E78 | Dr. Stephen Rush: Lessons from Cancer to Combat Medicine

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Lt Col Stephen Rush is a medical doctor who practiced Radiation Oncology from 1986 – 2015. He specialized in the treatment of brain tumors, head and neck cancer, and Gamma Knife Radiosurgery. In 2008 he joined the U.S. Air Force and became the Flight Surgeon for the 103rd Rescue Squadron where he oversaw medical training for the Pararescuemen (PJs). From 2012-2018 he also served as the U.S. Air Force Pararescue Medical Director. During that time, he:

• Modernized battlefield medical care provided by PJs during Operation Enduring Freedom (OEF)
• Created the protocols for combat trauma
• Introduced new equipment and techniques
• Rewrote the Medical Operations Handbook

He is currently creating a program for training new Air Force Special Warfare Flight Surgeons. In September 2019 he became the Medical Group Commander of the 106th Rescue Wing. His responsibilities include ensuring medical readiness of Wing members for deployment and the preparation of Medics for combat and domestic emergencies, such as the Air National Guard response to COVID. Topics Covered:

1. Why Dr. Rush left a successful career as an oncologist in NYC to become a Pararescue flight surgeon at almost 50 years of age
2. Dr. Rush’s responsibilities as flight surgeon and the medical capability of the unit he managed
3. How Dr. Rush went about auditing the medical readiness and training of the unit as an outsider with little military experience
4. How running a private practice prepared Dr. Rush for his responsibilities as a military physician
5. Practices Dr. Rush employed to help PJs perform under immense physical, emotional, and environmental duress
6. How to maximize readiness with limited training time and minimal patient contacts
7. Strategic insight about how to bring the best medical capability to the combat environment
8. Best practices from military and civilian medicine
9. How to improve medical education
10. Memorable missions and experiences

Links of Interest:

• PJ Med YouTube
• PJ Medcast
• Dr. Rush’s Pubmed
• Thai Cave Rescue Mission
• Journal of Special Operations Medicine

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Episode Transcription: Welcome to the Resilient Performance Podcast. I'm your host, Doug. And today I'm joined by Stephen Rush. Lieutenant Colonel Stephen Rush is a medical doctor who practiced radiation oncology from 1986 to 2015. He specialized in the treatment of brain tumors, head and neck cancer and gamma knife radiosurgery. In 2008, he joined the us air force and became the flight surgeon for the one-third rescue squadron, where he oversell medical training for the pair rescue men, or PJ's from 2012 to 2018. He also served as the US air force para-rescue medical director. During that time he modernized battlefield medical care provided by PJ's during operation enduring freedom. Created the protocols for combat trauma, introduce new equipment and techniques and rewrote the medical operations handbook. He is currently creating a program for training new air force special warfare flight surgeons. In September, 2019. He became the medical group commander of the one Oh six rescuing his responsibilities include ensuring medical readiness of wing members for deployment and the preparation of medics for combat and domestic emergencies, including the air national guard response to COVID-19. Doc Rush, thank you for coming on. It's nice to have you answering the questions instead of being the one, asking it. I want it to begin because I remember when we spoke on the phone, it was probably over, uh, 10 years ago when we had a mutual connection through my father. And I heard of you, but didn't know a lot about you. And I'm now that I have the perspective of how kind of. Crazy. It is what you were asking me. Like why, why is this guy in his fifties? Who's a successful oncologist in New York city deciding to, um, to join the military as a, the air force in particular as a, as a flight surgeon, when you already have this, like I said, very, very successful career. And, um, yeah, we talked about it because I had no other perspective on life. I was like, yeah, you should do it. But now being a little bit older, I'm kind of like, it really was crazy what you did. So what was the impetus for that? So it was very accidental and it was, uh, you know, I, I keep using this line from, uh, um, Louie pass. Sure. Chance favors the prepared mind. And in my career, I was in emerge. I started out, I did some surgery in New York and then moved to Los Angeles in the eighties and I was an emergency medicine physician, and I really enjoyed it. I remember one night. The Sheriff's helicopter came in and this tall blonde surfer dude in an orange jumpsuit comes out with a patient and he's like, Hey, I'm doctor blah-blah-blah. And he hands off the patient to me, I'm like, who are you? He goes, well, I do search and rescue for the sheriffs. And I'm like, wow. That's like the coolest thing I've ever heard. I'd love to do that one day. So that went in the back of my brain and I came back to New York and pursued a care, a career radiation oncology. And essentially was in a transition period out of my private practice, into part-time academic medicine and, uh, through a weird set of opportunities that are much too long to go into. I got involved with creating an event to honor PJ's on long Island, namely you and the team. And, uh, in that the process of creating an event, they recruited me to be the flight surgeon. And it was really complicated. I was 48 or at the time, and my wife wasn't into it. Um, and it was going to be a whole lifestyle change, you know, joining the military, going to bootcamp and officer training school and all these things. And, uh, and having run my own practice for over a decade, uh, I would then have to start listening to other people, give me orders. Thanks. Uh, so it was profound, but I think that, you know, the bottom line was that. I, there was something about the rescue mission I liked from this emergency medicine thing. I've been an outdoors person, you know, did a fair amount of climbing and back country skiing and mountain kind of stuff, and climbing. And, uh, so I had that part in me. I liked the emergency medicine piece. I had a lot of experiences in my outdoors experiences doing medicine of some fun stuff. And. Basically when I went to develop this event to honor PJ's on long Island, they said, Hey, we need a flight surgeon. I'm like, well, I'm a cancer doctor, brain tumor guy. And they said like, we just need a doctor. We don't have anybody. So they set the bar very low. Yeah. And they go, and I'll tell you, you know, chief Marx who was there. He said, listen, you don't understand. You could make of this, what you want. And I guess that was one of the magic lines that I heard. And, um, you know, I became exposed to the mission through, uh, Sebastian younger, his book, and then the movie, the perfect storm. And I had read a few books about PJ's after that, and then filed it away. And I was into bike racing. And one of the guys. Bike racing used to be a PJ Patrick in the nineties. And he's the one who told me about the team. So through all these crazy circumstances, I became an airmen at the age of 50 almost. And, um, you know, it was very weird and I maintained my civilian practice doing something called gamma knife radiosurgery at NYU for another seven or eight years. Until I was so taken with what I was doing and all these opportunities came up that I took advantage of them in terms of leadership and making an impact, and then committed myself to this air force work well, it's fortuitous for all the people that you helped directly and indirectly that you went to that fundraiser, I guess, um, for the people that don't know what, what our PJ's, and as far as like your responsibility to them, What are the, um, I guess what, what is the medical capability that PJ's, or pararescueman bring to the department of defense and prior to taking that job, what, what did you understand your responsibilities to be? And I guess once you started, did you think that, did those expectations meet, match the reality or was it totally different than what you expected? So let's, uh, just back up for one second and, you know, I know that. Um, your colleagues refer to you as this prior PJ. And basically I have a one-liner for the public, which is PJ's are tactical and technical rescue specialists with emergency medical and trauma expertise, and they perform search and rescue on behalf of the department of defense and the nation. So tactical referring to shoot, move and communicate technical rescue. Uh, everything you see a police and firemen do at, at home, which is vehicle extrication, structural collapse can find space and even Swift water rescue in, you know, in these rivers, overflowing rivers, things like that. So that's the technical rescue and then are paramedics with training beyond that, including minor. Lifesaving, uh, surgical procedures on the battlefield, as well as a few other specialties that are beyond civilian paramedic, but fit into the rescue world. So that's essentially what PJ's are when I joined. Um, and this was part of this whole journey. Nobody knew what my job was. Everybody knew that one component was what we call flight medicine, which is to take care of you guys and ground you from flying and operating. If you had a. Condition or were taking a medication that was incompatible with operating. And that was the main thing. And then the chiefs were like, Hey, and you're supposed to teach the guys how to do all this medicine. And I'm like, well, I don't know what the medicine is. And then they gave me the handbook and the handbook in retrospect was some book written by a couple of emergency room doctors in the nineties that had never been updated. And was written by emergency room doctors for the emergency room. It was not specific for the environments in which you operated. So I'm going to, for the rest of this, I'm going to still talk to Doug as if he's still our PGA. Um, because that's how I see him as a PJ and a physical therapist. Um, so I didn't know what was to be done. I thought the operators were going to tell me what to do and ultimately. I started traveling around the country to other bases to see what other people were doing. And unfortunately there was no codification of what I was supposed to do. There wasn't really organization of the medicine and because of my background and, you know, DNA or personality, I started chipping away at it, trying to figure out what was it, how do we codify it? And then it evolved into something much bigger. Yeah. And considering that. This wasn't your clinical specialty. You obviously had some background in emergency medicine, but you've been practicing as an oncologist for decades prior to joining the air force. How did you go about auditing the medical readiness and training for the team? I mean, you've always struck me as somebody who is very self-aware and even if you didn't know the answers to something, you knew, the people that did and you're, you're really a great connector. Um, but also as an outsider, like how did you feel comfortable? Saying, Hey, I know that, you know, this isn't my background, but like maybe you guys aren't good at some of this stuff that you're supposed to be good at. So the first thing I did, I have tremendous self-awareness and it's like, if I don't know something, I don't know something. And either I learn it or find the expert to make the decision for me. Or I sat on no it, and we have to find somebody else to do it. So, you know, one of the things that we try to bring from American medicine to the battlefield is develop your capabilities and work to that capability and don't work beyond it because we'll kill somebody. God forbid. And essentially what I did was it became clear to me that there was no one in New York who was going to mentor me. I couldn't find another flight surgeon who could really mentor me. So I developed a relationship with one of the senior air force trauma surgeons, and I said, you know, how do you think I go about learning this? And he emailed me 60 articles. So I literally locked myself in a room for three days and I read the articles and I abstracted them. And I created some semblance of order, which didn't really exist. Well, you know, it was sort of. As T triple C, which is something we could talk about later. It was a doctrine as that was settling in. Um, I was trying to figure out how do we codify it and how do we package it in a way to train people? Because this whole idea of being like a paramedic and just giving you guys PowerPoints and saying, this is the medicine is a fantasy that that's going to be useful. You know, the, and we could talk about this later. I later spent a little time trying to understand the neuroscience of how adults learn and how it's different from children. And essentially it's all experiential. You have to do it and you have to do it in a certain way. And there are a couple of books that describe this, but in the end it became obvious that you just had to do it and do it a lot of times and do a well, and then, you know, I knew I could count on you guys to do it. So I built up my own repertoire of. Cognitive knowledge. I felt my skills as an emergency medicine physician from 20 years prior were never left me in terms of clinical judgment ability to determine who's sick and not sick, how to take action. I felt very comfortable with that stuff. And then translating that stuff from ATLs or advanced trauma life support, which we do in civilian hospitals to the T triple C was just a matter of learning. The actual military protocols that were out there and then trying to improve how we taught them. So, uh, I work to develop these systems, to codify the medicine and then how to simplify them and how to teach and communicate the medicine in a way that made sense to both me and the PJ. So one advantage of me not being an emergency medicine physician or trauma surgeon was that as a cancer doctor, my litmus test was, if it didn't make sense to me, there's no way I could teach it to somebody who's paramedic level. So that was one of the things. And then. The other thing I brought to the table as a academic physician was the ability to weed through these studies and say, Hey, these guys want you to doing this stuff on the battlefield because there's a statistically significant benefit at the 0.002 level. But in reality, in absolute terms, that's only a 2% benefit. It's not worth bringing this glass vial of something for 98 people who don't need it. You know, it's what, what do I want you guys to have in your pack over other things? And w and, and I took it as my job to start weeding through the, you know, sort of the academic intellectual side of what's, what makes sense in the context of what can you actually do and what are the limitations of the environment? So, I would say one thing that I did that I think was different than a lot of other predecessors was I spent more time in the field, on the ocean surface. High angles scenarios, you know, rappelling down, tying myself off, watching what guys were doing on a ledge, um, going out and watching tactical scenarios and seeing the things that were in the books. I'm like, well, you could do this all you want, but if you're in Alaska responding to a helicopter crash and it's 18 degrees. Your first, your only priority is warm and keeping the patient warm because they're going to die shortly of hypothermia. And if you can't take your time, gloves off without getting frostbite and becoming incapacitated, there's no good medicine you're going to do other than a shot at Decker drawn. Or something there's no fine motor skills that you could do when it's 15 degrees out. So what are the limitations of a patient on a Stokes litter on allege? What are the limitations of responding to a plane crash in Alaska? When it's 10 degrees out? What are the limitations to being in a sea state of eight foot seas, you know, and what's realistic to do. And. Uh, you know, how is protecting a wound on the ocean surface different than protecting a wound in the mud? Uh, you know, in, in, you know, in Normandy or, or Belgium or whatever. So all of these, you know, we could come up with all the protocols we want, which we should do, but then they have to get tailored to the environment and then get tailored to the operator capabilities and limitations. Something that we'll talk about in a little while, and then. Also understand that all the operators bring something different to the table. So in a field like pararescue, where you freefall parachute, static line parachute, get in and out out of helicopters about five or six or seven different ways, learn how to use ATVs motorcycles, jet skis, scuba dive, surface, swim in the ocean, jump out of the helicopters into the, you know, I could go on and plus all the tech rescue extrication tools. Swiftwater ropes were high-angle ropes work, uh, structural collapsed, lift bags. We add all those things to it. And there were some guys who really liked shooting and some guys who really like parachuting. Some guys who really like skydiving, which leaves about 80% of the guys who don't love medicine, quite frankly, it's, you know, what are people's natural loves. So with our guys who ran a medical school and who loved the medicine, I never even had a worry about them. I had to worry about people who maybe didn't go to college and weren't that into the medicine. It's like, how did I make them effective? Despite the fact that they're not that interested in, they have all these competing interests, you know, emotionally that they're interested in. And how do I make it worthwhile? And those were a lot of the challenges that I thought were there. Um, you know, so there was the interpersonal piece. How do I deal with each operator at his level to make him more effective, even though he doesn't know it, you know, until he saves that life. And then he texts me, he's like, Oh, we just, you know, we did something really good. And I'm like, all right, those are just some of the things. So, so, and then finally, You know, another thing we'll get to is, is my limitations from not being a military person for the last 20 years, but having a leadership role was that I didn't know that there was this test. I could hang over your heads that if you didn't pass it, you got grounded. And I didn't know that for eight or 10 years. And then I used it once on somebody and it worked and like he failed miserably on a test and he came back two weeks later and did the best of anybody. Because we grounded him and it was the first time I did that. So, uh, we essentially ultimately made a very easy test for you guys to take every 17 months or something. Um, that was go or no-go you had a pass or you're, you know, you're out until you pass it. And, but we made it very concrete and like, can you do the job or not? Do you know when to give a blood transfusion? Can you give it. Do you know, when an airway needs to be open and do you know the different ways to do it and you know, a little bit more than that. So we made it where everybody could study as much as they want. We want people to be able to pass that test every day of the year. And it's essentially, here's the bottom line of what you need to do. And can you demonstrate it rather than what we used to do or what the senior PJ's do was they make up these scenarios as they went along. And if you got the Ivy and you said you were going to give these meds. Then it was good to go and it was all, you know, they can ask leading questions and, you know, whenever he was trying to be good to each other, which is nice, but you know, the point I try to make is that so many of our medical treatments are done for, uh, accidents, training accidents that we want everybody to be solid every day of the year, because they're going to be treating their teammate who has a bad parachute landing one day. Right. And it happens several times a year and some of these are catastrophic and some of them are minor, but if you're not on your game with it, airway management and brain, brain injury management, or complicated orthopedic trauma, and you're not on your game that day, you know, I always say, great, it's you? Who has to go to somebody's wife or children or parents and tell them that you weren't prepared. So I try and do a little bit of Jewish guilt. You know, but I feel totally justified because I feel it's, it's the obvious truth and, uh, nobody should ever want to be in that position. So those are some of the things I did to audit, you know, trying to improve the readiness of the guys. Your experience speaks to the fact that a lot of times like the same things that are a blessing or also a curse, it sounds like you had very little direction as far as the, your expectations for the job, which meant that you could shape it. But it also means that, wow, like where do I begin? It's kind of like running my own business or your own practice. Right? Like you're in charge, which is great. But when things go bad, it's like, wow, it's all, it's all on me. And you've got to embrace that responsibility. So you came from private practice where you, you ran the practice, had a lot of responsibility, autonomy, and you're making all the decisions, which probably set you up for success in the relatively lacking direction role that you. Assumed in the air force. And what I always thought was funny is that in the military, like generally you've got 20 different bosses and there's a very, you know, kind of rigid command structure. Maybe if it seems like in the beginning, you kind of escape that a little bit, which probably allowed you to do you know what you did. So how do you think that maybe coming from the civilian side, running a practice helped you? How did it hinder you? And then what do you think maybe like maybe having more military experience. Would have helped with, especially earlier on first thing, you actually said it in the middle of your, uh, before your questions in your statement, which is when I had my own practice, I started with, uh, radiation oncology or radiation therapy practice, where it was. Um, I was by myself with one other doctor and about six employees in over four years, we grew to 57 employees and ultimately about six or seven doctors. And I would say the first thing is that when you're running a practice and you're responsible for cancer patients for life and death treatments every day, the first thing is, is when we had a problem, I problem solved until the problem was solved. There was literally no option of not fixing something, whether that meant, you know, God forbid we made a mistake and we had to keep that from happening again, or how to prevent mistakes. Or we had problem with an employee who, whose mind was elsewhere, or, you know, we had a regulatory thing because there was a lot of oversight, you know, with the radioactive materials or billing, you know, whatever all the issues were because it was. You know, my practice in a sense, and it was ours. We didn't have an option of not fixing something, uh, and resolving it. So I'd say that's one thing. And that's one thing that I hope that the PJ's feel I share with them, which is. You know, you guys call it never quit. Um, but it's this idea that, you know, if you're given a mission and you're told it's a no-fail mission, that mission is getting done. So I saw that in the treatment of people with cancer, and that was how my brain worked. And if I, when I came in the first few years, if I saw that, you know, the commander said, Hey, you're responsible for blah, blah, blah. And nobody gave me any direction. Well, I figured out what it was either from calling people. Or figuring it out and working with the leadership and saying, is this acceptable? So the first is if there's something that needs to be done, it's getting done, period. End of discussion. And I think that was one thing in my personality and my skillset that, you know, that fit in with the special operations community very well. Um, I brought in, you know, having grown this practice, I brought in executive skills, the ability to make definitive decisions, the ability to lead people. The ability to get things done, manage budgets, um, you know, in all, all the ancillaries that go with that stuff. And the decision-making was both admin related. How do I improve the, you know, the flight surgery, the flight medicine work that we're doing on base, uh, and make that better, but also, you know, My whole career was based on making hard decisions for patients with brain tumors and cancer and other parts of the body. So again, that's something that I had 20 years experience with that kind of decision-making, it was very comfortable with, you know, with the understanding that we don't make every decision correctly because we, you know, we just don't outsmart cancer a lot of times, but the same for battlefield medicine is. You take the information you have, you have science behind it. I see the people I'm working with the PJ's doing the medicine and then I make the best decision I can, based on the information that I have with all the intangibles and uncertainty that goes with that. And I would say that that was probably a big thing I brought to the table for you guys. And then. You know, because I had done a lot of academic research in the past and I also came off a period of teaching doctors, how to be doctors for 10 years. It became, and, and I, I was doing this back then with radiation oncology. I'm like, well, I think I can teach this better to the new doctors, the residents than the textbook is. And here's my way of doing it. We created a system that, that, you know, to this day endures it. Right. And why you, and you know, was, was well-received. So the creation of. Policies something, we call TTPs tactics, techniques, and procedures. How do you actually do stuff? And then, uh, again, you know, I've referred to interpersonal skills. Other things in my background helped me deal with adversity and difficult personal, you know, interpersonal situations. So. You know, if I had PJ's who didn't want to do things a certain way, I had to figure out what was the way to get them to think it was their idea so that they would do it and embrace it and own it. Um, and then finally, you know, I had a few people under me who helped me do this. And I'm just talking about New York now, before it became the air force pararescue medical director, but ultimately organizing and motivating a whole staff to focused on the interest of the patient. And in this case, the mission. So as I built my practice from six employees to 56 or 57 employees, uh, the practice was never about me, or it was never about those people in their jobs. It was always about the patient and the patient's families and the horror that they were going through and how we could best support them. And then also do our best. Technically and cognitively to take care of them. So I think, and this is one of the things that's made it easy for me to give people a hard time. If I don't think they're doing a good job, it's not about me. And it's not about you as the PJ. It's about that soldier, sailor, airman, and Marine, that we're going to pick up out of a gunfight and make sure we get that person home not only alive, but with the best. Condition that they could be in whether it's protecting their brain from a brain injury or protecting their limb from a mangled extremity that maybe could be salvaged or resuscitating them from bleeding in shock and getting the blood into them as soon as possible to keep them from getting kidney failure or brain injury from not at managing their brain injury appropriately. So I think in the end and none of these things are rocket science. I think the most important thing. I brought to the fight besides all these other skills was having everybody focus on the casualty. The focus was not about being the cool guy, special operator anymore. You know, you've been through the pipeline. You've been selected. You've been to all these cool schools and now you're a rescue professional. And now it's only about the people we're going to pick up. So your shooting needs to be great. Your tactics movement needs to be great. Getting to, and from the patient with all these different means that you guys use. And then finally getting to the patient. If he needs a tube, put down his trachea and you can't get that tube, all that other training was meaningless. All we are then is just a recovery team, bringing home. God forbid at the ceased warrior. Right. So, um, I think that, you know, and there's all this great stuff that's, you know, everybody's aware of now about getting past yourself and your ego and. You know, if we make it about the person we're going to pick up, that's all it's about. And you have a duty to be a professional and train as hard as you can. And that was the focus of our medical practice. Um, I understand that I have a strong personality. I get things done, but I also make it clear to everybody. It's not about me. It's about some six year old boy. Who's hoping that his father comes home and can remember his name. You know, going forward from his brain injury or that he can walk again and pick his kid up, you know, when he has to carry him. Right. So those are the things that I put in the guys. So I'm just got my phone. Cause I got notes on here. I want to make sure I do a good job for you. So, um, so that, I think that was probably the biggest thing was having a patient centric approach because then it's, it's not about us anymore. It's like you're either doing the job correctly to the best of your ability. And helping these people or you're not. So I think that's the easiest way to simplify it and motivate people to do the right thing. You spoke about simplicity. And one of the things that I think defines good military medicine is simplicity and doing basic skills really well. And th the kind of, you know, medical procedures that special operations, medics perform, they're not particularly profound. It's, you know, finding, stopping, bleeding, replacing. Replacing bleeding, you know, with whatever fluid you have available to you, getting people to breathe, you know, uh, removing airway obstructions and people can't breathe on their own doing it for them, things like that. Getting antibiotics like trauma is very, very transparent in that way. It's not like more subtle aspects of medicine where you have these complex disease processes that are chronic, and don't have a very obvious cause and effect, but people are performing these skills under very, very incredible psychological, physical, and environmental duress. So from a training and a management standpoint, what kind of practices do you employ to? And you've trained, not just the military medics, but also, you know, people from various, uh, special units in the federal and local law enforcement, um, even foreign foreign groups, mountain rescue groups. So I think the principles transcend just the military. So how do you get people to do simple things? Well, under stress, because even, even like you said in Alaska, You know, putting a target on somebody with a, you know, a thick glove on is not easy when you're cold yourself and you're tired. So yeah. Can you speak to that part? Sure. So there are a three points I want to cover in this question. And the first is to go over the word simplify. So the first and some of this, you know, I look back on what I did and then tried to codify it for these kinds of discussions, but also. To teach young flight surgeons who were following in, in a couple of our footsteps because we've tried to create a sustainable program. So the first thing is simplify, standardize and communicate. And when I say we, we use the word simplify, we don't mean make it simple. We mean, make it less cluttered because there is nothing simple about giving a blood transfusion in a gun fight, or you guys doing surgical airways or putting in chest tubes. Those are not simple things. We send doctors. To train in residencies to learn how to do things. But when we say simplify, we mean take out all the extraneous stuff. So there are lots of different things that we could do in the treatment of hemorrhagic shock or shock from bleeding, besides giving blood. But very few are really based in evidence. And a lot of these things that if you're in a trauma Bay in big hospital, you have the luxury of doing all these other things, because they're easy to do. They're right there. You don't have to carry them on your back. You're already trained to do them. So when I say simplify, and let's talk about bleeding and hemorrhagic shock. So if somebody's bleeding and then their blood pressure drops and they go into shock, literally you're going to stop the bleeding and replace their blood with a blood transfusion, stopping the bleeding. However includes like three or four or five different options of techniques that you have to be expert at replacing the blood. There were two or three different ways we can get access into the bloodstream. To give the blood or how to get the blood. So all those things are actually complicated, but the way we want to simplify it is that when you're in a gunfight and you're returning fire, or then you're told to take care of the casualty and there's still gunfire, you just need to know, Oh, stop the bleeding, give them blood. You know, maybe when things quiet down, we'll give them these other meds, TXA and calcium, but that's it. So that's when we say simplify, it means simplify that approach. Standardize it. So when I went in 2012, 2013 to Afghanistan, I did the sort of oversight tour. That's the three main rescue basis. And again, this was before I really figured out what the heck was going on. And it all three bases, the same career field had all different medications, had trained in dozens, not dozens, but several different training programs. Where they weren't doing everything the same way. And then that was out of that, grew my effort to standardize everything. So we have one way we do it and PJ's represent one standard and type of medicine, the department of defense. And that was a big thing. So standardize. So simplify, standardize. The last thing is communicate. How do I wipe this in the new handbook? How do I teach this in classes? How do I transfer this to other flight surgeons? So they could transfer it with fidelity to their PJ's. And how do we make all six, 700 PJ's operate at the same level at a very good level, not the highest of the high, but at like the 80, 90% level. And there were ways to do that. So simplify, standardize, and communicate. The second thing I did was figured out better ways to incorporate the medicine and the training. So into all the tactical training, when we were shooting and on the range or the rescue training, cutting cars, open we're being on the ocean. How do we incorporate the train, the medicine into these trainings so that you guys are practicing it in context, but while we're doing it, we figure out, you know, like I said, there were certain environments where certain things don't work, but other things work. And what is the right thing to do on the surface of the ocean and a Zodiac raft. Versus being in a field in Afghanistan, in the middle of a gunfight versus being on a high angle scenario where you're 600 feet up, you know, trying to lower somebody with a head injury, uh, you can't do all the treatments, but there are a few basic ones you can do. So incorporating the actual medicine into the actual training and learning what was realistic and what we should stress in each environment. And then the final thing. Uh, you referred to, which is master the basics. So I wish I could say most of this stuff is stuff I made up, but some of the stuff I made up, but I figured out other people that already codified it. So gentlemen, crystal who ran the Rangers in the early two thousands, uh, created this concept of mastery of the basics. Conditioning through repetition to develop automaticity. So we want to train you and to say what you said before in a different way, we want to train you to stop the bleeding, make them breathe and get ready to leave. Cause that was something people could remember. We wanted to train you. So that was automatic in, you know, in firefights. So everybody could be slick when they have time and nobody's dying on them. And. It's not dark out, but it's not muddy and it's not somebody, you know, dying and you have lighting and you have good tables, like an emergency room and you have all the gear you need, but how do we train you guys to do those basic things? Stop the bleeding, make them breathe, get ready to leave. Um, in a way that's, you know, reliable and reproducible and that's by focusing on the basics, uh, Drilling it enough. So it becomes automatic. And we have enough of these stories of where guys succeeded and failed because they did the basic stuff, which is the 90% solution, the real, super fancy stuff. We leave to the surgeons and that's why they do surgical training. And we'll, we'll cover a little bit of that later. So, um, this idea that, uh, simplify, standardize and communicate. Incorporate the medicine into the context of the actual operations that you do not assuming that what we do in an emergency room could be easily transferred to people who are not emergency room doctors in a non emergency room environment. And then finally master the basics conditioning through repetition to develop automaticity. And that's one of those tenants of adult learning that I was referring to Andrew doggie. Yeah. And one of the challenges that you face with the people you trained is. They have other responsibilities outside of medicine. So, I mean, in pararescue, right? Like they're scuba diving, doing technical rescue parachuting. Those are essentially full-time jobs in and of themselves. And there are jobs in the military devoted to each of those sub-disciplines and they don't have the luxury of working in an emergency room every day or doing ambulance ride alongs. And I looking back now, and now that like, I am, you know, doing civilian medicine and I'm treating patients every day. I'm kind of amazed that I was as prepared as I was not having that many patient contexts, because I feel like I've grown the most as a clinician just by being on my own and just getting a lot of reps treating patients. And you don't always get that in the military, especially because the kind of medicine you're doing typically requires a pretty extreme situation that you don't encounter when you're not overseas. So how did you. How did you maximize readiness in these populations? Considering some of these constraints, whether it's like logistical lack of patient context, and they're, they're still being held to a very, very high medical standard. So again, I, I think I did some of this deliberately, but as I look back on it, it may have been subconscious to take a PJ who is only getting a couple of weeks of medicine a year. And then. Having them practice medicine at the highest level in the worst situations is an extreme challenge. Like people want to talk about extreme sports. I would say this is an extreme teaching challenge or an extreme leadership challenge. And I will tell you, in retrospect, what I did was, uh, going for that 90, 95% solution. So the first thing was make the diagnosis and the treatment very concrete. Very black and white. So in medicine, and as you'll attest to this in your career, now you do all this training and then you get like five years experience under your belt. And your clinical judgment is very different, was than it was the day you walked out of school because you have all of these permutations and pattern recognition of all these different things. And you're like, I know what that is. I know what that is. Well, PJ's, don't get to do that because they're not treating patients every day. So if I tell you that. If you see somebody who's got bleeding and they have a weak radio pulse, or they have altered mental status without a head injury, they're in shock. Do the shock protocol to IVs or other lines, two lines, blood, and then TXA. And now calcium, that's it. We simplify it for 90 to 95% of the people in shock. That's going to be perfect because you guys are not seeing patients all the time. There will be whatever the number is. Two, three, four, 5% of patients. Who were in shock, but you can't recognize it. And instead of me spending all this time, trying to get you to recognize something that you have to recognize and see by pattern recognition, I can't like I could tell you cool and clammy, decreased, capillary, refill, all these things, all I want. But until you have that experience where you put your hand on somebody. And you, and they're like moaning and groaning and you see a bleeding source and they're like, all right, cool. And clammy, they're in shock. You need to touch that. And I remember this with rich, one of your colleagues, rich R went on to become an anesthesiologist. When we started going to Cornell to do the burn unit, or maybe one of the ERs, he came back one day. He goes after all these years of being told subcutaneous emphysema is rice Krispies. If I had done that in the field and felt that like, I think I would ultimately figured it out, but now that I touch that, I immediately know that what that is. I'll never forget it. Yeah. So to make the diagnosis and let's face it, it's the body. There's only so many parts of the body head, head, neck, chest, belly, and pelvis and extremities. If I could teach you to recognize and manage the 95% solution of the obvious stuff, we're going to lose the subtle stuff. But if I could have 700 guys. Never missing those 95%. We're going to save more lives, limbs and eyes than trying to spend four of my eight days or 10 days. I get with you trying to do the esoteric stuff. So like, I remember you came back once and you're like, I learned all these cool nerve blocks. I'm like, well, that's great. You're into anatomy. You're, you know, you're a PT student. Then you took exercise physiology. But I have these other guys who don't have all that knowledge. And if I could get them to do March pause correctly, We'll just give them ketamine for that pain instead of doing a nerve block. But if I could make sure that they could stop the bleeding and get them to breathe, we're going to save more lives that way. And that's, I looked at it as a numbers game, quite frankly. So making everything very concrete was the first thing. Uh, no gray areas. I didn't want people using judgment because they didn't see enough patients to, to have clinical judgment. And then understand that there are limit limitations set by our career field leadership. They wanted you guys doing all these other things. So there was only a certain amount of medicine to do. And if I could make sure that you were good at the first stuff, stopping the bleeding, make them breathe, protect the brain, and then go on to wound care, splinting antibiotics, and managing pain correctly. That was the 95% solution. And we actually went on to write a paper about that and show that that was the night actually the 99% solution in the field. So, um, that those were some of the strategies. Yeah. I think the lesson there for anybody, not just people who are in this field is like, really have to define what your, your mission is and your capabilities and, and train to. What you really are supposed to be doing, not when you imagine yourself to be right. Yeah. And be realistic. Yeah. You know, especially in this nebulous, military special operations world, where, you know, we do expect the guys to accomplish these incredible things, but the more realistic we can be in focus and tailor our training, the more successful we'll be. And if we have to provide other assets, then we should be providing the other assets. Yeah. And you've had the good fortune of being exposed to really high level of medicine at NYU in the civilian world, and now in the special operations community. And I think that there's things that both of those populations do well. What do you think that the, the military and civilian medicine can, it can learn from one another. So it's changed over the 10 years I've been in, but it's. So the answer I'm going to give you is a lot based on when I came in and, and where this all began for me, the military can teach the civilians better, focus on defining the mission and accomplishing the mission, organizing themselves with task organization that are very defined. So everybody knows each other's role and where there's redundancy and where there's not. Mutual respect and teammate teamwork within the teams and then working in resource and time constraint environments, the most perfect example, being the COVID search, you know, how do we work with surges? How do we triage? So that's all stuff that we do well. And from the civilian side, I felt, you know, that there were some people in the army, a few in the air force, but particularly in the army, there were like, Like literally world-class trauma surgeons bringing academic rigor to all this stuff, which is what led to the, the repopulation of tourniquets, the use of ketamine, whole blood in trauma bays now instead of blood components. And this is something that the military has brought back into the civilian side, but there were a few. Surgeons who were really academically oriented. So I really liked the background. I came from at NYU with the academic rigor and standards of care. And I think those are things like, I want PJ's to understand they have a standard, they have a bar, they say, Oh, we have a bar. We need to get to the medicine. We call it a standard of care. And I think those are things that I've tried to inculcate into air force medicine in pararescue, at least on the prehospital side where I had a. Larger role was to bring in this idea of, Hey, let's collect data, study the data, analyze it, and then do process improvement. And what kind of training and what kind of equipment, what kind of medications do we need to, to add, to make us better? But also at the same time, how do we pair down everything we need so that we're doing sort of the Marie cuando of. Prehospital medicine, which is, you know, what's the right stuff to bring for the right job, because you only have a certain amount of space in your backpack. So I think those are the things the military does, task organization, mission focus, organization, teamwork really well. And I think the civilian academic rigor of creating a standard of care and holding people to that were things that I felt like I tried to bring to the table for us. Yeah. And, and having worked in those both worlds and you're an educator yourself, what do you think, how would you extrapolate what you just said to medical education in general? Because there's always this debate between how much theory do we need versus practical application having, you know, taught, uh, fellowships, uh, students at NYU, and now having trained special operations physicians and medics, what would you, if you were in charge change about. Civilian medical education with the educational insights that you've gained over the years, working with the military. Yeah. So I'm going to, again, just. Cause, this is how my brain works. On the PJ side. I felt it was important to keep the T PJ's as technicians. This is what you do for this situation, and this is how you do it for the 15 to 20% of PJ's who were really interested in medicine, I would then go into the pathophysiology and the anatomy, but in the end, if I had 700 guys. Who could stop the bleeding on all these patients and give them blood and reverse the shock. That's a home run, whether they understand the coagulopathy of trauma and how five rental license and hyper fiber rental license work and the anatomy of where the arteries are and all that, if they understood that fine. But if they could stop the bleeding and resuscitate the patient, that was sort of a technical thing on the doctor's side. It's more important to include the, you know, the, the intellectual cognitive piece, because that's, what's makes us doctors, you know, we're not technicians in the end. Many of us become technicians because maybe I treat just breast cancer and prostate cancer. And there are only 18 permutations of that. And I do all 18 really well. So you can almost call me a technician, even though I understand all of the molecular genetics. Of cancer, metastases, initiation, promotion, local invasion, invasion of the basement membrane, all the science of it, which I showed as a doctor, because that's what makes me a doctor versus being like a physician's assistant where maybe I know how to write a radiation prescription for a very particular disease, you know, which is where we're going with nurse practitioners and physician assistants. So I still think physicians should be held to a level of. What we go to medical school for, which is learning all this stuff. And, and, uh, but the thing that I would add now that I'm remembering exactly what your question is, is I look at how we train you guys to do trauma and we don't train civilian emergency medicine residents to do it the same way. And I will say that Jordan on our team who, you know, has done for surgical airways before he hit the age of 29, right. I will say how many images see medicine, physicians have done four surgical airways and how many have done none? The vast majority do none. Wow. Because they primarily intubate and they don't see that much maxillofacial trauma that somebody else isn't going to actually manage. Um, so I think that there are training tools that we use in the military that emergency medicine physicians should be using. To make them better at the immediacy of hemorrhage control and airway management that they don't use and do enough repetitions. So when that person is in his own emergency room and only learned about it on a plastic model and maybe cadavers, there were a couple of other things that they could do that we do in the military. And I would say that's and I, when I speak to my buddies who are trauma surgeons and emergency medicine professors, I'm like, you guys are crazy. Not to practice these things this way. Um, so that's, and I could be wrong, you know, as a cancer doctor looking at it from the outside, but yeah, that's my feedback. I do think there was something they could do. Yeah. So, I mean, it's been what, 10 to 12 years, you've, you've been doing this in the military. So can you speak to some of the, um, the missions or experiences that made you glad you made this career switch? Yeah, so. I want to start the answer with the thing that made me glad is the totality of the whole thing. So one of the things I didn't fully expound upon in what did I think my role was when I got in and then what did I learn it to be? I thought it was this business of flight medicine, grounding people, not grounding people on the battlefield medicine, but the other part, which is where we continue to overlap. The other two parts are human performance optimization, which includes injury reduction in injury prevention, but also the. Rapid diagnosis and treatment of injuries to minimize the time the guy is off and maximize the time he's operating. So human performance optimization. I love that stuff. I had some background in my prior life in USA, cycling, going to two world championships as a physician. So I brought in this experience of working with the world's best athletes, which is what you guys are in this business and that mindset. And that's something that I really loved. And the other part which came up, which I didn't plan to was the mental health piece. So the job, this totality includes operational medicine or battlefield medicine, flight medicine, the actual nuts and bolts of being a flight surgeon and then the human performance piece. But then the mental health piece, it turns out that I really had to start interacting and supporting a lot of our guys. Who saw the worst of the worst and experienced the most horrible things and had mental health issues after it. And I had to develop a process to deal with that which didn't exist, or it was, you know, was falling short. And to be honest, my background as a cancer doctor of dealing with death and dying and, and being supportive to families and patients and their loved ones through these process. Processes, I think gave me a sensitivity that I was not planning on using in this job, but became a integral piece of the mental health piece. So the totality of racial medicine, flight medicine, human performance, and the mental health stuff that I've gotten very involved in. We've done research, uh, we've enacted programs that. You know, we all should be proud of. So the totality is what I love, but I do want to mention a couple of things specifically that, um, that are feathers in the cap of pararescue and things for us all to be proud of. So one thing, particularly the New York team, our last two deployments and operation enduring freedom. I got a lot of feedback. From things we did in the helicopter that you guys did in the helicopter that weren't being done regularly. When we resuscitate shock patients, we were putting in two lines instead of one. So we got more blood in the patients before they got to the medical treatment facility, our impact on K9 rescue. There was a period where we were doing one to two canine rescues a month, and we specifically trained for that. And I got feedback on that from the veterinarians, uh, that you guys were doing something special that wasn't being done before. Um, And the other thing, you know, is the doctor thing. I think one of the things it helped me develop credibility on the team was bringing, using my relationships in the metropolitan area to get great care for people, the families, the people on the team. So I'll just give you one example. We had a guy, Jay, who you remember, his dad had developed a head and neck cancer and he didn't, he was a Vietnam veteran. He didn't have good insurance. And I got one of my buddies who was. The number one or number, but when I was there, maybe he was number two guy. Now the number one guy in long Island that had neck cancer. And I said, listen, here's somebody from my team, Vietnam veteran, crappy insurance. And in about 40 seconds, the guy said, yeah, I'll do it for free. And that's an example. He got a $35,000 value for free. So I appeal to people's patriotism and we did this all the time to expedite care, get people into the best doctors. Um, so I'm proud of that piece, the care we brought to the families of our team members, the care for the team members themselves. And then just to talk about three specific missions. One was my own involvement in the Thailand cave rescue PJ's from our team. Uh, overseas went and actually performed a lot of the work. You can go on YouTube and look up the MSNBC story of the Thai cave rescue. And you'll see a major Hodges and master Sergeant Anderson talk about the role of the PJ's. And I was lucky enough to play a role to provide command and control advice and supporting the mission, uh, which led to the successful rescue of the 11 children in the cave. Uh, and I say that because it was the whole world saw it and when it was going on, I was like, Oh my God, I. You know, if God forbid we have a problem, there's going to be a lot to answer to, but we, you know, we, we made a good decision and they did a better job of. Creating an amazing plan with great rehearsals. The second was a mission called the MV tomorrow. So if you go on YouTube, you can look up doc rush tomorrow. It's a four-minute video and it highlights the care we provided out in the ocean. 1300 miles away to do two critically injured burn patients of seven New York. PJ's who parachuted into the ocean at two in the morning with zero illumination. Uh, boarded the ship and took care of these guys and saved their lives. And, uh, thank God they're still alive, but that's something you could look up on YouTube. And then finally, uh, recently we had a case of a service member who was injured in all his extremities. Was in shock. Our PJ's brought him into the helicopter and in the 30, 40 minute flight, they figured out the only place they could put a device to get access, to give blood was actually into the pelvis. And, uh, we practice this technique because we have, you know, a series of 12 to 20 survivors of triple or quadruple amputations. And we practice the technique for this and he successfully used it and was able to get the patient alive to the surgeon. And survived the surgery. Um, and it was the first time this procedure was done in the department of defense. So these are some of the, you know, both the high profile things. The PJ's were involved in this world. These world-class rescues that very few other people can pull off. And then our bread and butter combat search and rescue where we've, you know, made a series of inroads through operation during freedom to create things that. Have become standard across department of defense using video scopes to look down the throat, to pass tubes, putting two lines in the helicopter, instead of one things that are not that complicated, but people didn't go out and fly enough and see, Hey, we could, this is an emergency room capability that we can bring to the helicopter and improve survival and improve the outcome of our patients. So the whole thing itself has been wonderful, you know? It was a big risk and challenge to go from being a civilian at 50 to joining the military. And I could say that, um, you know, that we do search and rescue, right? We are, you guys do the most noble. Mission to me as a doctor, right? I'm a doctor. So to me, it's all about the medicine and it is noble and it, the professionalism and the skill and the intellect and the persistence, and the ability to think outside the box and problem solve and, and get the mission done and save the lives of young Americans that we send into harm's way and improve their chances of having a better life, have all been the things in totality that. Uh, that have been very rewarding and, and, uh, quite frankly, I love it. And, you know, so glad to be a small part of, uh, my favorite 700 knuckleheads in the world who do this incredible mission. And we support all these other great organizations, you know, the Rangers, the seals, the green Berets, the Marines, and, um, and get to make a difference. Well, and one thing that you didn't mention, that's very timely as can you speak to, um, the coordinated effort that you were part of to help get pararescueman special operations medic to respond to that initial, uh, COVID spike in New York, because I don't know. I don't know how well you all were utilized, but you really did answer the call. I mean, that was, I remember just seeing the coordination for that. And you guys put that together pretty quickly, so. Part of this may be related to not being in the military and, you know, going by the usual set of rules. But listen, I practiced medicine in New York for two and a half decades. I had a lot of relationships. I was in the faculty of a New York city hospital. I practice on long Island and it turns out that through my relationships, I knew people in leadership at most of the major academic hospitals and some of the city hospitals beyond that, my daughter had just finished her training in New York city. And she had a direct ear to what was going on in the city, hospitals. And when the situation in April that'd become dire, where they had floors of people filled on ventilators. That have knee that's never happened before, and we didn't have the skills and enough people to manage them. I started to say, well, Hey, we have these special operations paramedics who aren't ventilator experts, but they know how to do them. And we could provide, you know, take some stress off of the doctors and nurses or something. And essentially it took, and those hospitals were making the requests to the national guard and it took a series of phone calls. To figure out who were the right people for them to call, to make the request, to utilize our guys. And this has been in the news and we had, uh, PJ's who went to Elmhurst hospital, which was the hardest hit city hospital in New York city. And for four weeks they spent times. They spent time. So if you imagine most hospitals have one kind of ventilator that everybody's an expert on. One of the things that wasn't talked about in the public when the five or six or seven or other eight kinds of ventilators were brought into hospitals, nobody knew how to work them. So they put the PJ's on ventilator teams. The first thing they did. And they learn how to work all these ventilators and went around all the floors and made sure the doctors and nurses were getting the settings correctly and knew how to use them. So they were on ventilator teams. The next thing they did was this thing of flipping the patients where they didn't have, quite frankly, they didn't have enough people strong enough to roll the people, prone to use better parts of their lungs, other parts of their lungs to air better. And they were the first proning team at Elmhurst. Um, so all that was a result of personal relationships, caring about patient outcomes. Having the guys wanting to get into the fight. Cause they, they were new Yorkers and they wanted to help New York. And ultimately it was finding out within the guard, who do we call at which operation center who can help make the taskings and coordinate that. Because at that point, the hospitals were calling and they weren't getting the right phone numbers and they weren't getting answers. So it was just a matter of. Just like I did in the Thai cave rescue, sitting on the iPhone and making calls, connecting dots, and making sure that the hospital was getting, had a realistic sense of what we were sending them and telling the PJ's, Hey, you're not going there to be these special operations saviors. You're going there to support New York doctors and nurses and technicians who are getting. The crap beat out of them and to support them and take some pressure off them. And they went in like the humble, special operations professionals they are because they made it about the docs, supporting the doctors and nurses and helping the patients. And it was not the cool guy, you know, here we are to do this. They were total professionals. And, um, and that's how some of that came about. It was cool to see the response cause we weren't there. Retired, uh, special operations, medics that just, it just flew there on a whim that wanted to help as well. That was a different mission. So the first one was Elmhurst where we officially sent the New York PJ's to the hospital. The second was more, uh, networky where I had a relationship with, uh, the COO at one of the major hospitals. And basically I knew the chief medical officer at two of the hospitals. I knew the COO at one. And. You know, a handful of leaders because some, you know, late fifties, these are my peers, right? They've gone on to become leaders in these institutions. And I would start checking in with them and saying, how bad is it? And when they started saying, we're turning the lobby into a COVID ward, we're turning the cafeteria into an ICU. We don't do surgery anymore. We put four people in each operating room. So they're managed by one resident and four ventilators. I was like, Holy cow. And then Columbia was like, well, we're going to open a field hospital on the football field. Cause we have a bubble. I'm like, Oh, that's really cool. How are you going to staff it? And they go, we don't know. I said, what if I were to provide you with special operations, medics who can do X, Y, and Z. They're not nurses, but they could do a lot of what nurses do. And I could get you a physician who. Had called me. She called me, she said, I'm coming up. She's a recent retired Colonel lots of leadership experience. I said, I can get you a medical officer to run this thing. And we could try to find people to support it. And basically we reached out to a couple of our vendor, friends on Instagram, excuse me, they needed 130 people or so to staff it by 24 hours, we had over 200 by 48 hours. We had over 400. Uh, Brian from our organization who was recently retired officer, I sit him up to become the liaison. And six days later they opened this field hospital. So we had people came in from out of town, including PJ's, but a lot of army special operations combat medic soccer owns 18 deltas. Mostly from the special operations community, because that's where this social media blitz went out. And then because of the leadership at Columbia university, they said, Hey, we're going to take responsibility for these, these people. They're going to practice to their capability. They're not going to, so it was, you know, managing IVs and giving meds. There were only two line items. So we figured out that they couldn't do that. RNs did that. They didn't do. And they had an RN associated with a certain number of beds. Who picked up the Slack and help manage the documentation, other things that were new to the operators, the medics, and then these handful of doctors, both from the institution and the military oversaw the treatments. And it was so successful that they later picked a handful of people to open another award inside the hospital. So there were ultimately two wards that ma military medics were managing because. You know, they didn't profess to do things they couldn't do, but they were really good at getting stuff done and working to their capabilities and, you know, doing the physical side and enduring the long hours and, and taking orders from the doctors and doing what they were directed to do and staying in their lanes and not going beyond it. And it was very successful. Yeah, you have so many great stories when it comes to this. I know that you host your own podcast, which tends to be more emergency medicine focused, but also speaks to leadership, teamwork, and some of these bigger picture performance and organizational issues. So working people learn more about the work that you're doing, your own, your own podcast and social media and educational content. Yeah. Yeah. Thanks. So the only reason a 60 year old is doing this stuff is because I had a friend from the Rangers. Who said, if you want to reach your young medics, you gotta be on social media. That's how I started. And originally I just made a podcast of our handbook so people could listen to it because a lot of people didn't want to read. And then I started having these discussions and it grew into something else. So the podcast is called PJ med cast. And you could find it PJ med cast, med CASG on iTunes, or you'd go to Libsyn. L I B S Y N I guess you could put it in the notes. PJ med.libsyn.com. So that's where you find the podcasts. We have hundreds now, but for you guys, if you go up and you look up the Thai cave rescue and the Tamar, just out of like pure entertainment, being proud of what these guys do as Americans, I wish you would all watch it. You could also learn more about PJ's by going to YouTube and search under PJ's air force. PJ's. Or pararescue and look up the MV Tamara T a M a R, which was our mission. And, and in also on YouTube, you can look up inside combat rescue is a six part series about the guys in Afghanistan. That was amazing and got the highest ratings for Nat geo for that year. And the other series I think is called rescue warriors. Sammy's in that, you know, some of the guys. Uh, on the discovery channel. So all that's on YouTube and they're very exciting. And, you know, we haven't gotten the press that the seals got and the green Berets, but we're the rescue specialists and all the stuff that those guys do, the parachuting shoot, move, communicate. We don't shoot as much, but you know, all that other stuff we do, like all the other special operators, do we just add the medicine and the rescuing and, um, And then I have an Instagram thing to try and reach more people. And that's under PJRQmed, where we put out like some of the summaries of the things that we're trying to get out and a couple of cool pictures. Cause everybody always likes cool pictures. And then finally, for those of you in the medical field, I want to learn more about what we've done. You can just look at my name, I guess, but in the journal of special operations medicine, we're very proud of the original research. As well as the very complicated mission reports that we've put into the peer reviewed literature. So on that level, uh, you could also find what we've done. So I appreciate that opportunity to share that. Great now, uh, I'll post all that stuff. Well, uh, thanks for your time. It's been fun because I know that you, you often, you don't, you don't like to talk about the things that you you've done. You'd like to ask people, you know, you're the one asking the questions, but it was fun to hear, uh, your answer is because I've been on the receiving end and, you know, tables have turned. Hey, thanks. Well, it's a, it's still teamwork to keep everybody in the fight. Uh, thanks so much. Thank you.