Surgical Angiology (VEINS & ARTERIES) with Sheila Blumberg AI transcript and summary - episode of podcast Ologies with Alie Ward

Go to PodExtra AI's episode page (Surgical Angiology (VEINS & ARTERIES) with Sheila Blumberg) to play and view complete AI-processed content: summary, mindmap, topics, takeaways, transcript, keywords and highlights.

Go to PodExtra AI's podcast page (Ologies with Alie Ward) to view the AI-processed content of all episodes of this podcast.

Ologies with Alie Ward episodes list: view full AI transcripts and summaries of this podcast on the blog

Episode: Surgical Angiology (VEINS & ARTERIES) with Sheila Blumberg

Author: Alie Ward
Duration: 01:18:10

Episode Shownotes

Vaping and vein health! Covid and clots! Easy bruising! Movie blood! Spider veins! Free socks! The heroic vascular surgeon Dr. Sheila Blumberg of NYU Langone Health let me ask her one million questions about how blood gets from point A to B all day. She explains the difference between arteries,

veins, capillaries, and vessels and we cover everything from fainting to teenage movie tropes, how to tie a tourniquet, atherosclerosis, aneurysms, stents and why your leg is asleep right now. View Dr. Blumberg’s publications on ResearchGateA donation went to BreakingGround.orgMore episode sources and linksSmologies (short, classroom-safe) episodesOther episodes you may enjoy: Diabetology (BLOOD SUGAR), Field Trip: My Butt, Colonoscopy Ride Along, Functional Morphology (ANATOMY), Hematology (BLOOD), Surgical Oncology (BREAST CANCER), Biogerontology (AGING), Proptology (THEATER & FILM PROPS), Vampirology (VAMPIRES)Sponsors of OlogiesTranscripts and bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, hoodies, totes!Follow Ologies on Instagram and BlueskyFollow Alie Ward on Instagram and TikTokEditing by Mercedes Maitland of Maitland Audio Productions and Jake ChaffeeManaging Director: Susan HaleScheduling Producer: Noel DilworthTranscripts by Aveline Malek Website by Kelly R. DwyerTheme song by Nick Thorburn

Summary

In this episode of 'Ologies with Alie Ward,' Dr. Sheila Blumberg discusses the complexities of the vascular system, including the functions of arteries, veins, and capillaries. Key topics include the aging process on vascular health, the risks associated with conditions like atherosclerosis and varicose veins, as well as the serious implications of deep vein thrombosis (DVT), especially in relation to COVID-19. Dr. Blumberg emphasizes the importance of lifestyle factors such as smoking and diabetes in maintaining vascular health, while also providing practical advice on techniques like wearing compression stockings and properly managing blood flow. The episode blends humor with valuable insights into vascular surgery and patient care.

Go to PodExtra AI's episode page (Surgical Angiology (VEINS & ARTERIES) with Sheila Blumberg) to play and view complete AI-processed content: summary, mindmap, topics, takeaways, transcript, keywords and highlights.

Full Transcript

00:00:00 Speaker_01
Oh, hey, it's that guy who watched your stuff at the library, so you could go to the bathroom, Ali Ward, and this is Ologies. And the lifeblood of the show is asking smart people, sometimes not smart questions.

00:00:10 Speaker_01
So let's take a trip through your vascular system for phlebology, which you will learn in a few moments is not a good name for the episode because it does not totally encompass what this ologist does. So we had to figure something else out.

00:00:21 Speaker_01
And this guest is a vascular surgeon. And from what I understand, that is a very difficult job and vascular surgeons have been called the surgeon's surgeon.

00:00:30 Speaker_01
So if you're a surgeon who can impress surgeons, I'm going to want to come to your workplace and ask you all about it.

00:00:36 Speaker_01
So this doctor is a clinical associate professor of vascular surgery at NYU Langone Hospital in Brooklyn, where she did her fellowship and residency after getting her MD from Boston University.

00:00:47 Speaker_01
And it said that what inspired her was having grown up in Kenya, where she saw access to high quality surgical care, not readily accessible. So helping people has always been important to her. She's very good at it.

00:00:57 Speaker_01
So she's been on my list to help us learn about our circulation and we're going to get there in a minute. But first, thank you to all the patrons who submitted great questions for this ahead of time. And you can join that at patreon.com slash ologies.

00:01:08 Speaker_01
It costs like a dollar. Thank you to everyone out there for wearing ologies merch from ologiesmerch.com and finding each other in the wild.

00:01:15 Speaker_01
And of course, thank you to everyone who leaves reviews, which help the show stay pretty cozy at the top of the science charts.

00:01:20 Speaker_01
such as this one, this was left by Fisker 4, who wrote, Ologies has quickly become my go-to podcast for every activity from baking to drawing to postponing a spiraling mental breakdown, while I focus intently on centipede facts.

00:01:32 Speaker_01
And I gotta say, Fisker 4, that's a hell of a review to leave right as we splash down into an episode about blood tunnels, but I think everyone's gonna like it nonetheless. This is a great one.

00:01:43 Speaker_01
Also, reviewer of Save Spiders, I see you, and yes, we have an arachnology episode in the works. Also, if anyone's looking for kid-friendly episodes, we have Smology's in its own feed, which is linked in the show notes.

00:01:52 Speaker_01
It's great for car trips with the kids. Okay, let's get into this episode. Get your knitting, fire up the lawnmower, put your feet up for everything from vaping and vein health, why you can get a prescription for new socks, scary airplane blood clots,

00:02:06 Speaker_01
teenage movie tropes that are true, using science for cinema, how to tie a tourniquet in a pinch, spider veins, arterial health, atherosclerosis, stents, what is an aneurysm and how not to have one, COVID and clotting, and why your leg is asleep right now with NYU Langone vascular surgeon, phlebologist, as well as surgical angiologist and general medical hero, Dr. Sheila Blumberg.

00:02:46 Speaker_00
I do do karaoke. Do you really?

00:02:50 Speaker_04
I used to, when I had a good voice. I would try to do Aretha Franklin and tear the house down, but the less I sing, the better. The less I get good, so I can't destroy her songs anymore. I mean, you're still so good at it.

00:03:07 Speaker_00
If you could do Aretha Franklin one time, I feel like you're going to destroy it.

00:03:12 Speaker_04
Sheila Blumberg, she, her, hers.

00:03:15 Speaker_00
I've been wanting to talk to you for so long. This is very exciting. And would you say that levitology, is there an ology for this that you would.

00:03:25 Speaker_04
Phlebology. Phlebology. If that's specific for veins only, but then vascular also includes arteries. So that would, I guess, arteriology, but that's why we just say peripheral vascular.

00:03:36 Speaker_01
Okay, so vasculology has been used one time, but some countries refer to the study of blood vessels as angiology, meaning vessel in Greek, but angiology sometimes deals with the lymphatic system, which we don't get into, and angiologists are not always surgeons like Dr. Blumberg, but since she is generously letting me ask her, a smart person, not smart questions, and giving us a lesson in all things blood vessels, we're gonna go with that.

00:04:00 Speaker_00
I mean, the first question I'm sure a lot of people don't know, including myself. Veins, arteries, capillaries. What's going where? Okay.

00:04:11 Speaker_04
So those are all different sizes, first of all. Okay. Decides whether it's a vein or a capillary. And then arteries are different pipes. So they're all pipes.

00:04:21 Speaker_00
Okay.

00:04:22 Speaker_04
So I'm a fancy plumber. And so arteries are the main way blood gets away from the heart. Those are the pipes that take blood away. Veins bring blood back to the heart.

00:04:33 Speaker_01
So arteries go away, A. Veins think V, valentine heart. And if the blood is leaving the heart, going away via artery, it's ready for the journey with a full tank of gas. In this case, the gas is oxygen.

00:04:49 Speaker_01
Now veins are heading back to the Valentine's heart on empty and they're returning home to the lungs for a resupply of oxygen and then into the heart and out through, what are they going out through? Arteries, nice, sexy.

00:05:02 Speaker_01
Arteries carrying that oxygen rich blood are typically bigger than veins. Veins, typically smaller. Smaller still though,

00:05:11 Speaker_04
Capillary bed is within the tissue and that's where veins and arteries meet and sort of form a web at a very microscopic level. So we're talking microns. And that's where the exchange of oxygen happens at the level of the tissue.

00:05:26 Speaker_04
And so the arteries come in to, let's say, your kidney.

00:05:30 Speaker_04
and then go to the capillary bed, become smaller from arteries to arterioles, and then capillaries, and then the capillaries exchange into venules on the other end, and then the venules become veins. So the veins are the larger parts of things.

00:05:45 Speaker_04
And that brings the blood back to the heart. And so that's your circulatory system.

00:05:49 Speaker_01
So arteries, arterioles, capillaries, venules, and veins, they're all vessels or tubes that circulate blood. Now, from biggest to smallest pipes, we got small venules branched toward the full-size veins as they come closer to your heart.

00:06:06 Speaker_01
Veins have thinner walls. They're typically closer to the surface of the skin than arteries, and arteries are located deeper in the muscles, and arteries have thicker walls. So oxygenated blood leaves the heart via the arteries.

00:06:18 Speaker_01
Artery literally means to keep air. It's kind of like a train system that leads to major stops in the organs and the tissues of your body.

00:06:27 Speaker_01
And then that goes down roads into smaller arterioles, which go into teeny capillaries, which are like little trails to the tissues. And capillaries are around 1 10th the width of a human hair. So tiny.

00:06:42 Speaker_01
And while you're minding your own business, you're eating kettle corn, you casually have 40 billion capillaries. You're magic. Can you believe that? 40 billion, you have that. I hope you flirt using that fact.

00:06:54 Speaker_01
Are there capillaries that are so small, they're like single file in terms of blood cells? How small do they get?

00:07:00 Speaker_04
Yeah, they have to be because at that level, in order to exchange oxygen between the tissue, oxygen is just a molecule. It's got to be able to transfer itself across the bed of the cell layer to get to whichever organ it's perfusing.

00:07:15 Speaker_04
So they're almost less than a cell layer thick at that level. Yeah. So extremely, extremely small, not visible to the human eye without a microscope.

00:07:24 Speaker_01
So it's been estimated that the human circulatory system would stretch out to be over 95,000 kilometers in order to pump more than 7,500 liters of your blood every day. By the way, that's 60,000 miles and 2,000 gallons, America.

00:07:41 Speaker_04
To exchange it that quickly, every second that we breathe and get blood through and the rate at which it's flowing, it has to happen just like that. So it's miraculous in a way.

00:07:52 Speaker_01
Do our veins and arteries, do they get less elastic or less robust or I guess hardening of the arteries is a situation?

00:08:03 Speaker_00
What happens to us as we age? Do we start off with amazing veins and arteries and then they get kind of shittier? What happens?

00:08:10 Speaker_04
Well, yes, I think the aging process, unfortunately for arteries, they tend to become harder. And there's obviously a lifestyle and environmental things that we can do to make that worse or at least better.

00:08:24 Speaker_04
And so things like smoking and exposure to smoke and diabetes in general, those are the major factors in our environment and our lifestyle choices that end up hardening the arteries. And so you get plaque formation, and then calcium deposits.

00:08:42 Speaker_04
And you can really see the calcium on imaging now, which they are doing more routinely for coronary arteries in the heart to see what level of disease you have.

00:08:51 Speaker_04
You can scan and you can literally see the whiteness of the calcium that's deposited there. So they get harder. And that's not good because you want arteries and veins function well when they're softer, more compliant, right? So they can,

00:09:05 Speaker_04
squeeze and open as the heart beats and relaxes. The hardness, let's say, of the arteries is diseased. So that's unfortunate. And a lot of that's not reversible once it happens.

00:09:19 Speaker_01
What is the calcium deposits? Where are those coming from?

00:09:22 Speaker_04
They're coming from the bloodstream essentially, right? So most of it happens over time and the exposure to things like smoking per se makes that layer in between the inner layer and the outer layer thicker.

00:09:37 Speaker_04
And so it's essentially deposits in there and the effect is calcification. Yeah.

00:09:42 Speaker_01
So I'm so sorry. I'm sorry.

00:09:44 Speaker_01
But smoking can swell those inner walls, choking the flow and making it easier to collect plaque, which contains cholesterol, cellular waste, clotting stuff called fibrin, and calcium that can cause atherosclerosis, which is a thickening or the hardening of the arteries.

00:10:02 Speaker_01
But again, since this episode would have been easier to name phlebology, but phlebology is only about veins, let's get more into it. What about Veins and arteries, do they have different properties in terms of their structure?

00:10:15 Speaker_04
Yeah, absolutely. So veins, at any point in time, 75% of your blood is in your veins. Oh, okay. The 25% is your arteries. So veins have to have a high capacitance. They have to be able to hold that much volume at any amount of time. So they're

00:10:30 Speaker_04
much more compliant. They're much more relaxed. And in order to get the blood back from your foot, right back up to your heart, the way they do that is in a couple of mechanisms. They have valves on the inside. Arteries do not have valves.

00:10:45 Speaker_04
Valves are kind of like gates. They open, they let the blood go up, and they're supposed to shut tight so it doesn't drop back down. And so as blood goes up the column, it doesn't return distally, distally meaning back to the foot.

00:10:58 Speaker_04
What else happens is when we breathe, that also changes the pressure gradient in the veins, so that also moves the blood up. So veins have to be compliant because part of their activity is by breathing.

00:11:11 Speaker_04
So every time you breathe, you change the pressure in your chest, that allows blood to come through and come up. However, arteries. So arteries are not based on that. They're based on your heart, right? Cause that's where the, their blood's coming from.

00:11:26 Speaker_04
So they have to be strong enough to take that pressure. So like, for example, if you're exercising, right, and you're fairly young, your pressure can go up to 200 millimeters of mercury, right? That's normal. We're exerting ourselves.

00:11:40 Speaker_04
And so arteries have to be, tough enough to take that amount of blood pressure. So they're much stronger vessels in general. So they're thicker, more muscular. And so every time the heart beats, pumps blood through.

00:11:52 Speaker_04
So they don't need valves or anything like that. And in fact, valves would be a problem in the artery because they just got to get the blood down across to all of our organs, meeting a lot of resistance.

00:12:03 Speaker_04
So the arteries have to be strong enough to do that. And the heart provides that. pumping action forward, so very different.

00:12:11 Speaker_01
And that upper number of your blood pressure is the force that your heart is beating that blood out or down to your organs. And the bottom number represents the pressure when things relax in between the beats.

00:12:24 Speaker_01
You don't faint at the sight of blood, I'm guessing?

00:12:26 Speaker_04
No. No? That's been from a young age, so I'm in the right business, yeah.

00:12:32 Speaker_00
When you were going through med school, was there a really big divide in terms of like who could deal with a lot of blood and who is like, you know what, I'm really going to be more of an outside doctor.

00:12:42 Speaker_04
A radiologist or something? No. I think most people who go into medicine have a capacity to deal with injury and or blood. So I don't think that's very common. I've seen it in lay people who are not in the medical field so far. But I think what

00:13:00 Speaker_04
sort of sorts people out is what kind of fluids they can tolerate. So it's not just blood. I think blood is pure, it's clean, it's sterile, it's red, it's pretty, I like red, but some people, like phlegm, forget it. Stool, forget it.

00:13:16 Speaker_04
So, you know, there's some things that everyone can tolerate. So I wouldn't do colorectal surgery because that's not for me. And so I prefer blood.

00:13:24 Speaker_04
And so I think that's what sorts people out, is what fluid you can tolerate, not necessarily an aversion to blood so much.

00:13:30 Speaker_00
Do you have to deal with that in your patients? Let's say someone needs a blood draw. I know for me, I have to look away and I was getting a blood draw once and I looked away.

00:13:40 Speaker_00
I just averted my eyes and I realized I was staring right into a reflective surface. And so I accidentally was watching at the same time, but I've fainted just cutting my finger.

00:13:50 Speaker_00
And I don't know why it happens because I think my brain is like, you're going to die. But do you see that in your patients at all? Anyone just keeling over?

00:13:59 Speaker_04
Oh, especially the blood draws. So even now we have to be very good about making sure most people are seated just in case they do pass out. They're already in a reclining position and we can sort of keep them safe from themselves.

00:14:12 Speaker_04
But yeah, it does happen. That's not uncommon actually.

00:14:15 Speaker_01
So we chatted with Dr. Joy Reidenberg, who's a functional morphologist who does whale necropsies. And the first time she witnessed a veterinary surgery, she was so excited. But then she straight up fainted in the room with all these surgeons.

00:14:30 Speaker_01
And she explained that she had what's called a vasovagal reaction, which is an autonomic discharge of your nervous system that no one can predict is going to happen. And when that vagus nerve is stimulated,

00:14:42 Speaker_01
It causes a sudden drop in your heart rate and also maybe the dilation of blood vessels to your legs, which causes blood to pool there away from your brain, causing you to pass out.

00:14:52 Speaker_01
And it can happen from standing too long or heat exposure, stress, the sight of blood in an anesthetized animal. And in April of 2020, when the pandemic was very fresh and people were having things like hobbies, I tried whittling.

00:15:10 Speaker_01
And within the first few minutes of attempting to craft a spoon, I cut my finger and I fainted into the kitchen sink. What about when you're watching movies and you see a pool of blood? Are you ever like, that's not oxygenated.

00:15:25 Speaker_04
That is too much for what they hit. My commentary about movie blood is none of it looks really good.

00:15:33 Speaker_01
Why is that?

00:15:34 Speaker_04
I don't know what they use. And I heard they use paste of some sort.

00:15:39 Speaker_04
I can't think of which movie had really good, maybe like Kill Bill, like Quentin Tarantino has good blood, but the rest of them it's, and that's, I always like look at the characteristics of it. And so I'm like, ah, that's so fake.

00:15:51 Speaker_04
Like, so you don't, I don't particularly get gory about those kinds of things because it doesn't look realistic.

00:15:57 Speaker_00
Is it the viscosity or the color?

00:15:59 Speaker_04
Both. Okay. Yeah. So the only thing that looks, accurate most of the time is old dried blood. Like if it's an old crime scene, that looks more realistic because it's congealed at that point, right?

00:16:13 Speaker_04
So I think the fresh blood of when they cut people and they're sort of like spurting, I'm like, really? No, I don't.

00:16:18 Speaker_01
She's not wrong. I researched this for way too long. And according to a 2022 slash film article titled Quentin Tarantino only wanted the best blood for Kill Bill special effects.

00:16:29 Speaker_01
It says it's really difficult to recreate blood digitally, and Tarantino prefers practical, real-life goopy effects.

00:16:37 Speaker_01
He also told a Time magazine reporter that, quote, I'm really particular about the blood, so we're using a mixture depending on the scenes. I don't want horror movie blood, all right? I want samurai blood, he says.

00:16:49 Speaker_01
You can't pour this raspberry pancake syrup on a sword and have it look good. You have to have the special kind of blood that you only see in samurai movies, quote. So that's his take on it.

00:16:59 Speaker_01
And in yet another article, a 2015 Vulture piece, there will be lots of blood. One of his producers divulged that Tarantino films require a separate blood budget and blood of such a specific range of hues that no other filmmaker is allowed to use it.

00:17:15 Speaker_01
And this range of bloods, plural, are under the label Tarantino Reds by the special effects house that furnishes his custom supply. He has a custom blood supplier. I hope this is a lesson. People make art, make science, make stuff.

00:17:31 Speaker_01
We're only here for a little bit. Life is short, make stuff. Also, I was having a discussion with my favorite cheese monger today that French horror director, Alexander Aja has superb blood and I trust them.

00:17:42 Speaker_01
But back to Tarantino, another one of his producers has described the director's blood use as different and balletic in the way that it moves and squirts and gushes. Does that happen?

00:17:54 Speaker_01
Cause I always feel like you hear if you hit an artery, you're screwed.

00:17:59 Speaker_00
Veins are less of a problem. Is that true or is that complete nonsense?

00:18:04 Speaker_04
Well, that's to do with the pressure in the system. So artery is a high pressure, right? So when, you cut an artery, the pressure at which it's coming out at you is high. So you're going to lose more blood quickly. Veins are low pressure systems.

00:18:17 Speaker_04
So if you cut a vein and you bleed, it's going to be sort of a slow kind of ooze and more controllable. And the second thing is because veins, like I told you, are very soft and compressible.

00:18:29 Speaker_04
you're more likely to be able to control it just with pressure alone. You can call pressure and arteries and get pretty decent control as well, but that becomes the other part of it.

00:18:38 Speaker_04
Depending on which part of the body it is, you may not be able to compress it properly. And that's why it can be more life-threatening, obviously, if you, if you injure an arterial injury versus a venous injury. Yeah.

00:18:49 Speaker_01
So that's not flim flam.

00:18:51 Speaker_04
That's not flim flam.

00:18:52 Speaker_01
Okay, and remember, arteries tend to be deeper in the muscle, so harder to compress. So imagine trying to stop the flow of a garden hose under a tarp, which is like a venous injury, versus crimping a fire hose under a mattress, arterial.

00:19:07 Speaker_01
Now this is an exaggeration, but you get it.

00:19:10 Speaker_00
What about your work? What is a lot of your practice looking at? What is the, what's your day like?

00:19:16 Speaker_04
My day is, and this is why I've asked for surgery, it's varied. I do a very large venous practice. So that's a lot of varicose veins and venous ulcers and those kinds of patients. And then the other side of it with arterial disease,

00:19:31 Speaker_04
which is more sort of limb threatening problems, right? So you have peripheral arterial disease where they're not getting enough blood flow to their extremity, most commonly to the foot. And this is why diabetics suffer from a lot of this.

00:19:44 Speaker_04
And then obviously, like I mentioned, smokers as well. And those patients who are at risk of limb loss, those are the ones who obviously I get involved in and try to revascularize them, try to improve the blood flow to that area.

00:19:56 Speaker_04
For the venous patients, it's definitely not a limb threatening problem, but it's definitely a lifestyle kind of issue, right?

00:20:04 Speaker_04
Because people's legs do not function well if they have a lot of venous insufficiency where the veins and the valves have become destroyed for whatever reason.

00:20:12 Speaker_04
We call them incompetent now and they're unable to get the blood out of the leg fast enough.

00:20:17 Speaker_04
They can start off with things, there's a swelling to begin with, and then progress to skin changes where they start darkening their skin because the blood's just pooling at the ankles.

00:20:28 Speaker_04
And then the worst case scenario for a lot of those patients is getting skin ulcers at the ankle because their skin's been damaged over time.

00:20:35 Speaker_04
So there's a spectrum of disease that we see in the venous space, and each person's sort of treated a little bit differently with that. So every day is a little bit different. Every patient's a little bit different.

00:20:46 Speaker_04
Every patient needs something a little different from the last patient.

00:20:49 Speaker_01
And when it comes to surgery, if you're doing surgery, especially on an artery, which is high pressure, did I just learn that? Are you having to clamp them off at either end? How do you stop someone from just bleeding out if you cut into that thing?

00:21:02 Speaker_04
Right. So typically we have control. So vascular surgeons, we love getting control of things. So it's usually above and below where the hole is, regardless of where that is in the body. And once you have control of it, you can actually,

00:21:17 Speaker_04
take a beat and just repair what you need to.

00:21:20 Speaker_04
And there's various ways to do that, whether or not it's patching it with a piece of vein of the patient, you can use that, you can take the vein as a graft and use that to replace the hole in the artery and or repair it just with sutures alone, put some stitches in it, and that should be enough to control it.

00:21:39 Speaker_04
So as long as you can get control above and below the injury, most things can be fixed.

00:21:45 Speaker_01
And then does blood find its way around other places? Is it like a detour on the highway?

00:21:50 Speaker_04
While you have it clamped down? Yes, it can, depending on where the injury is. So for example, in the leg, commonly people get shot in the leg in trauma situations, and it happens to be in an artery in the thigh, which is a femoral artery.

00:22:03 Speaker_04
You can repair that. There's another deep femoral artery that they can get blood supply around it, but you are having some time of ischemia. There's some time you're not getting any blood flow.

00:22:12 Speaker_04
which is why the repair has to be somewhat expeditious because after, you know, in the leg, it can probably tolerate at least four or five hours maybe of ischemia before you start to get now death and muscle death and tissue death.

00:22:25 Speaker_04
So that has to be taken into consideration for sure.

00:22:29 Speaker_01
Anischemia is the term for not getting enough arterial blood because you've been shot in the leg, in the femoral artery, and thus not getting enough oxygen to those parts, which can lead to very unhappy tissues and muscles.

00:22:46 Speaker_01
When you're doing surgery and they say, oh, we've got to get up to say a valve in the heart. We're just going to pop into the femoral artery in your crotch. I'm like, how do you get that far? There's got to be twists and turns, right? How do you do it?

00:23:01 Speaker_04
How? Well, thankfully, at least the first person who designed was a Seldinger technique of putting a needle and a wire and a catheter into a vessel. That principle has been taken to make larger and bigger

00:23:15 Speaker_04
sheets and catheters and just devices basically that can transfer catheters and balloons and even valves directly into the heart. So it's a straight shot because like I said, it's a pipe.

00:23:27 Speaker_04
like any other pipe and you can go through the pipe with any sort of tool as long as it's a decent size and there's not a lot of clot or anything that would be obstructing. That's medical advancement.

00:23:41 Speaker_04
It's been probably one of the most remarkable things that we've done in the last 60 years or so is being able to do a lot of things minimally invasively because there's a direct route. So that's great.

00:23:53 Speaker_04
The anatomy is pretty consistent and well-described.

00:23:56 Speaker_01
So Swedish radiologist Sven Ivar Seldinger debuted this technique in 1953, which uses a hollow needle to get under the skin in which you can insert a thin wire as a guide through your blood plumbing, which then guides a catheter to, quote, previously unreachable vascular areas of the body.

00:24:15 Speaker_01
And then you withdraw the guide wire. What a revolution, right? But no, he wasn't carried on people's shoulders through the town square. No one threw confetti at him or gave him candy or named a day in his honor.

00:24:27 Speaker_01
It wasn't until 30 years later that the field of angiography, which is mapping the circulatory system, gave him the credit that he deserved. But still worth doing, even if it seems like people don't notice while you're alive.

00:24:39 Speaker_01
But whatever your hobby or your passion, it doesn't have to involve vascular surgery, even though it's pretty tight. It's so bonkers that that can even happen.

00:24:47 Speaker_00
And when it comes to history and your history, how did, of all of the winding, twisting roads one can take, how did you end up in this field?

00:24:58 Speaker_04
I chose vascular surgery and it takes a while to become a vascular surgeon in terms of the route from medical school to surgery training at the time.

00:25:07 Speaker_04
As I'm getting older now, there wasn't a direct route from medical school direct to vascular surgery. So I actually did general surgery first, which is operating on every part of the body.

00:25:17 Speaker_04
And then while I was doing that, I had to make a decision about which specialty I was going to do within surgery. So I think that part of my decision was based on the fact that vascular surgery is very delicate. We deal with

00:25:31 Speaker_04
very also sick patients and the actual procedures themselves require sort of a very gentle hand, which I think I have and I enjoy that delicacy of operating. And also we have a lot of variety as well. So like I said,

00:25:47 Speaker_04
One day I'll be doing veins, one day I'll be doing arteries. And then I operate on various parts of the body, in the neck, in the leg, in the chest, in the abdomen.

00:25:55 Speaker_04
So there's a lot of places where you have to be sort of facile with what's there and how to get to some areas because arteries and veins aren't just sitting waiting for you, you got to find them.

00:26:06 Speaker_04
And so that's always been very interesting to me and I just loved that kind of surgery. So that's how I ended up picking this specific specialty of all the other specialties. And like I mentioned before, blood is a very nice looking fluid.

00:26:20 Speaker_04
The other ones I don't have a lot of affinity for, so I was happy to pick vascular. Does blood look different when it's leaving the heart versus when it's on its return trip? Absolutely. Yeah.

00:26:32 Speaker_04
When it leaves the heart, now it's been freshly oxygenated, so it's nice and bright red. So arterial blood looks really red, like scarlet. And then venous blood, when it's returning, is much darker because now it's, quote unquote, deoxygenated.

00:26:45 Speaker_04
There's not a lot of oxygen in it anymore. And so it's darker, kind of violacious, like a color that we can describe it.

00:26:53 Speaker_01
So arterial oxygen rich blood is bright red and venous blood is a little more purplish. Arterial is the color of bright ketchup and venous blood looks a little more like a plum sauce or the color of raspberry jam. I'm trying to make this appetizing.

00:27:09 Speaker_04
So you can tell if you puncture a vein or puncture an artery sort of immediately in a healthy person, you can tell whether you're in an artery or a vein just by the quality of the blood you're looking at.

00:27:20 Speaker_00
What about when we look at veins and they look blue from... They should. Yeah, they should look blue.

00:27:26 Speaker_04
Why are they looking blue? Because the blood is dark now. So they should look blue in a healthy vein. That's its right color. Yeah. I remember hearing myths about that, that your blood is blue until it hits air.

00:27:39 Speaker_04
I think they're probably referring to the oxygenation. situation and the arteries being more red blood because it is oxygenated blood. Yeah.

00:27:47 Speaker_00
I mean, I heard all kinds of stuff when I was a kid. I mean, I think we thought unicorns were real. So, you know what I mean? And what happens when you blush or when you're embarrassed or when you get hives? Is that blood just flooding capillaries?

00:28:04 Speaker_04
Yeah, capillaries and very small arteries and veins in the face, really, and they just dilate. So it's a parasympathetic response and a sympathetic response. And you get huge vasodilation and then it bursts and then it goes away.

00:28:19 Speaker_04
So it's kind of like a big flash. It's mysterious, really, why it's so specific to certain areas that we still don't understand.

00:28:27 Speaker_01
I did find a 2020 paper titled, The Unique Contribution of Blushing to the Development of Social Anxiety Disorder Symptoms, results from a longitudinal study, the methodology of which involved making kids perform a song in front of a parent and a stranger, and then watching themselves back on video before a researcher aimed an infrared temperature gauge at their cheeks to determine if they would be prone to later developing what's known as SAD, social anxiety disorder.

00:28:55 Speaker_01
Why blushing happens? I don't know. But what's valuable about this study is that it will be cited often in those kids' future therapy appointments. Someone's making money off that. Do you ever think about that stuff?

00:29:07 Speaker_00
Are you aware of your own blood day-to-day?

00:29:10 Speaker_04
No, thank God. I don't really think about it that much, quite frankly, at least on my own day-to-day. What I do think about is being as health in a way, not necessarily the blood itself.

00:29:23 Speaker_04
But for example, like I wear compression stockings at work because I don't want to have swollen feet, et cetera, because it's more common in jobs where you're standing all the time. The second I knew about that,

00:29:34 Speaker_04
In residency, I started wearing them like right away. I was like, this is important. And I feel like more people should know that if they're in jobs where they stand all the time.

00:29:43 Speaker_04
Or when you get pregnant, you should wear compression stockings as much as you can. Yeah.

00:29:48 Speaker_01
What about on airplanes?

00:29:49 Speaker_04
Absolutely. Yeah.

00:29:50 Speaker_01
What's going on with that?

00:29:52 Speaker_04
So the gravity, which is sitting down with your legs that way, and then the pressure changes in the air. are more likely to make blood pool at the ankle and you get swollen, especially for long flights. It's a game changer.

00:30:05 Speaker_04
So I tell everybody who listened to me to wear them on the plane all the time. But I think that's caught on. I feel like a lot of people are doing that now.

00:30:14 Speaker_00
You know, I have a friend who's a doctor who's also at NYU, Mike Natter, who got me a pair of compression socks, and I should have packed it for my flight.

00:30:21 Speaker_01
But what about varicose veins? You said that you work on that. How do those happen? And are we treating them, we, as if I help, treating with lasers more? Do you have to go in there and pluck them out?

00:30:35 Speaker_04
So I think that's another part in which we've had a lot of advancements over the last 30 years.

00:30:39 Speaker_04
So varicose veins, and you'll hear a lot of terms used to describe it, like venous insufficiency, venous incompetence, varicose veins, but ultimately what it means is that one part of the venous system is not doing its job correctly.

00:30:55 Speaker_04
And this is all in the lower extremity for the most part. So in the lower extremity, you have two systems of veins, two main ones. You have the deep veins, which live in the muscle. That's why we call them deep because they're in the muscle layer.

00:31:09 Speaker_04
And those are the most important veins. They do about 90 plus percent of the work of getting the blood from your foot. back up to your heart. They also have a secondary system of veins, which is a superficial vein.

00:31:21 Speaker_04
So the reason they're called superficial is because they're above the muscular layer and they're just surrounded by our skin and fat, but it's connected.

00:31:30 Speaker_04
to the deep system, we call the connections between them sort of perforators, and together, they're supposed to transfer the blood from your foot back up to your heart.

00:31:39 Speaker_04
What happens to a lot of people over time, about probably 20 million people in this country suffer from this, the superficial system becomes incompetent.

00:31:48 Speaker_04
And what that means is the valves in the inside of the superficial veins, they stop closing tight. So these are the gates that I described that open, shut to let the blood go up.

00:31:58 Speaker_04
they become incompetent, they become weak so they don't close as much as they're supposed to. And so blood takes longer to get out of that superficial vein.

00:32:06 Speaker_01
So what happens if there are venous blood traffic jams because the gates and the valves went wonky and they can't merge from the superficial veins to the deeper ones and then back to the heart for more oxygen? What happens?

00:32:19 Speaker_04
Over time, your body's way of dealing with sort of, we call it this venous hypertension in the leg is to make varicose veins. So you'll see these large sort of bulging little varicosities that come out of there. They're not supposed to be there.

00:32:32 Speaker_04
Your body made them to deal with the pressure in the system. And so that's a sign that you have quote unquote venous disease. Right. And the treatment pretty much for thousands of years is you get rid of it somehow.

00:32:45 Speaker_04
Olden times, they used to have to strip it. Right. Which is basically make incisions in the groin and lower leg and then remove the vein entirely. And that would be it. What's my other option?

00:32:55 Speaker_04
And then now, thankfully, we have lasers, which is what you were describing before. which essentially do the same thing, but they do it through a catheter.

00:33:04 Speaker_04
Again, like I told you, needle wire catheter through there, and then seals the vein from the inside, which essentially shuts it down. So the technology is a lot better now.

00:33:13 Speaker_04
And that's kind of like an outpatient in the office procedure, takes half an hour, patient's too well, we check on them probably a week later and they can return back to work the next day. So it's very, it's ambulatory and their legs improve.

00:33:30 Speaker_04
pretty remarkably quite quickly. So it's very rewarding. And this is the part I was talking about. It's in terms of lifestyle, they're able to walk further, do whatever they need to do, less likely to get wounds in the future.

00:33:40 Speaker_04
But, you know, their data about that is still soft because we don't really follow them for 40 years to see what they're going to look like, unfortunately. But that's something that I think intuitively makes sense.

00:33:50 Speaker_00
Are varicose veins just a cosmetic concern or are those a concern in terms of your actual vein health that like, if you're making extra veins, you've got some issues down there we should solve anyway?

00:34:00 Speaker_04
Yeah. So I think there's two camps about that. There's certain patients who will start off with just varicose veins and may just stay like that for the next 40 years. Okay.

00:34:09 Speaker_04
They'll have probably some like swelling, some heaviness, fatigue, and they can tolerate that.

00:34:15 Speaker_04
There's some patients who will start off with varicose veins and they'll end up and I'll see them in their 60s and say, you know, this started when I was 30 and they told me it was just cosmetic and now they have horrible wounds and all sorts of problems.

00:34:28 Speaker_04
And so the question is, had we started to treat them in their 30s, would they have been this miserable in their 60s?

00:34:34 Speaker_04
And I think that I fall into that second camp of trying to make sure that their veins are as healthy as they can be throughout their lifetime.

00:34:42 Speaker_04
So it's really a conversation with the person that you're treating about what it is that they're trying to accomplish, what their life goals are, what their functional status is, what they want to be able to do.

00:34:51 Speaker_04
And that becomes more important to me than the other parts of it. Do compression socks help your veins with that too? So I think having compression is an assistive device, right?

00:35:02 Speaker_04
Because it creates a higher pressure at the ankle so that the blood doesn't pull there. So even if you do have vein problems, that will help at least boost some of the flow out of the leg. So yes, I think that they're important.

00:35:15 Speaker_04
I wear them, like I told you, even though I don't have venous disease, because I just want to make sure that they're as healthy as they can be.

00:35:23 Speaker_00
What about crossing your legs? Um, not bad actually.

00:35:27 Speaker_04
It's bad for your hips. And apparently I have to stop doing that.

00:35:31 Speaker_00
I do it all the time. I'm doing it right now.

00:35:33 Speaker_04
Yeah. And the compressing blood flow node, what that will do is mostly muscular and then nerve. It can pinch your nerve in your palpiteal fossa.

00:35:40 Speaker_04
And that can cause, you know, when you cross for too long and you feel like your foot's numb and you can't feel it, that kind of thing, but not the blood flow will still be fine.

00:35:48 Speaker_01
So your foot falling asleep is not usually a blood issue, but it's a neurological one. the nerve. And you mentioned deep veins, deep vein thrombosis. Yeah, I feel terrified of it. I have a friend who went through it recently as well.

00:36:02 Speaker_01
And luckily, she's on the men but has to be on blood thinners.

00:36:05 Speaker_00
So when we hear about blood clots versus deep vein thrombosis, what what's going on in there?

00:36:11 Speaker_04
Yeah, deep vein thrombosis is the part of venous disease that can be life-threatening because a not insignificant number of people, around 600,000 people die a year from a deep vein thrombosis.

00:36:22 Speaker_04
And the reason they die isn't from the clot itself, it's from the clot traveling. to their heart, because like I said, it's connected. And then once it goes into the heart and then into the lung arteries, it's called a pulmonary embolus.

00:36:35 Speaker_04
And that can kill you because if their heart has obstructed flow and it can't get blood out, you get a heart attack and then they die. And it's a cause of sudden death.

00:36:46 Speaker_01
And heads up, so DVT, or deep vein thrombosis, happens when a blood clot, or a delightfully named thrombus, forms in the deeper veins and usually a leg, like at the side of those valves or gates.

00:36:59 Speaker_01
And symptoms can include swelling, pain, fluid retention, some discoloration, and even fever.

00:37:06 Speaker_01
Now, if you have DVT, a doctor may put you on blood thinners to prevent that clot from detaching and just going on a walkabout to places you don't want it, like the lungs or the heart or your brain.

00:37:18 Speaker_01
As for COVID and clotting, a 2023 study risk of thrombosis during and after SARS-CoV-2 infection.

00:37:25 Speaker_01
Pathogenesis Diagnostic Approach and Management in the journal Hematology Reports says that coronavirus disease, COVID-19, increases the risk of thromboembolytic events, especially in patients with severe infections requiring intensive care and cardiorespiratory support, and that COVID-19 patients with thromboembolytic complications have a higher risk of death, and if they survive, these complications are expected to negatively affect these patients' quality of life.

00:37:54 Speaker_01
So, COVID increases the risk of blood clots, and the worse your case of it, the more at risk you are for that. It also says that recent data show that the risk of thromboembolism remains high months after the infection. Now, why is this happening?

00:38:09 Speaker_01
And there was another study, a 2023 study, SARS-CoV infection triggers pro-atherogenic inflammatory responses in human coronary vessels.

00:38:17 Speaker_01
in the journal Nature, and it presented data that established that SARS-CoV-2 infects coronary vessels, inducing plaque inflammation that could trigger acute cardiovascular complications and increase the long-term cardiovascular risk.

00:38:33 Speaker_01
So COVID ups your chance of clots and data show that it can infect coronary vessels. So how do you not get blood clots and thrombosis? It's never a bad idea to avoid getting COVID. Remember to get your boosters.

00:38:45 Speaker_01
Don't be afraid to mask up because a blood clot is scarier than a weird look from a stranger, in my opinion and experience. But other ways in general to prevent blood clots and deep vein thrombosis are to keep it moving.

00:38:58 Speaker_01
Move your bod if you have the option.

00:39:01 Speaker_04
So I think it's important for people to know about it and the ways to prevent it really are minimal. A lot of it can happen in a hospitalized setting where you're immobilized for a long time or you've had orthopedic surgery, et cetera.

00:39:17 Speaker_04
This is where compression becomes important. Moving is important. Also, if you have had a surgery or you have a family history of blood clots, then you may need to be on blood thinners to prevent that from happening.

00:39:30 Speaker_04
But it is something that is a serious problem. Right. And can happen in an unrecognized fashion. It's still rare. We'll say that like most people aren't going to have it.

00:39:41 Speaker_04
Like I said, 20 million people have superficial brain disease, but not a lot of people get DVTs in general, but that's something that should be recognized more. I think in general in public health, because

00:39:54 Speaker_04
The people who tend to do worse from it tend to be minorities, underrepresented minorities specifically, especially after childbirth and women. That's something that we've seen.

00:40:04 Speaker_04
I think even Serena Williams had one and had a second one, I think at her second pregnancy and that wasn't recognized, but she knew what was happening and she had to tell the doctors, this happened to me last time.

00:40:15 Speaker_04
And so that's how, when they recognized it and treated her appropriately. So it is something that, should be announced widely and people should be concerned about. What do you look for?

00:40:26 Speaker_01
Dr. Blumberg explains.

00:40:27 Speaker_04
Typically it will start with some swelling and pain in the leg and it's usually not both legs. It's usually just one leg. that's asymmetrically for some reason feel swollen, it's more painful, they should get checked out.

00:40:40 Speaker_04
It's a very simple test to look for it. It's an ultrasound that's cheap, effective, and highly diagnostic for that if you get it.

00:40:48 Speaker_00
Do you find that, especially with people who are going through childbirth or Is it a fact of certain people just not being listened to or more predisposed or I imagine a combination of both?

00:41:02 Speaker_04
I think a combination of both. There are people who are hypercoagulable, right? That's what we call in their blood clots for some reason. Pregnancy by itself is a hypercoagulable state.

00:41:13 Speaker_04
So women who are pregnant can form more clots because that's kind of the coagulation pathway of of carrying a child. So there's a heightened risk and assessment in those patients.

00:41:23 Speaker_04
And OB-GYNs, I think, are very cognizant of that and do a good job of that. I think in our medical community, there are people whose pain and or concerns aren't addressed as they should be.

00:41:35 Speaker_04
And I think that's hopefully changing, especially as the workforce that takes care of them changes, right? So if you're more aware that this happens to and there are some minority doctors that helps to move that forward.

00:41:51 Speaker_04
And so I think that's improving, but it has been an issue historically.

00:41:56 Speaker_00
When it comes to getting the word out about venous health too, and arterial health, what are things that you wish people knew before something becomes a problem?

00:42:07 Speaker_04
Yeah. So I think we'll start with arterial disease first. I'll say simply smoking is bad. It's always been bad. It's going to continue to be bad.

00:42:18 Speaker_04
And I don't think, and I know that now New York state has ads about people losing their fingers and their toes too. And there's quit smoking campaigns. And that's important because they've previously never addressed the fact that that's actually

00:42:33 Speaker_04
a risk factor of smoking is that. So I think that's the one thing. If you can just not start smoking, it's extremely hard to quit. And we talk to patients about this all the time. Don't do that. The second thing is diabetes.

00:42:45 Speaker_04
That's the still today now is the number one cause of amputations in this country. after trauma. So if you're not an accident where you lose your leg, diabetes is the number one cause of you losing your limb in this country. And that's a big problem.

00:43:00 Speaker_04
So diabetes control, which also stems now from obesity.

00:43:05 Speaker_01
We've mentioned this in previous episodes as recently as last week, but some people object to the word obesity to refer to certain body compositions that could potentially impact health negatively.

00:43:16 Speaker_01
But it is the current medical terminology that doctors use.

00:43:19 Speaker_01
And while some doctors have overlooked actual causation of illnesses by wrongfully blaming body composition, most, like Dr. Bloomberg, are relying on years of research to keep us all living longer and healthier with fewer complications.

00:43:33 Speaker_04
So it all starts there. So this is the thing. So health and wellness. I'm sort of an end stage doctor. By the time you get to me, a lot of things have happened along the way that hopefully could have been reversed.

00:43:46 Speaker_04
So I think weight control, obesity management, diabetes management, smoking. Those are sort of the pillars of arterial health and also venous health because we'll now switch to veins. Remember, veins return blood to your valentine heart.

00:44:03 Speaker_04
Function of veins is dependent on returning flow from a foot up to the heart. Weight plays a big role in that. If you're overweight, that's just a harder job for your veins to do.

00:44:15 Speaker_04
And that contributes to the development of the disease and also the outcomes after you start treating the disease. It's not just lasering everything, right? Those are the things I wish people knew beforehand.

00:44:25 Speaker_04
And then also wearing compression socks if you stand for too long at any job, because I see a lot of people, mostly women who did factory jobs, machinists, nurses, doctors, and they're all like, yeah, my legs have been killing me for years.

00:44:38 Speaker_04
And I think we used to have a fair once a year at NYU where we would just give out compression socks and you could sign scripts for people just so that the workforce could have it because we knew that this is the thing. So that's important, I think.

00:44:51 Speaker_00
You mentioned smoking too, and I have been in New York for just this past week and I'm from California and I have walked through absolute fogs of weed and I feel like more people smoke

00:45:03 Speaker_01
not just cigarettes, but just in general, people who don't smoke cigarettes or maybe smoking more weed and vaping, do those have any impact on your venous health? You ready for this?

00:45:13 Speaker_04
Yeah, I think the data on vaping is that it's pretty much as bad as tobacco. And also the particulates in vaping may actually be worse, at least for lungs in general. But that's a different ballgame altogether.

00:45:26 Speaker_04
The marijuana smoke and the legalization of marijuana has actually opened up a huge can of worms, I think, for people regarding public health, because you'll have conversations where people think it's natural. Me and Mother Nature.

00:45:43 Speaker_04
and therefore it's not going to harm them, but we don't have enough data on long-term use of marijuana and how that affects the arterial system. I can say our suspicions from the early reports now are that it's

00:45:59 Speaker_04
quite damaging to your circulatory system. And unfortunately with the widespread use, I think we're going to start seeing that in younger people who are consuming it at these high rates.

00:46:11 Speaker_04
And that's a big concern to me because I think this concept of it's a plant And if I smoke it, it's not tobacco, so it's not going to hurt me, is a problem. There's other things that are natural that occur in a plant.

00:46:27 Speaker_04
Well, it's just heroin comes from a flower. It's not necessarily good for you. Now that it's legal, it can actually be studied, right? And the natural population, natural studies will start to come out.

00:46:38 Speaker_04
And I'm not optimistic that it's going to be good news. So.

00:46:42 Speaker_01
Stick to gummies, maybe.

00:46:44 Speaker_04
Yeah, if you need it, yeah.

00:46:46 Speaker_01
Okay, smoking weed. Definitely not without its bodily consequences from a vascular biology standpoint. Sorry to say. And for more on this, you can see the 2019 paper, Harmful Effects of Smoking Cannabis, A Cerebrovascular and Neurological Perspective.

00:47:00 Speaker_01
And also news came out in 2022 that if you're an adult who has a bleeding stroke and you have enjoyed the ganja in the last month, you're twice as likely to die or have serious injury from that stroke.

00:47:13 Speaker_01
But it's really hard to determine what's caused by the smoking or the vaping factor, right? So I did this deep dive on edibles and you don't want to hear this, neither do I, but I have a responsibility to tell us that

00:47:25 Speaker_01
A 2019 Annals of Internal Medicine paper, acute illness associated with cannabis use by route of exposure, did find that according to the Colorado Behavioral Risk Factor Surveillance System, about half of THC users just smoke, and about 4% just do edibles, and the rest are kind of a combo of both.

00:47:44 Speaker_01
But edible cannabis did account for more ER visits for acute psychiatric symptoms. So don't let your mom eat the whole brownie. and visits for cardiovascular symptoms. So that's concerning.

00:47:57 Speaker_01
Does it have to do with all the snacks you like to eat when you're cooked? Jury's still very much out, and more research needs to be done, and doctors and scientists still need more questions answered, as do you.

00:48:08 Speaker_01
Can I ask you a couple of questions from listeners? Do we, is your heart out nine? Just checking. No, we have some time. Okay. Okay, sweet.

00:48:15 Speaker_01
So let's lob your questions to her about bruises, cold feet, why you should get an Ottoman, how to make a phlebotomist stay, barbers, gossip about royal families and much more. But first let's toss some money down the pipes to a good cause.

00:48:29 Speaker_01
And this week, Dr. Bloomberg selected breaking ground, which enables people to forever escape the trauma of homelessness.

00:48:35 Speaker_01
And their wraparound services include benefits assistance, primary medical care, mental health care, substance use referrals, and skills building to help each person get and stay on the path to permanent security.

00:48:47 Speaker_01
And each year, Breaking Ground serves more than 10,000 vulnerable New Yorkers. And to find out more about Breaking Ground, head to breakingground.org. And that donation in honor of Dr. Sheila Blumberg was made possible by sponsors of the show.

00:49:00 Speaker_01
Okay, let's tap it. Let's let these queries flow. You can submit your question before we record at patreon.com slash ologies, and it costs just a buck a month to join.

00:49:09 Speaker_01
This first topic was a curiosity of patrons Sheepin, Perry Wilson, who just got their first old lady bruise, the very clumsy Atticus Atlas, Etta Rose, first timer Madeline Ash, Key Lime Pie, Clark Bennett, Miles Paxton, Vanessa Adams, Mark Rubin, Anna Dillon, Olivia, Anna Thompson, Barb Miller, Greg Lewis, Audrey Hudak, and Val be listening.

00:49:27 Speaker_01
A lot of them want to know.

00:49:28 Speaker_00
Audrey Hudak asked, bruises, what are they exactly? Why do some people, in sheepens words, why do I bruise so badly? Is it because I'm vampirically pale? Perry Wilson said, I just got my first old lady bruise with broken capillaries.

00:49:44 Speaker_00
What is happening with bruising?

00:49:46 Speaker_04
So bruising is at the very superficial level of the skin. where the, I guess we can say capillaries slash veins burst just from injury, right? So it's very localized. You're obviously going to see it more if you're pale.

00:50:01 Speaker_04
Some people are more prone to bruising because they have either some platelet dysfunction where they don't clot fast enough.

00:50:08 Speaker_04
because if they're able to clot fast enough, it shouldn't bruise as much or shouldn't have as much spread of blood in that area.

00:50:14 Speaker_04
And so people who are prone to easy bruising, they should just have a simple blood test just to make sure they don't have an issue with clotting disorder or bleeding disorder.

00:50:23 Speaker_01
Other factors that can cause easy bruising are taking medications like ibuprofen or Advil, naproxen, like Aleve, blood thinners, antidepressants, and antibiotics. Now, another cause of easy bruising is not having died yet.

00:50:37 Speaker_01
And as we continue to age, our skin gets thinner, it has less cushion for that blood tubing we've got. And I asked the Mayo Clinic how not to have purple legs, and it offered the following solutions. Use good lighting in your home.

00:50:52 Speaker_01
Have your vision tested. Arrange furniture and electrical cords so that they're not in your way when you walk. Avoid clutter. So doctors say lovingly, either check your meds or get your shit together.

00:51:03 Speaker_01
I was getting a ton of bruises and then I realized it was because I was eating too many baby aspirin. I'd get a headache and be like, ooh, baby aspirin's delicious. And then I was like, oh, I have one more. And then I thought I had leukemia.

00:51:14 Speaker_01
Turned out I was just eating too many. What about circulation? So many people wanted to know, why are my hands and feet so cold? Diana Burgess, Rosalind Hesby, Bennett Renderbosch, Anastasia Press, Mary Ann Sienna, Rick T., Kyla Frett, Jackie Chee.

00:51:27 Speaker_01
Is it poor circulation or is that just a myth?

00:51:29 Speaker_04
Dr. Casey asks. So the cold hands, cool feet. There's some people who have perfect circulation. and have cold hands and cold feet. And they'll come in and there's not much we can do for them because there's no blockages, right?

00:51:43 Speaker_04
There are some people who have a phenomenon called Raynaud's where essentially they spasm. There are very, very tiny arteries in their hands and especially gets worse in the wintertime.

00:51:54 Speaker_04
What we recommend is just warming for those kinds of people because it's usually related to underlying rheumatologic problems that they may also have.

00:52:03 Speaker_01
So with Raynaud's, your blood vessels may kind of slam shut. And my friend Mackenzie has this and a few of her fingers can just suddenly turn white. I think it looks cool, but as an equestrian who's outside a lot, she's got to keep those fingies warm.

00:52:15 Speaker_01
But if you start to notice that you're just developing cold hands or feet,

00:52:19 Speaker_01
and you haven't just moved to Canada, it could indicate a new issue, like peripheral artery disease, which is when plaques form in the arteries of your limbs, or something like an autoimmune disease, like lupus, or rheumatoid arthritis, or maybe a thyroid issue.

00:52:32 Speaker_01
And yes, we do have an episode on thyroids coming up. Also, in terms of chickening out on something, the origin of the phrase cold feet is hotly debated. But in 2005, Slate published the article, when did we get cold feet?

00:52:45 Speaker_01
The Germans had them first, which is accusatory, but it traces the popularization back to German soldiers apprehensions in getting killed in World War I. They were like, I can't get out of this trench. My feet are too cold.

00:52:58 Speaker_01
But centuries earlier, an Italian proverb involved being cold in the feet to mean being shoeless, to mean being broke, which then meant that a gambler was too belly up.

00:53:09 Speaker_01
So they backed out of a bet, which if you're broke, backing out sounds like a great idea, like 10 out of 10 would bail ASAP. But if your actual feet and hands and nose are cold, and it's been like this for a while, that's kind of your brand.

00:53:22 Speaker_01
Docs say that it's healthy for your body to say, hey, I'm cold, I'm just gonna hoard more blood in our organs, if that's cool. Because you can't put a beanie on your liver, babies.

00:53:32 Speaker_04
It's very, very rarely a limb-threatening or a digit-threatening problem, but there are some people who just have perfectly cold hands and cold feet, and my daughter is one of them.

00:53:42 Speaker_00
There's nothing to do about it, so it's... She's not like, Mom, fix it.

00:53:47 Speaker_04
Yeah, yeah. It was like freezing hands since the day she was born.

00:53:52 Speaker_00
So, pockets. A few people, Bjorn Fredberg, Miranda Panda, Sadie Vipond, wanted to ask about hemophilia. What is it in Bjorn's words that hinders the blood from clotting or lack thereof?

00:54:07 Speaker_04
Yeah, that's taking me back to sort of med school. That's more in the hematologic sort of realm as opposed to circulation. genetically inherited, at least the most famous one is from mothers to sons, because it's on the X chromosome.

00:54:23 Speaker_04
So it tends to be more profound in boys because at least girls have two Xs, whereas boy has one X and one Y. So if they tend to present in boys, because they're the ones who will manifest it, whereas the girls will have protection from the second X. And those are the ones who can't make that factor.

00:54:41 Speaker_04
And then they've they bleed. And I think one of the czar's sons had it, Nicholas, back in the Russian revolution. And he was basically contained in a bubble as long as he can until the revolution. And they killed his whole family and his well, but yeah.

00:54:58 Speaker_04
And that was passed from, I think the czarina's line of families, but yeah. So it's a coagulation pathway problem where one of the factors is missing and it's, those are, those are still quite rare in hemophiliacs.

00:55:11 Speaker_01
Okay, so this side quest of info dumping kind of warrants its own three part episode. So I'm just gonna give you some broad strokes, if you will, and move on.

00:55:18 Speaker_01
So there was this mysterious blood and bleeding disease among European royal families, and it all traced back to a blood disorder transmitted to various European royals by Queen Victoria.

00:55:28 Speaker_01
who also went by the title, Her Majesty Victoria by the Grace of God of the United Kingdom of Great Britain and Ireland, Queen Defender of the Faith, Empress of India.

00:55:38 Speaker_01
And yes, one of her descendants among royals was Alexei, the great grandson of Queen Victoria. And he was a chunk of a baby, 11 pounds of butterball baby, but he had this royal disease.

00:55:51 Speaker_01
It was found out when his umbilical cord bled for hours and hours, his royal family was freaked out, but they didn't disclose his health problems to the public.

00:55:58 Speaker_01
Now, over the course of his childhood, he nearly bled out externally or internally from events as slight as a bump to the leg or a nosebleed.

00:56:08 Speaker_01
And there was this peasant monk who came along named Rasputin, and he was said to have the powers to cure Alexei by just pushing aside doctor's care. and healing him through hypnosis and spells and just Riz in general.

00:56:21 Speaker_01
But medical historians are now like, it may have just helped that he told the doctors to stop giving him aspirin because the aspirin thinned his blood. Also, placebos, they don't not work. Science knows that.

00:56:32 Speaker_01
But sadly, Alexi's fate was sealed by execution in a cellar at age 13. during the February Revolution in 1917. Now, the family's remains were discovered 90 years later.

00:56:45 Speaker_01
And finally, in 2009, the paper, Genotype Analysis Identifies the Cause of the Royal Disease, revealed that the royal disease was hemophilia B, a blood clotting disorder, which can be carried by females but can manifest in male descendants,

00:56:59 Speaker_01
or it can just arise spontaneously in a family line, especially by mutations resulting from older dad's spermies.

00:57:07 Speaker_01
But speaking of history and shady medical treatments, I do want to let you know that yes, bloodletting was a thing up until like the 1700s. And back in the day, barbers, they were the only ones with sharp tools in town.

00:57:19 Speaker_01
So they were tasked with all kinds of things like opening veins up and extracting teeth, applying leeches and setting bone fractures. They were the original med spas. Barbershop surgeons also cut hair and stuff.

00:57:34 Speaker_01
And that striped barber pole that you see outside modern day establishments.

00:57:38 Speaker_01
So legend has it that it descended from the shape of a basin of leeches at the top and the stick that patients would grip to encourage little suckers to do their business faster. Now others say that the red stripes are reminiscent of stained

00:57:55 Speaker_01
bloody strips of gauze, they would hang outside to dry.

00:57:58 Speaker_01
Either way, next time you have any medical procedure done, be glad that you're not surrounded by stray beard hairs and a weirdo with a leech and that you have a nice person in a clean lab coat in front of you.

00:58:12 Speaker_00
When it comes to drawing blood, people asked, Bulky Kibble says, when I'm getting blood drawn, I'm always told I have good veins. What does that actually mean? Bart Miller asked, why do phlebotomists always have a hard time finding my veins?

00:58:26 Speaker_00
When it comes to bloodletting, why do some people don't do as well as others?

00:58:32 Speaker_04
Well, we're hopefully we're not bloodletting anybody anymore. Drawing blood, if you have good veins, it basically means that you've made everyone's job easier because you're plump veins and hydrated.

00:58:43 Speaker_04
And there's some, when you put the tourniquet up in order to see the veins, when they're drawing blood, some people's become more prominent than others. Depends on the state of hydration.

00:58:53 Speaker_04
Sometimes they dehydrate, et cetera, and their veins are not visible or You can't touch them. You can't feel them when you touch them. That makes it more challenging.

00:59:03 Speaker_04
So people who have more prominent veins, who may have, you know, probably thinner arms, et cetera, it may be easier for us to get blood from.

00:59:11 Speaker_04
There's some people who, for whatever reason, and it's usually most difficult in hospitalized patients who've had multiple blood draws or who need blood repeatedly. At some point, the vein's been touched and

00:59:23 Speaker_04
injured too many times that it can't be accessed. We call them quote unquote tough sticks, like you can't find a good vein in there. Right. And most of those people, you want to try to find places where the skin is kind of the thinnest.

00:59:37 Speaker_04
So that's why a lot of people end up getting blood drawn in the

00:59:41 Speaker_04
not armpit, but here in the elbow pit, the antecubital fossa is what we call it, because it's probably the thinnest place where the veins come up to the skin at a level which most people can access.

00:59:52 Speaker_00
So you could make a phlebotomist stay by hydrating a little.

00:59:56 Speaker_04
Yeah, if you're able to, because sometimes they make you either fast for a blood test or something like that, depending on what it is. But ideally, chug a bunch of water beforehand. If you know you're a tough stick, that will help.

01:00:08 Speaker_00
I just love the idea of behind the scenes, someone saying, Oh yeah, Room 14 is tough stick, man, tough stick. What about rolling veins? A ton of people asked about, Gabrielle Heiss asked, she said, fantastic about the topic, excited about the topic.

01:00:22 Speaker_00
Why are some veins rollier?

01:00:26 Speaker_01
I've never heard the term rolly veins.

01:00:29 Speaker_01
Also on the minds of Kay Lucas, Gabrielle Heiss, Dethnell Kieran, Nehemiah Miles, Miranda Panda, and first-time question asker Bethany Schulz, who has roly veins, and after seeing them via a nurse using a laser vein finder, asked, why hasn't the goth clothing industry capitalized on vein pattern arm sleep?

01:00:48 Speaker_01
Asking as a goth scientist, Bethany says. Bethany, you're living in the future, but you still have roly veins. What's up with that?

01:00:54 Speaker_04
I think that's more common in a way in very thin people, because if you have less fat surrounding the vein, when you try to come after it, it just moves along the skin and you'll see it. And it's just like, oh gosh.

01:01:08 Speaker_04
So you have to kind of stabilize it a little bit as you're trying to access it.

01:01:12 Speaker_00
You got to chase them kind of, going side to side?

01:01:15 Speaker_04
You have to kind of anticipate where it's going to go next and find it there. That's how I do it when the veins are rolling.

01:01:24 Speaker_00
Sean Thomas Kane and R.P. Bergman wanted to know, in Sean's words, is there a scientifically proven best practice for stopping nosebleeds? Is that a vein? Is that an artery? I mean, everything at some point is in her artery.

01:01:37 Speaker_04
But if you're having a nosebleed periodically, I mean, it's now head down and compressive. even with like a tampon actually in the nose and just let it hold pressure and it'll stop. But don't do this. Don't put the head back.

01:01:52 Speaker_04
You don't want to swallow the blood into your mouth. So head down and put some tampons in it, in one nostril, or if not a cotton ball, something that you can actually pull out easily. You don't want to get anything stuck there either.

01:02:04 Speaker_01
The head down, that's new information to me. Non-menstruating people, keep a tampon in the glove box. You never know who, you never know what hole might need it.

01:02:14 Speaker_01
Now this one was on the minds and in the bodies of patrons Storm, Addie Capello, First Timer, Jasmine Tsai, and Marine Flood, which is a great name for a blood episode. Collapsed veins. People have asked when they've donated blood, a vein collapsed.

01:02:27 Speaker_00
Does that have to do with the musculature?

01:02:30 Speaker_04
I think when they tell you your vein has collapsed, it basically, for whatever reason, at the point at which they've drawn blood, it's just kind of spasmed. Okay. So that's usually temporary. So don't freak out if your vein collapsed? Don't freak out.

01:02:44 Speaker_01
No. If someone tells me a vein collapsed, that's terrifying. And you're like, I need that.

01:02:47 Speaker_04
Yeah. It's still there. It'll be back. It just needs a break. It's had enough.

01:02:52 Speaker_05
Just give me a minute.

01:02:54 Speaker_01
Carlos de la Rosa and the Severinos asked about chemotherapy and vascular health. Is there a way to recover, heal the veins from the back of your hands or anything during chemotherapy that you would recommend?

01:03:06 Speaker_04
So chemotherapy is tough because it really does destroy the cells within the lining of the veins, just because of the nature of the drugs that are going through, which is why they prefer to put it sort of directly through a port.

01:03:20 Speaker_04
as opposed to peripherally, although sometimes now they are using the veins in the arms directly for chemotherapy. Unfortunately, we don't have good reversal for that once that happens to it or protection for that. Where does the port go?

01:03:35 Speaker_04
It goes in the, depending on where the, either the subclavian vein, which is up here by the clavicle, or in the neck, IJ, the internal jugular vein.

01:03:45 Speaker_04
And then the port sits at the chest level here, because it's a clean area, less likely to get infected. And they can then access it repeatedly, especially if you need multiple rounds, as opposed to trying to access a vein multiple times in the hand.

01:03:58 Speaker_04
Like we said, it can collapse, it can spasm. And then just tolerating the toxic chemicals, it's kind of easier because here's a direct shot into the heart.

01:04:07 Speaker_04
So they get the medication sort of straight centrally, and then that gets distributed throughout the body.

01:04:14 Speaker_01
And you mentioned the jugular vein, which is the scariest sounding vein in the body, just because it's like, oh, I'm going for the jugular.

01:04:21 Speaker_00
Why is that jugular so important?

01:04:23 Speaker_04
I think the jugular vein has sort of been mythologized as like the one that will murder you if somebody cuts you. But I think what people forget is what was causing death wasn't the jugular vein. It was the carotid artery that was next to it. Okay.

01:04:37 Speaker_04
So when, you know, for example, in Quentin Tarantino, when they cut somebody's neck and all that blood and everyone's like, Oh, it's the jugular vein. That's the carotid artery that's been injured.

01:04:47 Speaker_04
So the jugular vein is famous, but it's not really earned its place in our mythology. But I think it's mostly carotid injuries are the ones that are the life-threatening scary things as opposed to the jugular vein.

01:05:01 Speaker_01
So we've been lied to. And in case if it ever comes up over dinner, maybe with extended family, someone mentions a stent, no one else knows what that is.

01:05:10 Speaker_01
You now are about to know that stents are these little mesh tubes that vascular surgeons might use to open up a blocked or collapsed vein. And they can be made out of metal or biodegradable materials. They can have medication embedded in them.

01:05:25 Speaker_01
Although the metal stents can become overgrown with scar tissue, which is why there are some newer options. So I hope that answers some stent questions, Brooke Dombroski, Amber McIntyre, and Mark Hewlett.

01:05:36 Speaker_01
Now, patron Rebecca Fitchett issued a command, a polite command, please talk about aneurysms. And that was echoed by Kelly Shaver and Stephanie McKechnie.

01:05:45 Speaker_01
And the quick FYI is that an aneurysm, it means dilation in Greek, and it's when a blood vessel, like a vein or an artery, weakens or bulges outward like a little balloon.

01:05:56 Speaker_01
And that can cause symptoms, especially neurological ones, if it presses on structures in the brain and can even lead to strokes or insufficient blood supply to parts of the body.

01:06:06 Speaker_01
So managing high blood pressure can prevent aneurysms because then the pressure inside the veins is lower and it pushes outward less. And Stephanie, I hope your dad's okay. And everyone else, I hope this helps you understand episodes of Grey's Anatomy.

01:06:20 Speaker_01
Now, most of my familiarity with the term aneurysm is from movies like in the 90s where someone has a house party and they're like, well, my mom sees this carpet, she's gonna have an aneurysm or something.

01:06:32 Speaker_01
And I thought that's kind of insensitive, but it turns out that yes, a sudden burst of anger or physical strain or untreated high blood pressure or just ongoing stress can cause an aneurysm or an existing one to rupture.

01:06:48 Speaker_01
So please chill for your own survival. And now other patrons, Jackie G, First Timer, Sean Cavanaugh, Haley Kirby and EDM asked about vascular surgery in general.

01:06:57 Speaker_01
Like what, when you're going in there as a surgeon and you're working on veins and arteries, How are you sewing them up? Is it the tiniest thread you've ever seen? Or are there glues? What's happening?

01:07:09 Speaker_04
It's sutures. They're pretty small. We grade them on most sutures at a level of zero to like 14, and the 14 being very tiny, tiny, almost less than even a hair, quite frankly. But we use microscopes, so we have loops to magnify what we're doing.

01:07:25 Speaker_04
But it does need to be a fine suture, which is why I was telling you about the delicacy of it, which is why I like it. Do you do crafts as well? I used to knit a lot when I was younger, and now I don't do anything fun like that.

01:07:38 Speaker_00
Like enough embroidery at work, I'm sure.

01:07:40 Speaker_04
Knitting and crocheting were my go-tos when I was younger.

01:07:44 Speaker_01
Can you not drink coffee before a surgery like that?

01:07:47 Speaker_04
No, I drink coffee.

01:07:48 Speaker_01
And your hands don't shake?

01:07:49 Speaker_04
Yeah. Okay. I'm good. Some people had to stop. Apparently when I get older, I might have to stop, but for now, I'm so good.

01:07:56 Speaker_00
Steady hands. You mentioned tourniquets earlier. My husband is a big safety nerd and has like a tourniquet on him in his fanny pack at all times. He took like a stop the bleed course just in case. Good for him. Go figure. I guess CPR is next.

01:08:10 Speaker_00
We should both probably know CPR. But when tying a tourniquet, what's the protocol?

01:08:16 Speaker_04
So the tourniquets that are available now have their own, each can be a little bit different, right? But depending on where you're putting it, you're going to go above the injury, right? So if it's in the calf, you want to go in the thigh.

01:08:30 Speaker_04
If it's in the lower leg, then you want to go upper in the thigh. And when you place it, you have to try to turn the tourniquet so that it's tight enough that it's occlusive. And the point is once you see that the bleeding has stopped, right?

01:08:45 Speaker_04
That's the perfect point at which you can stop sort of turning the tourniquet. Cause that's usually just a life saving measure that should be, you know, limited time, right?

01:08:55 Speaker_04
Because anytime the tourniquet's up, you have to start counting down the extremity that you're treating or that's the arm or the leg is not getting any blood flow. So once it's up, you start the clock on the tourniquet.

01:09:08 Speaker_04
I think that's the important part people forget. Cause once you stop the bleeding, you'll be able to stop blood flow.

01:09:13 Speaker_04
And then, um, depending on the situation, I don't want lay people getting too crazy about it, but you can also elevate the leg as you're putting the tourniquet on just to decompress the venous system and then put it on, just put it on, turn it till the bleeding stops.

01:09:27 Speaker_04
And then someone's already calling for help. Please call an ambulance.

01:09:31 Speaker_00
Call an ambulance. Yeah. Don't just rely on someone with a fanny pack tourniquet, but it's good to have.

01:09:37 Speaker_04
Yeah. I'm surprised. I know now that civilians have a lot of things which are pretty amazing.

01:09:43 Speaker_01
I mean, I suppose he likes to be prepared.

01:09:45 Speaker_04
Disaster preparedness, yeah.

01:09:46 Speaker_01
You figure. Yeah. Okay, on to some more chill stuff.

01:09:49 Speaker_01
Alex Vangelatos said, I've always wondered if there was a difference between what would be clinically considered varicose veins and just having very prominent veins, especially in lower legs and feet and hands that really show off, aka bulge.

01:10:04 Speaker_01
and pulse after exercising, Alex says. And Alex, I found you the article, lifting made my veins stick out, but here's why I love them anyway.

01:10:13 Speaker_01
In which a fellow vascular biologist and surgical angiologist, Dr. Jonathan Levison explains that strength training causes the muscles to engorge and swell with plasma, which pushes the veins closer to the surface, making them be like, hey, especially if you happen to have thinner skin.

01:10:31 Speaker_01
And whether or not you got a pump today, just kick back a little. Putting your legs up at the end of the day when your feet hurt, good idea?

01:10:38 Speaker_04
Yes.

01:10:38 Speaker_01
Good for the veins?

01:10:39 Speaker_04
Yes. Yoga upside down inversions. Yes, good for you. Take some time, go upside down. Get the blood out of your feet. Yeah. Okay. Just be in a different position elevation. I tell a lot of patients who have vein problems, elevate the legs as much as you can.

01:10:53 Speaker_04
The worst positions you can be in are sitting for too long and standing for too long. Moving, exercising is great. And then upside down if you can.

01:11:02 Speaker_04
as much as you can, or just elevate to whatever degree, you know, if you're older and it's harder, I'm not saying to go a standing, you know, inversion, but yeah.

01:11:12 Speaker_00
Acroyoga? Yeah, yeah. I mean, maybe. The last two questions I always ask, what is the hardest part about surgery for you? What's the hardest part about your job? The most challenging part?

01:11:23 Speaker_04
Most challenging part is when I can potentially fix the acute problem but I know that the patient's not going to make it. For example, this past week I had a patient who clawed at his leg. I can fix that.

01:11:39 Speaker_04
But if his heart is so damaged, me doing that, it's not going to change his ultimate outcome. And I think that for me is still the most challenging part.

01:11:47 Speaker_04
Like I can do the best thing that I can, but you're still not going to survive for whatever other reason. So that's, that's still a challenge. And that will always be a challenge with this job.

01:11:56 Speaker_01
Well, you mentioned that you sometimes see people when they're more advanced in a pathology.

01:12:03 Speaker_00
Any other advice that you want people to know to take care of that vascular health?

01:12:10 Speaker_04
Find a vascular specialist. There's not a lot of us. We're lucky in New York City, there's a lot of everybody.

01:12:17 Speaker_04
But just speaking around the country, there may not be a lot of people, especially if you're in rural areas, et cetera, who are specialists in this, and this is where

01:12:26 Speaker_04
Telemedicine can be helpful because you can always connect with someone who's not necessarily regionally close, but can at least give you advice on how to get to the help that you need. A lot of patients don't have good access.

01:12:38 Speaker_04
So please find somebody who's a specialist in vascular care because It's a very sub-specialized specialty, and when done well, can be very helpful. So that's something I wish people knew more of. We're kind of like an underdog specialty.

01:12:53 Speaker_04
Do we need more of you? We do, we're going to have a shortage in the next probably 10 years, but yes, we do. We need more of pretty much most doctors, but yes, definitely we do need more of us.

01:13:07 Speaker_01
So folks in med school have a rotation in the vascular area.

01:13:11 Speaker_04
Yeah.

01:13:12 Speaker_01
Amazing. Favorite part about your job? Favorite part about surgery?

01:13:16 Speaker_04
Favorite part about it is always the aftermath. So I think a lot of people who do surgeries, cause we do like sort of immediate gratification.

01:13:25 Speaker_04
And it's very gratifying when you see your patients and they'll come back literally within a week and be like, I feel amazing. Right. And then you're like, okay, great. Like I did something good and I helped somebody and now they're going to do great.

01:13:36 Speaker_04
And if you can help somebody, that's always great.

01:13:39 Speaker_01
And the mood in the OR, because you're doing such delicate work, is it like classical music and hush, or do you need energy?

01:13:47 Speaker_04
Depends on the case. But for the most part, I don't have music anymore. I used to have music in the OR, but then I found that my voice isn't loud enough for anybody to hear me when I need something.

01:13:58 Speaker_04
So I stopped with the music, and we only get music if I have everything that we need, and then we can have music. Because the team around me who's not focused, they like the music.

01:14:09 Speaker_04
And so I try to sort of meet them halfway, because I want them to be happy, if it can help me. And then depending, if it's an emergency, no music. Yeah. Focus time.

01:14:20 Speaker_04
Focus everyone because everyone's running around and trying to get stuff and we have to just stay focused. So emergencies, absolutely not. Regular cases, if everything's good. So whatever they pick. I actually don't pick the music.

01:14:32 Speaker_04
I say whatever they want. Yeah, it's fine with me.

01:14:35 Speaker_00
Aretha Franklin, maybe? You don't just belt out Aretha Franklin? Well, I can't start singing because then I lose focus because I'm trying to hit my notes.

01:14:43 Speaker_00
It was news to me that they even played music because obviously anytime I've been in an OR, I'm not super present.

01:14:48 Speaker_04
It's like, what, really? We actually take requests from patients sometimes because they want to set the mood for themselves when they come in. Yeah, they should offer you your choice. Spotify playlist.

01:15:01 Speaker_00
Thank you so much for doing this. This has been such a joy. Again, you've been on my list for so long because there's not a lot of vascular surgeons and you're just at the top of the game. So this was so great to talk to you. Thank you so much.

01:15:12 Speaker_00
It was fun.

01:15:15 Speaker_01
So ask cool surgeons weird questions, because now you know about fake blood, karaoke, and how to die less. Thank you so, so much to Dr. Sheila Blumberg for letting me meet up with her, and thank you to the NYU team for connecting us.

01:15:28 Speaker_01
Links to Breaking Ground are in the show notes, as well as a link to our website where we have so much info, links to the studies we mentioned, et cetera, all for you. We are at ologies on Blue Sky and Instagram. I'm at Allie Ward on both.

01:15:41 Speaker_01
We also have an ologist starter pack on Blue Sky, so find us there for sure. Smologies are shorter, kid-friendly episodes you can find anywhere.

01:15:48 Speaker_01
You get podcasts, and those are linked in the show notes along with merch and a link to support Ologies on Patreon and submit your questions that I may read on the show. Thank you to Erin Talbert, who admins the Ologies podcast Facebook group.

01:16:00 Speaker_01
Aveline Malik makes the professional transcripts. Kelly R. Dreyer makes the website. Noelle Dilworth is our scheduling producer. Managing director is Susan Hale, who makes sure everything flows on time.

01:16:10 Speaker_01
And the heartbeats putting it all together are editors Jake Chafee and lead editor Mercedes Maitland of Maitland Audio. Nick Thorburn wrote the theme music. And if you stick around, I'll tell you a secret.

01:16:19 Speaker_01
And this week, it's that we have okras in the yard, and I harvested a bunch of acorns a few weeks ago. And I've had them in this cloudy jar in the fridge. trying to cold bleach the bitter tannins out of them.

01:16:31 Speaker_01
And then I got impatient, so I tried to do one batch with boiling water and then dry them in the oven, but they looked burnt to shit. And my almost former spouse, your mother, Jarrett, said that they were not palatable. And this broke my heart.

01:16:44 Speaker_01
And I happened to meet up with my lovely friend and foraging ecology guest everyone loves, Alexis Nelson, aka Black Forager on TikTok and Instagram. and she was in town last week and she agreed to sample my acorns and I was nervous.

01:16:57 Speaker_01
Here's what happened.

01:16:58 Speaker_03
I have one here. You can be completely honest. Okay, well, it hasn't hit me yet. Oh, no, Ally, you should try this. It's more nutty. The bitterness at the end is reminiscent of like a fresh walnut. This is edible.

01:17:14 Speaker_03
You could dry that and put it in a baked good.

01:17:19 Speaker_01
Verdict, edible. Jarrett then tried another. He said, oh, it was good, and that maybe he just got a weird one. So he remains my spouse. Now, I'm going to attempt to grind these into flour and make acorn cookies, and I'm going to report back.

01:17:32 Speaker_01
But having a beloved and professional forager say, hey, you're not going to die from ingesting this, and I found it pleasant, is really enough of the goal for me. I'll let you know how it goes. All right, be safe out there. Get those socks. Bye bye.

01:18:03 Speaker_02
The pipes, the pipes are calling.