Coffee + Cardiology
Branch's Trials
Have you ever wondered how a WWII MASH surgeon's legacy could shape a modern-day cardiologist's career? Get ready to be inspired as Dr. Kelley Branch from the University of Washington Division of Cardiology shares his incredible journey into medicine, deeply influenced by his grandfather's remarkable history. Join us for engaging personal anecdotes, from his childhood in San Diego to his transformative research at UCLA with Nobel laureate Louis Ignarro, all of which shaped his passion and expertise in cardiology.
We then turn the spotlight on the revolutionary advancements in cardiac imaging technology. Discover the fascinating backstory of the CT scanner's development, thanks in part to the Beatles' success, and follow its evolution from single-slice models to the latest photon-counting CT technology. These cutting-edge innovations are providing doctors with higher resolution images at lower radiation doses, transforming how we diagnose and treat heart diseases. Hear how these advancements could potentially reduce the need for invasive procedures and improve patient care.
Finally, we delve into the critical realms of post-resuscitation care and clinical research. Learn about the groundbreaking Sudden Death CT scan and the ongoing trials focused on lipoprotein A (LP(a)), a significant marker for early cardiovascular events. Dr. Branch also shares a thrilling adventure in Beirut, blending high-stakes experiences with his signature humor. This episode is a heartfelt tribute to the profound impact of innovative cardiology and the dedicated professionals who drive it forward—don't miss it!
Have you ever wondered how a WWII MASH surgeon's legacy could shape a modern-day cardiologist's career? Get ready to be inspired as Dr. Kelley Branch from the University of Washington Division of Cardiology shares his incredible journey into medicine, deeply influenced by his grandfather's remarkable history. Join us for engaging personal anecdotes, from his childhood in San Diego to his transformative research at UCLA with Nobel laureate Louis Ignarro, all of which shaped his passion and expertise in cardiology.
We then turn the spotlight on the revolutionary advancements in cardiac imaging technology. Discover the fascinating backstory of the CT scanner's development, thanks in part to the Beatles' success, and follow its evolution from single-slice models to the latest photon-counting CT technology. These cutting-edge innovations are providing doctors with higher resolution images at lower radiation doses, transforming how we diagnose and treat heart diseases. Hear how these advancements could potentially reduce the need for invasive procedures and improve patient care.
Finally, we delve into the critical realms of post-resuscitation care and clinical research. Learn about the groundbreaking Sudden Death CT scan and the ongoing trials focused on lipoprotein A (LP(a)), a significant marker for early cardiovascular events. Dr. Branch also shares a thrilling adventure in Beirut, blending high-stakes experiences with his signature humor. This episode is a heartfelt tribute to the profound impact of innovative cardiology and the dedicated professionals who drive it forward—don't miss it!
This is Coffee and Cardiology.
Speaker 2:In this podcast, we sit down with a faculty from the University of Washington Division of Cardiology to discuss the very latest in diagnostics, therapeutics and, as a special bonus, we ask what makes our cardiologists tick. We have before us the great Kelly Branch, and one of the things I just learned in the hallway as we're talking about this is that Kelly's father was actually a radio guy. So I am proposing that perhaps we ought to at least conduct some of this podcast with our radio voices today.
Speaker 3:I think that's a great idea. Thanks, Jim. I appreciate this opportunity to be here, and what a wonderful setting here today.
Speaker 2:Well, Kelly, I'm just so proud to have you on, it's such an honor. I have to say Well, tell me, Kelly, how are you doing today?
Speaker 3:I'm doing great. But you know what, jim? I'm always doing great. So it's almost like every day is sunshine in the Kelly Branch world. But that's just what I picked up from my father and all of those years in San Diego, where we learned a lot when we go from the sea all the way to the mountains. That's right, because San Diego has just about everything except for the beauty of the Pacific Northwest.
Speaker 2:Well, it is quite beautiful here. I must say, I'm not even going to try.
Speaker 1:That's great. Great work guys.
Speaker 2:Great work Well this is going to be a fun one, absolutely. For those of you who don't know, the great Dr Branch also is kind of, I would say, one of the more humorous people on our faculty. Everyone knows him for that and respects him greatly for that. He kind of really does light up the room whenever he enters it, and so we're expecting him to do. Nonetheless, it's unfortunate you can't see the aura that is actually emanating because you're listening.
Speaker 1:Is this off the cuff? Is this dad jokes? What is your repertoire?
Speaker 2:Oh my goodness, Dad jokes for sure, okay.
Speaker 3:Yeah, well, we're going to refrain on the dad jokes because you know the groaners are definitely there. I will say that. But yeah, well, maybe we are definitely there I will say that Maybe we'll fit in a few little bits.
Speaker 2:That's good. We'll definitely appreciate that. But all joking aside, the good Dr Branch is also a nationally recognized expert in computed tomography of the heart and we are so grateful to have him actually on faculty as a leader in the professional societies and also as sort of a resident expert in cardiac CT, and he also leads our clinical trials unit and that is a very important thing that we want to hear some more about. Kelly's a great imager. He also sees patients in the General Cardiology Clinic. He's just an all-around nice guy. I can't wait. This is great. Yeah, it is fabulous. Well, kelly, you hinted a little bit the fact you grew up in sunny San Diego. I did that, but tell us the rest about your journey in medicine.
Speaker 3:Yeah. So I always knew I wanted to be a doctor ever since I was a little kid and a lot of this came from my grandfather, who actually had an interesting course himself Graduated from Tulane back in the day Many stories about medical school and things like that and actually was a MASH surgeon in World War II and actually went island hopping interestingly in the same division as my father-in-law both in the same division, so they but he came back and could not handle that kind of acuity and that kind of mortality and came back and, even though he was a full-fledged surgeon, went back to Pennsylvania and actually became a psychiatrist. Wow. So which is a complete 180. It's a little different 180.
Speaker 3:But one of the most intelligent guys in the world Photographic memory. I remember that I was sitting in his one of his chairs just kind of flipping through this huge Shakespeare book that he had trying to figure out what the heck was going on and he says, oh, oh, is that Shakespeare's soliloquy? Looked me straight in the eye and did the entire soliloquy from memory reading, from his photographic memory, and I said this is an intelligent man but also a kind soul, and so with that he has the humility and the kindness, but actually started psychiatry, basically west of the Rockies, starting at University of Utah, started the division there excuse me, department there, as well as helped with starting the School of Medicine, and so he was a huge influence, wonderful man and just someone I inspired to be. And so I knew from about the age of four and, yes, at the age of eight my number one request was Grey's Anatomy for Christmas, wow. So at the age of nine I went back to my grandfather and quizzed him on all 200 bones of the body and he did rather poorly until it came to the wrist and then I corrected him and so some of us were a little more geeky than others, but it's been a lifelong passion.
Speaker 3:And so I went to UCLA for undergrad and there met some wonderful people, worked for cardiothoracic surgeons there and actually met Louis Ignaro, who subsequently was working with our lab and actually won the Nobel Prize for figuring out nitric oxide.
Speaker 3:So it was fun to see those kind of interactions of some really wonderful people and that really started my career in research, because I was helping with the cardiothoracic research and figured this is a really great way to do things and then went off to medical school and that was really the sorry. And then, in the interim I should say, medical school, and that was really the sorry. And then, in the interim I should say, I started working for a private group that actually had some money. And so for three years after I had first gotten married right out of college to my lovely and what I say long-suffering bride, heidi, is that we had so I was the Rosie Zeus Research Scholar and then from that got a bunch of papers out, figured out that research is really where I wanted to go, and then matriculated to medical school, where I continued as a research coordinator in San Diego while being in Philadelphia and doing medical school. So yet that was just the start of the craziness in my world and spending a lot of time doing many things.
Speaker 3:So from there went to Michigan, had a wonderful time, lots more research, met some wonderful people that I still emulate to this day, and then came to the University of Washington and the rest, they say, is history. As I established here and was going to come as a heart failure transplant LVAD specialist, was going to be doing those artificial hearts. That's what I really wanted. To come as a heart failure transplant LVAD specialist, I was going to be doing those artificial hearts. That's what I really wanted to do. Again, I think I took a lot from my grandfather because the high acuity and the mortality and the sickness of the people just couldn't do it. So I didn't think about psychiatry. I only a slight pivot and went to imaging, because people tend to do a little bit better when you image them. And then we started to do that In 2004, we got this new machine.
Speaker 3:It was right off the GE line. It was the first 64-slice CT. It was the serial number 001. And so we got that machine and one of my mentors, who was the vice chair of radiology, said we have these new CT scans. I know you're looking around for research. I think this would be wonderful research, and so we started to do CT scans in 2004 when there were only two training centers in the United States, and so we just basically kind of learned by ourselves. I went down to see Matt Budoff back in LA, my good friend Matt, who helped me kind of finish up my training, and then ever since then that's been the journey, wow.
Speaker 2:That is quite a journey.
Speaker 1:Where did the heart come into all this? Where was your? Why? For why you got into cardiology?
Speaker 3:Oh, it's a great the I had known for a while. There were two things I was very interested in. One was the brain and then one was the heart, and for kind of different reasons, right, brains are very interesting just because they are so. They're us, they're human, right, and you know so much of who we are and so much of everything is just the brain. What I found out as we were going through is that when the brain gets injured, there's not much you could do.
Speaker 3:And this was in the heyday where we're going to have all of these wonderful new medications that were going to help the brain and none of them worked. At the same time, I had gotten an experience with cardiothoracic surgery and cardiology, and that was a wonderful mix of intellectualism, of being able to do something for people, of really being able to, and then also having kind of the ability to treat patients and having that acuity that makes things a little bit more interesting, kind of had that whole, kind of had everything. And so that's where I really kind of said, well, I'm either going to do neurology or neurosurgery, cardiothoracic surgery or cardiology, and those surgeons work way too hard.
Speaker 1:I'm sorry, they work way too hard.
Speaker 3:So love them to death, but I'm not that crazy. So cardiology was really the mesh of all of those wonderful things, and I'm still interested in neurocardiology, don't get me wrong but cardiology is really where this ended up, yeah that makes a lot of sense.
Speaker 2:So imaging in particular, you gave us a little bit of a window about how you headed into that. What sort of changes have you seen in CT other than that we're no longer on 64 slices, but? But where else has CT gone? And what continues to captivate you about cardiac CT? What?
Speaker 1:are we at now?
Speaker 3:Yeah, so we are on. Well, we've expanded. So there are many different types. Now, right, really, the vendors have gone two different ways, one of which is to use what's called a wide detector, so one rotation, one heart is what we call it. So you get everything within less than a second. That's it, you're done. One of the other vendors uses two CT scanners that are basically mounted at 90 degrees to one another Also a very quick way to do that in wonderful images. So people have gone a couple different ways. The newest kit on the block, which is something that we are looking into and we'll be getting a prototype here, and then hopefully, we'll be getting another vendor down at Harborview there's something called a photon counting CT. Now Godfrey Hounsfield, when he was first creating the CT scanner. And, by the way, quick aside. So what is the relationship between the Beatles and a CT scanner? Do you know? Is this a dad joke?
Speaker 1:No, no, it's a good question.
Speaker 3:It's a good question. No, this is honest to goodness, honest to goodness. Do you know the? I do not know the answer. Okay, this is one of those wonderful connections. So Godfrey Hounsfield of Hounsfield Units right, was an engineer at EMI which was also supporting the Beatles. Now the Beatles had been doing so well for EMI and Godfrey Hounsfield, his engineering crew, had kind of been put a little bit on the wayside. So he had some time and with this time he said I've been kind of brewing this a little bit, this idea of this CT scanner. And so while he was at EMI, which is basically supported by all of the Beatles, he was able to create the CT scan and actually develop that while getting paid by EMI. Wow, so the Beatles were indirectly supporting the development of the CT scan. Wow. So there you go. So there's your trivia for today.
Speaker 2:So really, when people are in that scanner, we should be playing the Beatles.
Speaker 3:I think that would be completely appropriate, even though it's so short. I mean, yeah, exactly.
Speaker 1:So, but then didn't hit the US until 2004?.
Speaker 3:The 64 slice. This it got it. We did have the. We did have the early slice, the one slice, the four slice, the 8-16. We had this kind of era. The 64 slice was really the first era where we were able to create cardiac CT. We were able to get the images good enough and still enough that we were able to read them in a robust way. The older slices, the older scanners sometimes those took minutes. They weren't gated to the cardiac cycles. There was a lot of motion so it was hard to tell.
Speaker 3:64 slice was really that first era.
Speaker 3:Now we've gone through a couple of iterations with different kinds of scanners, and really what we're at now is this thing called the photon-counting CT.
Speaker 3:Godfrey Hounsfield wanted to develop the idea that, as photons are being kind of pushed through the body, there's very complex interactions that are happening at the molecular level.
Speaker 3:If you're able to measure those, those kinds of interactions, rather than having just a photon that hits a detector yes, no, there are some subtleties to the kind of energy as it hits the detector and from that you can get much better resolution and you can figure out things that are metal, calcium and bone and other soft tissues, and so that's the new revolution. Right now there's only one vendor that has it, but other vendors are in development, and so I think that's going to be the new revolution, in that we are going to be seeing much more than we're able to see today. We're going to be able to take out a lot of the artifacts which CT is really prone to, and with all of the other technologies that have been developed over time, we do this with a low radiation dose very, very quickly. Oftentimes these are less than a second, or sometimes maybe within two to three seconds. And again, these are 3D data sets. You can go back forever and go back and reconstruct these and take a look as you like. So that's the new revolution.
Speaker 2:So how do you think that's going to play out in clinical cardiology right now? I think most of our listeners are probably very aware of the coronary calcium scores and cardiac CT for coronary artery disease detection and characterization. What else are we doing or what is on the horizon for CT in the clinical realm?
Speaker 3:Yeah. So I see two different ways that this is going to go for cardiac CT. Number one, because of the way that the new scanners are working and kind of the benefit of the new scanners, especially with photon counting CT, the idea of taking someone to a diagnostic, invasive coronary angiography where you do it from the hand, you know the arm or the groin, where you're just going to look, a lot of that's going to go away because we don't have to worry about the things that are in the way now the stents, the calcium, things like that. The motion artifacts are going to be reduced. All of those things are going to be working in our favor. So we may not. So when we're doing an angiogram, we're doing the invasive coronary angiogram, we're actually going there to try to fix something, so we're really going to be reducing that angiogram. That really didn't have much of a purpose other than to rule out disease. It also allows us, because we're able to see the plaques better. We can start to treat the patients accordingly, and that's what I've been doing is to say, yes, I see the stenosis, you have symptoms, I don't need to get any additional studies. I know that this is probably, you know, a blockage that's significant. Here are your medications that are going to allow you to go off and do the things you want to do. You don't necessarily need a stent. It's equivalent as far as putting in a stent versus not for many, many people. And so now we can start to just use CT scans and then move forward, and that is the only modality that you need.
Speaker 3:The final thing that I think is going to be revolutionary and a lot of us are working within this field now is to actually do something called plaque characterization, and that is not just looking inside the vessel, which shows the blockage, but looking outside the vessel. And outside the vessel is where a lot of the machinery for atherosclerosis and the laying down of atherosclerosis. What I tell people is, I said it's like an asphalt machine. It keeps laying down layer after layer after layer, right, and a lot of those get stable when they're down at the bottom and that first layer can become calcified and that's that calcium score that you see, it's the endpoint of atherosclerosis. That's mature. It's not going to go anywhere, it's not going to affect anything, it just sits there. You can't get rid of it either, at least not very easily, but it's the hot top layer. That's the thing you can get rid of with medication. But we're able to start seeing that top layer and start seeing those hot zones right, we call them the low attenuation plaques and we're starting to see the total plaque volume and the non-calcified plaque volume.
Speaker 3:All of these measurements now in a very robust way, and we think the revolution is that when patients come to see us ask how am I doing, I can say you know what. I could get a CT scan. I can see where your atherosclerosis burden is. Are we better, worse? Do we have more calcium, which is sometimes good because it's maturing, but do we have a lot more atherosclerosis? If we do, I need to be more aggressive and so we are able to do this in a more robust way rather than just relying on serologic, you know, like blood draws and those kinds of and then the risk factors modification. So those work okay, but if I really want to know what's going on inside your vessels, I'm going to be able to see, you know, and this just strikes me.
Speaker 2:The overall role that CT is playing is one of nuance and sophistication. This is the new thing. It sounds like what you're saying. Yeah, because in the past we looked at calcium Well, it's a marker for disease. We looked at even stenosis Well, that is another marker for badness and bad things are happening. But now we're drilling down and I have a surprising number of patients you know well we need a statin. Well, I really don't want to take a statin. And they ask very probing and insightful questions and with our current way of risk stratification I can't really answer them. But it sounds like in the future CT is holding some promise for that, absolutely, absolutely.
Speaker 3:Yeah, it's really going to give you an insight that we've never seen before, and it's not only for the coronaries, it can be for other vessels too. Actually, those other vessels are much easier, they don't move as much and they're much larger, so you can get kind of an idea about what's going on within not only a coronary, but you can actually get a whole-body atherosclerosis burden if you want to go down that track. What we just don't know is we know that these are associations. We know that certain medications can regress atherosclerosis versus if you're not on the medication. We know that it progresses atherosclerosis.
Speaker 3:Things like testosterone actually increases atherosclerosis versus if you're not on the medication. We know that it progresses atherosclerosis. Things like testosterone actually increases atherosclerosis rather than regressing atherosclerosis. So there are things that are actually detrimental to atherosclerosis, and so the idea right now for one of the groups that I'm working with is that we are going to FDA to say, rather than doing these large studies on every single compound that could possibly come out, because these studies are $300, $400, $700 million, you just can't do that for every compound you're interested in. What if I said that for $3 million, I would be able to tell you in 18 months whether or not this reduces atherosclerosis, and I'd be able to tell you in 18 months whether or not this reduces atherosclerosis.
Speaker 3:And I'd be able to do it with 400 patients, not 27,000, right. So now we see this new revolution of being able to do these smaller programs, interesting compounds that may actually affect atherosclerosis in a way, but people just don't have hundreds of millions of dollars to do the study. But if it looks promising then we can move forward to a more robust way of looking for, you know, kind of the usual endpoints, the major adverse cardiovascular events, which unfortunately takes thousands, sometimes tens of thousands of people in years to figure out. But I'm going to be able to figure out whether or not this is a good idea in 18 months.
Speaker 1:And that's because of the nuance of the technology we have now versus got it.
Speaker 3:Yeah, because that atherosclerosis we can actually measure it in a quantitative way and compare when we begin and when we stop, and we can randomize people to either placebo or the medication and then know whether or not it's good or, in the case of testosterone, detrimental.
Speaker 2:And it sounds like it's going to be much more nuanced than just more calcium or even more atherosclerosis. It's going to be? What type of atherosclerosis? We're talking about, yeah, and actually calcium is going to be good yeah more calcium better.
Speaker 3:A little bit of calcium is good. Too much is bad. Too much is bad. There's always this middle ground.
Speaker 2:Well, this is a great segue actually into your work with the Clinical Trials Unit. Could you tell us a little bit about what that is, what you do, how that fits into the Division of Cardiology?
Speaker 3:Sure. So the Clinical Trials Unit really has two facets to it, one of which is that we serve as a resource for these large trials that I just talked about, these very, very expensive trials. We serve as a site for these trials, which allows our patients access to a lot of these new potentially beneficial medications. Now, the important part of what I just said is the potentially beneficial medications. We don't know. As Einstein said, if we knew what we were doing, we wouldn't call it research right, and so we do this. But if you think about it and this is what I tell patients a lot if you think about all the medications that you're taking that we know are beneficial, it's because somebody, just like the people that are already enrolled in the CTU, stood up and said I'm going to be in this research study and I'm going to help you find information. It may not help me, but it's going to help people down the line. And so, really, all of these people that are in the CTU and we appreciate them so much for volunteering for research they're really standing on the shoulders of all of the millions of people that had volunteered for clinical research previously, the millions of people that had volunteered for clinical research previously, but the clinical research. So we do site, what we call site trials. Right, so we will be one site of, say, 600 sites within the world that are asking a very important question, and they come in different flavors Sometimes they're smaller trials, sometimes they're bigger trials, sometimes they're trials that we own or we do, and sometimes they're larger trials. And really all of this is to try to drill down and again kind of move the needle forward, so we're always on the cutting edge and looking at what's new.
Speaker 3:There's another side to this, called the Clinical Trial Service Unit, which my mentor, now colleague, jeff Probstfeld, had started 30 years ago, and this helps with fostering these large, large clinical trials.
Speaker 3:Okay, and so we generally run the United States for one of our groups in Canada called PHRI, and so these trials are anywhere between 10,000 to 50,000 people, and so we kind of help run the United States, work on the steering committees and then have a little bit of a different effect in that we are helping to foster other sites, not just our site but other sites and many of the sites in the United States, and this has really helped to kind of push things forward and a lot of these things have ended up in very influential places like New England Journal and Lancet and JAMA, and this kind of work actually really propels things forward. The site is very, very important, but sometimes the 50 sites or 60 sites that we oversee are equally important. So we kind of serve two different roles. But that kind of cross-fertilization has really allowed us to really become a robust place, because we know what the sponsors want from us, because we're a sponsor right, because we know what people want, and so we become very, very good sites.
Speaker 1:And when you say we University of Washington at large for that service unit.
Speaker 3:This is University of Washington, correct?
Speaker 1:And then we have our clinical trials unit within cardiology. Correct, got it, yep. Talk a little bit about that team that you have. Yeah, I got to meet them briefly.
Speaker 3:So, okay, we're good. Well, they're a wonderful team. So we have 18 people right now that are underneath the CTU all very dedicated people and at all different levels of experience, and so we love to bring people in and train them, to show them how to do this kind of work, and then they either go on to bigger and better things or stay with us for long periods of time. But these really are highly dedicated people to again getting answers, getting important answers to important questions, and making sure that patients, once they become in a trial we call them participants, because that's really what they are. They're not patients anymore, they are participating, actively participating in this. We make sure participants are well treated. So what I tell people is that participants that are here, they get to fly first class.
Speaker 1:If they have a problem they come to me right.
Speaker 3:So if they're my patients, then we say you have this problem, I got a guy. I'm going to give the guy a call. You got a problem, that's, you know, with your gastroenterology tract or something like that. I got a guy. So it kind of allows people, if they're going to be this generous, then I'm going to have to reciprocate by kind of greasing the skids a little bit and making sure that they are very well taken care of from a medical standpoint and otherwise. Point is and otherwise. So we really kind of foster that within the clinical trials unit have wonderful people and you know couldn't say enough about Jennifer Schaefer who really runs it. Laura Curtin is one of our senior coordinators. Those are really the. You know, laura's kind of the heart of the CTU and Jennifer kind of keeps us all in line and it's good to have both of those people. They're really kind of heading it up and of course, all the other wonderful people within it.
Speaker 1:This may be a little self-serving of a question, but how do you find and engage and get participants?
Speaker 3:Yeah, so there are a lot of different ways that we find it. Sometimes we'll screen through this massive amount of data that we have. That's called an electronic medical record right, that's a common way of finding it. Sometimes we'll find people in the clinic that will be referred by our colleagues, or sometimes we screen for them. So we're actively looking for them. Once in a while we'll actually have, you know, tv or radio that will go out and we'll say, hey, we're doing this wonderful trial about this particular problem, if you do give us a call, and so we sometimes find people. So there are many different ways that we do it. We have placards and things like that and little posters and things. So there are many different ways that we identify these people. But it's amazing how many people are so altruistic that they actually search us out, and especially if there's something really interesting.
Speaker 3:One of the things that I've been working on a lot is lipoprotein A or LP, little a. It's kind of what we call it. Sticky ldl is a way of thinking about her sticky bad cholesterol, and it's just a driver for very early cardiovascular events, for someone that has recurrent cardiovascular events, something that everyone should be screened for once in their life, at least once in their life. But we see we now have a lot of people that are now coming to us because we're doing this work and saying I have elevated lipoprotein a, what can I do right? And so, along those lines, we have one trial that's actually looking for major adverse cardiovascular events.
Speaker 3:That's the large trial. Okay, that's an 8 000 patient trial. And then, along the lines of that plaque characterization that I talked about, we have a much smaller trial, 700-patient trial that's actually looking at plaque characterization in people that have not had events yet, that have not had a heart attack, stroke or a cardiovascular event. So they're early. And so now we have two prongs for people that have already had events and people that have not had events, so that we actually get that full gamut of experience for this particular thing. But it's amazing how many people come find you.
Speaker 2:Well, that's great. So some of our listeners may actually be wanting to refer patients to you. How do they do that?
Speaker 3:Yeah, so on the UW website you can look for clinical research, and there are a couple of different ways that in the Division of Cardiology there's line items that are there as well. Couple different ways that in the division of cardiology there's line items that are there as well. Within what's called the ITHS, which is our large clinical group, there's also a listing for clinical research. If you're interested, go to one of those websites and then there will be a link there that you can click. It actually emails us or emails ITHS and they'll get to us if you're interested in what's going on. If not, then just say hey, you know these are my problems. I'm interested in getting to clinical research and we'll be happy to chat with you and see if something fits and if it doesn't, we also know what's kind of going on around town as well, and sometimes there's a better fit somewhere else. We're more than happy to refer to those places as well.
Speaker 2:Oh, that's just fantastic.
Speaker 3:Well, I want to pivot a little bit and talk about patients who are probably not going to be intentionally referred to you, and that is your work in resuscitation, that's true, that's true, that's yet another hat, but it was born out of kind of my and I guess it's a passion for being able to do more with very, very little right and really trying to be as efficient as possible. I love efficiency. I really don't like to, you know, kind of lollygag around. That's kind of not my modus operandi, even though I am from San Diego, so I'm supposed to be very chill. I can use dude in a sentence, don't get me wrong.
Speaker 2:I have no doubt, but there's a little burning fire underneath all of this.
Speaker 3:So part of that was to try to figure out, because when I was at Harborview and this was actually as a trainee when I was a fellow I noticed that all of these people would come in after a sudden death event and the real question was what do we do with these people? How do we work these patients up? What was the initial problem that they had that had their sudden death event? Because that's going to inform what we're supposed to be doing. Was this because of blockages in their arteries? Was it because the heart wasn't working? Was it because of a blood clot that went to the lungs or some other problem? Well, what also ended up happening is that they would have resuscitation, which in and of itself, is kind of a traumatic event. There's a lot that happens with CPR and being in a breathing machine and being cooled and you know all of the things that go on with trying to optimize. You know, bring people back and then optimize them.
Speaker 2:So you're seeing, it's not like daytime soap opera resuscitation, it is not. It is not Good to know.
Speaker 3:It's been a very, very long time since I've actually pulled any paddles and kind of rubbed them together and put them on anybody's chest, okay, so Hollywood needs to catch up a little bit. But suffice to say that the question was how can we work this up in a robust way to try to figure out what the resuscitation problems that they had, what caused the sudden death event, and how are we supposed to treat these patients differently? And so we came up with this thing called the Sudden Death CT or SDCT, and basically it's the pan-man or pan-woman scan. It's basically from head all the way to the pelvis and evaluating all of those structures that could actually cause sudden death or could be affected by the resuscitation or falls or anything else. And so from this development we found out that actually the yield was very, very good with this. So we were able to instead of having 25% of people we had no idea why they died, had no idea why they died. Now we're up to 92%. Now we know 92% of people. We had no idea why they died, had no idea why they died. Now we're up to 92%. Now we know 92% of people. We know why they died.
Speaker 3:Okay, so there's a huge increase in. Now we know what the problem was, okay, and then we looked at all the complications and the complications that are not just there right from the resuscitation because they had a little pneumonia or whatever, but also things that need action right, and about 30% of people we were finding things that needed some kind of action right. Something needed to get changed, and this was sometimes resuscitation problems. This was sometimes there was a whopping pneumonia that we didn't know that they had things like that. So now, 30% of the time, we're actually changing what we're doing based on the CT scan, and this is a CT scan that is done within two hours of the patient arriving. They're sedated, they have all of the things of the post-resuscitation care, but it really guides what we're doing as far as resuscitation goes, and so I think it's a new paradigm for how people are going to be evaluated as they move into the post-arrest setting.
Speaker 2:Yeah well, that certainly makes a lot of sense. You know there had been some research and even people setting up a cath lab in the emergency department so you could cath all of these patients with all the potential complications that are happening. If they have bleeding complications, it can arise from that and create other problems. It sounds like this kind of gets more to the issue and potentially avoids all that.
Speaker 3:Yeah, it really does. The big thing was is that what people were finding out? Is that by bringing people in and taking them directly to that invasive coronary angiography, if they did that, for all comers there was no difference. It made no difference for whether or not they did or didn't do it early. So the idea is we don't need to do it in everybody. But one of the things is the way that we created this sudden death CT is we actually get a cardiac CT so we're able to see the actual vessels. So since we can see the coronary arteries, we can make decisions whether or not that patient needs to go to the invasive angiolab sooner rather than later. If the coronaries are fine, well, we've ruled out coronary disease. Let's go look for some other issues.
Speaker 2:Yeah, powerful, and we can't wait till this gets disseminated more widely Indeed.
Speaker 1:Was there any direct change that happened if you do something every time now when someone comes in, Like you said, 30% of patients that you looked at there was something.
Speaker 3:Yeah, so well, right now, at most of the people that come in with sudden death actually go to Harborview. Okay, that's because that's where the center of excellence is for those kinds of patients. So they're now doing sudden death CT routinely on all of those patients that come in. So we have all of those data. So what we're finding out is that there were sometimes bleeding complications that go along with this. We're finding pneumonias that are being treated earlier. We're finding sometimes that there are.
Speaker 3:Sometimes the lung can be pierced from all of this or the lung can have a problem, something called a pneumothorax. So that gets treated very, very early and very rapidly. Sometimes you can't see that on a chest radiograph. You need it on a CT scan. We've seen people that have had brain bleeds and that's the reason why. But you have no idea because they can't give you a history, right? You don't know what's going on. And so now you know you shouldn't be giving them medications which would otherwise thin their blood, because you think, well, maybe it's cardiac source. We want to thin their blood, open up their arteries and the blood clot in the arteries. No, no, no, no. Don't do the opposite. Definitely don't give those medications and now it's time to go talk with our neurosurgeons to see if there are things that we can do for that patient. So it's that kind of inference and change in management that I think is really important.
Speaker 1:So wait for the CT is the big change, absolutely.
Speaker 3:Now, the other thing that's interesting is that I was just reviewing a paper today that was saying this, and I agree the negative impact of a normal scan cannot be overstated, right? Okay, it's the FOMO, the fear of missing something, right? The fear of missing out, right, the fear of missing something. So if I miss something, right, I'm going to feel really, really bad about that. But my tools are limited. So what the sudden death CT showed is that, for the proportion of people that had no findings whatsoever, there's nothing that you need to do for those patients other than your usual sudden death care, right, so you don't need to take them to the cath lab and do the invasive angio.
Speaker 3:You don't need to be doing any of these more aggressive things. That was a normal scan. Now look for other things, and unfortunately, what we're seeing is that many of these people have had overdoses, and so we're making a diagnosis of nothing on the CT scan, even prior to their talk screens coming back, and so it gives the emergency room physicians, as well as whoever's taking care of those people, a lot of reassurance. They don't need to be doing anything more aggressively, right, and so you're not going to get into trouble by doing things you shouldn't, and then by refraining and doing the things only you should.
Speaker 2:Yeah, that makes a lot of sense. Well, your work takes you all over the world. You're probably one of the more better traveled people on our faculty. And I know, you've got some interesting stories about some places that you have been.
Speaker 3:Oh boy, okay, I'll have to think about this and make sure that it's rated for the radio here.
Speaker 1:Okay, we're back from that. Yeah, we'll be all. Right, had to cut that last one, yeah right, Exactly Anyway hold on for that one. I've got to think about this for a second. I've got to think about this for a second. Anyway, hold on for that one.
Speaker 3:I've got to think about this for a second, I've got to think about this for a second. What are some?
Speaker 2:good. Well, I know you had a rather interesting taxi ride in the Middle East, oh.
Speaker 3:Lebanon. Okay, all right, I'll do the Lebanon story Okay.
Speaker 1:And is this all CT related, usually with your travel.
Speaker 3:This is usually big trials. It's usually big trials and CT. Yeah, big trials and CT. So I'll give you my most interesting trip, and that was that I was asked to go to the Middle East, and specifically the first stop was Lebanon, flying into Dubai and then flying to Lebanon to give a number of talks to the physicians there and to talk about one of the compounds that we had been working on that actually decreased mortality, so a very important medication.
Speaker 3:When we got there it was very late at night, and so I hopped into this white Toyota Corolla and we were driving along and the guy said we're going to get you there safely, everyone's having a good time. And I said I don't know really where you're going with this. But as we were driving along, I suddenly found that the entire five lane highway both ways was blocked by burning tires and a bunch of young people out there directing people off the off-ramp. We had found out that the Lebanese government that day had imposed a large tax, which was actually on all of their phones, and so in retaliation they did this. So we did a little Mr Toad's Wild Ride, including going backwards up a freeway, which I had never done before. He did get me to the hotel on time.
Speaker 3:Now after that, lots of people quote-unquote celebrating or protesting this tax, and so we never were able to really leave the hotel very much and we weren't able to give any of the talks. I was unfortunately not able to meet everyone there and, by the way, this was about a half a mile away from where the explosion had subsequently occurred, right on the water. So I was told well, it's time for us to go. We have found transportation. We can't get us all the way to the airport. I said, wonderful, that would be okay, just get us as close as you can, we'll be fine.
Speaker 3:So again piled into a white Camry, this time just not to be done by the Chikorola, and so seven of us, wedged into a Camry, were driven again all over up and down, past burning tires and dumpsters, and then subsequently stopped and said this is as far as we can go, thinking full well in my full suit that I was wearing at the time, that we were just going to kind of, you know, wheel it in or something like that. He said, no, we have found transport. So I was loaded on to a scooter with a very nice young man named Muhammad, who was really wonderful and was very interested in cardiology. So we had a wonderful conversation, dodging various burning things as we rode through the streets and freeways of Lebanon trying to get to the airport.
Speaker 3:At one point there was one wall of fire that was literally four lanes across. They had stacked tires 10 high, and so this was a conflagration. Mohammed looked at this and found out that there was about a four-foot opening on the left-hand side and gunned it. They said so I've never been in a blast furnace except for them. And so we blasted through the furnace and there we were at the airport. And so, again, my long-suffering wife. I chose not to speak with her about this until I came home, but the best part is I have video of all of this.
Speaker 1:I was about to say I have video. Do you have a GoPro on your head? It was the. That would be great.
Speaker 3:Because it's interesting on the radio. It is better when you visualize it.
Speaker 1:I might have to tease that for why you listen. I'll have the clip embedded.
Speaker 2:We can put the AVI on me, no one will miss this interview.
Speaker 3:We can be on the me on the back of a. There's actually video of me on the back of the scooter with Mohammed having a wonderful conversation about cardiology in the Middle East.
Speaker 1:They would make that better as a sidecar, but that's how it is.
Speaker 3:That's great, this worked pretty well.
Speaker 2:Well, this has been wonderful and extremely entertaining.
Speaker 1:Yeah, absolutely I would actually say I need at least one dad joke, though.
Speaker 2:Alright, we do need to we need to end with a dad joke in the radio voice. Dad joke in the radio voice.
Speaker 3:This is a little bit of a can I do my highbrow?
Speaker 1:we are extremely highbrow. We need to go for another five minutes with as many dad jokes as you got. Alright, alright, just are extremely highbrow. We need to go for another five minutes with as many dad jokes as you got. Okay, all right, all right, all right Okay.
Speaker 3:There's a little highbrow, highbrow, okay. Okay. So a priest, a pastor and a rabbit walked into a bar. The bartender walks up to the rabbit and says hey, why are you here? He said spelling error.
Speaker 1:Solid, you here, he said.
Speaker 3:Spelling error.
Speaker 2:Thank you very much. It was a little highbrow it was a little highbrow.
Speaker 1:It really tested reading comprehension, that's a groaner, only the best for this podcast.
Speaker 2:Exactly right. Well, this truly has been amazing, and we so appreciate you joining us today and giving us not only insights into CT and clinical research, but also among the most groaning dad jokes, that there possibly can be.
Speaker 3:That was pretty good.
Speaker 2:No, but really this has been amazing. I really appreciate you. I appreciate all you do for the division and the role that you have taken on, and really one of the things I just want to highlight, too, is your view of the research participants. That really is amazing. I just think that's so wonderful and I think when people refer patients to research studies here, when patients sign up, they know that they're gonna get treated well. That's not true everywhere, but I think because of what you have done and the way that you look at things, that actually is is as a reason to come here, not just because you get access to the cutting edge, not just because you get to participate in this, but because because you're going to actually be treated well and you might actually hear a bad dad joke too.
Speaker 3:Yeah, great. Well, thank you so much for having me. I do really appreciate it, and I'll do this in my regular voice rather than my big boy voice. But it's been wonderful having this conversation and kind of reliving some memories I haven't had for a little while as well. So, thanks so much. Some memories I haven't had for a little while as well.
Speaker 2:So thanks so much. Fantastic, and thank you very much. See you next time.