#208 It's an OpenAnesthesia Takeover Show

Unlock the secrets of enhancing perioperative patient safety with insights from experts in anesthesiology and critical care. Join us as we welcome Dr. Debnath Chatterjee, the editor-in-chief of OpenAnesthesia, who sheds light on the incredible educational resources available on the platform. From peer-reviewed mini-reviews to engaging podcasts and vodcasts, discover how OpenAnesthesia is making a global impact, benefiting both trainees and seasoned clinicians.

We are excited to share one of the OpenAnesthesia Ask the Experts Podcasts on our show today.

Journey with us into the realm of pediatric anesthesia as Dr. Britta Regli-von Ungern-Sternberg and OpenAnesthesia Editor Dr. Jina Sinskey discuss perioperative respiratory adverse events in pediatric patients. Reflecting on the pivotal 2010 Lancet study and the more recent APRICOT study, we explore how anesthesia practices have evolved. Learn about the significant shift towards Total Intravenous Anesthesia (TIVA) and the reduced use of Desflurane, alongside practical recommendations like using propofol for high-risk children and preoperative salbutamol administration to mitigate respiratory risks.

Gain a unique perspective on the challenges faced by Perth’s sole children's hospital, especially in managing pediatric cases involving upper respiratory tract infections, including COVID-19. Through detailed insights, understand the criteria for proceeding with or canceling procedures and the logistical hurdles for rural and remote patients. Emphasizing the importance of experience, communication, and tailored approaches, this episode also navigates the balancing act of pursuing a career in academic medicine. Discover the value of mentorship, the necessity of maintaining personal relationships, and the flexibility required to thrive in both professional and personal spheres.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/208-its-an-openanesthesia-takeover-show/

© 2024, The Anesthesia Patient Safety Foundation

Transcript

Marjorie Striegler: 0:01

You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

Alli Bechtel: 0:28

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel and I'm your host. Thank you for joining us for another show. We have an exciting collaboration announcement and takeover show for you today. I will give you a hint. We are collaborating with a team that provides high quality, peer-reviewed educational content for trainees and professionals in the field of anesthesiology and other related fields. Before we dive into the episode today, we'd like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, blink Device Company. We wouldn't be able to do all that we do without you. To kick off the show today, we have a special guest to tell us all about open anesthesia. Here he is now.

Debnath Chatterjee: 1:37

Hello. I'm Debnath Chatterjee, a pediatric anesthesiologist at Children's Hospital Colorado and a professor of anesthesiology at the University of Colorado School of Medicine. I'm the editor-in-chief of Open Anesthesia. Open Anesthesia offers free online access to comprehensive, peer-reviewed educational content on various anesthesiology, critical care and pedioperative medicine topics. Our website includes summaries, which are essentially mini-reviews, of ABA keywords and high-yield topics, podcast interviews with experts in the field, vodcasts covering a wide range of subspecialty topics and many more valuable resources for trainees and clinicians and many more valuable resources for trainees and clinicians. Open Anesthesia is sponsored by the International Anesthesia Research Society. I'm very passionate about Open Anesthesia because our educational content is widely disseminated and the outreach is incredible. Our website is used by trainees and clinicians not only in the United States but worldwide, including some low resource settings. Our goal is to advance patient care by providing high quality educational resources, and it is very professionally satisfying to be able to do that.

Debnath Chatterjee: 3:03

I have been involved with open anesthesia since 2015, when I started as a pediatric anesthesia section editor, recording podcasts and videos. I interviewed several amazing thought leaders in our field and learned a lot in the process. I became the editor-in-chief in 2022. Since then, we have put together a new editorial board with several awesome section editors and associate editors, and the support from the IARS has been fantastic. I'm constantly inspired by all the incredible work done by our team. We have several new collaborations and projects in the works. We have several new collaborations and projects in the works. This collaboration with APSF, sharing podcasts and videos, is one example. In another collaboration with the Society for Pediatric Anesthesia, the SPA, we are developing a curriculum on non-technical skills for anesthesiologists. We are also working on a DEI curriculum with the SPA and the Society for Education in Anesthesia. A Latin American special interest group from the SPA is creating new educational content in Spanish, which is going to be awesome. I'm really excited about all these projects.

Alli Bechtel: 4:20

Thank you so much to Chatterjee for helping to kick off the show today. We are really excited to explore all the new projects too. Open Anesthesia is such a great resource for educational content related to anesthesia care, perioperative care and critical care. Keeping up to date with a strong knowledge base is vital for keeping patients safe during anesthesia care. We hope that you will head over to openanesthesiaorg and check out their podcasts, mini reviews and additional resources. Plus, you can find the APSF podcast and APSF safety videos over at openanesthesiaorg under the resources heading. I will include the links in the show notes as well. Now we are so excited to tune in to one of the great Open Anesthesia Ask the Experts podcast shows. This show is the Open Anesthesia Society of Pediatric Anesthesia Ask the Expert podcast perioperative Respiratory Adverse Events in Pediatric Patients, published online on May 10, 2024. In this show, D dr. Britta Regli von Ungern-Sternberg and Open Anesthesia Editor, D dr. J Gina Sinskey discuss perioperative respiratory adverse events in pediatric patients. Let's take a listen now.

Jina Sinskey: 5:52

Hello, this is Dr J Gina Sinskey and you are listening to the Open Anesthesia and Society for Pediatric Anesthesias Ask the Expert podcast. I am here with Dr Britta Regli von Ungern-Sternberg to discuss perioperative respiratory adverse events in pediatric patients. Dr Regli-Von Ungern-Sternberg is a specialist pediatric anesthetist at Perth Children's Hospital in Australia. She holds the foundation chair of pediatric anesthesia at the University of Western Australia, which is the first of its kind in Australasia, which is the first of its kind in Australasia. She is also the Director of the Institute for Pediatric Perioperative Excellence at the University of Western Australia and the Program Lead for Perioperative Care at Perth Children's Hospital. She leads the most active pediatric anesthesia research program in Australasia, which is also an internationally leading program focusing on continuously driving improvements in the safety and quality of care along the perioperative pathway. Dr Wrigley von Ungern-Sternberg, thank you and welcome.

Britta Regli-von Ungern-Sternberg : 6:52

Thank you so much for having me this morning. It's a real pleasure to be with you here.

Jina Sinskey: 6:56

Absolutely. Can you begin by telling us about your personal journey and how perioperative respiratory adverse events in pediatric patients became a clinical and research interest of yours?

Britta Regli-von Ungern-Sternberg : 7:07

Absolutely. Actually, I have to go quite a way back in that, and it all started with a bit of a random event. We moved from Munich into Freiburg, which is a university city, when I was 14. And I hardly knew anyone, and one of my very few friends convinced me randomly in the school holidays we had nothing better to do to do a nursing aid course. How on earth we got to that, I don't know the only thing. I know that I went to do the course and my friend didn't. So I got in contact and I learned about this on John's Ambulance and really enjoyed it and actually in the end from that went on to, while finishing school and doing medical school, also training as a paramedic. And while I was training as a paramedic and then working as a paramedic, I was the only female paramedic at the time in town, so people were always looking at me a bit like who's this person? That's really strange. Why is this girl coming off the ambulance? Off the ambulance?

Britta Regli-von Ungern-Sternberg : 7:52

One night it was really hectic and I kept coming to the intensive care unit dropping off patients directly because ED was too busy which again was something very, very rare to happen and the doctor got really upset and said why is there no doctor? Because we have emergency doctors on the street. Why is there no doctor? Why do you keep bringing patients and you're not a doctor and you shouldn't be bringing it and the doctor should be there. I'm terribly sorry, but he left us another patient, so we were just tasked to bring the patient I'm here. And he said well, why are you here? As a girl and I felt quite offended and we kept coming back and then at the end of the shift he said I'm so sorry, I was really inappropriate. Can I make it up? Can we have breakfast together? So we did. We actually became quite close. He said well, at the end of breakfast I actually had not only sort of forgiven him for his inappropriate comments but also signed up to do an MD thesis with him at the university, to do my MD course in experimental anesthesia, which was sort of really by the chance of many chances. So there I was working on different ventricular modes and lung physiology and my professor was actually someone very different, was a professor for physics and bioengineering, professor Goodman, an amazing person. Professor Goodman was then the one who really sort of sparked my interest into lung physiology and ventilation, and then again by many other weird coincidences which I won't go into.

Britta Regli-von Ungern-Sternberg : 9:09

I did electives in lots of places overseas and one of them was Sydney. That was all now doing medical school, and in Sydney I was working in an adult hospital and again some consultant said to me oh, I think you would really like pediatrics. And I hadn't even thought about pediatrics at all. And he said well, what about tomorrow? You just come along and because he was working in different hospitals, took me along and I did pediatric anesthesia with him and I went like this is amazing, and I always had that in the back of my mind wanted to go and start my first residency job, which I had a verbal offer.

Britta Regli-von Ungern-Sternberg : 9:36

Due to, again, a huge amount of various weird circumstances that one actually fell through and I went to Switzerland instead where the team was working on respiratory physiology and was again doing lots of research as a very junior trainee. Obviously, I wasn't included. But then again in a night shift I was talking to one of the consultants who was working on that research team and he said to me oh, I can see you already have an MD, because in Germany if you finish medical school you are a doctor but you don't have an MD. So he could see that I've done a proper research MD and said, oh, what was it in? And it turned out that he had done his PhD in the partner group of my group where I had done my MD.

Britta Regli-von Ungern-Sternberg : 10:14

So very early on, actually my very first year out of university, I went back into research in parallel to my clinical training and working in lung physiology and I sort of got stuck there and while working and going through training I realized where are the big problems? I said, well, let's improve the outcomes where the clinical problems are, because of the big background I had in lung physiology. Obviously respiratory complications come very close if you work in pediatric anesthesia and that's how it all came along, wow.

Jina Sinskey: 10:40

So many things aligned for your career to be the way it has been, and you've been all over the world.

Britta Regli-von Ungern-Sternberg : 10:45

It sounds like and just by chance, going places by chance, just following my instinct, my love for traveling and, yeah, having an open mind, going oh this is interesting, let's go there, and people just suggesting things to me and going with the flow, and it brought me to where I'm really happy to be.

Jina Sinskey: 11:03

That's fantastic. Our pediatric patients are so lucky that you are on this path because you've done some really groundbreaking research in this topic. And I agree, in pediatric patients, respiratory events can be really, really scary and difficult to manage. So before we jump into our topic today, for our listeners, can you describe what would be defined as a perioperative respiratory adverse event for pediatric patients?

Britta Regli-von Ungern-Sternberg : 11:26

Unfortunately, there's actually no official standardized definition of perioperative respiratory adverse events in the literature, but we in general sort of see them and more and more people are taking over that it is a group of laryngospasm, bronchospasm, hypopneas, apneas, breath holding, hypoxemia, desaturations.

Britta Regli-von Ungern-Sternberg : 11:43

Again, the definition of desaturation varies widely, whether it's under 95 percent, under 90 percent, under 80 percent, severe persistent coughing, airway obstruction and stridor. I think what is one of the things we actually work towards is really defining them strictly. Obviously, in a lot of work we've done with our collaborators, we had very strict definitions how we define the respiratory adverse events and because we have done with our collaborators a lot of work over a long time, a lot of our body of evidence follows the same definitions. But a lot of the evidence out there unfortunately follows very different definitions as well, which also explains why the differences in respiratory adverse events are so enormous. When looking at literature, Some report 0.1 percent, some 15, some 30 percent. It's mainly down to the definitions, which also is the problem with many international studies. If they haven't had clear definitions, the results can be very, very difficult to interpret.

Jina Sinskey: 12:32

That's a great point. You can't study what you can't measure accurately. Interpret that's a great point. You can't study what you can't measure accurately, and when there's different definitions depending on who's doing the study, then it can be really difficult to bring all that data together. One paper that I've read as a trainee and I've actually recommended to my trainees is a paper that you published a while ago in Lancet in 2010., and it was titled Risk Assessment for Respiratory Complications in Pediatric Anesthesia, and it was a prospective cohort study and it's considered to be a landmark study on this topic in children. One of the key findings was that an upper respiratory tract infection, or URI, was associated with an increased risk for having a perioperative respiratory adverse event if it was less than two weeks before the procedure or when patients had symptoms. And do you think much has changed since this study was published in 2010?

Britta Regli-von Ungern-Sternberg : 13:23

Good question. So the answer would be yes and no. Our understanding has greatly advanced. There have been multiple follow-up RCTs from our large team but also from other teams around the world. Obviously, in Europe the APRICOT study also was an even bigger cohort looking at slightly different outcomes but very similar to ours. Not very surprising because Wollet Haber, who the APRICOT study, was actually my ex-boss in Geneva and I trained under him. He helped me design our cohort so we had both a lot of say in each of them. So they are more comparable than others, even though they didn't have the exactly same outcomes, but they had a lot of similar definitions. Interestingly, the apricot study had very, very similar values. What they found in the respiratory complications, also even the decrease in respiratory adverse events with every increase in age. So we see about an 11 percent decrease in respiratory adverse events every year you get older and it's near identical in apricot. So that is fascinating that the data have actually been sort of validated from a completely different area in the world. But we've gained understanding so far with lots of follow-up rct. So, for example, assessing iv versus inhalation induction in high-risk children and looking at different airway devices when to take out the airway device.

Britta Regli-von Ungern-Sternberg : 14:35

So we have learned, we have moved on. We have learned and also changed our anaesthesia practice. So when we did it back in 2007, when the data is actually 2007, 2008, there was basically everyone had a zero fluorine anaesthetic. There was isofluorine still there, which we hardly use. Desfluorine was still used, which we're not using at all anymore. Andiva was very little, whereas I think we have extremely changed now and using a lot more tiva around the place. We're using our different agents which come with a different profile for respiratory adverse events.

Britta Regli-von Ungern-Sternberg : 15:05

So, yes, some things have changed. We have actually have two more cords in the pipeline which we're analyzing at the moment and we can actually see some changes, but a lot of it still holds true. So, for example, the less than two weeks before the procedure holds true. We have, I think, in general, through the RCTs which have been done around the world, found slightly better ways, for example, using more laryngeal mask airways and ATTs, less invasive airways in general. That has brought down complications. Using more TEVA has brought down complications. Using more Teva has brought down complications. So I think we have moved forward as a speciality, particularly through our great international networks, because we have such wonderful networks all around the globe of researchers and clinicians working together, and I think that's what's really helping us to improve the care we give to our children.

Jina Sinskey: 15:51

I love the fact that you know you're talking about working with Dr Harpreet, who's in Europe, and just it's such a small world and the fact that you're able to collaborate with people across the globe. I think that really brings strength into your studies and generalizability. And what I really like about your work is that you know you've not only defined the problem but you've gotten this like one step further and really conducted studies on strategies to reduce the risk of perioperative respiratory adverse events in pediatric patients. And going back to what you mentioned about TEVA, are there specific agents that you would recommend for pediatric patients?

Britta Regli-von Ungern-Sternberg : 16:25

Pediatrics. It's not a black and white field. So, for example, what we know and even a lot of the studies we've done, for example, iv versus inhalation induction so it brings, you know, propofol or gas at induction We've shown that a very high-risk patient is safer to do an IV induction. Would I now say everyone should have an IV induction? No, because a lot of children with needle phobia. It wouldn't be good. You upset them before they come into the state and they actually then do worse. So I think yes, if it's appropriate for the child, they're cooperative.

Britta Regli-von Ungern-Sternberg : 16:54

To have propofol, it's hugely beneficial. We know it blunts the airway reflectors a lot more, has some bronchodilatation properties not as much as Sivaflorene, but still enough. So it is a safer agent to use compared to our gases. It's also better for the environment and greenhouse gases. So I think there's a lot of things to speak towards using more Teva in our patients Using Sabutamol, for example, before procedures, either in children who are undergoing tonsillectomies or in children who have an ongoing upper respiratory tract infection.

Britta Regli-von Ungern-Sternberg : 17:24

It's very cheap. It's a drug which is everywhere available. I think that is also an agent which we should be using more and more. We can then later, you know, give the puffer back to the families and they can keep on using it, because the kids at risk factors tend to be the ones who have it prescribed anyway. So you don't have the extra cost or environmental load because of it. So I think, yes, we should be changing our agents a little bit away. Desiroin is definitely. We in Perth don't have it at all anymore. We can't even find it in the storeroom anymore. It's not good for the environment and it's definitely not good for kids lungs. It's really we can see that as soon as we turn it on, the lungs bronchoconstrict and we see a massive increase in resistance, even children who don't have any bronchohyperactivity. So it's a drug we should definitely avoid. But I think at least in australia most centers have stopped using it.

Jina Sinskey: 18:09

Yeah, I believe that's the case in the States too. Especially with the greenhouse gas effects and as well as the bronchospasm and other airway complications in both children and adults, I feel like the use of despoin has decreased quite a bit. You talked about albuterol. I use a lot of that. Actually, after reading your studies, in any patient who has a URI and is presenting for a case, thinking about translating this to clinical practice, how do you manage a pediatric patient who's coming in for an elective case with a recent URI? Like when would you, for example, decide to postpone and, if you're proceeding, can you walk us through your approach and your thought process to these patients?

Britta Regli-von Ungern-Sternberg : 18:45

It's obviously kids we see every day because colds are so common. I maybe have to say also in Perth how we practice. We're the only children's hospital over a massive amount of geographical area so some of our patients travel for two and a half thousand kilometres to get to us. So to cancel them and say please come back tomorrow is not such an easy task. In some of them Obviously our metropolitan patients in the city, like in any other major centre, but a lot of our regional and rural patients it is very hard and we have to think about three times whether we actually cancel them because the impact on the families would be enormous. So I probably have to put that as a cautionary background for everyone to know where we come from. But in general, so if someone comes with an upper respiratory tract infection actually including COVID-19, we assess them whether they have a mild upper respiratory tract infection as we normally define as a clear runny nose or a dry cough. So very clinical, no measurements, no assessments of any viruses, a moderate urt which is more like a green runny nose, a severe dry cough or mild moist cough, or whether it's a severe upper respiratory infection, a good going covid and a really lethargic child with a green non-Urban really severely ill. If a child has a severe urt or current covid, we will cancel the child unless obviously it's an urgent procedure. If they have a mild URTI we will nearly always go ahead. There are only very few circumstances where it's more the surgeons who don't want it. So for example, our cochlear surgeons, they don't want anyone with a cold, they will not do the cochlears. But in general, for anything else we will go ahead. For the moderate early it's really the individual looking at that particular patient. What is that particular patient's individual risk-benefit ratio? So if we look at factors which will be in favour in proceeding, we obviously have an experienced paediatric, anaesthetist and team. We have some sort of satellite places where people might work or work in private practice. The experience of the team might not be the same, even though it's the same in A3s, who's greatly experienced, but the nursing recovery maybe not. If we're, for example, in Perth Children's, it's not a problem. We've got a fantastic positive care unit. Then we can go ahead with a lot more cases. So I think it's really important to think about where am I not, what are just my skills, but what is actually the skills of the people around me, because what happens if I've started the next case and I can't go and solve the problem? Who's going to actually solve the problem? So I think that's what we have to do is number one really in our mind.

Britta Regli-von Ungern-Sternberg : 21:00

Has the patient been cancelled many times before? Are there any logistical considerations, like, for example, our rural, remote patients? What is the institutional setting, as I said before, or is extended monitoring possible if we need it? So if you're in a pure day clinic and the child might be more desaturating afterwards and they can't stay overnight, well it's probably not the setting to go ahead, to postpone, if the parents are really worried, we hardly ever go ahead because that can just land you in trouble. If they're worried, we just don't do it. If the patients are immunocompromised if we do, for example, metal, we really talk to our surgical teams. How urgent is it still really to do it? If they're very young kids or have some comorbidities, we'll also not go ahead. But in general we cancel very, very, very rarely.

Britta Regli-von Ungern-Sternberg : 21:44

If we do go ahead, we obviously see what is infectious. Is this problem? So if it's a COVID-19, they're the ones we do cancer with. That's a lot of logistical issues with isolation If there are any other virus. Interestingly, isolation issues not very logically and I have wonderful debates with my infectious disease colleagues about it that I believe that we should probably isolate some of the RSVs also more than others.

Britta Regli-von Ungern-Sternberg : 22:10

But there we go. We need an experienced paediatric team. You probably want to give them all a pre-medication. We'll sell butymol, albuterol as you call it, if we can. An IV induction with propofol would be great, but I will not enforce if the child is not cooperative for it. I'll try and use a non-invasive airway if I can, but we use nearly LMAs in most of our cases in general. Anyway, if you still have it, avoid dextran but they said we don't even have it and then Teva or at least the bolus at the very end before we take the airway out, and take the airway out deep in nearly all of the patients. If I do have to cancel the patients I said we do it very rarely it is good to re-evaluate them at around two weeks and then do the child about two weeks after full symptom resolution.

Jina Sinskey: 22:54

You're talking about art versus the science, right. And when you're thinking about medicine, you know each child is so different, right.

Britta Regli-von Ungern-Sternberg : 22:59

Absolutely, and you just can't. A lot of people say, well, I want the exact values of this one is going to be cancelled and this one is not going to be cancelled, and I don't think that's how we can do it. If a child is lethargic and really unwell, we won't do it, but then most of the time they don't even come into the hospital because the parents won't even bring them in. The ones who are brought in, if they run around, they're happy, they are actually well in themselves and they undergo minor surgery. We do go ahead, but then we do more sort of low risk anesthetics, which, on the other hand, I tend to do for all my patients, so we actually don't have so many changes.

Jina Sinskey: 23:32

I really like the fact that you're thinking about all the social factors as well as the hospital factors, because all of us practice in very different settings and so you have different comfort levels with pediatric patients.

Britta Regli-von Ungern-Sternberg : 23:43

Absolutely. It's a partnership between the whole medical team of everyone, not just us doctors. I think that's what sometimes gets missing. It's really the whole team and the whole family. What is the impact on them? For example, in Switzerland, people have more personal leave when they're sick, more personal leave when the children are sick. In Australia it's very limited so for people to be cancelled and particularly after translecting, the kids are not allowed to go to school for two weeks, so that people have to take a lot of time off, which is really difficult for them in jobs. And you have to actually take that into consideration as well, because you're not going to do anything good for the child if the family gets into financial trouble. It is so many things you have to look after and take into consideration. Where that family's at obviously always at the heart and center is the safety of that particular child. But safety comes in many, many facets as well, that's great advice, especially for pediatric patients.

Jina Sinskey: 24:37

It's not just the patient, it's like this whole kind of microcosm of the family and everything else that's going on. I want to switch gears a little bit from the clinical practice to your research. We talked about the studies you've done and you've had a very successful research career and, as we talked about, you've had multiple collaborations all across the globe and you know I'm sure there are some of our listeners who are really interested in a budding career in research, and do you have any advice for them on how you can build such a career?

Britta Regli-von Ungern-Sternberg : 25:05

I think the main thing is listen to your patients, listen to the families, listen to your colleagues to see where the problems are.

Britta Regli-von Ungern-Sternberg : 25:12

Go around with open eyes and open ears and see where the problems are. You actually start tackling problems which are really problems, because you sort of see researchers hunting something down which academically is highly interesting and I can get absolutely fascinated by it. But the question is, does it really have an impact and does it really change clinical practice? So I think the more it changes clinical practice, so I think the more changes clinical practice, the more it drives you and the more happy your colleagues will be, can come with you on the journey. And so I think if you want to do it, you have to really be passionate about it. Find something which drives you. Don't find something which your boss finds very interesting and you just want to go on the journey and be the good person and try and build your career by being the follower. I think you have to find something which actually drives you which you are happy to do. The main thing is don't be discouraged. One of my big mentors, professor Thomas Erb, who's in Basel in Switzerland, where I spent a lot of my training, he actually always said to me persistence makes the difference. And he kept to me constantly and I've gone like, oh my God, don't tell me again. In the meantime, I actually tell that to my mentees. It is probably one of the best advice. Don't be discouraged.

Britta Regli-von Ungern-Sternberg : 26:16

The road you'll be going in academic medicine is never as straight as the outback roads we have in Australia. They are just dead straight. You can go for hundreds of kilometers. There will not be a turn. It is really more like the windy Swiss mountain roads. There will be twists, there will be turns, there will be weird obstructions, there will be turns, there will be weird obstructions, there will be rock falls, but you will still go up. You will go up that mountain and I think that's the main thing. If there is an obstruction, it's normal. Just move on, be persistent, don't give up. And I think what is also important, keep in mind that we're all more than just researchers. If you just follow the research pathway and you just follow oh, I just want to get the maximum amount of papers out. I want to get the maximum amount of papers out. I want to have the maximum amount of I don't know presentations and meetings or whatever. You forget everything around you and you'll get lost.

Britta Regli-von Ungern-Sternberg : 27:03

I think it's really important to find your own priorities and stick up for yourself and your family, because I'm a mum of three kids. My husband is a full-time intensivist. He works crazy hours. We have absolutely no family here in Australia, so we have very clear rules in our household what we will do and how often we will travel and how often we can go away, and that's why sometimes a lot of the conference invitations I get, I actually have to turn them down, and I turn them down because of the kids, and I'm very happy to do it because I am a mum and that will be my main priority over anything else. So I think that's really important, because you can go down rabbit holes and then that just drains you and it drains the people around you and they're the ones you need to actually keep you going.

Britta Regli-von Ungern-Sternberg : 27:41

It's something I had to learn because sometimes it's very easy to get dragged down, particularly for people around you who are very enthusiastic as well, and you go, oh yeah, just follow this and follow this, but yeah, you have to really find your boundaries. Find open-minded people who don't care that they have to be right, but they care to understand you who also agree that there's no right or wrong answer, particularly in pediatric anesthesia. So many things are right. There's so many gray things, as we talked about before. It's just about understanding and finding good mentors who help you.

Britta Regli-von Ungern-Sternberg : 28:09

The best is to have actually multiple mentors mentors to help you in this area and in this area and this area, and people who understand and who don't take ownership of you. So over the years when I was a trainee, there are people who say you have to come and follow me, you have to come and and take over for me. Like no, actually I have to find my own way and I think that's really important. I encourage all my mentees. They have to follow their way and their way might be similar to my way, but they might be also totally different, and that's fine and they can follow. So one of my longest terms mentees just decided to go down the pathway of being a rural gp in rural, remote australia and I still mentor them and we still do an enormous amount of projects together and initially they came and they wanted to be a pediatric anesthetist and now they don't and that's perfectly fine because I can see that is actually the best road for them and I can see how happy and how driven and how fantastic they're going to be in there.

Britta Regli-von Ungern-Sternberg : 29:02

So I think really, my tip is to find the people around you who, when you doubt yourself and we are in these situations, often as academic people they believe in you until you can believe in yourself again. I think that's really the important thing and who are open for you to take your own way in your own pathway which really suits you. But don't get too much stuck on your pathway. Be open. What's around that turn? As I've alluded in the first question, my path was never very straight and we came here to australia nearly 18 years ago for one maximum two years. We're still here.

Britta Regli-von Ungern-Sternberg : 29:35

Sometimes it comes differently, but we have to say it always came for the better. My husband and I always made all decisions together. It had to work for both of us, not just my career, not just his career. It had to work for everyone and, in the meantime, for all five of us. Yeah, so just find really good people to work with and, if you have, have them. It really builds great networks for your family, but also great networks for collaboration, and there are such awesome people in the US and Canada and Europe and all over the world I work with who share the philosophy, and we often talk and we share the same philosophy how we do things, how we run things, and it works well.

Britta Regli-von Ungern-Sternberg : 30:09

And some of the people I work with, like, for example, clive Machado, we've been working for many, many years and actually this year the world congress was the first time we met in person. So people I work with, like, for example, clive Matava, we've been working for many, many years and actually this year the World Congress was the first time we met in person. So you can work with people, even if you and you can publish them, you can write a trial to them. You talk to them on the phone and on Zoom, but you don't have to meet them. So I think there's often the pressure on us you have to go to this conference, you have to interact, only if you see them in person, particularly for the women who are listening. You don't have to.

Britta Regli-von Ungern-Sternberg : 30:36

I know a lot of people will probably go oh my God, what is she saying? You really don't. You have to protect yourself, protect your families. You can do a lot just by talking to people. A lot of people tell me I will never do a trial, unless I had a beer together. That's a sort of quite typical boys club attitude. You can work together without even meeting people, and claude and I've shown that very successfully over many years, and there are a lot many more academics who are the same. We may have met once or twice, or sometimes never, and still work together. So yeah, find good people, find a good network and if someone is really negative around you see, do they have a good reason? Why do I need to change? But then they might be negative for their own personal reasons.

Jina Sinskey: 31:15

Then take your distance and find the people who believe in you and you can work with you just covered so many pearls like not just you know career advice, but such great life advice, protecting your boundaries, doing things you love. I just love this and you've obviously very successful in what you do and I love that you you're able to do this and protect your own well-being, so that's fantastic.

Britta Regli-von Ungern-Sternberg : 31:36

Trying to protect my own well-being, and sometimes the workload is way too much. I still have to keep learning on it. We're all in the journal, we all keep learning, but yeah, we try to really protect ourselves. I think that's a key factor how it works in academic medicine. But yeah, follow your dreams and let nobody ever tell you that you can't do it, because anyone can do it. You just have to be persistent.

Jina Sinskey: 31:55

That's great advice. Before we wrap up, is there anything else you want to share with our listeners today?

Britta Regli-von Ungern-Sternberg : 32:00

I think another thing which I'm very passionate about is also that, yeah, you speak up how you feel and what you think and be honest about it. I think there's a lot of people who fear they can't say, they can't be themselves, because how people might perceive them, and obviously we have to have normal ways to be interactive. But still, if we keep to normal, well, we have to be able to speak up, particularly when things are not right, and I see that the longer I'm in the systems anywhere in the world. There are things which are not right within institutions or within societies, within communities, and I think the importance is that we do find the courage to actually speak up and fight for those people and support the people who speak up when things are not right. We have the Speaking Up for Safety programs here in Australia which have a very, very good theory behind them. Unfortunately, it is not always safe to speak up, and I've experienced that myself, but still try and do it, because that's the important thing. If we want to really change something, it can only change if people speak up, whatever it is, whether it's in medicine and academia or otherwise in the community. If things are not right, we have to voice it and really speak up for the people who can't speak up, and don't let others put you in a box or tell you who you need to be.

Britta Regli-von Ungern-Sternberg : 33:12

You're you and that's perfectly fine, and I think that's sort of one of my opinions and, most importantly, what I tell my kids. Impossible is just an opinion, it's what we deem impossible, but if I really want it, probably it's not impossible. It's on my screensaver and my kids, my youth, are also against me. When I go like you can't do that, they go like you can't do that. They go like why are you saying impossible? It's not my opinion, but yeah, I think you just have to be patient. It won't happen overnight if you want an academic career, but if you hang in there and you have faith and you keep working hard, you can't. If you want to do it within your normal workouts it won't work, but if you work hard in it, you find something you're passionate about. Anyone can do it.

Jina Sinskey: 33:52

That's such great advice. I feel like I need to hear that myself. So thank you so much, and I've just learned so much from you today and I really enjoyed our conversation. Dr Regley von Ungern-Sternberg, thank you so much for taking the time to share your insight and wisdom with me and our listeners, and I just had a wonderful conversation. Thank you.

Britta Regli-von Ungern-Sternberg : 34:10

Well, thank you so much and, yeah, big thank you to you to making this wonderful podcast and actually making that possible for the communities to listen to. So thank you so much and thank you so much for having me.

Alli Bechtel: 34:22

Thank you so much to Open Anesthesia for sharing their show with us today. We hope that you add the Open Anesthesia podcast to your playlist to stay up to date on high-yield topics in anesthesia and perioperative care Plus. We are working on an Open Anesthesia APSF Ask the Experts podcast series that will launch later this year, so stay tuned. If you have any questions or comments from today's show, please email us at podcast at apsforg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apsforg for detailed information and check out the show notes for links to all the topics we discussed today.

Alli Bechtel: 35:16

The June 2024 APSF newsletter has been released. We are so excited to feature many of these excellent articles here on the podcast. In the meantime, you can check out the articles online over at APSForg and click on the newsletter heading. The first one down is the current issue, which is now the June 2024 APSF newsletter. Stay tuned for all new podcast episodes on these articles coming soon. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.