1 00:00:00,080 --> 00:00:02,560 Hello. This is Francesca Matthews with the Becker's 2 00:00:02,560 --> 00:00:03,699 ASC review podcast. 3 00:00:04,160 --> 00:00:05,919 I'm thrilled to be joined today by Armin 4 00:00:05,919 --> 00:00:06,419 Voskaridjian, 5 00:00:06,799 --> 00:00:10,240 director of anesthesia services at Jefferson Surgery Center 6 00:00:10,240 --> 00:00:12,400 at the Navy Yard. Armin, thank you so 7 00:00:12,400 --> 00:00:13,619 much for being here today. 8 00:00:14,214 --> 00:00:15,835 Oh, thank you for having me, Franchesca. 9 00:00:17,095 --> 00:00:19,995 A lot has gone on since, our last 10 00:00:20,695 --> 00:00:21,195 Becker's, 11 00:00:21,975 --> 00:00:23,675 podcast we did with Alan, 12 00:00:24,135 --> 00:00:24,875 in November, 13 00:00:25,335 --> 00:00:27,570 2024. 14 00:00:28,129 --> 00:00:30,050 For those of you that missed that podcast, 15 00:00:30,050 --> 00:00:31,809 you may wanna go back and take a 16 00:00:31,809 --> 00:00:34,369 quick listen. It's only nineteen minutes long to 17 00:00:34,369 --> 00:00:36,530 that podcast, but we're gonna be I would 18 00:00:36,530 --> 00:00:39,509 like to follow-up with, the information I presented 19 00:00:39,570 --> 00:00:41,509 there. At the time, it was pretty preliminary, 20 00:00:42,369 --> 00:00:43,429 but we've got some 21 00:00:44,024 --> 00:00:46,204 rock hard facts. Now we got some data, 22 00:00:46,265 --> 00:00:48,424 enough for two studies, and I would like 23 00:00:48,424 --> 00:00:50,204 to share that with the Becker's community. 24 00:00:51,144 --> 00:00:51,644 Absolutely. 25 00:00:52,905 --> 00:00:54,984 Very excited to hear all about that. But 26 00:00:54,984 --> 00:00:56,424 just to start us off, could you please 27 00:00:56,424 --> 00:00:58,024 introduce yourself and tell us a little bit 28 00:00:58,024 --> 00:00:58,844 about your background? 29 00:00:59,289 --> 00:01:01,690 Sure. Sure. Again, as you said, my name 30 00:01:01,690 --> 00:01:02,909 is Arman Voskarygian. 31 00:01:04,090 --> 00:01:07,549 I'm a double board certified in internal medicine 32 00:01:07,609 --> 00:01:08,189 and anesthesiology, 33 00:01:09,609 --> 00:01:12,829 physician. I work primarily at a a small 34 00:01:13,174 --> 00:01:15,895 ambulatory surgery center in the Navy Yard in 35 00:01:15,895 --> 00:01:16,715 South Philly. 36 00:01:17,575 --> 00:01:18,234 I trained 37 00:01:18,615 --> 00:01:20,694 mainly in New York. I'm actually going to 38 00:01:20,694 --> 00:01:23,015 my fortieth high school reunion at the end 39 00:01:23,015 --> 00:01:24,534 of this month, so I give a little 40 00:01:24,534 --> 00:01:26,454 shout out to the Bronx High School of 41 00:01:26,454 --> 00:01:28,635 Science, if there are any alumni out there. 42 00:01:29,109 --> 00:01:30,770 I went to college at NYU, 43 00:01:31,230 --> 00:01:33,549 medical school at the State University of New 44 00:01:33,549 --> 00:01:35,010 York downstate in Brooklyn. 45 00:01:35,549 --> 00:01:36,609 Shout out to Brooklyn. 46 00:01:37,790 --> 00:01:41,250 And then I did my, internal medicine residency 47 00:01:41,310 --> 00:01:42,290 in Staten Island 48 00:01:43,015 --> 00:01:45,334 and passed my boards and then did the 49 00:01:45,334 --> 00:01:47,754 anesthesia residency at New York 50 00:01:48,295 --> 00:01:49,274 Hospital Cornell 51 00:01:49,655 --> 00:01:51,894 on the Upper East Side. Stayed there for 52 00:01:51,894 --> 00:01:54,234 two years, as a teaching adjunct. 53 00:01:54,709 --> 00:01:56,869 Did private practice for two years. Did not 54 00:01:56,869 --> 00:01:57,849 like it at all. 55 00:01:59,030 --> 00:02:01,030 And then I came to Philadelphia to be 56 00:02:01,030 --> 00:02:02,950 closer to my family where I worked at 57 00:02:02,950 --> 00:02:04,649 Albert Einstein Medical Center 58 00:02:04,950 --> 00:02:07,369 in North Philly for about ten years. 59 00:02:07,750 --> 00:02:10,384 And then I found this job, 60 00:02:10,925 --> 00:02:12,384 at the Navy Yard, 61 00:02:13,245 --> 00:02:15,324 which was primarily focusing in, 62 00:02:15,645 --> 00:02:17,425 outpatient ambulatory orthopedic 63 00:02:17,724 --> 00:02:18,224 surgery. 64 00:02:19,164 --> 00:02:22,145 We do everything except for joint replacements, 65 00:02:22,760 --> 00:02:23,260 unfortunately. 66 00:02:24,360 --> 00:02:26,840 But, everything else we do, we work on 67 00:02:26,840 --> 00:02:28,460 everything from collarbone fractures, 68 00:02:28,919 --> 00:02:31,020 shoulder cases, rotator cuff repairs, 69 00:02:31,400 --> 00:02:32,699 elbow, wrist, 70 00:02:34,120 --> 00:02:34,860 hip scopes, 71 00:02:35,925 --> 00:02:38,824 knee scopes, ACL repair, MPFL repairs, 72 00:02:39,444 --> 00:02:40,185 quad tendon, 73 00:02:41,125 --> 00:02:42,104 patella tendon, 74 00:02:42,405 --> 00:02:44,824 and foot and ankle cases. Everything from Lisfranc 75 00:02:44,884 --> 00:02:45,944 fractures to, 76 00:02:46,645 --> 00:02:48,025 Achilles tendon repairs. 77 00:02:48,620 --> 00:02:49,060 And, 78 00:02:49,500 --> 00:02:53,419 I became director of the, anesthesia services there 79 00:02:53,419 --> 00:02:54,960 about three years ago now. 80 00:02:55,340 --> 00:02:55,840 So 81 00:02:56,379 --> 00:02:58,800 that's basically my CV in a nutshell. 82 00:02:59,740 --> 00:03:01,659 Excellent. Great. Well, we we do have some 83 00:03:01,659 --> 00:03:03,040 questions here kind of about 84 00:03:03,444 --> 00:03:05,465 ASCs at large and sort of some, 85 00:03:06,004 --> 00:03:08,645 zoomed out large level industry questions, but I 86 00:03:08,645 --> 00:03:10,004 am first interested in, 87 00:03:10,564 --> 00:03:12,245 in these studies that you were discussing. If 88 00:03:12,245 --> 00:03:14,324 you could just enlighten us a little bit 89 00:03:14,324 --> 00:03:16,264 as to what you've been working on. 90 00:03:17,110 --> 00:03:19,110 Sure. So, last time, 91 00:03:19,430 --> 00:03:20,730 I spoke with Becker's, 92 00:03:21,349 --> 00:03:24,810 we we I was bragging about some incredible 93 00:03:24,870 --> 00:03:26,170 results we've been getting. 94 00:03:26,710 --> 00:03:29,430 At this point, we have submitted our first 95 00:03:29,430 --> 00:03:29,930 paper, 96 00:03:30,824 --> 00:03:33,305 to the online journal of sports medicine. This 97 00:03:33,305 --> 00:03:34,764 is our ACL study. 98 00:03:35,224 --> 00:03:37,305 Our, subjects were a 131, 99 00:03:37,305 --> 00:03:38,985 so n equals a 131. 100 00:03:38,985 --> 00:03:40,525 We split that into two groups. 101 00:03:41,384 --> 00:03:42,525 One group getting 102 00:03:43,209 --> 00:03:44,349 liposomal bupivacaine, 103 00:03:45,449 --> 00:03:47,150 with mixed with aqueous bupivacaine, 104 00:03:47,449 --> 00:03:49,550 and then the other group would get liposomal 105 00:03:49,610 --> 00:03:50,110 bupivacaine 106 00:03:50,569 --> 00:03:51,870 with the aqueous bupivacaine 107 00:03:52,169 --> 00:03:53,069 and the additional 108 00:03:53,370 --> 00:03:54,669 preservative free dexamethasone. 109 00:03:57,314 --> 00:03:59,634 Now although the the theory being that the 110 00:03:59,634 --> 00:04:00,134 dexamethasone 111 00:04:00,514 --> 00:04:01,254 would prolong 112 00:04:01,555 --> 00:04:02,215 the effects, 113 00:04:02,514 --> 00:04:03,574 we didn't see 114 00:04:04,114 --> 00:04:05,014 that greater 115 00:04:05,394 --> 00:04:06,775 reflection of prolongation 116 00:04:07,394 --> 00:04:09,814 of effects on the ACL study. 117 00:04:10,194 --> 00:04:11,159 We'll get to that, 118 00:04:11,639 --> 00:04:13,719 in the foot and ankle study. There was 119 00:04:13,719 --> 00:04:16,699 only approximately about twenty four to thirty hours 120 00:04:16,839 --> 00:04:18,379 extra by adding the dexamethasone. 121 00:04:19,319 --> 00:04:19,819 However, 122 00:04:20,519 --> 00:04:23,080 the more stunning result is in both groups, 123 00:04:23,080 --> 00:04:24,439 if you just take the n of a 124 00:04:24,439 --> 00:04:25,660 hundred and thirty one, 125 00:04:26,204 --> 00:04:28,524 seventy seven percent of those hundred and thirty 126 00:04:28,524 --> 00:04:29,264 one patients 127 00:04:29,805 --> 00:04:31,264 took zero narcotics 128 00:04:31,725 --> 00:04:34,524 after their ACL repair surgery, and that includes 129 00:04:34,524 --> 00:04:36,225 quad tendon, patella tendon, 130 00:04:37,805 --> 00:04:38,704 and allograft. 131 00:04:39,289 --> 00:04:42,110 The allografts did the, did the best, obviously. 132 00:04:42,410 --> 00:04:44,509 They're known to have less pain because it's 133 00:04:44,569 --> 00:04:46,669 a cadaveric donor of the ACL 134 00:04:47,370 --> 00:04:48,349 of the, ligament. 135 00:04:48,889 --> 00:04:49,289 And, 136 00:04:51,050 --> 00:04:52,569 those patients usually come out, 137 00:04:53,194 --> 00:04:56,154 complaining of zero to one pain. The ACL 138 00:04:56,154 --> 00:04:58,235 patients came out complaining of about three to 139 00:04:58,235 --> 00:04:59,995 four on average is the score out of 140 00:04:59,995 --> 00:05:00,495 ten, 141 00:05:00,954 --> 00:05:03,675 and they took zero seventy seven percent took 142 00:05:03,675 --> 00:05:04,495 zero narcotics, 143 00:05:05,035 --> 00:05:07,274 and this is now documented. This is gonna 144 00:05:07,274 --> 00:05:10,360 be published. I'm hoping we'll get the results, 145 00:05:11,000 --> 00:05:13,240 the yes or no from the online Journal 146 00:05:13,240 --> 00:05:15,720 of Sports Medicine soon. Of the twenty three 147 00:05:15,720 --> 00:05:18,759 percent of patients that did take narcotics after 148 00:05:18,759 --> 00:05:20,379 their ACL repair surgery, 149 00:05:20,839 --> 00:05:22,939 the average number of pills they took 150 00:05:23,425 --> 00:05:26,485 was less than two five milligram oxycodone pills. 151 00:05:27,504 --> 00:05:30,145 These these are, in my opinion, incredible results. 152 00:05:30,145 --> 00:05:32,004 I think any orthopedic surgeon 153 00:05:32,305 --> 00:05:34,324 would be hard pressed to deny that. 154 00:05:35,264 --> 00:05:37,824 So we're very proud of these results, 155 00:05:38,145 --> 00:05:39,209 that we're getting here. 156 00:05:40,410 --> 00:05:42,009 For the foot and ankle study, we have 157 00:05:42,009 --> 00:05:44,329 not yet submitted that for publishing, but we 158 00:05:44,329 --> 00:05:46,430 have our abstract out. We have the preliminary 159 00:05:46,649 --> 00:05:47,470 data out. 160 00:05:47,930 --> 00:05:49,689 Our end, I believe, was a hundred and 161 00:05:49,689 --> 00:05:51,529 twenty nine patients for the foot and ankle 162 00:05:51,529 --> 00:05:54,669 study. And there, we did notice a significant, 163 00:05:55,564 --> 00:05:56,064 improvement 164 00:05:56,444 --> 00:05:58,865 in the block length duration, 165 00:06:00,524 --> 00:06:02,845 for those that for the group that did 166 00:06:02,845 --> 00:06:03,745 get the dexamethasone, 167 00:06:04,125 --> 00:06:05,904 the preservative free dexamethasone 168 00:06:06,685 --> 00:06:09,720 in the, foot popliteal and saphenous nerve blocks. 169 00:06:09,959 --> 00:06:12,279 So again, two groups of patients, total a 170 00:06:12,279 --> 00:06:13,420 100 and twenty nine. 171 00:06:16,360 --> 00:06:17,420 One group received, 172 00:06:17,879 --> 00:06:18,939 liposomal bupivacaine 173 00:06:19,800 --> 00:06:20,300 with, 174 00:06:20,680 --> 00:06:22,699 aqueous bupivacaine and no dexamethasone, 175 00:06:23,160 --> 00:06:24,459 no preservative free dexamethasone. 176 00:06:25,154 --> 00:06:28,055 The second group received liposomal bupivacaine 177 00:06:28,595 --> 00:06:30,055 plus aqueous bupivacaine 178 00:06:31,074 --> 00:06:31,574 and 179 00:06:31,875 --> 00:06:34,675 preservative free dexamethasone. So one group basically had 180 00:06:34,675 --> 00:06:36,055 no preservative free dexamethasone, 181 00:06:36,435 --> 00:06:38,194 the other group did. And we took all 182 00:06:38,194 --> 00:06:39,574 types of surgeries from 183 00:06:40,110 --> 00:06:42,509 surgeries that the surgeon had requested a block 184 00:06:42,509 --> 00:06:43,730 previously from the anesthesiologist. 185 00:06:44,350 --> 00:06:46,770 So that included everything from Lisfranc fractures 186 00:06:47,230 --> 00:06:47,730 to, 187 00:06:48,589 --> 00:06:49,649 complex bunionectomies, 188 00:06:51,069 --> 00:06:52,449 Achilles tendon ruptures, 189 00:06:52,834 --> 00:06:54,095 trimal bimalleolar, 190 00:06:54,675 --> 00:06:55,574 ankle fractures. 191 00:06:56,754 --> 00:06:58,694 Of those hundred and twenty nine patients, 192 00:06:59,875 --> 00:07:00,615 I believe, 193 00:07:01,555 --> 00:07:03,475 and don't quote me on this, but I 194 00:07:03,475 --> 00:07:06,709 believe the average number of pill takers, narcotic 195 00:07:06,709 --> 00:07:09,669 pill takers in both groups was I'm sorry. 196 00:07:09,669 --> 00:07:11,910 I'll take that back. In the dexamethasone group 197 00:07:11,910 --> 00:07:12,410 was 198 00:07:12,949 --> 00:07:15,209 zero point seven percent. 199 00:07:15,910 --> 00:07:18,069 That just means that out of every hundred 200 00:07:18,069 --> 00:07:18,569 patients, 201 00:07:19,110 --> 00:07:20,729 only seven people took narcotics. 202 00:07:21,824 --> 00:07:24,544 Mhmm. So Yeah. These are remarkable. Yeah. Yeah. 203 00:07:24,544 --> 00:07:25,044 Unbelievable. 204 00:07:25,504 --> 00:07:27,204 And the length, duration, 205 00:07:27,664 --> 00:07:28,564 that the dexamethasone 206 00:07:29,024 --> 00:07:31,285 was able to extend was approximately, 207 00:07:32,944 --> 00:07:33,444 thirty 208 00:07:34,410 --> 00:07:36,730 six to forty hours. But, again, don't quote 209 00:07:36,730 --> 00:07:38,490 me on that. I'd have to look I 210 00:07:38,490 --> 00:07:39,770 don't have the results in front of me 211 00:07:39,770 --> 00:07:41,689 right now, but I did send them to 212 00:07:41,689 --> 00:07:43,770 you, and, I can go over them later 213 00:07:43,770 --> 00:07:45,310 on. But these are un unbelievable 214 00:07:45,689 --> 00:07:47,714 results. This is unheard of right now. The 215 00:07:47,714 --> 00:07:50,115 only thing that comes close to these kinds 216 00:07:50,115 --> 00:07:52,375 of results was when we were placing catheters. 217 00:07:52,834 --> 00:07:54,294 And catheters were 218 00:07:54,675 --> 00:07:56,375 great for what they were accomplishing, 219 00:07:56,754 --> 00:07:57,495 but, unfortunately, 220 00:07:58,115 --> 00:07:59,794 we were only placing them on one of 221 00:07:59,794 --> 00:08:01,629 the two nerves that we blocked, the one 222 00:08:01,629 --> 00:08:04,189 that did the most, lifting, the heavy lifting, 223 00:08:04,189 --> 00:08:06,189 which was the popliteal nerve. We would let 224 00:08:06,189 --> 00:08:09,170 the saphenous nerve go. So patients invariably 225 00:08:09,790 --> 00:08:10,449 had a, 226 00:08:10,990 --> 00:08:11,490 plateau, 227 00:08:12,270 --> 00:08:13,650 of pain control wherein 228 00:08:14,545 --> 00:08:16,384 they felt great when they left the surgery 229 00:08:16,384 --> 00:08:18,705 center. But after twenty four to thirty six 230 00:08:18,705 --> 00:08:19,764 hours when the, 231 00:08:20,145 --> 00:08:22,464 saphenous nerve block wore off and they were 232 00:08:22,464 --> 00:08:24,725 just relying on the catheter for the popliteal 233 00:08:24,785 --> 00:08:27,449 nerve, you'd see a spike in complaints about 234 00:08:27,449 --> 00:08:31,129 pain, obviously, because the, saphenous nerve is now 235 00:08:31,129 --> 00:08:31,629 activated. 236 00:08:32,169 --> 00:08:32,669 And, 237 00:08:33,610 --> 00:08:35,690 but narcotic use would go up. Depends on 238 00:08:35,690 --> 00:08:37,309 the patient, depends on the surgery, 239 00:08:38,169 --> 00:08:40,409 all that taken into account, though, this was 240 00:08:40,409 --> 00:08:41,470 what we were seeing. 241 00:08:42,335 --> 00:08:44,414 And so it was it was it was 242 00:08:44,414 --> 00:08:46,115 good for what it was at the time, 243 00:08:46,335 --> 00:08:46,815 but, 244 00:08:47,215 --> 00:08:48,355 it was not 245 00:08:49,375 --> 00:08:51,215 it was not the best that we could 246 00:08:51,215 --> 00:08:53,154 do. And I believe this is, 247 00:08:53,615 --> 00:08:55,634 going above and beyond providing, 248 00:08:56,654 --> 00:08:57,394 both nerves 249 00:08:57,720 --> 00:09:00,940 with a complete blockade that's lasting us about 250 00:09:01,159 --> 00:09:02,620 six to seven days. 251 00:09:03,240 --> 00:09:04,279 And I'm saying that, 252 00:09:04,839 --> 00:09:06,459 with some hesitation because, 253 00:09:07,079 --> 00:09:09,159 and I'll get to this, a little bit 254 00:09:09,159 --> 00:09:09,639 later. 255 00:09:10,360 --> 00:09:11,659 But, I've modified 256 00:09:12,120 --> 00:09:12,620 my, 257 00:09:13,884 --> 00:09:17,085 use of the liposomal bupivacaine after the first 258 00:09:17,085 --> 00:09:20,144 podcast came out in November. 259 00:09:20,684 --> 00:09:23,485 I got some shout outs from colleagues across 260 00:09:23,485 --> 00:09:24,144 the country, 261 00:09:24,605 --> 00:09:25,904 and the most disconcerting, 262 00:09:26,610 --> 00:09:27,830 comment I was receiving 263 00:09:28,210 --> 00:09:30,470 was that you I'm very fortunate 264 00:09:30,929 --> 00:09:33,009 myself. I'm very fortunate to be able to 265 00:09:33,009 --> 00:09:35,809 use this much liposomal bupivacaine, and we'll get 266 00:09:35,809 --> 00:09:37,589 into the amounts in a moment, 267 00:09:38,610 --> 00:09:39,509 simply because 268 00:09:40,004 --> 00:09:40,504 their 269 00:09:41,125 --> 00:09:43,524 institutions, the pharmacy wouldn't even allow them to 270 00:09:43,524 --> 00:09:46,165 touch liposomal bupivacaine. Or if they did, it 271 00:09:46,165 --> 00:09:48,085 would only be the 10 cc bile, not 272 00:09:48,085 --> 00:09:51,045 the 20 cc bile. So liposomal bupivacaine comes 273 00:09:51,045 --> 00:09:53,865 in two volumes, 10 cc and 20 cc. 274 00:09:55,220 --> 00:09:56,759 And that made me rethink 275 00:09:57,220 --> 00:09:59,959 this is after the studies were already finalized, 276 00:10:00,179 --> 00:10:02,019 but it made me rethink my approach. I 277 00:10:02,019 --> 00:10:03,879 was very fortunate to have an administrator 278 00:10:04,259 --> 00:10:06,579 at our ASC at the Navy Yard, Jefferson 279 00:10:06,579 --> 00:10:08,414 Surgical Center at the Navy Yard, 280 00:10:08,975 --> 00:10:09,475 who 281 00:10:09,934 --> 00:10:12,254 saw the results we were getting, saw the 282 00:10:12,254 --> 00:10:15,394 patients almost taking minimal to zero narcotics, 283 00:10:15,855 --> 00:10:18,595 saw the responses of the surgeons, which were 284 00:10:18,894 --> 00:10:22,014 positive all across the board, and allowed me 285 00:10:22,014 --> 00:10:22,860 to sort of 286 00:10:23,339 --> 00:10:25,039 she didn't complain about my, 287 00:10:26,220 --> 00:10:29,019 liposomal bupivacaine use. And as everybody knows who's 288 00:10:29,019 --> 00:10:32,000 listening, liposomal bupivacaine is definitely expensive. 289 00:10:33,259 --> 00:10:35,500 So another report I'd like to make on 290 00:10:35,500 --> 00:10:38,245 this podcast is that I've reduced the amount 291 00:10:38,245 --> 00:10:39,625 of liposomal bupivacaine 292 00:10:40,085 --> 00:10:42,004 with minimal in both of those blocks, the 293 00:10:42,004 --> 00:10:44,644 foot and ankle and the ACL, with minimal 294 00:10:44,644 --> 00:10:47,845 changes in narcotic use and patient satisfaction and 295 00:10:47,845 --> 00:10:49,845 patient pain scores, but I don't have any 296 00:10:49,845 --> 00:10:51,269 data for that. But I'd be more than 297 00:10:51,269 --> 00:10:53,450 happy to share that if you're interested in 298 00:10:53,589 --> 00:10:55,690 delving, giving me a couple more minutes more. 299 00:10:56,629 --> 00:10:58,470 Yeah. I mean, go go into any more 300 00:10:58,470 --> 00:11:00,250 detail that you feel like is is appropriate. 301 00:11:00,309 --> 00:11:01,990 I, yeah, wanna get the full breadth of 302 00:11:01,990 --> 00:11:03,990 this before we kinda dive into how it 303 00:11:03,990 --> 00:11:05,850 might affect the industry going forward. 304 00:11:06,284 --> 00:11:09,424 Wonderful. Thank you, Francesca. I appreciate it. So 305 00:11:09,644 --> 00:11:12,365 the study for the ACL that is being, 306 00:11:12,845 --> 00:11:15,245 submitted for publication at the online Journal of 307 00:11:15,245 --> 00:11:16,065 Sports Medicine, 308 00:11:16,845 --> 00:11:19,889 in that initial study, we were using thirty 309 00:11:19,889 --> 00:11:22,769 ccs of liposomal bupivacaine. So one twenty c 310 00:11:22,769 --> 00:11:24,789 c vial and one ten c c vial. 311 00:11:24,929 --> 00:11:25,909 In my subsequent, 312 00:11:27,569 --> 00:11:28,069 reevaluation, 313 00:11:28,850 --> 00:11:30,850 I've gotten that down to one twenty c 314 00:11:30,850 --> 00:11:31,575 c vial. 315 00:11:31,894 --> 00:11:33,575 And if anybody wants to reach out to 316 00:11:33,575 --> 00:11:35,355 me, I'd be more than happy to share, 317 00:11:35,735 --> 00:11:37,735 how I'm doing it. You can reach me 318 00:11:37,735 --> 00:11:40,455 on LinkedIn, or I'm sure if you they 319 00:11:40,455 --> 00:11:42,715 can contact me through Becker's as well. 320 00:11:43,815 --> 00:11:44,875 So the ACL, 321 00:11:45,920 --> 00:11:48,720 amount of liposomal bupivacaine was reduced by one 322 00:11:48,720 --> 00:11:50,960 third. So instead of using thirty cc's, I'm 323 00:11:50,960 --> 00:11:53,460 using twenty cc's. For the foot and ankle, 324 00:11:53,519 --> 00:11:55,860 I was using 20 cc's for the study, 325 00:11:56,320 --> 00:11:58,879 of liposomal bupivacaine for a final volume of 326 00:11:58,879 --> 00:12:01,620 30 cc's. I've got that down to now 327 00:12:01,715 --> 00:12:04,134 ten cc's of liposomal bupivacaine, 328 00:12:04,595 --> 00:12:07,475 a final volume of about 21 cc's with 329 00:12:07,475 --> 00:12:08,054 the dexamethasone 330 00:12:08,434 --> 00:12:11,095 in it. Having reduced the amount of bupivacaine, 331 00:12:11,634 --> 00:12:14,215 I'm now administering preservative free dexamethasone 332 00:12:14,915 --> 00:12:15,575 to everyone. 333 00:12:16,100 --> 00:12:18,740 So, basically, what these studies have shown is 334 00:12:18,740 --> 00:12:20,600 that even though the manufacturer, 335 00:12:21,540 --> 00:12:23,460 states that you shouldn't be mixing anything with 336 00:12:23,460 --> 00:12:26,440 liposomal bupivacaine besides aqueous bupivacaine 337 00:12:26,980 --> 00:12:29,620 with the caveats for how much you can 338 00:12:29,620 --> 00:12:30,120 add, 339 00:12:30,625 --> 00:12:32,404 how many milligrams you can add. 340 00:12:32,784 --> 00:12:35,985 I've shown we've shown at the Navy Yard 341 00:12:35,985 --> 00:12:37,125 that you can actually, 342 00:12:38,784 --> 00:12:40,324 add preservative free dexamethasone 343 00:12:40,625 --> 00:12:42,725 without comp compromising the liposomes. 344 00:12:43,105 --> 00:12:45,179 That's the first thing. And then we've shown 345 00:12:45,339 --> 00:12:48,700 that, with adding the preservative free dexamethasone, you 346 00:12:48,700 --> 00:12:49,440 can prolong 347 00:12:49,980 --> 00:12:51,919 the effect of the blocks that you're getting. 348 00:12:52,299 --> 00:12:53,120 And finally, 349 00:12:54,139 --> 00:12:57,120 that you can do this with less liposomal 350 00:12:57,259 --> 00:12:59,475 duplicates than our studies actually showed. 351 00:12:59,954 --> 00:13:02,514 And that's anecdotal, that part, but, I'd be 352 00:13:02,514 --> 00:13:04,434 happy to talk to anybody that's, willing to 353 00:13:04,434 --> 00:13:05,975 talk to me about it. So the ACL, 354 00:13:06,194 --> 00:13:08,214 again, twenty cc's liposomalpivacaine, 355 00:13:09,074 --> 00:13:10,995 and the foot and ankle blocks will get 356 00:13:11,074 --> 00:13:13,334 we're using ten cc's of liposomalpivacaine. 357 00:13:14,779 --> 00:13:17,679 And, to add to that, Francesca, I believe 358 00:13:17,740 --> 00:13:20,300 we discussed this, during the interview we had 359 00:13:20,300 --> 00:13:22,559 a couple of weeks ago. This formulation 360 00:13:22,860 --> 00:13:25,519 where you're mixing the liposomal bupivacaine, 361 00:13:25,980 --> 00:13:28,639 the aqueous bupivacaine, and the preservative free dexamethasone 362 00:13:29,365 --> 00:13:31,045 will work on any of the blocks that 363 00:13:31,045 --> 00:13:34,004 we're doing. So this works for superficial cervical 364 00:13:34,004 --> 00:13:35,945 plexus blocks for clavicle fractures. 365 00:13:36,325 --> 00:13:38,245 It works for the interscalene, and that's the 366 00:13:38,245 --> 00:13:40,424 last study we'll be publishing. That's still underway. 367 00:13:40,485 --> 00:13:42,149 We're still collecting data for that. 368 00:13:42,710 --> 00:13:44,889 So it will work for the interscaling blocks. 369 00:13:45,029 --> 00:13:45,930 It will work 370 00:13:46,389 --> 00:13:46,790 for your, 371 00:13:49,110 --> 00:13:52,070 ACL blocks and, as a side and foot 372 00:13:52,070 --> 00:13:54,870 and ankle blocks, your pops up blocks. As 373 00:13:54,870 --> 00:13:57,715 a side note, the final discovery that we 374 00:13:57,715 --> 00:13:59,894 were able to publish in the ACL study 375 00:14:00,195 --> 00:14:02,535 was that we've added a third infiltration 376 00:14:03,394 --> 00:14:04,375 for ACL 377 00:14:04,754 --> 00:14:05,495 knee surgeries. 378 00:14:06,434 --> 00:14:09,100 In other words, your standard blocks for the 379 00:14:09,100 --> 00:14:11,679 ACL surgeries were your adductor canal block, 380 00:14:12,220 --> 00:14:13,820 done at the apex of the triangle of 381 00:14:13,820 --> 00:14:14,799 the adductor canal, 382 00:14:15,100 --> 00:14:17,899 and your IPAC block for behind the knee 383 00:14:17,899 --> 00:14:20,059 pain. I've added a third block to that, 384 00:14:20,059 --> 00:14:21,040 which is the suprasartorial 385 00:14:21,580 --> 00:14:22,080 infiltration, 386 00:14:23,785 --> 00:14:25,305 and we get into that in the study 387 00:14:25,305 --> 00:14:27,384 as to, how I was motivated to do 388 00:14:27,384 --> 00:14:27,884 that. 389 00:14:28,185 --> 00:14:30,105 And by adding that third block, I think 390 00:14:30,105 --> 00:14:32,504 we've that that is also another strength, and 391 00:14:32,504 --> 00:14:34,285 it's not just a liposomal bupivacaine. 392 00:14:34,665 --> 00:14:36,445 It's by doing these three infiltrations 393 00:14:36,985 --> 00:14:38,205 that you can truly 394 00:14:38,669 --> 00:14:41,710 get superior coverage of blocking the knee. So 395 00:14:41,710 --> 00:14:42,370 the suprasartorial 396 00:14:42,830 --> 00:14:43,330 infiltration, 397 00:14:43,950 --> 00:14:46,190 your adductor canal block at the apex of 398 00:14:46,190 --> 00:14:46,850 the triangle, 399 00:14:47,710 --> 00:14:49,490 and your iPAC infiltration. 400 00:14:49,870 --> 00:14:52,665 I've used this on four total knee replacements. 401 00:14:52,965 --> 00:14:54,485 One of them for a very close friend 402 00:14:54,485 --> 00:14:56,024 of mine, three of them, 403 00:14:56,565 --> 00:14:59,205 at the Rothman Orthopedics actually, all four were 404 00:14:59,205 --> 00:15:02,825 the Rothman Orthopedic Specialty Hospital in Bensalem, Pennsylvania. 405 00:15:03,445 --> 00:15:06,585 And narcotic use was, basically eliminated, 406 00:15:08,029 --> 00:15:08,529 postoperatively 407 00:15:08,909 --> 00:15:10,750 by the patients. And these are patients that 408 00:15:10,750 --> 00:15:11,649 went to rehab, 409 00:15:12,429 --> 00:15:14,909 approximately eight hours after their surgery, six to 410 00:15:14,909 --> 00:15:16,289 eight hours after their surgery. 411 00:15:16,909 --> 00:15:19,709 The PT the physical therapists were pretty impressed 412 00:15:19,709 --> 00:15:21,384 at the results they were getting. And so 413 00:15:21,384 --> 00:15:22,985 this is not a motor block. There's no 414 00:15:22,985 --> 00:15:23,804 motor blockade. 415 00:15:24,184 --> 00:15:27,325 The volumes are kept low, and the satisfaction 416 00:15:27,544 --> 00:15:29,644 and the pain control is superlative. 417 00:15:30,105 --> 00:15:32,664 I can't I can't express how happy we 418 00:15:32,664 --> 00:15:34,524 we are with the results that we've gotten. 419 00:15:35,940 --> 00:15:38,259 Absolutely. And kind of given all that, taking 420 00:15:38,259 --> 00:15:40,339 a step back, what do you see as 421 00:15:40,339 --> 00:15:41,000 the potential 422 00:15:41,379 --> 00:15:43,559 influence of this discovery on, 423 00:15:43,940 --> 00:15:46,179 the ASC industry at large and for outpatient 424 00:15:46,179 --> 00:15:46,679 surgery? 425 00:15:47,865 --> 00:15:50,044 I can only speak from personal observation, 426 00:15:50,664 --> 00:15:53,164 but, what we're seeing is basically, 427 00:15:53,945 --> 00:15:55,884 with the government cutting funding, 428 00:15:56,585 --> 00:15:59,784 for reimbursements for procedures, and then the private 429 00:15:59,784 --> 00:16:01,485 insurance is following suit. 430 00:16:02,860 --> 00:16:03,360 Reimbursements 431 00:16:03,660 --> 00:16:04,480 for anesthesia, 432 00:16:06,220 --> 00:16:08,799 both the CRNA and the anesthesia physician 433 00:16:09,179 --> 00:16:09,679 are, 434 00:16:10,139 --> 00:16:10,960 getting less. 435 00:16:11,820 --> 00:16:13,519 Salaries are going up. 436 00:16:14,220 --> 00:16:17,179 This makes for an impossible scenario. You can't 437 00:16:17,179 --> 00:16:18,000 cut reimbursements 438 00:16:18,875 --> 00:16:21,195 and increase and have an increased cost of 439 00:16:21,195 --> 00:16:21,695 living, 440 00:16:22,955 --> 00:16:24,095 and plus competition 441 00:16:24,475 --> 00:16:25,134 as well, 442 00:16:25,835 --> 00:16:26,894 increase in salaries, 443 00:16:27,355 --> 00:16:27,855 and, 444 00:16:28,315 --> 00:16:28,815 expect 445 00:16:29,355 --> 00:16:31,534 the revenue from your insurance company 446 00:16:32,860 --> 00:16:35,980 reimbursement to cover everything. So what I've been 447 00:16:35,980 --> 00:16:37,120 seeing in our institution 448 00:16:37,659 --> 00:16:40,459 is that, unfortunately, our anesthesia group has had 449 00:16:40,459 --> 00:16:42,959 to ask the ambulatory surgery center 450 00:16:43,259 --> 00:16:46,059 to start paying outside. In other words, paying 451 00:16:46,059 --> 00:16:46,559 the 452 00:16:46,914 --> 00:16:49,095 ambulatory, the anesthesia group separately. 453 00:16:49,634 --> 00:16:50,134 And 454 00:16:50,674 --> 00:16:52,774 the anesthesia group is telling the, 455 00:16:53,235 --> 00:16:54,774 ambulatory surgery center, 456 00:16:55,715 --> 00:16:56,855 you keep the collections 457 00:16:57,315 --> 00:16:59,830 because it's just not enough. And this, unfortunately, 458 00:17:00,050 --> 00:17:02,450 means that the ambulatory surgery center has to 459 00:17:02,450 --> 00:17:04,769 dig into its profits to pay for an 460 00:17:04,769 --> 00:17:05,990 anesthesia group now. 461 00:17:06,369 --> 00:17:06,769 And, 462 00:17:07,410 --> 00:17:07,970 this is, 463 00:17:08,529 --> 00:17:10,210 this is a big strain. It's a big, 464 00:17:10,609 --> 00:17:11,170 it's a big, 465 00:17:12,454 --> 00:17:13,894 chunk of money. This is not, 466 00:17:14,934 --> 00:17:17,015 small amounts of money we're talking about here, 467 00:17:17,015 --> 00:17:19,095 especially if you're running a four to six 468 00:17:19,095 --> 00:17:21,994 room ambulatory surgery center. So 469 00:17:23,015 --> 00:17:26,079 what does this bring? This brings the anesthesia 470 00:17:26,079 --> 00:17:28,480 group saying that we're not just here asking 471 00:17:28,480 --> 00:17:31,839 for reimbursements and and increased reimbursements or increased 472 00:17:31,839 --> 00:17:32,339 money. 473 00:17:32,720 --> 00:17:34,319 This is what we're bringing to you. They 474 00:17:34,400 --> 00:17:36,480 we're bringing to you top of the top 475 00:17:36,480 --> 00:17:38,964 of the top of the line, cutting edge, 476 00:17:40,164 --> 00:17:40,664 anesthesia 477 00:17:41,045 --> 00:17:43,605 nerve blockade for outpatient surgery where your patients 478 00:17:43,605 --> 00:17:45,605 are going home, and they're basically not taking 479 00:17:45,605 --> 00:17:48,825 any narcotics. The surgeons have almost stopped prescribing 480 00:17:48,964 --> 00:17:49,464 narcotics 481 00:17:50,005 --> 00:17:52,904 if if if not severely curtailing their narcotic 482 00:17:53,269 --> 00:17:53,769 prescriptions, 483 00:17:54,149 --> 00:17:55,529 sometimes switching to 484 00:17:55,909 --> 00:17:59,509 lesser, quote, unquote, lesser forms of, narcotics like 485 00:17:59,509 --> 00:18:00,730 tramadol versus, 486 00:18:01,429 --> 00:18:02,329 using oxycodone. 487 00:18:03,190 --> 00:18:04,950 And, some of the patients are not even 488 00:18:04,950 --> 00:18:05,690 taking that. 489 00:18:06,149 --> 00:18:07,130 This is a big 490 00:18:07,634 --> 00:18:08,115 deal, 491 00:18:08,434 --> 00:18:11,174 when it comes to advocating for the group. 492 00:18:11,714 --> 00:18:13,555 The surgeons will be the first person to 493 00:18:13,555 --> 00:18:16,275 advocate for them. Any anesthesia group that adopts 494 00:18:16,275 --> 00:18:17,255 this type of, 495 00:18:18,755 --> 00:18:21,555 for outpatient orthopedic surgery or for perhaps other 496 00:18:21,555 --> 00:18:23,519 types of surgery. This will work for tap 497 00:18:23,519 --> 00:18:25,059 blocks. This will work for, 498 00:18:25,680 --> 00:18:27,299 the surgeons doing infiltrations 499 00:18:27,600 --> 00:18:29,619 when when they're using liposomal bupivacaine, 500 00:18:29,920 --> 00:18:32,500 whether they're general surgeons or OBGYNs. 501 00:18:33,359 --> 00:18:35,299 If they add preservative free dexamethasone 502 00:18:36,095 --> 00:18:39,134 to their liposomal butpivacaine and acryl's butpivacaine mixture, 503 00:18:39,134 --> 00:18:41,535 it's gonna make their blocks last longer. Again, 504 00:18:41,535 --> 00:18:43,535 no data. It needs to be studied. This 505 00:18:43,535 --> 00:18:45,134 needs to be shown to be the case. 506 00:18:45,134 --> 00:18:47,295 Maybe like the ACL study, it'll be shown 507 00:18:47,295 --> 00:18:49,789 that the difference in adding the in the 508 00:18:49,789 --> 00:18:51,009 preservative free dexamethasone 509 00:18:51,549 --> 00:18:54,350 doesn't make a clinically significant difference. But, again, 510 00:18:54,350 --> 00:18:56,769 this is, these are avenues right for, 511 00:18:57,230 --> 00:18:59,330 study in the future. But, again, the anesthesia 512 00:18:59,390 --> 00:19:00,670 group can say, look at what we're doing 513 00:19:00,670 --> 00:19:03,090 with your outpatient ambulatory orthopedic surgeries. 514 00:19:03,544 --> 00:19:06,025 This is what we're bringing. No pain, no 515 00:19:06,025 --> 00:19:08,664 narcotic use to minimal narcotic use. That's a 516 00:19:08,664 --> 00:19:09,404 big draw, 517 00:19:09,865 --> 00:19:11,804 especially in this day and age of, 518 00:19:12,265 --> 00:19:12,765 opioid, 519 00:19:13,304 --> 00:19:13,804 epidemics, 520 00:19:14,585 --> 00:19:16,424 the no pain act that was just passed 521 00:19:16,424 --> 00:19:17,464 for 2025 522 00:19:17,464 --> 00:19:18,204 in congress. 523 00:19:20,190 --> 00:19:21,910 The the this can be only a feather 524 00:19:21,910 --> 00:19:23,589 in the cap of the anesthesia group that 525 00:19:23,589 --> 00:19:24,730 adopts these measures. 526 00:19:25,750 --> 00:19:27,349 Mhmm. Absolutely. I mean, it sounds like a 527 00:19:27,349 --> 00:19:29,349 a win win for, you know, physicians and 528 00:19:29,349 --> 00:19:31,029 for patients, you know, given the the benefit 529 00:19:31,029 --> 00:19:31,529 to, 530 00:19:32,309 --> 00:19:35,384 the added value that anesthesiologists would be bringing 531 00:19:35,384 --> 00:19:37,184 given, you know, this clinical development. And then 532 00:19:37,184 --> 00:19:38,444 it is also the 533 00:19:38,744 --> 00:19:41,865 improvement in patient patient satisfaction and overall outcomes. 534 00:19:41,865 --> 00:19:43,944 Just, yeah, like, that seems win win. When 535 00:19:43,944 --> 00:19:45,325 you mentioned patient satisfaction, 536 00:19:45,625 --> 00:19:47,819 we're going to be start to be reimbursements 537 00:19:47,819 --> 00:19:50,079 are gonna be tied to patient satisfaction scores. 538 00:19:50,859 --> 00:19:53,039 Mhmm. So all of it comes it becomes 539 00:19:53,099 --> 00:19:53,839 one big 540 00:19:54,220 --> 00:19:56,619 box present with a bow tie on top, 541 00:19:56,619 --> 00:19:58,240 and you give that to the anesthesia, 542 00:19:58,940 --> 00:19:59,440 ASC, 543 00:20:00,615 --> 00:20:01,835 provide the administrator. 544 00:20:02,295 --> 00:20:03,035 And, hopefully, 545 00:20:03,335 --> 00:20:04,775 you know, they take it with a grain 546 00:20:04,775 --> 00:20:06,375 of salt, and they see the benefit in 547 00:20:06,375 --> 00:20:06,875 that. 548 00:20:07,575 --> 00:20:08,075 Absolutely. 549 00:20:08,535 --> 00:20:09,035 Yeah. 550 00:20:09,654 --> 00:20:12,215 Great. Yeah. Absolutely. And, you know, taking a 551 00:20:12,215 --> 00:20:14,215 bit of a step back away from, this 552 00:20:14,215 --> 00:20:16,529 development, are what are some other trends that 553 00:20:16,589 --> 00:20:19,069 you're following in health care and in ASCs 554 00:20:19,069 --> 00:20:19,569 today? 555 00:20:22,349 --> 00:20:22,849 So 556 00:20:24,029 --> 00:20:26,430 the to me, these are the number one 557 00:20:26,430 --> 00:20:27,730 and number two issues. 558 00:20:29,075 --> 00:20:31,815 For at least for ambulatory orthopedic surgery centers. 559 00:20:32,515 --> 00:20:34,515 Obviously, what I'm saying is not going to 560 00:20:34,515 --> 00:20:36,615 affect places that do colonoscopies 561 00:20:37,075 --> 00:20:38,694 and endoscopies. That, 562 00:20:39,714 --> 00:20:42,035 that I that is outside of my purview. 563 00:20:42,035 --> 00:20:44,309 We don't do that at my institution. But 564 00:20:44,309 --> 00:20:47,450 any place that does outpatient ambulatory orthopedic surgery 565 00:20:47,670 --> 00:20:50,569 is definitely gonna be benefiting from this. And, 566 00:20:50,710 --> 00:20:52,869 unfortunately, what I see in the future is 567 00:20:52,869 --> 00:20:55,029 is is is this is the trend that 568 00:20:55,029 --> 00:20:56,710 we're seeing. We're going to be seeing more 569 00:20:56,710 --> 00:20:58,170 and more anesthesia groups, 570 00:21:00,115 --> 00:21:00,615 requesting, 571 00:21:01,234 --> 00:21:03,494 their payments directly from the ASC 572 00:21:03,795 --> 00:21:06,055 with cutting into the profits of the ASC, 573 00:21:06,115 --> 00:21:08,115 while the ASC now struggles to make their 574 00:21:08,115 --> 00:21:11,154 collections from the insurance companies for anesthesia services 575 00:21:11,154 --> 00:21:11,640 provided. 576 00:21:12,680 --> 00:21:14,779 This puts an undue burden on the ASC, 577 00:21:15,240 --> 00:21:15,740 unfortunately, 578 00:21:17,079 --> 00:21:17,579 but 579 00:21:18,119 --> 00:21:20,920 I there there's just I don't see how 580 00:21:20,920 --> 00:21:22,619 it's going to change. If 581 00:21:23,160 --> 00:21:25,660 the government keeps cutting reimbursement rates, 582 00:21:26,204 --> 00:21:29,664 and as we know, inflation is constantly there, 583 00:21:30,125 --> 00:21:31,744 as a backdrop to our 584 00:21:32,125 --> 00:21:33,025 yearly lives, 585 00:21:33,724 --> 00:21:35,644 in cost of living is gonna go up. 586 00:21:35,644 --> 00:21:37,724 They're gonna have to be competitive. ASCs are 587 00:21:37,724 --> 00:21:38,784 gonna have to offer, 588 00:21:39,089 --> 00:21:40,849 or an anesthesia groups are gonna have to 589 00:21:40,849 --> 00:21:41,990 keep up with their salaries. 590 00:21:42,450 --> 00:21:44,289 And the salaries are increasing by two to 591 00:21:44,289 --> 00:21:46,609 3% every year, if not more, since some 592 00:21:46,609 --> 00:21:47,109 places, 593 00:21:47,410 --> 00:21:49,269 depending on where you are. And 594 00:21:49,650 --> 00:21:51,490 in order to do that, you're not you 595 00:21:51,490 --> 00:21:54,525 can't depend on reimbursement from the private insurance 596 00:21:54,525 --> 00:21:55,744 companies or the, 597 00:21:56,924 --> 00:21:59,244 government. Obviously, not the government for a long 598 00:21:59,244 --> 00:22:00,865 time. It's not been enough. 599 00:22:01,164 --> 00:22:04,544 But, with the the the the what's really 600 00:22:04,779 --> 00:22:06,460 been impactful in the past couple of years 601 00:22:06,460 --> 00:22:08,880 is that now even the private insurance reimbursement 602 00:22:08,940 --> 00:22:09,920 rates are not enough. 603 00:22:10,940 --> 00:22:13,839 If you're sick and your ASC patient population 604 00:22:14,220 --> 00:22:16,160 starts to change, what was good 605 00:22:16,539 --> 00:22:18,884 two, three, three, four years ago may not 606 00:22:18,884 --> 00:22:21,545 be any good anymore because suddenly the demographics 607 00:22:21,684 --> 00:22:23,924 of who's coming to your surgery center. New 608 00:22:23,924 --> 00:22:27,065 surgeons are onboarded. Old surgeons start to retire. 609 00:22:27,285 --> 00:22:28,585 So the patient demographic 610 00:22:29,445 --> 00:22:30,809 may start to mix also. 611 00:22:31,210 --> 00:22:33,690 And once that happens, you can't rely on 612 00:22:33,690 --> 00:22:35,930 past performance. As we know, past performance is 613 00:22:35,930 --> 00:22:37,470 no indication of future returns. 614 00:22:38,490 --> 00:22:38,990 So, 615 00:22:40,009 --> 00:22:42,410 this is a big stress on ASCs, and 616 00:22:42,410 --> 00:22:44,490 I think we're gonna see a slowing down, 617 00:22:44,490 --> 00:22:46,394 if not already, in the, 618 00:22:46,955 --> 00:22:49,835 upstart of new openings of ASCs around the 619 00:22:49,835 --> 00:22:50,335 country. 620 00:22:51,355 --> 00:22:53,515 Absolutely. This is a big time. This is 621 00:22:53,515 --> 00:22:54,955 an alarm sort of a canary in a 622 00:22:54,955 --> 00:22:55,695 coal mine. 623 00:22:56,555 --> 00:22:59,039 Mhmm. Yeah. Definitely. And I think that that's 624 00:22:59,279 --> 00:23:01,600 echoing concerns I've heard from other ASC leaders 625 00:23:01,600 --> 00:23:02,259 as well. 626 00:23:02,720 --> 00:23:04,000 Kind of on the flip side of, you 627 00:23:04,000 --> 00:23:06,240 know, concerns, this is obviously an incredibly exciting 628 00:23:06,240 --> 00:23:06,740 development. 629 00:23:07,119 --> 00:23:09,279 What else are you excited about right now 630 00:23:09,279 --> 00:23:10,340 in this space? 631 00:23:11,275 --> 00:23:11,775 Oh, 632 00:23:14,474 --> 00:23:16,875 if anything. I I that's what I just 633 00:23:16,875 --> 00:23:19,194 said. Really nothing because everything I just told 634 00:23:19,194 --> 00:23:20,015 you has eclipsed, 635 00:23:20,795 --> 00:23:22,234 my view of, 636 00:23:22,634 --> 00:23:25,089 of the future for it's been a while 637 00:23:25,089 --> 00:23:26,769 now. My head's been my nose has been 638 00:23:26,769 --> 00:23:29,169 in the grindstone, and I'm just now taking, 639 00:23:29,409 --> 00:23:31,649 time to look up and get get some 640 00:23:31,649 --> 00:23:34,630 air. So I I'll I'll defer that question, 641 00:23:35,329 --> 00:23:37,190 to perhaps another interviewee. 642 00:23:37,845 --> 00:23:39,605 Gotcha. Gotcha. No worries. I mean, I can 643 00:23:39,605 --> 00:23:42,005 completely completely understand that. And everything you've discussed 644 00:23:42,005 --> 00:23:43,365 so far is also just kind of so 645 00:23:43,365 --> 00:23:45,625 interconnected between the clinical developments, 646 00:23:46,164 --> 00:23:48,664 you know, outcomes for patients, and then obviously, 647 00:23:48,964 --> 00:23:51,684 the sustainability of, ASCs in the future. So 648 00:23:51,684 --> 00:23:54,069 I can understand how that's definitely, like you 649 00:23:54,069 --> 00:23:55,529 said, just eclipsing everything. 650 00:23:56,230 --> 00:23:57,669 We are kinda close to time here. Is 651 00:23:57,669 --> 00:23:59,829 there anything that we haven't touched on so 652 00:23:59,829 --> 00:24:01,289 far that you would like to mention? 653 00:24:03,109 --> 00:24:06,389 Again, I, if, anybody's interested in the work 654 00:24:06,389 --> 00:24:07,049 we're doing, 655 00:24:07,755 --> 00:24:10,234 obviously, we'll be publishing soon in the online 656 00:24:10,234 --> 00:24:11,615 journal of sports medicine. 657 00:24:12,154 --> 00:24:13,755 We will be submitting the foot and ankle 658 00:24:13,755 --> 00:24:16,154 study, but I we haven't decided which journal 659 00:24:16,154 --> 00:24:18,955 yet to, we're waiting to to hear from, 660 00:24:19,195 --> 00:24:21,210 back from a few. But if anybody has 661 00:24:21,210 --> 00:24:21,950 any questions, 662 00:24:22,410 --> 00:24:23,950 feel free to reach out to me. 663 00:24:24,250 --> 00:24:26,809 You can either do that through LinkedIn or 664 00:24:26,809 --> 00:24:28,509 I'm sure through Becker's ASC. 665 00:24:29,210 --> 00:24:30,650 People can get in touch with me as 666 00:24:30,650 --> 00:24:32,029 well. I would love to share, 667 00:24:32,809 --> 00:24:34,990 my data anecdotal or or otherwise 668 00:24:35,315 --> 00:24:37,234 with anybody interested in bringing this type of 669 00:24:37,234 --> 00:24:38,054 cutting edge, 670 00:24:38,835 --> 00:24:41,815 regional ultrasound guided regional anesthesia to, 671 00:24:42,275 --> 00:24:44,454 their ASC. I it would be my pleasure. 672 00:24:45,474 --> 00:24:45,974 Absolutely. 673 00:24:46,434 --> 00:24:47,875 Alright. Well, that is all I have for 674 00:24:47,875 --> 00:24:49,529 you today, Armin. Thank you so much for 675 00:24:49,529 --> 00:24:51,049 for joining us. Thank you so much. I 676 00:24:51,049 --> 00:24:51,869 appreciate it. 677 00:24:52,730 --> 00:24:53,230 Yes. 678 00:24:53,930 --> 00:24:55,609 Yeah. Yeah. Of course. We're yeah. I'm so 679 00:24:55,609 --> 00:24:57,789 excited to hear more about your findings, 680 00:24:58,090 --> 00:24:59,609 and I look forward to connecting with you 681 00:24:59,609 --> 00:25:00,509 again in the future. 682 00:25:01,289 --> 00:25:03,605 Likewise. Thank you so much. Absolutely. You have 683 00:25:03,605 --> 00:25:06,265 a good one. Thank you. Bye bye. Bye.