Medicine

Veterinary cardiologist Dr. Anna McManamey joins the podcast to talk about how she approaches the coughing cat. Is this a cardiology problem, or is it something else? If it is a cardiac problem, how do we even get diagnostics without putting the patient in danger? All that and more on this episode!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

ACVIM Consensus Statements: https://www.acvim.org/news-publications/consensus-statements

Practice Managers’ Summit – March 22, 2023: https://unchartedvet.com/upcoming-events/

Uncharted Veterinary Conference – April 20-22, 2023: https://unchartedvet.com/uvc-april-2023/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021.

Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).

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EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with the one and only Dr. Mack, cardiologist at Purdue, is back and we are talking about the coughing cat. This is a great episode for working with these cases. It’s interesting what percentage of these are cardiac cases and what percentage is not, and how do you separate them, and how do you know. And so we go through that. This is quick and to the point. It’s a great episode. I took a ton of notes on this. Oh man, I just love having Dr. Mack here. Guys, you’re in for a treat. Let’s get into this episode.

Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManamey. Thanks for being here, Dr. Mack.

Dr. Anna McManamey:
Hi. It’s nice to be here.

Dr. Andy Roark:
Oh man, I love having you on the podcast. You’re so great.

Dr. Anna McManamey:
[inaudible 00:01:04].

Dr. Andy Roark:
I was just thinking back. I was just thinking about recently, when you and I met, and I just happened to sit next to you at a table at the VMX conference a year ago, and we started talking, and I was like, “This person is super fun. And so you’ve been on the podcast I think at least four times now.

Dr. Anna McManamey:
I think so, yeah.

Dr. Andy Roark:
And so anyway, maybe six. I don’t know. You’re up there. Gosh, I enjoy my time with you.
I got something super fun for you today. I want to talk to you about coughing cats. And when I was in vet school, I distinctly remember being taught coughing cats are an emergency and they’re a cardiac emergency, and so I just wanted to stop and run through that. I have had some stressful situations in my career where the coughing cat or the heavily breathing, gasping cat comes in, and I’ve had those patients die, and it is awful, and it’s scary and stressful. I just want to talk through that with you. Talk to me about the coughing cat, if you don’t mind, and how do you look at these cases, and what should general practitioners know?

Dr. Anna McManamey:
Yeah, I think it’s a great question, and I think there are kind of like two schools. I’ve had people that say, “Well, I was taught cats cough with CHF in school,” and then I have the others who are like, “Pretty sure they said they don’t cough with CHF.” So it’s still I think cats in general are so challenging even for cardiologists.
So I would say that anecdotally, so I’m still a young cardiologist, and I’ve been a doctor since 2016, but only a cardiologist for a year and a half, but anecdotally, it’s very uncommon for cats with pulmonary edema from heart disease present with cough. It’s unlike dogs. And I don’t think we still know. We all give this just it sounds good answer of, “Oh, their cough receptors are different.” But it is interesting to me that cats with pulmonary edema secondary to cardiac disease, they don’t tend to cough. I mean, they might have a cough, but it’s not like a dog with mitral valve disease or with DCM. So it’s interesting. I would say the ones that I have seen cough because of congestive heart failure have had severe pleural effusion or severe pericardial effusion. So I don’t think it’s fair to say that they never cough with CHF, but I do think it’s uncommon to be cardiogenic pulmonary edema as the cause. So if I have a referral for a coughing cat, we don’t roll our eyes, but we’re like, “Oh, it might not be even heart disease.” The animal may have concurrent heart disease, but we may have more work than just saying, “Oh yes, this is congestive heart failure.”
So typically when I have a coughing cat, ideally the most important test is going to be thoracic radiographs. That’s the most important thing. And I think you bring up a really good point that some of these animals are very fragile by the time they get to you. And we have that saying, “No animal should die in radiology,” and I think that’s very true. So things that you can try to do… My thing, I’m in favor of doing a dorsal-ventral view. Might not be great. Don’t get a hand in there. But just do something that gives you a quick snapshot. Does this animal have severe pleural effusion? Does this animal have severe edema? Or is there no edema, and this is an asthmatic cat with [inaudible 00:04:21] and bronchial coughing. So I think at least that view gives you something to work with.
I think treatment-wise, oxygen is never a bad idea unless the animal’s on fire.

Dr. Andy Roark:
Yeah, exactly.

Dr. Anna McManamey:
[Inaudible 00:04:37] oxygen. I think sedative-wise, butorphanol is my favorite, because it is probably one of the safest cardiovascular drugs we have, and it is a cough suppressant, so kind of two birds, one stone with that. I’ll use doses anywhere from 0.2 MGs per K all the way up to 0.5 MGs per K, IV or IM, for butorphanol in kittycats. But I think that ultimately that thoracic radiographs are going to give you the most important information in that nitty-gritty timeframe. Then I think if you have it, point-of-care ultrasound, so those little Sonosites that you can use to do cystocentesis on, I think that’s a great way to just look. Is there severe pleural effusion? I can tap that and stabilize this animal. Yes or no? That can be very helpful. Once you get skilled enough, you can actually start to look at chamber sizes of the heart, the left atrium in particular. But I think that that’s a little bit more specialized of a skillset and so not going to [inaudible 00:05:34]

Dr. Andy Roark:
I’ll be honest, that’s beyond me. I can see the heart. I can see it beating. I have not crossed that threshold of being able to [inaudible 00:05:40]. I’m like, “Yep, there it is.”

Dr. Anna McManamey:
Fluid, no fluid is really all you got to know. [inaudible 00:05:46]

Dr. Andy Roark:
All right, good. Now, see, that’s what I need, validation. I feel good.

Dr. Anna McManamey:
But when it comes to trying to decide, “Does this animal have heart disease? Does this animal have a thing I need to do further investigation for or start treatment for congestive heart failure?” I would say the nice thing about congestive heart failure is that it’s very treatable and it should respond very quickly to medications. So unlike… I always pick on pneumonia, but unlike pneumonia, where there can be a radiographic lag between when the pulmonary pattern shows up and when it resolves, congestive heart failure, it’s like it’s there or it’s not there. And then once you start giving a diuretic, it really should start working within an hour of giving that. So it’s something that’s easy to rule out if they fail therapeutic trial for that disease process. That’s the nice thing about it.
I think cats in general with heart disease, it’s everybody’s nemesis. They can be so tricky. They don’t have to have a heart murmur. I think having the presence of a murmur, the presence of a gallop sound, so it’s like that third heart sound that kind of sounds like a horse literally galloping, or the presence of an arrhythmia, those things would increase my index of suspicion that there is truly heart disease. But there are so many other reasons for cats to get those, so it’s not the most sensitive, but at least lets you go down that pathway.
So if I have any of those findings on my physical exam, then what I do is I do things like… I know it sounds kind of off the wall, but a T4, so including in my blood work check their thyroid level, because if I think this cat has heart disease, I need to rule out hyperthyroidism and I need to rule out systemic hypertension. So T4, blood pressure, those are going to be on my list if I’m going down the cardiac pathway.
The other test I think could be helpful is the BNP test. So this is the biomarker. I think I talked a little bit about it in one of the podcasts previously, I should say. But this is a biomarker that basically assesses for heart stretch. So it’s like the heart’s own diuretic, if you will. It’s a natriuretic peptide, so it’s released by the ventricles when they feel stretched, and it goes to the kidney and tells the kidney to urinate sodium, and then therefore water follows. So this tells you if the heart feels any type of duress. Doesn’t tell you why it does. It just tells you that it’s got some sort of disease going on. So there’s a send-out test and there’s a SNAP test, and you can use the greater severity of that number to help you say, “Is it likely CHF? I should treat this,” or, “Unlikely CHF. I need to go down a different pathway.”
And so I think it’s still the most prudent to rule out congestive heart failure, because, again, it’s the easiest thing to treat, fastest thing to treat, probably most life-threatening. And then once you’ve done that, then you can feel a bit more comfortable about doing things like treating for airway disease, chronic inflammatory airway disease, asthma, bronchitis, those kinds of things, which will need beta agonists like albuterol or steroids, which is always a little bit scary to do with cats [inaudible 00:08:58]

Dr. Andy Roark:
Yeah, always.
Hey guys, I just want to jump in here with a quick update. Have you seen the Dr. Andy Roark team training courses yet? Guys, over at drandyroark.com, I have got resources for people who want to work with our team. I have my angry client course, and I have my exam room toolbox course. These are great little modules that are made to be broken up and popped into staff meetings so that you can cover a quick topic about either dealing with angry clients, complaining clients, or to talk about different tools and working with clients in the exam room. Guys, this is fantastic. I’ve got discussion questions to ask your team, so they can talk about what they do, and just is a great way for everybody to see the same thing together, to talk about what works in the practice and what they think is important, and just to get on the same page. Anyway, I hope you guys will check it out. It’s over at drandyroark.com. I’ll put a link in the show notes. Let’s get back into this episode.
Talk to me a little bit more about the interaction with hyperthyroidism and cardiac disease. Are you okay to break that down a little bit?

Dr. Anna McManamey:
Sure, absolutely. So I kind of teach it as there are three hypers whenever you see a thick left ventricle. So you could have primary hypertrophic cardiomyopathy, so HCM, which technically is idiopathic, so there’s just this innate thickening of the muscle and rearrangement of the fibers. There’s no underlying other disease. But you could also have something we call an [inaudible 00:10:22] phenotype, so it’s thickening of the left ventricle, but it’s because of systemic hypertension or hyperthyroidism, which is pretty common in our older cat populations.
So I could talk probably an hour about how the thyroid hormone affects the heart, but the nitty-gritty is that ultimately it puts the body in an upregulated metabolic demand. So we have hypertrophy of the heart muscle. Even if there’s no systemic hypertension, this still will happen. And they get fibrosis of those cells. The thyroid hormone acts inside the nucleus, so it affects the DNA of those heart cells, so it’s long-lasting change. And so these animals can get these thick ventricles, these dilated hearts, big left atrium, and still have congestive heart failure just because of hyperthyroidism. And so the nice thing with it is it’s reversible in a lot of cases.
So one of my favorite stories is a cat named Sylvester, who was 18 years old. He had never been to a vet ever. And he showed up in my residency dying. He went on the ventilator, and his thyroid was 13.4, his T4. And we were like, “This isn’t good. You’ve never been to a vet. Are you okay to manage heart failure ventilation and [inaudible 00:11:34] therapy?” And she did it. And that cat lived for three more years. It came off all of its heart meds. Ended up dying of like a gastric carcinoma. But I think-

Dr. Andy Roark:
[inaudible 00:11:44].

Dr. Anna McManamey:
I mean, something’s got to get them. But I think that it just reemphasizes the importance of looking for those underlying comorbidities that could be reversible and lead to a really more positive prognosis.

Dr. Andy Roark:
Yeah, that’s amazing. Cool, cool. All right, wonderful. That totally makes sense. It checks all the boxes for me. Is there anything else, any other pearls that you can think of to be looking for in these patients? Anything that tends to get missed when things get referred to you?

Dr. Anna McManamey:
Yeah, I think that for coughing animals that get referred, I think one of the biggest probably pitfalls is that there’s just not the time for that clinician to really get a good history on these patients. I think we’re also busy, and unlike academia where I’ve got hours to talk to clients in my day, you guys have to do these cases in like 15 minutes.
And so I think what I started doing was to have a history form that my clients filled out, so they filled it out at the time of the appointment or in the waiting room, whatever it is. And that just really helped me, because I think help having the knowledge of, how often is this animal coughing? When is it coughing? Is it self-limiting? Is there something that always incites this coughing? What’s the character of the cough? Do they have a video recording of the cough? Whatever that is, it really helps narrow down your differential list. And so if you don’t have the ability to run all of the tests, you can focus your energy on the things that are more likely. So I think the thing that gets overlooked the most is just really getting a good history and asking questions, sometimes repeating them, ’cause I feel like as a student, we always ask, “Is your dog vomiting?” They’re like, “No.” And then the doctor would go in, and they’d be like, “Oh yeah, five times a day. Vomiting [inaudible 00:13:29].”

Dr. Andy Roark:
Exactly.

Dr. Anna McManamey:
So I think it helps to just really hone in on that history question. And I think that’s something that gets missed quite a bit, just because of time.

Dr. Andy Roark:
Yeah, that totally makes sense. Are there any resources that you really like? Any tools in the toolbox that you’re like, “Oh man, I wish more people knew about this.”

Dr. Anna McManamey:
I think for cats in particular, it’s a little nerdy, but the ACVIM consensus statements. So this is the American College of Veterinary Internal Medicine. They publish these big old articles usually once every five years on a certain topic. You can Google it, ACVIM consensus statement. You don’t need special memberships to read these. And it’s basically a bunch of specialists’ just opinions/what is proven/what they would do with all of these situations. And so they have one for feline cardiomyopathy. They have one for mitral valve disease, systemic hypertension, pulmonary hypertension, hyperthyroid. They have them for everything almost. So I think those are really helpful, and they also are filled with references at the bottom, so if you want to learn more you can always go there next.

Dr. Andy Roark:
That’s fantastic. That’s great advice. Thank you so much. Thanks for being here. I always appreciate having you. Where can people find you if they want to reach out?

Dr. Anna McManamey:
Yeah, I think the easiest is probably on the Purdue Veterinary Medicine website, so I’m one of three cardiologists there. You can Google Anna McManamey in Purdue, and you should find me there. My email’s listed there, as well as some information about our clinic and what we do.

Dr. Andy Roark:
That’s outstanding. Thanks for being here. Hey, take care everybody. I hope you enjoyed it.

Dr. Anna McManamey:
Thanks, everyone.

Dr. Andy Roark:
And that is our episode, guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, share the episode with your friends. Honestly, I just want to share the learning, and that’s how we do it. Also, it always helps me if you write an honest review wherever you get your podcast. It’s how people find the show. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later on.

Dr. Tannetje’ Crocker joins Dr. Andy Roark to talk about the idea of “intentional discounting.” What happens when veterinarians are able to openly discount (or even give away) services to pet owners in need? Let’s get into it!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Dr. Crocker’s Homepage: www.drcrockerpetvet.com

Uncharted Veterinary Conference – April 20-22, 2023: https://unchartedvet.com/uvc-april-2023/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Tannetje’ Crocker is a 2009 graduate from the Texas A&M University College of Veterinary Medicine. She is passionate about mentorship and empowering veterinary professionals to embrace the profession and find joy and success. Growing up Dr. Crocker competed on horses and was inspired to become a veterinarian. Since graduation she has worked as an equine ambulatory vet, small animal general practitioner, and emergency veterinarian. She currently lives in Texas with her spirited 10 year old daughter, funny 6 year old son, and supportive husband of 16 years.

She works as an ER Veterinarian for Veterinary Emergency Group in Dallas, TX. Recently she was excited to purchase Alta Vista Animal Hospital in Fort Worth, TX. She plans to continue her support of fellow veterinary professionals, both virtually and in person through her various endeavors.

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EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my friend Dr. Tannetje’ Crocker. This is a good episode. It’s going to roil some people up, though, there is definitely some interesting conversation and ideas here. We’re talking about discounting and vets discounting. And you guys can hear me asking the questions that I’m struggling with as we go through this interview. I like a lot of where this goes, and I end with questions of how does this scale? It’s really an interesting conversation. If you think about discounting in your practice or what that looks like, this is a really good conversation.
There’s a lot of interface here with spectrum of care. There’s a lot of interface here with keeping care affordable. There’s a lot of interface with Dr. Autonomy, meeting the mission and values of staff, all that stuff is here. And also, we got to run healthy, profitable businesses where we can set budgets and do strategic planning and pay for equipment and raises and continuing education and things like that. And so a lot of nuance in this conversation. Anyway, I’m going to stop talking about it. You guys should check it out, Dr. Tannetje’ Crocker.

Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the

Dr. Andy Roark:
Welcome to the podcast, Dr. Tannetje’ Crocker. How are you?

Dr. Tannetje’ Crocker:
I’m good. A little tired, but I’m excited to be here.

Dr. Andy Roark:
I know. You should not have done this podcast. You should have just been like, “I’m sorry, I’m working until the butt crack of dawn, and then I don’t have enough time to sleep and then talk to you.” You should have said that.

Dr. Tannetje’ Crocker:
If I do that though, I would never get anything done, because that’s the ER life. So I’m excited to be here. It’ll be fun.

Dr. Andy Roark:
For those who don’t know, you are a practicing emergency veterinarian, and you are a big presence on social media. And I think the world of you. I have really enjoyed getting to know you over the last year or two, and I love that you’re a positive voice for veterinary medicine. I like the stuff you do. When there’s so much negativity on social media, I like it. I like that you tell the truth about what it means to be a veterinarian and also emphasize the positive. I just think that’s a perspective that is valuable for people to hear, and just be reminded that we do cool stuff. So thank you for that.

Dr. Tannetje’ Crocker:
I started this whole thing because of that, so I’m glad it actually resonates and works. And I hear that a lot, where people say, “I had a hard shift or I had a hard day. Thanks for sharing.” But then also reminding me of all the very cool, very amazing things we do. So it-

Dr. Andy Roark:
Well, there’s a lot of people on social media and there’s a lot of people in vet medicine on social media. I don’t think that there are a whole lot of people, and I’m going to get blown up for this, but I think there’s space for more people to be honest about what medicine is, and talk about what they enjoy about it and what makes it good and what’s fun. Or look at it honestly and find the ability to laugh.
I think that’s what I’ve always tried to aspire to, it’s not toxic positivity. It’s not pretending that every day is great. It’s not telling people, “You should just smile.” But it’s being honest and saying, “No, this is a hard job, and there are some really good things here. And let’s sit with them for a second. Let’s look at them. Let’s pull them out. Let’s laugh about the hard parts together.” And I think that that’s so valuable and just… I don’t know. I don’t see a whole lot… I feel like social media has kind of drifted away from that in a lot of ways. And so it’s just, those people out there who are putting that positivity on I think are really important.
Well, you’ve got a talk coming up. You’re speaking at Western Vet Conference in Las Vegas in a couple of months, and I will see you out there. But you’re talking about something that I’ve really been interested in for a long time. And so we’re talking about discounting. And I think a lot about discounting, and the fact that as a doctor, I am often in the exam room talking to people about money, and some people can’t pay for the care that they need to have.
I feel like there’s been a lot of evolution this way in our profession, but when I came up, it was not uncommon for vets to change the prices, and just be like, “Oh, hey, ear cytology, it suddenly costs half of what it usually costs.” And they would just do that, and it was normalized. And I know people who would slam their fists on the table desk and say, “That’s embezzlement.” It was common practice back in the day of discounting prices.
And again, we have practice managers come in and do things like that now. Where they look at it and they say, “Well, we may just be able to take this off of here.” And it comes from a good place. The thing that I was always interested in is why do we discount? And how do we discount? And are we actually helping the people who need help when we discount? And that’s where your sort of talk on intentional discounting comes in. And so I’m going to stop talking here, and kind of turn it over to you for a second, and say, when you say intentional discounting, what do you mean by that? Because I want to make sure that we’re seeing the same vision.

Dr. Tannetje’ Crocker:
The emphasis is on intentional discounting. I feel like what’s happened over time is discounting has become a dirty word. It’s something that, honestly, I think we all still do, in some way, shape, or form, but we try to hide it. And maybe that is because we have management oversight, that we’re worried we would get in trouble for giving stuff away for free-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… or for discounting. Or maybe it’s because we work off of a certain production number or we’re trying to meet certain standards. And so the idea that we would just give something away is seen as a very negative thing. And what I want to talk about is reframing it as doing it intentionally with a purpose, communicating the value of what you’re doing to the clients, and actually making the experience better for the clients and you in the hospital setting. Obviously, I work ER, so finances are a huge thing. And fortunately, I work for Veterinary Emergency Group and one of our things that we say is, “We give shit away for free.” So we openly discount. [inaudible 00:06:33]-

Dr. Andy Roark:
You say that, that’s on the website?

Dr. Tannetje’ Crocker:
It’s not on the website, but that’s the thing that we say and we really truly believe in. So doctors have the ownership to do what they want with a case, financially, what they feel good about, and intentionally discount for a reason and for a purpose. And we can get into what some of those are.
But one of the first points-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… that people have to realize are everyone discounts. It happens. And I think a lot of times we’re sneaky about it or we see it as a negative, and we’re trying to restructure and reframe it to, “It’s happening already. Let’s spin it into a positive thing for the team and for the client.”

Dr. Andy Roark:
Okay, so I want to pause on this, because, actually, I’m with you at this point. So to me, I do think that at some point, when push comes to shove, we all end up looking at this crying pet owner, and saying, “I desperately want to help this person and I desperately want to help this pet and they don’t have the finances that they need.” And what I say to people is, “We need to own this as the cost of doing business in this industry. We don’t have people who are going to kick that person out onto the street. That’s not who we are. That’s not our culture. That’s not what we want it to be our culture.”
At some point, we are kind, giving people who want to serve. That’s what we want to do. And so there is a discount cost of doing business in medicine. I don’t think that’s ever going to go away. I think people who try to make that go away are going to have real problems keeping their staff motivated, feeling good about work. I think that the culture part, it all plays into this. I really like how you’re sort of setting this up.
I think, for me, one of the things, and you didn’t mention this, when we talk about discounting and where people come down, you talked about management oversight and you talked about production bonus and being injured there, I think a lot about fairness. And when I think about discounting, I think about, “Is it fair for me to give this person who’s complaining loudly a break and not this person who just sucks it up? And I don’t know what their struggle is, but they just suck it up and they don’t say anything and they pay their bill.”
And I kind of feel like I think I treated that person who sucked it up unfairly, and maybe rewarded the person who just griped and complained loudly, and who knows what that person’s real situation is. So anyway, I wrestled with the fairness part as well in discounting and said, “How do I get my head around this?”

Dr. Tannetje’ Crocker:
I think that one of the things that I would argue with is it’s not that-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… you discount because someone gets angry or because someone says, “This costs too much. How could you charge me for that?” It’s because you discount, because you have communicated what this pet needs, you have shown the value of what they need, and people just truly can’t pay for it. Whether it’s in that moment, whether you need to just buy them some time to maybe reach out to family and friends.
You’re obviously not going to do a $10,000 surgery for free. That’s not happening. But there are cases where you could do something and you could help the pet not be painful anymore. You could maybe stop the vomiting, so they can get to the regular vet if they’re in your ER. And you could do those things for free, not completely break the bank on the hospital side of things, but have the owners feel like you actually care.
And it’s not because they’re acting like jerks, it’s not because they’re asking for it. It’s because you’ve had a conversation and said, “This is what’s going on with your pet. This is what they need. This is what it’s going to cost.” And they have said, “We really and truly just can’t do that. It’s not an option.” Or, “That high number’s not an option. This is where we are. This is our budget,” and you have to work within a budget.
So let me give an example. I have had people come in and were really suspicious of a foreign body. Well, in our ER, X-rays are expensive. The emergency fee is expensive. But I need to see is this actually something surgical or not? And then we need to be able to talk through the options for surgery. So sometimes what I’ll do is I’ll say, “You know what? Let me shoot an x-ray no charge.”
Let me just shoot a lateral x-ray, no charge, see if there’s an obvious foreign body or not. See if this is something that I could maybe give Cerenia, and you could see your vet in 10 hours. Or is this something that we have to figure out how to get this dog surgery. And owners, just the fact that I’m willing to get an answer for that and give away a $120 x-ray is very valuable to them. And so we shoot the x-ray, we see a foreign body, and they say, “Oh crap. The dog actually needs a procedure.”
So now it’s trying to figure out how do we make that happen either in our hospital, can it wait until they go somewhere else? But it’s getting them an answer, and it’s kind of working with them as a team and establishing that trust and that communication, so that you can take the next step. Does that make sense?

Dr. Andy Roark:
I have questions. I have questions.

Dr. Tannetje’ Crocker:
That’s fine.

Dr. Andy Roark:
And so-

Dr. Tannetje’ Crocker:
That’s fine. But it’s not the jerk client that’s yelling and arguing. That’s not who I’m discounting. That might be who the-

Dr. Andy Roark:
No, no. No, I get that.

Dr. Tannetje’ Crocker:
… medical director is discounting. I’m discounting for the people who truly need something done for their pet in that moment, and they just really can’t afford it. Or they don’t have an answer, yet, that helps them move on to that next step financially and work through it.

Dr. Andy Roark:
Okay. I like this. So when we start to talk about what intentional means, now we’re starting to get into the weeds. Because I think what neither of us is talking about is willy-nilly takes $5 off of this, we’re not going to charge for that. And just kind of going through scattering discounts around.
And I really want to emphasize that, for me, I have seen that my whole career and it’s awful. It’s not-

Dr. Tannetje’ Crocker:
It’s not right.

Dr. Andy Roark:
I don’t know that it actually moves the needle in a way that matters. It’s bad for the practice. You can’t budget for the practice. You can’t set your profitability expectations, so you can raise salaries. You just can’t do these things when people are randomly giving away money here and there, and not charging for this and that. And I have seen those practices. I have seen those practices. And I remember in the past, and it’s been probably a decade since I saw these numbers, but I remember stuff about your average veterinarian gives away six figures worth of services every year.
And I believe those numbers. And I don’t know if they’re still true, I suspect they are, they’re just better hidden than they used to be. But this was kind of willy-nilly giving. And so I use this analogy when I think about discounting like this, and just sort of willy-nilly, we’re going to do a little of this and do a little of that. There’s two things. There’s the research with Adam Grant, so he wrote the book Give and Take.

Dr. Tannetje’ Crocker:
I love him.

Dr. Andy Roark:
And he had this research, where he talked about how people feel about charitable work. And so what he did was he looked at people who just help people throughout the day, and they would just do a little bit of this here and a little bit of that there. And they would just kind of along and along, they just help people. And then they looked at people who blocked time on their calendar, say, one morning a week, and they went to the soup kitchen. And they did three hours at the soup kitchen on Thursday mornings.
And he looked to say, “Who’s happier? Is it the people who give along and along throughout the day? Or is it the people who just have a block of time, and they say, ‘This is how I give, and this is where I give and I go and do it'”? And what he found was the happiness, the feeling of satisfaction and pride in the people who block the time and was like, “This is how we do it,” their happiness was a lot greater.
And so I think about veterinarians that kind of take a little bit off of this and take a little bit off of that, I’ve probably done things like that in my career and generally felt crappy about it the whole time. Because I feel like I’m not doing a good job, I don’t know if I’m really helping them. I worry about the fairness thing I talked about before. So that’s the first part.
The second part is when I think about impact that we have through giving, and I look at, it’s the difference from me in giving money to someone who’s panhandling beside the road versus donating a chunk of money to the local soup kitchen. And I’m not trying to put values on anything, and say, “You should do this or you should do that.” I feel like when I stop and say, “If I’m going to do a certain amount of good in the world, am I better off handing it out to people as I see them? Or am I better off rolling it together and doing something meaningful with it in an organized way?”
And I’ve come down in the second camp, and again, I’m not saying other people should feel this way. But I do feel like, “You know what? If I take a couple hundred bucks a month and do a thing with all of it as opposed to giving away 20 bucks whenever I pass somebody, I feel like I’m making a bigger difference.”
And so I take those two thoughts, the happiness and then the impact, and roll them together. And to me the way that we discount it needs to hit those buttons for me. I need to feel like I’m making an impact and then I need to feel good. Like, I’m not doing stuff I’m not supposed to, that I’m not coming up short as a veterinarian, that I’m being dishonest with my employer. All those things are important to me.
So as you started to talk about the intentional discounting and stuff, when you’re talking about the radiographs, I’m just trying to get my head around that. When you say, “Hey, we bring this pet in, let’s do a lateral radiograph, and just take a look.” I know there’s a lot of people who are going to scream and be like, “Standard of care!” And we can talk about what that looks like in a second. “One view, what are you talking about?” And I get it, and there’s people who are going to have that reaction.
My initial reaction is, what’s this system here? How is this intentional versus just being like, “Let’s just snap this”? Help me get my head first around the system part of it. Is there some guidelines about when we do this? Is there any sort of laid out system or process for making these decisions? Help me understand.

Dr. Tannetje’ Crocker:
I think there’s a couple important points. One, we do know that burnout is contributed to by not being able to practice the way you want to. So that feeling of everyone who walks in the door, you have to charge them every single thing. Someone’s looking over your shoulder. You can’t practice medicine the way that makes you feel good. There’s not access to care. You’re constantly being questioned about the standard of care, and there’s no ability to work in the gray zone, work with owners as a team, work within their finances, and actually help the pet, and feel good at the end of the day.
So when you have that dynamic, we know that, even if you’re practicing the best medicine in the world, you are charging, you’re making a ton of money, we still sometimes don’t feel good about what we’ve done. So it’s saying, “Hey…” Especially for the team as a whole, think about your technicians that have to go tell somebody, “Hey, your dog needs this. It’s going to be this much money.” And then have to work through the owners. They have no money. Why are we not helping their pet? And that feeling.
So I think it puts a team at a disadvantage if it’s just, when someone walks in the door, you have to get this money before we touch the pet, before we do anything. I just don’t think that’s a great way to work overall. And so at our hospitals, VEG, we are allowed to practice and make those decisions as doctors with what feels good. Some of the doctors I work with discount weigh more than me. I am actually one of the lower discounting doctors in the practice, but I have really great, I guess, client feedback that they’re happy with what I’ve done. I don’t have those crazy interactions in the ER where people scream at me over finances and not helping their pets.
So it’s looking at it at a case by case basis, and knowing what is most important, and what does the owner need in that moment? What does the pet need in that moment? Maybe you’re not going to work the pet up for every single thing they have going on. Maybe they’re vomiting, and you are going to give subcut fluids and Cerenia with the understanding that that is not the best thing.
That you do not know exactly what you’re treating, but you’re trying to buy time for that pet, or you’re trying to see if it works or it doesn’t. And if it doesn’t work, they need to find finances and come back to get a full workup. But it is operating, I guess, autonomously, am I using the right word? And being able to make-

Dr. Andy Roark:
Yeah.

Dr. Tannetje’ Crocker:
… those decisions to be able to sleep better at night. So I don’t know that I answered your question just now, but I want to make sure that everyone understands that you have to work in a model and in a culture and in a hospital that is trusting of their doctors and their team overall. And there’s really not a set plan, right?

Dr. Andy Roark:
Yeah, okay.

Dr. Tannetje’ Crocker:
That it’s based off of those interactions one-on-one. Does that help at all?

Dr. Andy Roark:
It does. It does.

Dr. Tannetje’ Crocker:
And it’s being open about it. You’re open about it. You’re telling the clients. They know what you’re doing. You’re not [inaudible 00:19:00]-

Dr. Andy Roark:
I think that’s interesting. I think that’s what you’re talking about, it’s basically veterinary medicine that I’ve seen a million times, just being really open about what’s happening as opposed to, “Shh, don’t tell anybody.” It’s an interesting concept.

Dr. Tannetje’ Crocker:
You know how we say, drop that pet on the… All the time, and I’ve worked so many places, “Oh, look, the pet fell on the x-ray machine, and we took x-rays. Oh, look like…” Right? I mean that happens-

Dr. Andy Roark:
Yeah.

Dr. Tannetje’ Crocker:
… all the time. You’re like, “Well, let’s just do it.” But not really be open about it and not really charge for it. And I’m like, “No, be open about it. Say, ‘I’m going to take this x-ray for free. Let’s get some answers. Okay, guess what? Your pet has bicavitary effusion. We need to put them to sleep.'” But we got you an answer and you feel better about it. And what I suspected has been confirmed.

Dr. Andy Roark:
I cannot look at you in the face and tell you I have not stepped on the x-ray pedal and said, “Oops,” before.

Dr. Tannetje’ Crocker:
Yes.

Dr. Andy Roark:
Okay. Yeah, we’ll just… Real talk here.
Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one-of-a-kind conference. It is all about business. It is about internal communications, working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you can be practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people.
This is all about building systems, setting expectations to work effectively with your people. Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we’re going to talk about the things that you are interested in. It is always, as I said, business communication focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about.
We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look, come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
I think that’s really interesting, all right. And I think this is really, really interesting, and this is why I want to talk with you about it. When I look at where medicine’s going and rising standard of care, meaning, we get more and more advanced in what we can do and what the gold standard of care is, and significant increase in prices and that’s higher wages, which is good. This is the thing is I want people to make a living wage in vet medicine. I want them to be taken care of and I grip my teeth, and go, “Ugh.”
I talked to practice owners last week at the Uncharted Practice Owner Summit, and a number of them said pretty straightforward, “The average member of my staff could not afford to be a client in my practice, and that bothers me at a deep level.” And I thought that was very sort of vulnerable, candid conversation. But I see that as well and go, “Man, I don’t want to…” I think it’s hard to keep people motivated when they say I’m performing a service that I couldn’t afford to have, and telling everyone this is what they need to do and this is what it means to be a good pet owner.
And so I think that what you’re talking about, and we sort mentioned the standard of care before about doing the one lateral view, this is very much at the heart of what the spectrum of care conversation looks like in practice. There’s a lot of hand waving of, “Spectrum of care and what does it mean?” And this is what it actually looks like in the practice is going, “Yeah, I understand two views are better than one. I get it. I understand that they’re exponentially better than one. I get it. That’s not what we have the resources to do. And so we’re picking the better of not great options here.”
And so I think you’re really very much getting into functional standard of care or spectrum of care kind of work. And then integrating the finance part of that too is to go, “Well, there is spectrum of care, and then there’s also how do we make this affordable?” And there’s a lot of different ways to do that. I think it’s got to be a multimodal approach to keep care affordable, and to help pet owners out.
Talk to me a bit about what tracking this looks like. Because I want to believe that this is very much not the old school, the vet kind of does what they want and nobody tracks it. It’s like, “Oh yeah, I don’t know what he… We just give stuff away.” But I have to believe that the modern version of intentional discounting, if you go this way, it’s got to be built on tracking, so that we can see what we’re doing, so we can see what we’re giving away.
I think to me as I listen to this, I go, “That’s got to be what’s different, is by making it an open thing we talk about, we can at least track it, we can budget for it, we can understand it.” It’s not kind of old school vet clinic, where the books are a ledger in the back and they never balance it. It can’t be that. Help me understand the tracking, the measuring, the monitoring.

Dr. Tannetje’ Crocker:
I am going to put it on the bill, and I’m going to zero it out so the owner sees what the value is. When I add that discount in, it’s going to be under me. And so I can, with my medical director, look and see where I fell on the discount side of things, how much I discounted. But another component of that is your NPS. So people that rated you after their interactions with you, your net promoter score, what was that score?
So are you making clients happy? Are clients leaving and they are willing to recommend the practice to other people? Are they leaving good reviews? So there’s a lot of value in having clients be happy, in not having those really negative interactions in your practice that are traumatizing for all involved. So you’re balancing out those two things. You can’t look at it as just, how much did you discount?
I work hard enough and I make enough money that it’s okay if I discount a little bit. And I either get a client to do more for the pet, because I got them an answer or I get them to be happy and then recommend us and leave good reviews, and do things that are positive for the practice, then constantly having this caustic interaction with clients fighting over money.
I think it takes a little bit of a maturity. I see a lot of the younger vets that I train come in and they do, as soon as something gets a little uncomfortable with the client, they just want to give something away. And I’m like, “That is not it. That’s not it.” You’re finding something you can do. It’s a pain injection. It’s something that you can do, because you’re truly listening to the client. You’re listening to what the pet needs. They feel like you care, they trust you, you’re communicating what you’re doing, and that maybe it’s not everything you would like to do, but you’re trying to help.
And there is value in that that comes out that is almost immeasurable. But you can track things like net promoter score, and you can track things, how much you’re discounting, just to keep up with it.

Dr. Andy Roark:
Oh, talk to me more about net promoter score for veterinarian. That’s a term I’m very familiar with from the conference business, where we look at marketing and happy customers coming out of our events. But I haven’t heard that as a term that we track for veterinarians. So break that down for me a little bit, please.

Dr. Tannetje’ Crocker:
Every client that leaves your practice, leaves your hospital should get some sort of follow up. Now with the way things are electronically, you should be able to send a message, “Thank you so much for bring fluffy in,” whether it was for the vaccines. “We hope they’re doing well. If you get a chance, please fill out this survey about your visit.”
And what you’re looking to do is get people who actually reply to those surveys. You’re looking to see what was their visit. So if it’s one to 10, you ideally want only above sixes. People that are nine and tens and sometimes eights are willing to promote you. So they’re willing to talk about you outside of the practice, talk about their experience, and that is really valuable. People that are a little lower had a great experience, but they’re probably not going to tell people about it. And then anything under a six in general, you’re like, “Eh, we could have done a dramatically better job.”
But you’re looking to see what was their experience based on a lot of different categories, and where they kind of rank you. And you can do that and get enough data to see as a veterinarian, as a team, based on who they’re shouting out, how are we doing? How are we communicating? How are we interacting with people? And you should have a positive net promoter score. So you should have something that is higher. And I have a high net promoter score and I also discount.
And so I guess it’s not one or the other, but I think it is a good thing to sit down as a team and say, “How are we doing? What’s the perception of what we’re doing? How does the team feel about what we’re doing? How did the clients feel about what we’re doing? How does management feel?” It is an overall discussion. But when your culture is one where you can give step away for free, so that you can go home and sleep at night, it’s not something that’s hidden. It’s something that’s celebrated. We helped people. We helped their pets. And that’s just a different way of looking at things.

Dr. Andy Roark:
Are there guidelines on when you think the discounting is okay or things that are put forward? So I love that you say, “I discount because I see this as an opportunity. We’re making this difference.” And you also own the fact that there’s this natural tendency that when somebody gets upset at you, you can make them happy by giving them things.
And that’s very true. There’s so much nuance here. There’s so much nuance between. “We do not reduce our prices in any way, shape or form. They are what they are. And if you can’t pay them, then you need to go somewhere else.” And, “Just come on in. Just tell me, what do you feel comfortable paying? And that’s going to cost.”
There’s a lot of space between that. Lots of shades of gray here. Try to give me something tangible to put my feet on as I drift through this space, of this feels in bounds and this feels out of bounds. Are there guidelines something that I could communicate to someone else other than, “Let see how you feel”?

Dr. Tannetje’ Crocker:
SoI think I have some personal guidelines that I share with other veterinarians. There’s obviously a point, I don’t give away thousands of dollars of free stuff, but if there’s an emergency C-section and I’m worried that the pet’s life is in danger, the puppies’ life is in danger, and I know that I can skip some of those things that we can be considered standard of care.
Ideally, on a emergency c-section, you’re doing full blood work, full imaging, catheter, you’re doing all the things, you’re hospitalizing them for a while afterwards. There’s a lot. There’s some things that I can probably cut out of there, and make sure the patient is stable enough for surgery, but get the surgery done and help the pet and help those puppies. And I can discount it right down. I still need to charge a certain amount, but I can discount some things out.
And so it is looking at the case, but I’m not going to take a hit by car pet that has a completely shattered backend, pulmonary contusions, and the owner has no money for the follow-up care that this pet needs after their emergency visit. I’m not going to just give them $10,000 worth of hospitalization and management. So there needs to be the potential for a good outcome. There needs to be a pet that is not suffering, that if what you do and not maybe getting an answer, you’re not going to prolong suffering or make something worse for a pet. There needs to be the ability to communicate other resources.
So we have a lot of rescues and organizations we work with that we can direct people to, to get additional funding. And one of the biggest things that I try to teach young veterinarians is, if you give people time, people find money. So I have-

Dr. Andy Roark:
Yep, I agree with that.

Dr. Tannetje’ Crocker:
… a lot of owners that I will say, “Let’s do A, B and C. I will discount this, and take your pet home. If they continue to do what you came in for, come back. We need to do a full workup. We need to do more of a treatment, or we need to hospitalize. This is what that would look like.” And you would be surprised how many owners come back in 12 hours and say, “They started throwing up again, but I called Aunt Susan and I now have the money to hospitalize.”
So for me, I don’t do it on cases that the pet is suffering, that I know I can’t help them, I can’t save them. I don’t do it on cases where I think there’s something that I medically would cause an issue if I just made a guess. But I think after 14 years, I have a pretty good idea of what’s going on with a majority of pets. And so there is that innate understanding and ability to say, “I can do this. It’s not going to make it worse. And I am here if something changes and does get worse.”
It’s not a. “Let me do this, send you away, don’t ever come back here.” It’s a, “This is one step, but we might have more steps in the future.” And setting them up for that possibility and setting them up for the next thing. So it’s all about communication. I mean that’s really what it comes down to, right?

Dr. Andy Roark:
Yeah. Well, the part when you say, “If you give people time, they’ll find money,” that really tracks with what I’ve seen. How many times have I had a case in and treated it empirically, because that’s what we had the resources for and said to them, “This is not ideal. If the limping continues, if vomiting continues, if whatever, I will see you back tomorrow, and we’re going to need to do these other things.” And what I’ve found is that people tend to come back, if they need to. And when they come back, they have accepted what we’re going to do, and they’re generally much more prepared for it. And if you think about the cases that you see, I think most of us in the rooms will have that experience. That totally makes sense.
Talk to me a little bit about, “We still need to charge a certain amount,” is sort of what you said. And there’s things like hard costs. It’s one thing to say, “Well, I’m going to step on this x-ray pedal and make this digital image here to look at.” It’s another thing to say, “I’m going to go to surgery for two hours and spend a lot of anesthesia and pain medicines and tech time and things like that.” Those are just different things.
Does that come into your calculations at all? Walk me through any sort of guide rails, because you seem like you have them. Because you’re saying like, “Oh, we can do something here, but we can’t do everything here.” And do you have any sort of thoughts like that come in as far as how much you’re doing?

Dr. Tannetje’ Crocker:
Yeah, so in the ER there’s some really simple, like a blocked cat, a GDB, a hemo abdomen that needs a splenectomy, a mesenteric torsion. Those are just some things I saw the last couple days. I need to have very frank conversations with those owners about what that pet needs, what possible outcomes are, and financially, what it could look like. And I need a deposit and I need a substantial deposit for those. I am not taking those pets to surgery until there is a very clear understanding of what is going on with these pets.
And so there is no rushing into surgery if the owners have just no finances, because you don’t know the outcomes and you don’t know how long those pets might need to be hospitalized. And there’s too many uncertainties. And it’s not fair to this pet to not be able to do everything you need to for them. But if you have a golden doodle that looks great, that threw up three times, and maybe ate something, but maybe didn’t, and palpates normal and is happy and healthy. And you have a conversation, the owner says, “It’s Christmastime. I just got a lot of presents. I just really can’t afford to do all the x-rays and all the things.”
In those moments, I either say, “I really am worried about something significant,” so maybe I do an x-ray real quick for free, and I can take two views and no charge it. It’s not going to break the bank but I’m going to have them pay for subcut fluids and Cerenia and the emergency fee if everything looks okay on x-ray. And so it doesn’t mean it’s all or nothing, with a lot of these cases. I have a lot of owners that say, “I have $200.” Okay, I’m going to work within that $200, do what I can. But if they also need Clavamox to go home or an antibiotic, I will do the antibiotic, maybe, for free.
And so I think the thing that we have a hard time with as veterinarians, it’s like everything has to be black and white or there has to be rules. And unfortunately, this is a very innate thing. It’s kind of doing it a couple times and communicating and realizing what does and doesn’t make sense. Making sure you’re very clear about what you’re doing and the value of it. But I think the big picture you have to have is why are you doing it? How does it help the team? How does it help the pet?
And when you look at it that way versus what are all the possible negatives from it? Or what makes it hard or tricky? It gets easier and easier on a case by case basis. But it is hard for me to say, “This is it. These are the rules. And if you do this, it’ll work for you.” Because it’s very dependent on the practice and it’s very dependent on the communication, and it is a case by case basis. But I think being transparent about discounting has a lot of value in veterinary medicine, when done the right way.

Dr. Andy Roark:
This has been great. I have a lot to sit with here. I like your point on transparency. I do think that this is really where the rubber meets the road on spectrum of care, in a lot of ways. I mean, I think that are talking openly about things that have gone on, and it’s just sort of the built-in cost of doing business in the profession. I think you’re hitting on all these sorts of things. I’m going to sit with this a little while. So this has been outstanding. You are doing this presentation at Western Vet Conference in Las Vegas in February, I believe.

Dr. Tannetje’ Crocker:
Yes.

Dr. Andy Roark:
It’s February, right?

Dr. Tannetje’ Crocker:
And we’re going to do it on a, I’m going to try to do a case-based one, where we can actually say, “Let’s talk about these cases. Let’s look at this case. Why would we discount? How did we discount? How did it play out?” To give people like a little bit more of a tangible experience around it.

Dr. Andy Roark:
That sounds great. And then where can people find you online, Tannetje’?

Dr. Tannetje’ Crocker:
I am on all the social media platforms, Facebook, Instagram, TikTok, dr.tannetje.crocker. I do have a website, drcrockerpetvet.com. So if you need somebody for a speaking engagement, if you just want to connect, I love networking and hearing about things going on in veterinary medicine. And I absolutely love this profession and could talk about these things all day. So thank you so much for having me on, Andy.

Dr. Andy Roark:
Oh, absolutely. I’ll put links to your socials down in the show notes. Guys, thanks for being here. Take care of yourselves.
And that is it, guys. That’s the episode. I hope you enjoyed it. I hope you got something out of it. I hope you got a good amount to think about. If you did, as always, the kindest thing you can do is share with your friends. Spread the word, spread the joy. Help people know about what we do in the podcast. Write me an honest review wherever you get your podcasts. All that stuff is super helpful. Gang, thanks for being here. Take care of yourselves. I’ll talk to you later on.

The original Anesthesia Nerd, Tasha McNerney, is back on the podcast! In this pearl-packed episode, Tasha runs through her anesthesia crash cart and breaks down what she has ready to go and why. This is an excellent refresher for anyone who wants to cement their emergency anesthesia drugs into memory.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Veterinary Anesthesia Nerds: https://www.veterinaryanesthesianerds.com/

Recover Initiative Drug Chart: https://acvecc-recover.org/

Uncharted Veterinary Conference – April 20-22 – https://unchartedvet.com/uvc-april-2023/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

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All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.

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EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with my dear friend, Tasha McNerney. We are running through the crash cart. This is such a great episode. This is the most stripped down, practical, just refresher on Anesthesia crash carts, that I’ve ever seen.
Honestly, I say at one point in this episode, I wish that they’d broken this down like this for me in vet school, because this is a beautiful thing. If you’re a student, a tech student, a vet student, just bookmark this one, because this is great. If you are like me, been a while since I ran through the crash cart and really was, I know exactly what this does and why it does it and how it does it and how much I use. Man, this is a great episode for you. So, quick to the point, Tasha’s amazing. Let’s get into this episode.

Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Tasha McNerney, how are you?

Tasha McNerney:
I’m good. How are you?

Dr. Andy Roark:
I am so good. It is so good to see your face again. You are one of my favorite people. You and me go way back, way back.

Tasha McNerney:
Way back.

Dr. Andy Roark:
You were here visiting my house when the pandemic hit and I’ll never forget-

Tasha McNerney:
Yes.

Dr. Andy Roark:
You and I started the pandemic together.

Tasha McNerney:
Yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South Carolina town.

Dr. Andy Roark:
I still have those beans, a 100%. I’m, these are my survival beans. My wife’s [inaudible 00:01:48].

Tasha McNerney:
Yeah, well just save them.

Dr. Andy Roark:
She was, we’ll never eat these. And I’m, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be, what are we going to do if society ends?

Tasha McNerney:
Yeah. It was a good time.

Dr. Andy Roark:
When the world went sideways, you and I took action. That’s all I’m going to say. And most people-

Tasha McNerney:
Oh, 100%.

Dr. Andy Roark:
Did not, but we did.

Tasha McNerney:
No. People were, is this happening? And we both looked at each other and were, oh, we’d better stock up this pantry. Even though it wasn’t my pantry. I was, I’ll help you stock up this pantry.

Dr. Andy Roark:
Oh, you were with me.

Tasha McNerney:
I had gotten a call from my husband at home saying everything is off the shelves. It’s pandemonium here. And at that same CVS I bought two boxes of pasta and took them back in my luggage with me, because I was so worried that I wouldn’t be able to find pasta when I went home.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
Yeah.

Dr. Andy Roark:
Oh man. It’s great to be with an anesthesia specialist because when the world goes haywire, they take action. And I felt that was instinctual for you.

Tasha McNerney:
Oh, 100%. I always joke with the anesthesia, is that we are very cool, calm and collected. When everything is crashing in the ER or in the OR, or wherever we are, it’s very much, okay, here’s the problem, where do we go next? All right. And we start this checklist. It’s very much cool, calm, and collected in anesthesia.
And the joke is that we’re dead on the inside. And sometimes I would agree with that, in that we’re not going to be the people freaking out, oh my God, everything is crashing, go get this for me. Really? You know that actually with me, you know that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.

Dr. Andy Roark:
Yeah. Oh, man. Oh yeah. You are a bit dead on the inside though. That’s just [inaudible 00:03:55], different.

Tasha McNerney:
A little bit. And that’s fine. Yeah. And you know what? Listen, I got a therapist, we’re working on it. We’re good.

Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be… We all know of people who should be a little bit less alive inside. It would help them.

Tasha McNerney:
Just calm down.

Dr. Andy Roark:
Totally. All right. For those who don’t know you, you are a veterinary technician, specialist in anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s conference. This thing has grown to… How many people are involved, engaged with the Anesthesia Nerds Group now?

Tasha McNerney:
We have about 65,000 members around the world right now.

Dr. Andy Roark:
Yeah, it’s awesome. It is super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff, that I’m, I’m actually going to use this. And that is what you guys are all about. So I really love it.
I’m super glad that you’re here. I thought of you recently when I was… I had a pet under anesthesia and I can’t remember why, it was an emergency of some sort. And I had this pet under anesthesia and it just dipped there for a second. So when you pause for a second and you’re, is this going to be an issue? And then it stabilized and then comes back out.
And I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance, was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, eh, you know what? Let’s just freshen these skills back up.
And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a 100% refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel the dust has been blown off my crashing patient knowledge. Is that okay?

Tasha McNerney:
Oh, yeah. Let’s do it. Ooh, there’s probably a lot to cover, but we’ll maybe put it into categories when you’re looking at your crash cart. And again, I just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different.
But when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. If that’s cool with you?

Dr. Andy Roark:
Yeah.

Tasha McNerney:
All right. So first of all, in an emergency, again, when I say to you, hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out, are real emergency drugs. And when I say emergency drugs, with anesthesia in mind, when I’m talking about are emergency things like atropine and epi and then our anesthetic reversals.
So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycopyrrolate. But again, in an emergency, we want that fast onset, all right?

Dr. Andy Roark:
Mm-hmm.

Tasha McNerney:
Now there’s some stuff, and I will let you guys listening at home do some research, because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years, especially starting in human medicine, asking, is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recover guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago, that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency.
Our next is epinephrine, and that’s because we want that vasoconstriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs.
Then we need to get rid of whatever anesthetic… Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone.
Second, most common drug class that’s used are benzodiazepines, things like Midazolam or things like Valium. And we have a reversal for those. And a lot of clinics don’t even carry the reversal. But I would say if you’re utilizing things like Midazolam or Valium in your clinic, you need to carry the reversal, just in case things get crazy. And the reversal for those, is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your OR if you have an anesthetic emergency. The next reversal agent that is very important would be Antisedan or atipamezole. So this is going to reverse your dexmedetomidine, or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use in atipamezole as well, working on those receptors.
So you want to have Antisedan for your dexmedetomidine, right? So if we came into an urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, we don’t have a reversal agent for ketamine. So just realize that if you know things get crazy and you start reversing everything, that ketamine is still going to be on board. We don’t necessarily have a reversal for that.
Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart. One, maybe for some anti-arrhythmogenic effects. And then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine, and the other one is diphenhydramine.

Dr. Andy Roark:
Okay.

Tasha McNerney:
I like to keep these on board, especially with our patients that are not hemodynamically stable, certain breeds. If we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia. And when I say that, I mean a beat that is greater than 160 beats per minute.
So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen. So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give a two mg per kg lidocaine bolus if you see that your patient is in V tach.
Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow V tach or a ventricular escape beat, where they’ll see it, but maybe the rate is still only around a 100 beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies.
And then diphenhydramine, I usually like to have it on board because sometimes my surgeons will note, hey, I see that this patient has had a reaction to either… Maybe they have severe clipper burn or they’ve had a reaction to the chlorhexidine that’s been used to scrub their skin and now they have hives. So if we see something like that, we want to make sure that we can administer some diphenhydramine to them.

Dr. Andy Roark:
Okay, that makes sense.

Tasha McNerney:
Those are some emergency drugs. And so of what I like to have on my anesthesia crash cart. Now, these are adjunct drugs that I’ll talk about really quickly. And this is more blood pressure drugs.

Dr. Andy Roark:
Okay.

Tasha McNerney:
Because we know that inhaling anesthesia, along with a lot of the drugs that we are going to administer, like acepromazine, like propofol, like alfaxalone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypertension’s going to happen, we want to be ready for it.
Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus as a five mil per kg, is going to get you where you need to go for some animals. But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60, because then we know that oxygen delivery to really important tissues is going to be compromised.
And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient, a cat that’s under anesthesia for dentistry, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great, and they are also an elevated kidney value patient, and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient.
Again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate in the contractility. And the alpha is going to give you a little bit of a squeeze on those vessels. Similar to another alpha active drug, dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals, like your mitral valve disease patients, like your chronic heart failure patients, these little Shih Tzus that come in and they have heart disease. These guys, if we’re about to do a long procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily exit beta receptors. These little dogs sometimes can’t handle, with the heart disease can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys, because it’s having a party at the beta receptor. It’s all beta all the time. And that’s why I want to have dobutamine for those specific heart cases.
And then I also like to have ephedrine. And ephedrine is one of those because it is very cost-effective. It’s very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes. So I find ephedrine very helpful. It’s an alpha and beta, very similar to dopamine. But unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one mg per mil concentration.
But then you could give a dose of it. And sometimes if I say to my clinician, well, I’m already tried the vaporizer, I’ve maybe tried giving… I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine, or I don’t want to take the time to set up a CRI. I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket, if I just need a quick something, and I don’t want to set up or I don’t have access to set up, a syringe pump and an infusion, et cetera.
And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now, again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. We’re not going to shock V tach.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
But if you see it’s really critical, things go south and crazy and your patient is in V-fib, then we can shock that rhythm. But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
Okay. But this is just equipment. And the reason I’ll go back to the laryngoscope and the tube really quick, is on the off chance your patient during movement from induction into the theater gets extubated, during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient.
And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube, if there are any problems, et cetera. I want to be ready for those problems. And that becomes, especially, especially important, if you’re dealing with brachycephalic patients. Always have an extra tube and laryngoscope ready to go.

Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful, 15, 20 years ago. This is amazing.

Dr. Andy Roark:
Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is one of a kind conference. It is all about business. It is about internal communications, working effectively inside your practice.
If you’re a leader, that means you can be a medical director. It means you can be an associate vet, who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you could be practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people.
This is all about building systems, setting expectations to work effectively with your people. Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda, at the event, which means we are going to talk about the things that you are interested in. It is, as I said, business communication-focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about.
We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is.
Take a chance, give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration, ask anybody who’s been, it’s something special. All right, let’s get back into this episode.

Dr. Andy Roark:
All right, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like? Because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need? It’s not just epinephrine to effect, although that works.
But how do you track that information? How do you keep that in a very handy format? Because you just know it, you’re just… I know you know it, but is that the best way to approach this?

Tasha McNerney:
It’s probably not the best way to approach it, because again, unless you’re really dead on the inside and you can block everything out and just go to your Rolodex of drug dosages, nevermind that thing’s beeping and people yelling. Again, I can do it, but I think that’s just because, I don’t know, my brain functions a little bit differently.

Dr. Andy Roark:
I’ve had people say, how much? And I show them with my fingers like this much, and they’re, that’s not scientific.

Tasha McNerney:
That’s not a… Nope. Don’t do that, you guys at home.

Dr. Andy Roark:
Yeah, don’t.

Tasha McNerney:
But certainly I would say for anybody who is interested, look at the VECCS website. They have a lot of really great things. Look at the RECOVER Initiative, that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER Initiative and their website, they also have posters that a lot of clinics will use, that give you the dosages of, based on weight. They have a quick weight chart.
So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine, reversal drugs, things like… Again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that.
So I really would recommend RECOVER because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible. Another thing that I do recommend that every practice does is take those dosages and make an Excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go.
The time to print it out and put it into the Excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand. Because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg per kg dose, and then your brain is, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math, doesn’t usually work out well. And those precious seconds that you’re taking to calculate out this drug can make a huge difference.

Dr. Andy Roark:
Yeah, that’s fantastic. I’ll put a link to the RECOVER Initiative drug doses in the show notes, so people can check that out. I don’t think I need a link to Microsoft Excel, but…

Tasha McNerney:
No. I usually say… Because people can make their own Excel, again based on what they have in their clinic. Because I don’t think that every clinic maybe has vasopressin ready to go for their solutions.

Dr. Andy Roark:
Yeah. No. I love that. I think that makes a ton of sense. What are the most common pitfalls that you see? And what are the things that people are either putting together on a crash cart or using what’s on their crash?

Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
So for instance, [inaudible 00:22:36] I would give you… Yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go.
So having somebody check that before the procedure. And I’m a huge fan of checklists. You guys know me, I love checklists. I love anesthesia checklists. If you haven’t read the checklist manifesto, please do yourself a favor and read this. It’ll change the way you practice.
But certainly having checklist in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your CRI. I’ll just give you an example. I was doing, I was helping out anesthesia on a 62 kg-

Dr. Andy Roark:
Wow.

Tasha McNerney:
Great Dane.

Dr. Andy Roark:
Yeah, it’s 140 pound Great Dane.

Tasha McNerney:
Great Dane.

Dr. Andy Roark:
Holy crap.

Tasha McNerney:
In for a CT procedure. And I went to look at the crash cart in our anesthesia machine in CT, and I’m looking at it and I was, we only have one ML of atropine in this bottle. So, I have atropine and it’s in date, but again…

Dr. Andy Roark:
That’s not going to make one side of his mouth [inaudible 00:23:53].

Tasha McNerney:
If something goes crazy with this patient, now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that Dane.

Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about Anesthesia Nerds?

Tasha McNerney:
Yeah, so the Veterinarian Anesthesia Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website, veterinaryanesthesianerds.com. And on the website we have links to the Veterinary Anesthesia Nerds podcast, as well as a calendar of events.
So you can see where all of us are speaking. And when I say all of us, I don’t just run Anesthesia Nerds by myself. I am joined by Darci Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Satal, who is a VTS, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there.
So we have a calendar, so you can see if you wanted to come hear us talk or lecture. We have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the Anesthesia Nerds or you wanted to request some help for something, you can get us there.

Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here. Guys, thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.

Tasha McNerney:
Thanks for having me.

Dr. Andy Roark:
And guys, that’s what I got for you. I hope you enjoyed it. Hope you got something out of you it. Thanks again, Tasha, for being here. Guys, if you liked it, if you enjoyed this episode, tell your friends, share this thing, because really, this is great information.
Always, always feel free to write us an honest review, wherever you get your podcast. That means a lot. Gang, I will talk to you later on. Be well.