SPEAKER_00 0:19

Hello and welcome to Impatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the Working Hospitalist. Today on the show, we're doing something a little bit different. I'm joined by Dr. Emily Reims as we discuss what you need to know from SHM Converge 2026. We'll highlight the things that you can start doing in your practice now that will benefit your patients, like flu shots for patients with heart failure, holding aspirin in folks on full dose anticoagulation, using naltrexone and phenobarbital in patients admitted with alcohol use disorder, keeping up anticoagulation in folks with AFib and high stroke risk, even when you're worried about falls, and so much more. Thank you so much for being here, Emily.

SPEAKER_02 1:03

Thanks for having me, Mason.

SPEAKER_00 1:05

It's a pleasure to have you, Dr. Ames. Dr. Ames is one of my fellow hospitalists. She's an excellent clinician and also an excellent travel buddy, as it turns out.

SPEAKER_02 1:15

It was pretty fun.

SPEAKER_00 1:16

So we both just got back from SHM Converge, that's the Society of Hospital Medicine Converge Conference, which it's probably too much to call it the Super Bowl of being a hospitalist, but something has to be the Super Bowl. Lots of speakers, lots of clinical updates, lots of other stuff, lots of hospitalists. They are all getting together. Start off, what was your impression of SHM? What was sort of the your impression of the overall event, or what's your biggest surprise?

SPEAKER_02 1:45

Yeah, I have been doing SHM before. I went in, I want to say 2018. So things were very different then. It was a very pre-COVID world. And there were a lot of younger hospitalists who were making up the vast majority of who were at those meetings. I want to say the diversity in this group was much greater. And I think this conference was a good bit bigger. It was huge. I honestly didn't know there were 60,000 hospitalists out here. So I'm glad our field has grown so much. And even just in those eight years, it feels like it's much, much, much larger, which is great to see. And the enthusiasm was there.

SPEAKER_00 2:20

Yeah. Super Bowl.

SPEAKER_02 2:22

Yeah. Indeed.

SPEAKER_00 2:29

So let's get into our big takeaways of what's going to actually influence our practice going forward. So, Dr. Reeves, how often do you have someone on your service who has congestive heart failure?

SPEAKER_02 2:42

Every day.

SPEAKER_00 2:43

Every day. What if I told you, at least in folks with moderate to severe, that there was one single medicine you could give people that would um reduce both their mortality and their readmission over the year with a number needed to treat of 17. What would you think that medicine was?

SPEAKER_02 3:03

I would think that that would be. I would think that might be a beta blocker.

SPEAKER_00 3:08

Yeah, right?

SPEAKER_02 3:09

Entresto.

SPEAKER_00 3:10

Ooh, entresto. The cardiologists love entresto.

SPEAKER_02 3:13

Yeah.

SPEAKER_00 3:14

So actually, it's a one-time medicine. You've taken it this year. I've taken it this year. Or else I can't go to work, yes. Exactly. So the flu shot. So this is one that I didn't go to the heart failure session, but I was talking to a colleague in the hall who did Rahula Hoosia, and he mentioned a few of the stuff. And I was like, oh, that sounded like that was a better session than I thought. Or it just wasn't the one I picked. So I looked back at the slides and I was like, it just saw the slide. If you remember one thing, give your flu shot to everyone you admit with heart failure. And I just I looked into it a little more and looked at the slides some more. And I was like, whoa, this is super cool.

SPEAKER_01 3:57

Yeah.

SPEAKER_00 3:58

Um, just a flu shot and 17 patients, which takes like what? You know, two weeks on service. Two weeks on service. Maybe. And you've saved a life andor a readmission within the next year. And for adverse events they looked at, it was a number needed to treat a 15. I love a number needed to treat.

SPEAKER_02 4:16

I know, I do too. And there's something really nice about a one and done flu shot. And you really are gonna deal with CHF every single day. And you may not convince everybody. Our hospital's really gotten away from being aggressive with a flu shot and made me kind of think, oh, we do need to get back on that.

SPEAKER_00 4:32

I don't think about it. I I rarely I don't know when I've given someone a flu shot who was admitted. I was we were doing COVID. I was thinking, all right, are you vaccinated for COVID? Let's get you vaccinated if you're not. But I really I honestly don't think about it very much.

SPEAKER_02 4:46

And it used to be a lot more aggressive before COVID, which you weren't a hospitalist then, but we used to be very aggressive then about the flu shot. And but honestly, we haven't been getting enough in the hospital. And it used to be a hard stop on the EMR when you were in a chart. If the patient hadn't had a flu shot, it was something that we needed to look at. So I mean, that's something that we probably should get back into the chart, especially in the 100%.

SPEAKER_00 5:12

Yeah, this should be we should be triggering this. And because this the patient population they looked at was obviously heart failure. We got impressive numbers and heart failures. But kind of like my takeaway from this is like sick people, when they get the flu, they get admitted to the hospital and they die. So most of our population is like high risk for issues from the flu. And we should be using that hospitalization as an opportunity to protect them from that. There was other stuff from the heart failure session, like giving hypertonic saline to help diarrhee and stuff. That walking away, Dr. Hoosha was like, what? This was crazy. I'm like, and like, yeah, there's that kind of stuff that's underbaked. But then you get to something like this, like 100% I'll be doing this.

SPEAKER_02 5:53

Yeah. And I went to a different heart failure session that we didn't talk about the flu shot, but I see a lot of heart failure out in the community, and I work in rural hospitals and we're treating some really, really sick people. And you know, it's always good to have a little refresher. Like, I oh yeah, I think I know how to treat heart failure, but like low output heart failure is something that I really need to like keep in my mind. And I think also in the community I need to be given more flu shots too. So yeah, it's that session was helpful for me because it helped me identify some early markers that I needed to look for, like a lactate or if the creatinine's going up and reminded me to do silly things like touch somebody's feet to see if we're if we were actually in low output instead of we're over diuretic when our creatinine starts bumping. Um and you know, it's helpful then because I can get that patient to a place that's got a cardiologist, whereas they're sitting on the floor in these tiny hospitals and things can go south kind of fast. So heart failure session was uh kind of a banger.

SPEAKER_00 6:58

Um yeah, touching patients doing the physical exam. I feel like that's one thing I um I say one thing that's kind of more than what I do in practice in my physical exam is yeah, like how often do I actually touch legs? How often do I give my shock talk and be like warm versus cold and all of that stuff? And those things don't really correlate, but they should. They should. So that's part of what was great about the conference is it was just a reminder of stuff, like to give a flu shot. Like, duh. Of course I should be giving everyone a flu shot in flu season. But the fact that I have this, 100% it's gonna be on my radar going forward. I admit someone with heart failure. It's a season when we have a flu shot. I will be giving them a flu shot. I will be giving anyone who will let me a flu shot who gets admitted to the hospital during the time that there's flu shot.

SPEAKER_02 7:39

You're gonna become a menace. Just walking around with a flu shot. I'm gonna save lives. You are gonna save lives. And I think you should quote this study to all of your patients who refuse flu shots. I'm just trying to save your life. Mine is also something that has been studied a lot recently. And your patients who are on aspirin for CAD, but also on a doac for uh anticoagulation, generally for AFib, you need to stop the aspirin. And I thought about it, and we do this a some, but there are patients that are on aspirin for CAD from a MI that they had in 1982 and have been put on a doac in the last 10 years for AFib, and nobody ever took them off the aspirin. And honestly, you know, I've the double anticoagulation, the platelet of it all, the you know, the coagulation cascade. It looks like these things are a little more interspersed than we thought they were. And that's great. But multiple trials have shown that stopping the aspirin, you've decreased death from 13% to 8%. Um, so you're you're more likely to survive, you're less likely to have a major brute bleed, obviously, and you're less likely to have a hemorrhagic stroke. So it the studies conservatively are saying stop the aspirin a year after a stint, but it looks like you could really do it a six months out. And obviously things are different if you're on a Plavix and things like that, but you know, a year out, it looks like you don't really need to be on an anti-platelet. So I think that that's something that we can probably change once a week, also.

SPEAKER_00 9:33

Oh yeah. I'm yeah, I'm I'm totally with you. This this was huge. Like, you're right, like anything where it's like a significant mortality benefit. And if I recall, they like stopped the trial early because they were such a mortality benefit. It's all right, we're this is this is doing something.

SPEAKER_02 9:46

If you're stopping a trial early, I'm gonna listen. So I think I, you know, that was in the Things We Do for No Reason section, which we may get into it, but that's always a great session for the hospitalist to go through things and cut the fat. But this is something that again saved lives. And, you know, I think the biggest thing is major bleeding, hemorrhagic stroke, awful, awful. But like even just the oozy GI bleeds that you're just admitting again and again and again, you know, a lot of those we have already taken off the aspirin, but some of them haven't. And a lot of the cardiologists aren't on this yet.

SPEAKER_00 10:22

Yeah. And I wasn't on this until, you know, 2026 at all. Like I was not, and we actually, I think episode three with Dr. Ospino, we actually talked about, I think it's aquatic was the name of the trial. And I I hadn't known about it before then. And literally that week it was changing my practice. And also that week I wasn't seeing it consistently applied by other services, even like cardiology.

SPEAKER_02 10:47

Agreed. Agreed. Um, but it's a way for us to make a difference, though, just by doing a med rec.

SPEAKER_00 10:53

I think it's super cool that we've hit this. We've talked about, all right, we're saving lives, and so far, all we've suggested that we do is stop a medicine and do a flu shot.

SPEAKER_01 11:04

Yep.

SPEAKER_00 11:05

And this is one of my this is what I really like about evidence for a hospitalist is like our reps are so high. We see so many of these people who have coronary artery disease and a reason for anticoagulation, or we see so many of these people who have heart failure and are admitted to the hospital, that like we don't need a fantastic number needed of treat into the teens to make an impact. But like when you can do that, not by doing some new fancy medicine, not by doing something that sounds wild, like giving someone hypertonic saline. Yeah, not sure about it. Um, but the fact that you can just take these patients and do really simple things that make an impact is super cool. And the fact that we're we're learning these things in 2026 about aspirin and a flu shot. Yeah. It's like, wow, how didn't we already know this? And why were we doing it differently? So much out there. And I am like, how did these studies get funded? Because no one's making money off of stopping your aspirin or doing flu shots.

SPEAKER_02 12:02

Nope. I mean, I guess the big head bleed is really glad that we're doing that. But uh, you know, I think overall, um, yeah, so far for our hospitalists, these two have been easy to implement. And I think there'll be a lot of patient buy-in with both of these. Um, I don't think that there's gonna be huge, scary changes to be made.

SPEAKER_00 12:24

She says uh you've already alluded to how yes, there will be good patient buy-in. But telling people to take vaccines and taking away a medicine from someone that someone told them at some point in their history they really needed because it was gonna keep them have a heart attack and a stroke is doable but easier said than done. Do you have a high low of the trip? A high or a low or both?

SPEAKER_02 12:49

Um, I mean, the high of the trip was, you know, getting time away and hanging out with my my colleagues that I don't always necessarily get to spend time with. And especially outside of work in a fun setting. That's nice. The high is getting away from my children, the low is also getting away from my children. So I, you know, it's it's always a catch 22. But it was nice to sleep through the night. What were your what were your highs and lows?

SPEAKER_00 13:17

Oh, the same thing. Uh the so I liked like the social aspect. I'm glad we went to that honky talk. We went to the the what was it called? The is it was it West West?

SPEAKER_02 13:26

West Western world or something.

SPEAKER_00 13:29

Yeah, I should be able to shout them out directly. But like in retrospect, I'm like, oh, you know, Emerson, good idea.

SPEAKER_02 13:36

Yeah, we did one of our residents talked us into a honky talk.

SPEAKER_00 13:39

And we did something very Nashville. I'm glad we um slept. And in that vein, I don't usually dedicate episodes, but I'm gonna dedicate this episode to, and you'll probably have this exact same thing on your side, I believe. My wife, my in-laws, who helped with arranging overnight childcare while I was gone, and my parents who were here in person taking care of my children while I was gone.

SPEAKER_02 14:07

I agree. My husband was the rock star of all of it, but along with my parents who the kids slept at their house one of the nights. Um, and then also my in-laws who got up at 6 a.m. to come take the kids to school because my husband has to be at work at 6 30.

SPEAKER_00 14:21

So you know how they say it takes a village?

SPEAKER_02 14:23

I'm just really thankful for my village.

SPEAKER_00 14:25

Yeah, dedicating it to the village.

SPEAKER_02 14:27

Yeah, cheers to that. Cheers to the village.

SPEAKER_00 14:34

I've got another takeaway. In our vein of anticoagulating patients, this was something from the things we do for no reason session that really struck me. And that was in your patient that has AFib who's on anticoagulation or you're starting on anticoagulation for stroke risk reduction. Um, the kind of the sticky wicket of deciding should you be holding it because you're worried they're gonna fall and get a brain bleed.

SPEAKER_02 15:05

You we've all met old people.

SPEAKER_00 15:06

Yeah, right. Yeah, yeah, yeah. And so the the guideline is generally rest greater than or equal to 2%, which is a JADS vask of two in men and three in women. They recommend being on anticoagulation. And I always recommend that to my patients, but I do a lot of this is my opportunity for what sounds really sexy, but maybe isn't that great of like a patient-centered decision making.

SPEAKER_01 15:33

Yeah.

SPEAKER_00 15:34

Um, or what sounds not sexy but is very real of punt it to the primary care provider. Um I have these patients who are on anticoagulation. I'm worried for uh stroke prevention. I mean, 2% a year, I'm thinking, and I say this all the time when like people are worried about me holding the anticoagulation on a patient in AFib in the hospital who's gonna have surgery or something. I'm like, if it's 2% a year, their day-to-day risk of having a stroke is so low, which gives me a little bit of cover to be like, eh, this isn't an urgent decision, and I'm gonna kind of defer it to the primary care provider. Because I am worried that this same person whose Chad's FASC is elevated for whatever reasons also falls. And I'm worried, you know, I I'm always having the question for them like, which is worse, you bleeding out in your brain or you having an ischemic stroke.

SPEAKER_02 16:23

I think the interesting part about this thing that we're getting to is they were specifically talking about people who came in with hip fractures because they fell down. And this week alone, I have been admitting this week, and we have admitted someone who a healthy person with aphib fell down playing golf, broke a hip. Healthy person with aphib and six sinus syndrome fell down playing tennis. So I've literally encountered this twice in the last week, and these are healthy people, let alone the frail people that are falling all the time.

SPEAKER_00 16:58

And you know what's terrifying? Brain bleeds? Yeah. When they go bad, they go really bad. And so we see that, and I'm like, I'm I very much kicked a lot of cans down the road when it comes to this, whether it's in a patient who's already been on the anticoagulation or I'm diagnosing AFib new. And I'm saying, you know, it's tough. You are at increased risk of bleeding. It's just like a tough conversation to have and to put on the patient, which is part of like I I am like very much in favor of involving your patient in the decisions you make, but of course also it's such a hard decision to make.

SPEAKER_02 17:27

But it's hard because that's a lot of information for someone who's not medical that you're talking to about. Then you say like 2% a year, and people think that's very little, but we've all seen it.

SPEAKER_00 17:36

Folks are terrible and all of this stuff is terrible. Yeah, yeah, totally. All this stuff is terrible. And so I was very, I hadn't like dug into the literature in this. This is one of those things I just like was like, oh, it's a risk-benefit decision. Yes. Um, and so I was impressed by this session where they talked a lot about things we do for no reason holding the anticoagulation and folks who were concerned about for fall risk if they're on anticoagulation for AFib, because the risk of your stroke and the morbidity that comes with that is so much higher than your risk of falling and having a brain bleed that's going to end or change your life.

SPEAKER_02 18:15

Yeah. This is this is one of your favorite number needed to treat.

SPEAKER_00 18:19

So they looked, so the study um looked at what's the difference in quality adjusted life years and no anticoagulation versus anticoagulation with a bunch of trash that I wouldn't treat anyone with versus just doing aliquists. Right. And the really impressive number to which you are alluding was greater than 458 falls a year, is what you have to have so that your quality adjusted life years would be less off of anticoagulation than on.

SPEAKER_02 18:48

So you're telling me if I'm holding the anticoagulation, I have to assume that the patient is going to fall more than 450 times a year for the benefit to be there.

SPEAKER_00 18:59

That is correct.

SPEAKER_02 19:00

That is shocking.

SPEAKER_00 19:01

Right? Yeah, isn't that wild?

SPEAKER_02 19:02

I would I wish I published that study. That is amazing.

SPEAKER_00 19:17

And so I'm a little bit punty or hedgy about it, and sometimes just do it, and sometimes they're just like PCP. And this is three and a half years of people's lives. And this could get missed some other time. This is another one of those things. Like, so far, all of our studies have been sort of how the hospitalists, you get a touch point on people. Like, this hasn't really totally been hospital medicine, a flu shot and anticoagulation for aphib and coronary artery disease. This is like primary care, but we as hospitalists get this touch point and we can make this change. And so these people might not get another opportunity for me to tell them beyond the eloquence.

SPEAKER_02 19:54

You pun it to the PCP, the PCP has four minutes in a conversation of their entire hospitalization and a maybe they have a 20-minute appointment and then then they can dedicate three to four minutes to the anticoagulation. If we can do that on the front end and already have had that conversation, then that's gonna save everybody in the system and probably have better outcomes because you can have a thoughtful conversation. Cause I mean, we're seeing 14 to 17 and they're still seeing 22 out there in the in the outpatient world. And so it it's just a conversation that is probably better to have inpatient, unless that somebody has a very specific PCP that they have a different trust with.

SPEAKER_00 20:37

Sure, sure.

SPEAKER_02 20:38

I think it's something we should certainly bring up.

SPEAKER_00 20:40

Yep.

SPEAKER_02 20:41

The 450 falls a year is shocking.

SPEAKER_00 20:43

I should be getting everyone on AFib, everyone with AFib should be getting them on anticoagulation and essentially aliquists. So huge will definitely change my practice. And I'll be more aggressive, I think. Give people increased quality years.

SPEAKER_02 20:56

We should mention though, they did not mention anything about GI bleeding.

SPEAKER_00 20:58

So then that totally changes your calculus. And maybe they're they didn't give us any good data on this. But yeah, when we talked to at lunch to Dr. Maggie Thomas about it, she's like, Yeah, what about people who are bleeding their gut? And you're like, Yeah, that's a good point. And that is, I think that's a caveat. As far as I know, that pushes us back into the mushland of risk versus benefit.

SPEAKER_02 21:21

Mason and I both went to a wonderful session on alcohol use disorder and the treatment. Shout out Dr. Carrie Holmes Maybank, she was amazing. A lot of very interesting things are coming out about alcohol use disorder. And it's easy to say everybody knows how to treat alcohol use. Everybody knows how to treat withdrawal. You know, you just put them on the benzo, you just ride it out. Um, and that's all well and good. And it's successful in a lot of these people, but there have been in our hospital specifically, we've had a lot of this, and this is probably in bigger medical centers, but certainly is trickling down to everything. Everyone the ER is just throwing phenobarb at people.

SPEAKER_00 22:04

Oh yeah.

SPEAKER_02 22:05

And we don't know what to do with it once they come upstairs on phenobarb, like with a phenobarb load. And so we talked about that. And it was very helpful to hear the perspective and why this is happening, which is the ER can more easily administer phenobarb. It lasts longer. It has a long taper. And their literature is gonna start saying that this phenobarb is the gold standard. It's easier for a nurse to administer. They don't have to be at bedside for as long. This is starting to be the ER's gold standard. So we discussed whether or not it should be our gold standard. And all of this is still up in the air about the long-term dosing and all of those things, whether we should dose phenobarb with a benzo, whether we should do it by itself. But the big news on this is that this is not going away. There's starting to be more studies about the actual taper that we should be using and all of those things. And honestly, for me, I felt more comfortable with phenobarb afterwards. Um, I know that many hospitals are coming up with standard protocols and that will be very helpful. But it's coming from the ER. These patients are already on it. It is, it sounds like as of now, it is safe to use with a benzo. So if you feel more comfortable starting benzos on the floor, it is fine that they've been phenobarb loaded. But also if you want to try it just by itself, it seems like that's successful too. Um but phenobarb was something that was to me very scary. And when we walked into that session, I was like, all I need out of this is how is they're gonna talk about phenobarb and I'm just gonna figure out what to do about it. Cause it's been something that's been weighing on me that I feel out of touch.

SPEAKER_00 23:54

Yeah.

SPEAKER_02 23:54

Per se.

SPEAKER_00 23:55

Yeah. I am I was I had a little bit of a I had a little bit of a disappointment, not from the session and not from the speakers, but from a where the literature's at. Actually, in in one of our previous uh episodes featured a phenobarb article that was like not a randomized controlled trial. It was literally a natural experiment of IV Larazipams out. People are using phenobarb more. And hey, look, outcomes are better, wait times in the ED are better, hospital length of state was better, but like not incredibly rigorous. And my impression from the session was still we don't have incredibly rigorous literature. It feels like we're so close.

SPEAKER_02 24:39

It seems like there's a lot of stuff going on, and I think stay tuned to SHM next year.

SPEAKER_00 24:43

Right. I think there'll be stuff next year, but I don't think we're there from like, look at my randomized control trial that tells me the benzos are dead for inpatient management.

SPEAKER_02 24:53

And it's gonna have to be such a culture change that I think you have to have like a really good rigorous studies, you know, randomized controlled trial studies before everyone is ready to switch the culture of mass hospitals. So that one's a TBD, but also definitely on the horizon and something that is coming down the pipeline.

SPEAKER_00 25:15

Yeah, and you talk to a pharmacist about it, at least at our institution and some of them, they are so excited about the super barb. Because I mean, yeah, for all the reasons that it's so much more convenient and also just intuitively, really quick onset of action so you can give it again and again and not worry that you're gonna double stack because it's gonna build up in your system after. And also a half-life of four days. Four days, it's covering you for your entire it is self-tapering covering you for the entire window. I mean, it really makes sense that like you could do this a few times in the ED, and we do not need to be admitting people for DTs or concern for complicated withdrawal anymore. Like that that's what it and that's part of why I seem a little displayed. Because I feel like that's that's the horizon. Yeah, and we're so close, but we're just not quite there yet.

SPEAKER_02 26:00

There's one more thing from that session I wanted to bring up because this is also something that I am gonna change in my practice that I have not done previously, and that's using naltrexone as an inpatient. And I will say that it has always made me very nervous to use it in patients who are still tapering their withdrawal but still withdrawing. And the studies have proven that for people, unless even in even in cirrhosis, unless their child's PC are greater, so horribly decompensated cirrhosis, it is safe. It is safe essentially after probably after 48, 72 hours of being inpatient, even if they're getting some stuff for which we're all all you know concurrently. But the studies are so good about the decrease in alcohol amount. And it's not necessarily that these people are going home and abstaining from alcohol, because that's kind of a pie in the sky goal, especially if an alcoholic has been admitted several times, has been to rehab several times. This is really hard to say we're gonna have completely complete abstinence. But what it does aggressively do is decrease cravings and it decreases your alcohol drinks per day, and it increases your alcohol free days. So, overall, getting it started in someone who is very interested in remaining abstinent from alcohol at discharge, getting it started the day of discharge or the day before that, because there are some side effects associated with it on the front end, but getting it started, making sure they tolerate it and sending them home with it, it seems to be incredibly beneficial for readmissions for alcohol abuse or things like that. So that's something that I'm gonna change in my practice that I have not had. It's been on my radar, but it's not something that I was convinced until this talk that we went to.

SPEAKER_00 28:03

Yeah, agreed. This felt like this was a perfect just sit the hospitalist down and tell them you really should be doing this. Yeah. Because it's the kind of thing that like has a working hospitalist, you're like aware of naltrexone, it's on my radar, but I don't have any comfort with it.

SPEAKER_02 28:20

Isn't that an outpatient medicine?

SPEAKER_00 28:21

Right, yeah, exactly. Exactly. But it I thought it was very helpful to sit me down and say, yes, use this. This is this is your opportunity, just like some of the other studies we've talked about, of getting that touch point with someone with alcohol use disorder more than anybody almost. Take that touch point of they're here, you can do something for them, and give them this medicine that will, like she talked about, not only decrease the amount they drink, but actually actually decrease cravings and treat the disorder itself. Yes. Like some of that sort of mentality of thinking about it, of like the cravings are the disorder. I thought was interesting and and helpful. All right, cards on the table. If you have to pick a favorite session from the whole event, what was your favorite session?

SPEAKER_02 29:05

I know we've referenced this one and we've talked about multiple things that we've heard had from this session, but things we do for no reason is my favorite session. They are dynamic speakers. Um, this is the 10-year anniversary. Is that what they said? Yep. And I, you know, they went from publishing an article in the hospitalist magazine every quarter to every month because there's a lot of fat that we can trim. And it's a very important uh thing, you know, to be on the lookout for that there is stuff that we are doing that is too much. We are overordering, we are for stuff that's not making a difference. And this in general is they highlighted four things that I can make a difference tomorrow by dealing with. So I think that's a big deal.

SPEAKER_00 29:57

Yeah, I agree. I thought that was super cool. And indeed, my dog agrees. Yeah, she's uh she's shouting for praise.

SPEAKER_02 30:02

Big, she's a big fan. Yeah.

SPEAKER_00 30:05

Um, I'll shout out the anticoagulation talk. It was something of like updates and what's going on with anticoagulation with a lot of references to hot chicken um in it. Because similarly, multiple things we've talked about have been a takeaway there.

SPEAKER_02 30:20

Things are they're taking hot, they're hot chicken, yeah.

SPEAKER_00 30:23

Things are hot takes in an anticoagulation right now, and it's really simple stuff and really powerful stuff, and a similarly good speaker. And he did a goofy thing where he told us the history of Nashville hot chicken. But more importantly, he told us he also did what I liked. He said, Here's a study that came out recently. I think they were all within the past year, but at least recently. And he said, Me as an expert in this, this is what I'm doing different in my practice. And that was his summary. These are the studies, this is what I'm doing different. And some of it was kind of hedgy and some of it was really direct. I thought that was really excellent.

SPEAKER_02 30:57

I missed that talk, but I I mean, the amount of other talks that were clinical updates and other things that had anticoagulation changes in it were, I mean, almost every single one of them.

unknown 31:08

Yeah.

SPEAKER_00 31:09

So that one's hot.

SPEAKER_02 31:11

That one's that is yeah. I guess we're gonna have we're gonna have some, some, some talks about that one later in in future episodes.

SPEAKER_00 31:19

Um uh I think even poster sessions, because I saw an excellent poster. I think it, I think it won a blue ribbon. Do you remember uh who won first place in the poster for innovation?

SPEAKER_02 31:31

It was a green ribbon, just so we're all aware. But yeah, it was a dark green ribbon.

SPEAKER_00 31:36

Oh, I didn't I heard talk of green. I didn't realize the first place ribbon was green.

SPEAKER_02 31:40

Yeah, I'll um I'll have to show it to you because um our telemedicine program won that. But yeah, it was um I this is the only reason I went to SHM was to present this poster. And I'm glad I went for many other reasons, but yeah, we um we put together a telemedicine program several years ago, and it is innovative. And we are we are changing what's possible for all kinds of South Carolinians. So the it's especially important for rural South Carolinians.

SPEAKER_00 32:10

Yeah, super cool stuff and obviously like legitimately innovative because it's like our the work on that is has won multiple awards.

SPEAKER_02 32:19

Yeah, and we're uh we're the only ones doing it, but we're hoping to uh teach and spread elsewhere because the entire nation needs this. I was accosted by a an amazing amount of hospitalists who needed to figure out the details of how this worked because their states need it too. So it's um it is innovative. We it is something that we are very proud of and something that is interesting for everyone.

SPEAKER_00 32:50

You want to lead us on a journey? Yeah, uh you start our journey and then we'll move.

SPEAKER_02 32:54

Yeah, so um we went to this amazing session called Clinical Updates in Hospital Medicine. It's their main session where everyone is in a ballroom and what their five, all 5,000 of us are there, and they led us through six or eight, maybe even 10 things that were on the horizon. Big clinical updates for the hospitalist. Like these are the things you should take away from this entire session. And I will tell you, we've talked about a couple of them, but the first one they talked about, everyone was really uncomfortable. And it's do we hold metformin in the hospital? And did you go through an internal medicine residency? You hold metformin in the hospital. How dare you even question that? Um so I will tell you the study was very interesting. It was a large VA retrospective trial about metformin being held in the hospital versus giving metformin during a hospitalization. It seems like the outcomes are showing that at discharge, if you've given metformin during the hospitalization, you're less likely to have an insulin prescription at discharge. You're also less likely to have a hypoglycemic episode post-discharge. And they did show a little bit of decrease in readmission, which is interesting. And I think for me, my takeaway isn't I'm gonna give everybody their metformin because that seems too broad. But my takeaway maybe is some people can have their metformin if they're in for very like a cellulitis or something like that, where we're still where their sugars are a little more control dislike dysregulated than they normally are.

SPEAKER_00 34:44

I've been hearing murmurs of this for a while.

SPEAKER_02 34:48

Yeah.

SPEAKER_00 34:48

Where, like, yeah, 100% I I stop everyone's metformin when they're good at it.

SPEAKER_02 34:53

This is what we do.

SPEAKER_00 34:53

And I've been hearing these rumblings and have not paid it much attention. And um, and I think I'm probably have ended up like the butt of a joke, and like they're like, Yeah, now we have this data, but we've been doing this forever, right?

SPEAKER_02 35:07

Be and But why are we doing it and what is the benefit? And I do think in someone who's super sick, giving back four minutes probably not the right answer. Um, but maybe in these like patients who are in for ops, it might be the right answer. But also, I think the real takeaway is we should be mindful what kind of insulin we're discharging people on.

SPEAKER_00 35:31

I was with the crew of people, which was most of our crew sitting there during the session, being like, Yeah, I don't know. This doesn't feel like you've really thought this through. It feels like bad things can happen. I don't know, I don't know, I don't know. But in my combination of doing exclusively two things and reviewing this, and one, quickly asking open evidence why do we do this and should I be doing this?

SPEAKER_02 35:54

Open evidence is so smart.

SPEAKER_00 35:55

Looking back at the slides from the study, and now I'm thinking probably like, oh no, I think maybe I'm on board.

SPEAKER_02 36:01

Interesting.

SPEAKER_00 36:02

I'm not, I haven't been totally clear. Like, why do we stop the metformin? It's just the lactic acidosis we're worried about.

SPEAKER_02 36:10

Right. The IV contrast with the metformin causing a lactic acidosis that is undialysable.

SPEAKER_00 36:19

Yeah. Because it's a different lactic acid.

SPEAKER_02 36:22

Evidently.

SPEAKER_00 36:23

I don't totally understand. And so I'm very, I'm very I could be in that's I'm impressionable on this topic. I'm impressionable. Because I don't I don't totally get it. And so I'll tell you what open evidence said was yeah, hold it particularly basically in anyone you think is gonna have a lactic acidosis that's day or has impaired renal function. So yeah, no, that totally makes sense that particularly an impaired renal function, but they were like sepsis, etc. But this study, when I look back at it, knowing my open evidence quick search I did, they included people who were be admitted for sepsis in this study, and they continued their metformin and they did better and they didn't do worse.

SPEAKER_02 37:00

Yeah, it's an interesting study because it's retrospective. The initial study was retrospective, and it's really that means that was all based on the clinician's gestalt, which is always kind of difficult for me. Um, I think the way this is gonna change things for me. I may not continue everyone's metformin at the beginning of the hospitalization, but I may start it a day or two before they go home. If I think that they're if I think that there's an issue with glucose and things like that, we may have I just feel like we may have the need for more evidence before I feel really comfortable starting it. And I'm an old hospitalist. Yeah.

SPEAKER_00 37:41

And I'll tell you, open evidence did tell me, I asked specifically as a follow-up question, yeah, but like contrast and the metformin and lactic acidosis, and they were like current guidelines from radiologists are basically as long as GFR is greater than 30, the Metformin, it's fine. And I think about it often do I get a CT with contrast on someone who took Metformin that morning who came into the ED. And that's the answer is everyone who walks into the emergency department, it feels like.

SPEAKER_02 38:06

Yeah, but how many of those people have GFRs less than 30? And it's very little because we don't prescribe that medication to the people who have GFRs less than 30.

SPEAKER_00 38:15

And I'm not seeing the problems in these people when I admit them to the hospital. It's very rarely that I'm like, this lactic acidosis is from the metformin and the CT of abdomen with contrast that they got when they were in the ED. And they took their metformin that morning.

SPEAKER_02 38:28

So I feel like you're convincing me that maybe the issue is the GFR less than or greater than 30. And if they're actively looking at that and that's been the cutoff, then maybe we do continue the metformin. But also, I I really think the take home is just be careful what you're sending home diabetics on. And I think more studies need to be done. And I think metformin may have lost some stigma. So good for her.

SPEAKER_00 38:57

I'm gonna good for her. I'm gonna keep if GFR is greater than 30 and they don't have lactic acidosis. I think I'm gonna try just like continuing it. It makes me I just like saying that out loud, I'm not confident that I'm gonna do it.

SPEAKER_02 39:09

Are you gonna do that on your learner teams? Uh you're gonna tell your learners to do it.

SPEAKER_00 39:12

Well, no, I'm gonna cite this article on it.

SPEAKER_02 39:14

Yeah.

SPEAKER_01 39:15

How it should be.

SPEAKER_00 39:17

We may do a full episode on on this article and really delve into it because I'm a medium convention. Those are our biggest takeaways. But is there anything else that you think was overhyped at this at this conference?

SPEAKER_02 39:32

I think that for me, the most overhyped was AI. I there were multiple sessions, and I think it's great. Like, I think AI is gonna be something that is very helpful for us in the future, but for right now, everything they were presenting was gonna cost me more time. It nothing, very little is saving me time.

SPEAKER_00 39:57

And that's I mean, that's the time we live in. Like, if you don't have like AI in the name is an easy way to get picked.

SPEAKER_02 40:03

So sexy.

SPEAKER_00 40:04

Oh, it's so sexy. And and I'm and I'm a tech adopter. I use AI in my practice, and that I use our dictation or our scribe tool some. I'm happy to use, I mentioned open evidence. I'm happy to use AI in our practice. I have AI fatigue.

SPEAKER_02 40:19

The best comments that I've had about AI was when we were sitting waiting in the airport, and we were discussing, like maybe throwing every single document that's come from an outside hospital on a transfer into a co-pilot type thing. And we have them generate a hospital a one-page hospital summary and tell me when the last time they had antibiotics, tell me what medications they're on. So my med students and residents don't have to learn that their job is reading 400 pages of outside hospital transfer.

SPEAKER_00 40:53

I agree with you. If your institution has a HIPAA compliant large language model, like what better could it be used for than summarizing a document? And so using that, I think makes a lot of sense. But again, I'm just tired of hearing about it and I'm done, and I'd rather talk about anticoagulation or medicine. I would too. I'd rather talk about medicine. Yeah, I want to talk about medicine again. And I'm just like, AI is everywhere, and I'm tired of hearing about it, and it was on here too much. The other thing I would say ended up feeling a little overhyped for me, and I probably could have predicted this. That's new medications. It was hard. Because I went to a specific session about new medicines. I think maybe you did too, but just in general, honestly, like all the new guidelines of use this or use this expensive medicine for this new reason, or use this new expensive medicine. I'm not seeing that change my practice over the next year. I'm not seeing that change my practice until someone in my institution tells me, hey, we have this. We have this and we can be doing it regularly. And and kind of in that vein, just there were a few other things that I feel like were talked about a lot, or I was intrigued by or I heard, but I don't feel like I was ready to be like, this is one of my big takeaways. And one of those was, I don't even know if I'm saying it right. Phenenerone? Phenenarone.

SPEAKER_02 42:13

Pheneranone. Pheneranone. And one phenomena.

SPEAKER_00 42:17

And one of those ones was phenerone.

SPEAKER_02 42:19

Sure, I like that.

SPEAKER_00 42:21

Um, but that was one I heard about it multiple times. And anything I heard about multiple times and multiple times.

SPEAKER_02 42:26

Three different sessions I went to where they talked about this really sexy non-stero steroidal MRA with greater receptor selectivity. So it is a very good replacement for where you've used spironolactone in the past. And the studies are phenomenal.

SPEAKER_00 42:49

Yeah.

SPEAKER_02 42:50

But who has this?

SPEAKER_00 42:52

I don't know. And I don't honestly, I obviously haven't looked into it. I don't know if we have it or not. I don't know if my patients and stars come out. This has not been on my radar almost at all. I've like heard of it before, but it's not been on my radar.

SPEAKER_02 43:05

One has been on my radar for about a year because I read a study about CKD, and it is it is reducing the quickness in which if you have CKD diabetes with protonaria, it reduces your progression to end stage renal significantly. I don't have any of the numbers on me. But the new sexy study isn't hef path, it reduces your heart failure events. So it's not completely studied in hefref yet, but it is spironalctone without all the side effects. It still has hyperkalemia, but none of the side effects, you know, gynecomastia, any of those things, because it's non steroidal. And it's more selective for the kidneys and the heart. And it looks like this great medication that in 10 years we're gonna be using a lot.

SPEAKER_00 43:58

Have you given it to anyone yet?

SPEAKER_02 44:00

It to zero people.

SPEAKER_00 44:01

Have you tried?

SPEAKER_02 44:02

No, I haven't. I'm not sure it's available at our facility. And the heart failure lecture I went to said you need to start this prior to discharge and start the prior auth prior discharge. And you know what I love is when I'm told that I need to start a prior auth prior to discharge. There's nothing more gut-wrenching for a hospitalist.

SPEAKER_00 44:22

Two other quick takeaways that I had were from the anticoagulation sessions.

SPEAKER_02 44:28

And these Those were Mason's favorite sections.

SPEAKER_00 44:31

I loved it. I I mean, uh the podcast lately has been a lot of antibiotics, which I've gotten some feedback about. But it's also been some anticoagulation because I think maybe both of the no, only one of these was in a podcast episode. But one was the Cobra trial, and it was just like R.I.P. Zerelto. You don't have to worry about it anymore. You don't have to worry about riveroxaban. I wasn't prescribing you anyways, but now I'm definitely not. Oh, this was a study, had half as many bleeding events on a pigzeaban versus river oxaban, and the number needed to treat of 28 for and for how often? And this was specifically, I believe, yeah, specifically for clots. Um, so not specifically for Aetha, but it doesn't matter.

SPEAKER_02 45:14

What do you think your number needed to treat? 28. How many, how many weeks on service? Two?

SPEAKER_00 45:20

Yeah, yeah, yeah.

SPEAKER_02 45:21

I mean, the amount of patients we have on anticoagulation is staggering.

SPEAKER_00 45:24

Oh, yeah, totally. And so this, I mean, it's honestly not really changing my practice except for reaffirming me not giving rifler oxyman to anyone.

SPEAKER_02 45:32

I love the idea of a once-day anticoagulant. I do. That's not warfarin, because I have a lot of feelings about warfarin as someone who grew up in the 1980s. I was prescribing a lot of warfarin in the beginning of my practice. And so, like, do acts have been wonderful, but clearly having a distinguishable event. Initially, we I was prescribing Prodaxa, and that had a distinguishable event from a Pixband or a Vero Roxpan. And having now these two separate and how good they are at decreasing bleeding risks. Like that is very important. This is the problem with hospitalists, is it's not the prescribing of these medicines, it's the side effects. And so I'm team eloquist now. I've I've been team eloquist, but I am I'm cheering from the sidelines now.

SPEAKER_00 46:27

So super there. The other thing, which is just like another touch point of related to anticoagulation, is we should be reducing people's dose either three months or six months out, depending on why they had the clot, if they're on Eloquist for a clot.

SPEAKER_02 46:43

This was shocking to me.

SPEAKER_00 46:44

Yeah. I again, another thing that like hadn't been on my radar, the six-month um reduction for cancer patients, yes, which that was part of like this is what's so impressive, is even in cancer patients, but yeah, it hadn't been on my radar at all. And then that we actually featured that article on on a previous episode of Impatient.

SPEAKER_02 47:01

Oh, so you already knew. Sorry, I didn't know.

SPEAKER_00 47:03

Well, the but I hadn't been doing it. And in fact, my point then was like I made fun of someone who was giving half dose selequists because I'm like, they don't, they're not age over whatever, renal function, whatever, weight, whatever. And it's not for apib, so none of that applies, anyways. They're doing it wrong, and it's like, no, yeah, egg on my face, I'm doing it wrong.

SPEAKER_02 47:23

Now we've learned. I think that one of a lot of these is one of the most practice changing for me. I don't dose reduce for these people that have to be on long-term anticoagulation, especially in cancer patients. I wouldn't have thought to do that. I'm not sure our oncologists are doing that yet. So I'm interested.

SPEAKER_00 47:40

Fun. Um, the speaker at the anticoagulation talk, he said specifically, my practice change is if I have a patient who's has cancer, has a clot, is on Aliquist, it's been more than six months, I'm reducing their dose. And if I tell their oncologists, I'm FYI telling them I'm not asking them.

SPEAKER_02 48:00

Oh.

SPEAKER_00 48:01

And so, yeah.

SPEAKER_02 48:02

Big baller.

SPEAKER_00 48:03

Because I think this is all like this is all based on on very recent data. Um that like, but you know who loves data?

SPEAKER_02 48:12

Oncologists.

SPEAKER_00 48:13

Oh, yeah, specifically about their their chemotherapy drugs for sure.

SPEAKER_02 48:16

But it'll be this will trickle down. They'll do it. They'll they love data. It'll be fine. This will be this will be the easiest adapter adapters, like of all.

SPEAKER_00 48:24

Yeah, hopefully this ends up not being something that's even is from the cancer standpoint in our practice, because obviously the cancer patients tend to be pretty well plugged in, and their oncologists will just be doing this, and we're not taking care of someone in the hospital who it's been a year out, they've got had a clot, they've got cancer, and they're still on full dose. Everyone will be dose reduced. But right now that's not the case. And so we're doing it. Yeah. And then the non-cancer patients that we should be reducing after after we've treated the, you know, treated with full dose for the clot, like when we would stop if it was a provoked, we should just be dose reducing.

SPEAKER_02 48:59

We love that for them, but if I get a DVT, I'm gonna be pretty annoyed.

unknown 49:02

Yeah.

SPEAKER_00 49:04

Uh actually, the my patient that I was taking care of that had multiple myeloma and a clot, and it was on half dose anticoagulation, I was admitting him for a clot.

SPEAKER_02 49:14

Yeah. So he But they did say, I mean, that was the biggest thing is that there were similar rates of recurrent VTE in a dose reduced versus the full dose. Like it was very similar. Oh, yeah. And I mean, if you're gonna chain someone to a lifelong anticoagulation, essentially, I'd and then the bleeding risk obviously decrease if you're decreasing the dose.

SPEAKER_00 49:39

Yeah. I think the situation is basically like if you're gonna clot again, you're gonna clot again. You clot the same, you bleed less.

SPEAKER_02 49:46

Yeah.

SPEAKER_00 49:46

Cut the dose in half. Bleed less sounds great. Yeah. Must do that. Yeah. Um, you want to give me your take on uh red blood cell transfusions for folks with an MI?

SPEAKER_02 49:56

Yeah, I would love to. This one is shocking to me, and maybe I'm just behind the times because you know, the times. But the recommendation is in anyone who has an MI, STEMI, NSTEMI, demand ischemia type 2 in STEMI. A high sensitivity troponin that's red, uh red high sensitive troponin that took that took at least two times to come down. We should be transfusing them to a hemolobin of 10. And this is a new recommendation that was surprising to me for a lot of reasons. One, because I absolutely wasn't doing it, and two, because it decreased the number of deaths in 30 days by 1.23, which is not insignificant.

SPEAKER_00 50:49

I love decreasing deaths.

SPEAKER_02 50:51

I do too. Mortality is the worst part of our job, and I am absolutely not doing this in my practice right now. Um, especially maybe it's absolutely a STEMI, but that's not on my primary service. An N Stimmy, perhaps more. I was aggressively getting them to eight.

SPEAKER_00 51:11

Yeah, eight's been my number. I've never done ten. I've never done two.

SPEAKER_02 51:14

Just little like subtle demand ischemia from a pneumonia. I mean, obviously I know their heart's not great if their troponin jumps to if their high sensitivity troponin jumps to 120 because they have a pneumonia. Sure, I know things about them because of that. But like transfusing to 10 is interesting, and I'm not sure my institution is gonna buy into that.

SPEAKER_00 51:37

Right.

SPEAKER_02 51:37

But do you know I looked at But it's a blood bank study, correct?

SPEAKER_00 51:41

Exactly. So I looked back at because I didn't go to the updates and guidelines session that you did. I looked back at the slides and it was the AABB that recommended this. That was the guideline. I'm like, I don't know what the A B is B B is. So I Googled it, American Association of Blood Banks. So it's the blood bank that's recommending it. And then I looked at some of the cardiology, I don't know if it was in that same one, or I looked at some other slides from some cardiology sessions, and it doesn't sound like they're totally there yet, our cardiology society. It's like it was it's like consider doing it in certain populations, is I think the headline I got from the slides. Gosh, we I think we walked out of sessions. You and I went to several sessions together, and there were little things that like made us bristle. And it feels like a little bit like a couple days later, looking at it a little bit more, talking about it. We're not like 100%. We're not like 100% okay. I'm doing this now, but we are a little bit like maybe that's not so crazy. Maybe I'll consider this. I'm gonna keep my ear to the ground, I'm gonna think about my patients more thoughtfully when it comes to this. Whereas I was not, it wasn't like that. It wasn't on my radar.

SPEAKER_02 52:48

Yeah. I think I think putting the best thing about this meeting was putting stuff on my radar that has been ingrained in me forever. And maybe perhaps that's not the way to be a doctor, which obviously that's not the way to be a doctor, things change constantly all the time. But a little nugget that I also got from that session platelets only need to be 20,000 for LPs, and I've been transfusing up to 50 my entire life. They also included for that minimal IR procedures. The conversations I'm gonna have to have with IR after this.

SPEAKER_00 53:29

Yeah. Are they doing this? Are they not doing this?

SPEAKER_02 53:33

Is that your platelets only need to be 20,000 for LPs, which is great for our Malheen population because we are an institution that has a large Malheim population. In any academic institution where you're dealing with people that need IT chemo and things like that, this is incredibly important because getting them to 50 is probably detrimental.

SPEAKER_00 53:58

Um, and this is still something that has to be sussed out, but 50 for the hour that they're getting the LP and then they disappear.

SPEAKER_02 54:06

Because those platelets are just being eaten alive. But I think that that is something that will also in the next couple of years trickle down. I'm assuming that one is gonna be more powerful than maybe even the 10 with MIs.

SPEAKER_00 54:24

So uh we talked about Vegas a little bit. What do you think? Would you go back? Are you gonna? I mean, I know you've been before, but are you gonna go again to SHM?

SPEAKER_02 54:32

Yeah, I think so. I actually kind of it revitalized my interest. I'm a mid-career hospitalist, which is a really aggressive way of saying I'm old. Um, but I I think a lot of us get set in our ways, and it's nice to kind of have things shaken up a little bit. And there was this weird COVID time where everybody was kind of like, I don't know what to do, and like I don't want to go to a meeting, and it's nice to be around a lot of nerds who do what you do. And I love that for I I love talking about medicine, would much rather talk about medicine than AI, but there's a lot of innovations in medicine, there's a lot of things that we can do, and I feel like hospitalists are the people that are saving medicine that we're on the front lines just like the PCPs are. And I think for us, like it's important to meet with our people and have these discussions. And also, like, there's a lot of career growth in these things. Like, if that's your jam and you want to climb like the ladder for to do like a lot of inner facility like studies and things like that. This is a great thing for networking. This is a great thing for clinical updates, it's great for academic hospitalists. It's great for I don't do academics. This is great for just like primary direct patient care. Like I learned enough stuff that I'm gonna change in my practice that I think is gonna affect everything I do at least weekly. And that's that's enough for me.

SPEAKER_00 56:03

Oh, totally. You're right. Being, especially post-COVID, when it felt like we would never be in person again, and it felt like didactics would be YouTube videos videos and virtual for the rest of our lives. We were just gonna be reading open episodes with pro with human beings and talking to them or hearing them talk in person. And we know like the difference between we we went to one session that was unfortunately pre-recorded and these sessions where people were there in person, very different. Just being in the room with a human being, I found huge. And so we could bring the the take-home points to people in in podcast form, but there really was something about being in the room with other people that I found really powerful.

SPEAKER_02 56:43

Yeah, I mean, when you're in a full auditorium with let's say 500 people, and someone says something up on stage, and everybody like you literally hear gasps.

SPEAKER_00 56:54

The feelings, yeah.

SPEAKER_02 56:55

Yeah, yeah. And like, nerdy as it is, like it's like, okay, good, I'm not alone in the fact that I didn't know that thing. Like, let's all do this together, let's make changes, let's move medicine along. And in a culture where it feels like medicine is being suppressed a little bit, like it's nice to have a group of people around you that are trying to push forward. And I think that's the biggest deal.

SPEAKER_00 57:20

To science.

SPEAKER_02 57:21

Yo, hey science, we love you.

SPEAKER_00 57:27

Last thing if there's one thing that you say that I will do different in the future that you think is gonna be most value to your patients going forward, pick one thing.

SPEAKER_02 57:39

Mine's the stopping aspirin in CAD patients after six months after a stint, if they are also concurrently on a doac. I think that that is going to change lives. And I'm going, I think I can do that every week that I'm on service.

SPEAKER_00 57:54

Yep. I think I will counsel people to be on there, specifically eloquence for their AFib and not stop it for their falls. It's probably the biggest thing.

SPEAKER_02 58:07

And that's kind of like we make pro-Eloquis uh shirts.

SPEAKER_00 58:11

Yes. We should. In fact, uh, looking for sponsors if Eloquist is interested, I'm here for it. And then the other big takeaways we had were if you admit a patient with heart failure, give them a flu shot if you've got flu shot available and if it's flu season. And then for folks with alcohol use disorder, try and get more comfortable with starting them on now Truxone in the hospital. You don't have to be scared, and starting to use phenobarbital to control DTs. Well, Dr. Reams, thank you so much for being a um a travel companion for me. We fell into that and it was fantastic.

SPEAKER_02 58:50

Happy to go to any honky talk with you anytime, Dr. Turner.

SPEAKER_00 58:53

And thank you so much for joining me today on the podcast. Absolutely. All right, and as always, if you're finding this useful, seriously share it with other clinicians. So, as always, thank you, Dr. Reams, so much for joining us.

SPEAKER_02 59:06

Glad to be here.

SPEAKER_00 59:06

And thank you to the listeners so much for joining us. This has been Impatient Update.