott Weingart is like we have a calling, we have a mission, this is what we do, and it’s like he said, it’s maximal care and whether it’s palliative or whether it’s urgent, what’s your sort of overall formulation of this thing in terms of advice to the public as we’re talking about oh, Georgia’s opening up and this is happening? I tell you, I’ll just give you my peace because it’s tough. I go on a roller coaster ride myself. There are days when like they just made us wear masks on a trail system in the bay and I’m like okay, now we’ve lost our minds officially, but then you look at the New York experience, and you’re like hey, you know what, masks everywhere sounds like a good idea because it’s a dense population with a high RO, you know, so what’s you’re thinking? Give us some wisdom.

– You’re not gonna like this answer, Z.

– I like it already.

– Okay. I think the public may have a misunderstanding of what we’re attempting to do by social distancing, and I don’t know if I should dissuade them from it because it probably leads them to some solace but social distancing is not about them not getting COVID. We kinda need them to get COVID unfortunately. Social distancing is just keeping the case rate per day at a level that hospitals can manage, and therefore, lowering mortality by us not being overwhelmed, but if no one gets COVID, this ain’t never ending unless the vaccine was to be developed, and I think the 12 to 18 months is wildly optimistic.

– High, they’re high, they’re smoking, yeah.

– Yeah, so, unfortunately the public needs to get COVID. They just need to get it at a rate that we can manage.

– Okay, so first of all, this is why you are my brother from another mother because I said exactly that on a rant a couple weeks ago, I said you guys gotta understand what an area under the curve is, you flatten the curve, it doesn’t change the overall number of people who get infected. Now some people are saying, well no, but we’ll come up with a cure before that, man, or a vaccine, not in 18 months is wildly wildly optimistic. I had Paul Offit on the show, the guy makes vaccines for a living, and he doesn’t think that that’s a doable thing. So we need the people to understand that we have to do social distancing to make sure our hospitals don’t get overwhelmed but at the same time, this is not the cure for the thing so people who, this is what I hate, this is one of my pet peeves, people who get so high and mighty about that, they’re like you know what, how dare you go to the grocery store without gloves. It’s like are you smoking crack? Like take a breath, if we just do enough social distancing that our hospitals are okay, that’s what we need to do, that’s the target, we’re not trying to bring transmission to zero because that’s not, first of all, it’s not gonna happen, but second of all, it’s not what we want, so thank you for pointing that out.

– Yeah, when you see that joker who’s going around you know with no mask and you wanna condone them, you know, I mean condemn them rather, you should be condoning them, they’re taking it upon themselves to potentially be the people to keep the curve going to get rid of this virus. Now you don’t want them exposing others, but someone’s gotta get it.

– And then you just hope it’s somebody who’s not gonna die and it is true, so the next time, I’m gonna go into the supermarket here in the Bay Area, no mask, complete commando, and I’ma be coughing into my into my things so the people know I’m not to make them sick and I’m just going to sing “We Are the Champions” because I am taking a hit for the team. The problem is I’m going to die like a dog in a prone position on BiPAP, see that’s the thing, See, I’m gonna aspirate, I’m not planning to get intubated.

– You and me both, brother.

– Right, I’m gonna go out like Jimi Hendrix, man, choking on my own vomit and in a prone position, that’s just how I roll, dog. Scott, man, so how’s, your wife is a, can I mention what your wife does or is that–

– Yeah, yeah, yeah, absolutely.

– She’s a pediatrician, and

– Well, she’s a peds anesthesiologist.

– Oh.

– And the anesthesia side, was really where she came into her own in COVID because she was in one of the busiest, sickest hospitals in New York City.

– Oh my gosh.

– I mean, you know, I could bitch and moan about how much my nose hurts in my N95, but she was doing the lion’s share of misery.

– Wow.

– She’s a far stronger trooper than I am.

– Wow and how do you guys decontaminate when you get home?

– Yeah, you basically do silkwood showering, you know instantaneously, you know you strip down to your skivvies and then you skittle over to the shower, and you don’t bring anything from the hospital into your home environment.

– So basically what you’re saying is like every day in my life minus the shower.

– Yeah, exactly right.

– The minute I get home, I’m like , I’m like basically in a loincloth walking around. You know my daughter outed me on a live show I did the other day for Facebook and someone had asked in the comments like hey, can you say something that would embarrass your dad? And I’m like nothing can embarrass me, and she goes Daddy walks around practically naked 24/7 and I’m like okay, you may have succeeded there. That’s for our eyes only. Dude, Scott, man, it’s such a pleasure to get your perspective on this. I’m basically sending out all the vibes for you to first of all, solve this for us because you’re a genius.

– Not gonna be

– Second of all, stay safe. Third of all, when are we going to be able to have conferences again where we’re gonna hang out because I look forward to it all year being able to see you guys?

– Yeah, me too, it’s gotta happen, but who knows when man?

– We don’t know, we don’t know. We’ll do it by Zoom, who cares, it’s the same thing.

– [Scott] Sounds good.

– Yeah, 70% more nudity possible by Zoom because no authorities except for the Chinese hacker that’s watching us right now. So let me give a pitch for your podcast, “EMCrit.” You can find it on every single podcast. What’s the website?

– Emcrit.org, E-M-C-R-I-T.

– Okay, and again, most of you guys are already subscribers to it, but if you aren’t, especially if you’re in medicine and even if you’re not, it’s just a fascinating deep-dive into emergency critical care & beyond actually and Scott’s website, I’ve used early on to formulate my thinking on how we should manage COVID because there are just great contributors there that are bringing lots of knowledge, and it’s this idea, and Scott, by the way, was one of the pioneers in using social media to educate and he is one of the pioneers in both academics and outside of academics in doing that, so we need more physicians, smart and passionate physicians doing that. So Scott, thanks again, man.

– You’re too kind, brother. It was such a pleasure and I’m glad to be able to talk to your audience.

– Aw man, until next time, “EMCrit” for life, we out