Dr. Matt Sherrer (Host 1): Here we go. Another edition of the Fresh Flow Podcast. But first, Mitchell, I know we're going to end up talking about monsters and zombies and whatnot later on, and our listeners will understand that here in a bit. Favorite scary movie ever.

Dr. Mitchell Tsai (Host 2): Oh, what's the one—Not Redrum. That's the Shining. The Exorcist.

Host 1: Oh, yeah.

Host 2: That's the spinning around head and the pee, green, vomit kind of thing, right? Wasn't that that one?

Host 1: Yeah. Or maybe I just need my own exorcist. No comment. All right. Well, how about you introduce our guest.

Host 2: Alrighty. So today, I got the pleasure of introducing Dr. Roy Soto. I think we crossed paths many, many years ago at the ASA Practice Management meeting. It's now called the ASA Advance. Dr. Soto earned his bachelor's degree in neurophysiology. I am going to read the thesis. It says, A Human Model for Lower Limb Venous Afferent-Elicited Skeletal Muscle Pumping. So, how come they didn't bottle this into something called like Gatorade? Anyways, he graduated from Uniformed Services University of Health Sciences. And Matt, every now and then, I think our world aligns, because there's an ASA Monitor this month about the Uniformed Health Services.

Dr. Soto completed his Anesthesiology residency at the UCLA Medical Center. He's involved with federal aviation, space medicine. And then, looking through his CV, more importantly, I think he's worked for every private group out there, large group, NorthStar, MEDNAX, Corewell. And either he just jumped around or all those, all the groups just bought each other, and then he just got bigger and bigger. So without further ado, Dr. Soto.

Dr. Roy Soto: Hey, how you guys doing?

Host 1: Fantastic man. Thanks for being here with us today.

Dr. Roy Soto: No problem. The intro couldn't have been better if I'd written it myself.

Host 1: Did you write it yourself? That's entirely possible.

Dr. Roy Soto: I didn't this time.

Host 2: I think there's been several themes throughout the first two seasons on this podcast, Roy. And one of the things we touched upon is how TeamHealth and USAP are starting residency programs, whether or not that was a response to the workforce shortage, or just how do you work against a workforce shortage of both physicians and mid-level providers. But you sort of led the Vanguard 2009 starting a residency program from scratch for Oakland University. could you talk to us about it? What led to that decision and how's it been going?

Dr. Roy Soto: Yeah. So, I did my residency at UCLA,  like you mentioned. And then, I went off to the University of South Florida in Tampa, where I worked for four years. And then, that program shut down—it was not my fault—and went up to Stony Brook and Long Island for three years and through, through work with ASA and the AMA, I knew Jim Grant, who was the Chair of Residency of the Anesthesia Program here. At that time, it was called Beaumont Health. Now, it's called Corewell Health because I don't know, you can charge more money with a better name or something. But they wanted to start an anesthesiology residency program, because the hospital was building a medical school. And so, they had a number of residencies already in place, all the major ones, but they didn't have any anesthesiology residency. And so, to kind of fill out their bank of residencies, they recruited a bunch of folks out to start training programs. And so, that's why I was brought out here.

Originally in 2007, we started the program. The way it works is it takes a few years to get the paperwork in and get applications out. And we took our first class in 2010, and they graduated in 2014. And to your point, in the middle of that, in 2012, we, South Oakland Anesthesia Associates, sold our souls—I'm sorry, we sold our group to a company, or we entered indentured servitude, which is what I like to call it. We sold to a company called MEDNAX, which was a great group. And we were MEDNAX employees for a long time. And then, MEDNAX sold their anesthesia chunk of their group to a company called NAPA.

And then, the hospital, which at the time was a big eight-hospital system, half of their anesthesia groups were employed by NorthStar Anesthesia, and then the other half—us—was Napa, and they decided to unify the whole and we all became NorthStar. It was kind of a messy, ugly divorce. It was right around the time of COVID and killer hornets and race riots, and everyone was freaking out. We lost 50% of our faculty at the time.

And all of these changes in groups were kind of existential threats to the residency program because residents want stability. They want to know who their attendings are. They wanted to have continuity of education, and there was just a lot of turmoil over the years. But, you know, we weathered the storm. The residency has continued to do really, really well, and I'm still a NorthStar employee.

Host 2: We were talking about how the world connects, right? I think we had Jay Mesrobian on this podcast, and TeamHealth is rolling out a residency program in Tampa.

Dr. Roy Soto: Yeah. Well, you want to connect it even more? I just got an email asking me if I'd be interested in applying.

Host 1: There go. Wow. All things tie together. So Roy, you've kind of been doing this for a little while now. And we're seeing more and more of this. We've had quite a few people from the private practice world. There's a few big groups in the country now. And more and more, they are starting anesthesia residency programs to address the workforce issue. I think there are potentially some advantages to the residents for that, seeing more of that private practice environment that the speed of which we are required to work in that environment. What's the best scenario for training residents these days? Is that the old academic model? Is it these newer private practice models? What makes the best residency programs.

Dr. Roy Soto: That's a great question. You know, I'm 60 years old. And I talk about this a lot. I think the old style of anesthesiology training is gone where you have the old Nobel Prize-winning chairman of the department who brings in millions and millions of dollars of research funding. During grand rounds, you have the guy who raises his hand and says, "You know, in 1950, when I was doing the original succinylcholine research in rats, I found that..." That doesn't exist anymore. You know, the academic tenure tracks really don't exist very much anymore. And in hospitals, people have clinical tracks. And so, there's less depth of Ivory-toweredness, I think in residency programs everywhere. And there is a recognition and understanding moving forward that we, as anesthesiologists, have to practice quality, safe, fiscally conscious anesthesiology, right? And that's different than learning the MAC of sevoflurane. If I could teach anybody the MAC of sevoflurane very quickly, teaching them when it makes more sense to use low-flow sevoflurane versus high-flow sevoflurane, and what the impact of that on cost factors, this is a little more complicated.

So, part of my interview shtick is that as part of a private practice/university practice/employed by NorthStar Anesthesiology Program, we deal in the real-world every day. We have cost pressures, we have time pressures, we have quality metrics that are tied to first start times, wheels in, to induction start times, getting your paperwork completed times. Did you give the right number of POMV medications depending on the patient's risk factors? And that sort of stuff. And so, in addition to what's the MAC of sevo stuff, we're teaching these other things that are going to be very pertinent, I think, when these guys and gals graduate and go out into the real-world.

Host 1: That being said, the residents that we turn out these days are very different. With you coming out of your program, what do you want to see the ideal resident look like? What does that ideal resident going into the world now look like versus what it used to look like?

Dr. Roy Soto: I think it's not changed a lot. I think that the goal is always to have clinicians who are safe and practice evidence-based medicine, and are just good human beings, you know, that intangible thing where you're nice to the grandmother, you know, that sort of thing. That's kind of difficult to teach.

What has changed is, I think, in the past, you either graduated and went the academic track, and you were kind of the nerdy guy who kept his head in the book and did anesthesia once in a while, or you graduated and went straight into private practice, never again to think about quality, safety, morbidity and mortality and all that sort of stuff.

And I think that now, especially, you know, one of the benefits of these bigger groups, they all have M&Ms and quality metrics and safety conferences and CME requirements. And I think it's kind of normalized the idea of evaluating your own care and providing evidence-based care to your patients.

So, I think that's kind of improved over time. As a program director and speaking with other program directors, I'm involved with the program director, advisory group at the ASA level. It's harder and harder to recruit "academic faculty," people who want to go and do research, people are happy to go and make the money and get the vacation time and go home and play with their kids, but they don't necessarily want to spend the extra time to do the sim set sessions and do the research project.

So, I think it's harder to find people that want to teach that. And that, in turn, is going to change who the teachers are at residency programs. You're going to, again, have less of these ivory tower types and more just clinicians that, as a hobby, do teaching.

Host 1: I've got to start saying ivory-toweredness more. That's a new entry into my lexicon. Thank you for that. I will give you a shout out like this every time I say it.

Host 2: I want our listeners to know, I mean, in 2019, the ASA and the SCA awarded you the Inaugural Distinguished Educator Award in Anesthesiology. So, kudos to you. But we've talked about it and we've sort of touched upon it. How does this specialty ensure that we have a future as a profession if the trends that we're seeing, there's a workforce shortage, people are not necessarily academic, they're privademic. You know, they're interested in teaching. And I'm not saying it's the wrong thing. My group, my department started out as a private practice group that started a residency, right? And then, one day, they hired Dr. Rathmell, Jim Rathmell, Anesthesiology editor-in-chief as the program director, and he was my program director. And so, we've tried to pivot, but it seems like some groups are pivoting or some departments are pivoting the other way just because these are the resources and constraints they have. So, how do we ensure that we're able to build a faculty?

Dr. Roy Soto: I mean, it's really hard. Your privademic word—that's my new word that I've learned from you guys—is much more of a reality now. And if you look at the number of residencies popping up, there are more and more popping up. They're popping up in smaller and smaller hospitals that are classically more and more private-ish.

So, it's difficult. I mean, the right answer is that the chair of every department, large or small, should have monthly M&M meetings. They should have journal clubs, they should have of some sort educational offering. And importantly, it should be something that's multidisciplinary, which is something that's been missing for a long time from our specialty. Because that's where you really assure quality of care and kind of progression of good outcomes. But it's difficult. As the focus becomes more on making the widgets or churning out the patients, or whatever you want to call it, the time spent in academia gets less and less. And so, hopefully, you get the people that have fire in their belly that stay in academics and are willing to carry the torch. That was a weird mixed metaphor, by the way, of fire in your belly and carrying the torch.

Host 1: So, Roy, you just touched on something, the interdisciplinary or multidisciplinary aspect of education. We work in team environments now, but we still often train in silos. I noticed you have military background and worked in FAA. Is that where you kind of picked up on some of that stuff about, "Hey, let's actually train together if we're going to work together someday"?

Dr. Roy Soto: Yeah, absolutely. You know, I think we, in healthcare—I don't want to be Mr. Cynical here—you know, we talk a big deal about teamwork. We don't practice teamwork. The patient chooses their surgeon carefully. They show up, they get whatever anesthesia person they get. I end up with whatever surgeon I get that day. I get whatever CRNA in my room I get that day. I get whatever circulator and circulating student I get that day. Yeah, I assign my residents to the room so I can kind of control that. And the cases kind of come where the cases go, depending on how they shift patients around during the day.

Do we really discuss what the hard points of the case are? No. Have we over the last 10 years gotten better at timeouts at the beginning of cases? Sure we have. But they kind of focus on, I don't know, allergies, what the case is, who the patient is. I think everybody knows who the patient is. They've gone through 17 checks by the time they get to the room. Everybody knows the sterile indicators have been checked. And that's it.

There's really not a whole lot more of teamwork that takes place. Whereas in the military or in the aviation industry, it really is team-based. You train in a team-based environment, you simulate in a team-based environment, you know, as opposed to now where we do sim sessions with new residents. The aviation or the military—but I'm a big fan of now the Formula One—comparator to that is the whole team practicing together. And we absolutely do not do that whatsoever. We do a terrible job with debriefs in medicine. I just got an article published this week, talking about grieving after patient death.

And I think it's fascinating that we do these mandatory timeouts at the beginning of the case. If you have something terrible happen in the operating room—patient dies or there's bad outcome—end of the case, everybody scatters like cockroaches and never talks about it again unless it shows up at an RCA or M&M or something like that afterwards. There's really not good post-event debriefing. There's this maybe apocryphal story that when the plane landed on the Hudson, afterwards, Captain Sully took the flight crew aside on the dock there where they got out and debriefed everybody about what had happened. And that just doesn't happen very often in healthcare.

And so, I mean, that's the main difference, is that we talk about teamwork, but we don't necessarily practice it, train with it, or debrief with it, especially when there's bad outcomes.

Host 2: So if you're a medical student thinking and applying for anesthesiology residency, just know if you go to Beaumont Hospital, you'll be watching the movie F1 with Brad Pitt from last summer. It's a great movie.

Dr. Roy Soto: Have you been watching Drive to Survive, the Netflix series?

Host 2: No. Is that good?

Dr. Roy Soto: Oh. So, let me tell you, you can feel free to edit this all out, but we had three medical students, three medical students this cycle, who as hobbies, they listed F1. I was like, "What kind of a hobby is F1?" So, I asked them about it and they told me about you need to watch the series. If you watch the series, you'll be hooked. And so, I watched the series. I'm completely, totally entirely hooked on Formula One racing, and I'm actually going to go this year to a Grand Prix to check it out. But it's amazing. You think it's about the drivers, but it's not. It's completely about teamwork and coordination. It's absolutely amazing.

Host 1: What's the series called again?

Dr. Roy Soto: Drive to Survive. Formula One Drive to Survive. There's eight seasons of it. You'll get hooked after two episodes.

Host 1: It sounds like I'm going to get some new leadership and teamwork workshops out of this series if I watch it. So, that sounds like something I have to do. It's not that I want to do it, I have to go do it for my patients and for my teammates, right?

Host 2: Or more importantly, we might get a corporate sponsorship, Dr. Sherrer.

Host 1: Ooh, come on. Yeah, absolutely.

Dr. Roy Soto: Ferrari scrub caps that you wear during the podcast.

Host 1: So, Roy, I got to ask about the book, man. You wrote a book called XenoAnesthesia. It's about anesthesia for zombies and centaurs and all kinds of crazy stuff. There's got to be an origin story there, because it's a book that actually teaches physiology and medical care, right? But it's written in a very unique way. There's got to be an origin story to how in the world did that come about.

Dr. Roy Soto: Yeah. So, I wrote it with a guy named Mike Schostak, who's an anesthesiologist here in Detroit, who used to be in our group. And we're both nerds, and we were sitting around the lounge one time talking about nerdy stuff. And he said, "Yeah, I wrote this thing about how to take care of a zombie because they don't have circulating blood volume, right? So, how do you get drugs to him?

And to get to the example, Mitch, that you mentioned earlier about The Exorcist, would midazolam have helped kept her head from spinning around?

Host 2: Probably. Yeah.

Dr. Roy Soto: Since she spit up Green bile, should she have had a non-particulate antacid beforehand? So, those are the discussions that kind of led to this book. And so, I'm like, "Huh, we should turn this into a book." And I wrote a vampire chapter because the way you kill a vampire, you should drive a stake through its heart. But what if you miss? Now you got thoracic trauma in somebody who's—you know, if you do a scissors maneuver to open their mouth and you poke yourself with a fang, what happens to you? You know, that's a provider safety issue. You've heard about universal donor blood? Well, they're the universal accepter, right? Because they can receive any type of blood type because they've been drinking it all their lives. So, once you start doing that snowball, it all falls apart because, "Oh wow. Werewolves and silver bullets. And holy cow, Borg and mechanical disconnects." And so, it just became a thing.

Host 1: What about the process of writing it? It's self-published, right? So, how did that go? Was it a hassle? Was it fun, the publication process?

Dr. Roy Soto: It was a lot of fun. So, the process of getting it done, the goal was to have 20 chapters. And my vision was to have somebody different write each chapter. So, I put it out there to the program director Facebook group. And we only got one taker. So, one chapter is written by a different guy, Steve Gibson. I self-published on Amazon. I'd done a few little medical texts already on Amazon for our residency, one on how to set up for heart surgery and one on intraoperative discussion questions for residents and attendings.

And so, it was actually relatively simple. It's a different file for the electronic version, the paperback version, and the hardback version. And so, you kind of have to figure that out. The editing process is really simple, and the pricing process is pretty simple too. My electronic version is 99 cents each. I get exactly zero dollars and zero cents for that. But I think I get like 30 cents for a hardcover. And so, my mom has done a good job of helping me with my retirement by buying a bunch of those for her friends.

Host 1: Do you need to sign them?

Dr. Roy Soto: I've signed a couple. Yeah. I was just at the oral boards last week, and I had a couple people say they were buying hard covers for me to sign. So apparently, next year at the oral boards, I'm going to sign the ones they bought this year.

Host 2: That's awesome.

Host 1: Come on. That's awesome.

Dr. Roy Soto: Yep. I haven't decided what to say yet for them, but I'll come up with something pithy.

Host 2: We tend to build a time machine here. And we've talked about finding the right people in academic programs or training programs. And it's obvious and it's clear you're one of them, right? But did you know that you were going to do this 20, 30 years ago, that this is the track that you were going to head down and you were going to be committed to anesthesiology education, trying to define the future for our specialty, or what would you have told the younger Dr. Soto?

Dr. Roy Soto: Well, so the answer to your question is, did I know? Heck no. I had no idea. So, indecision is the key to flexibility. So, I figured if I was indecisive for a long time—and by the way, in the Air Force, flexibility is the key to airpower, which means that indecision is the key to airpower. But I digress.

So when I was in med school, I didn't know what I wanted to do. I originally thought about doing ENT. I didn't get into ENT. I was just a general practitioner in the Air Force for a long time. And then, I was working in urgent care clinic as a doc in a box after my military commitment in Southern California. And we had some guys from the anesthesiology residency at UCLA that were moonlighting there on the weekends and they said, "Oh, dude, you need to come check it out. And you know, now, we're a very, very competitive specialty. Back then, nobody was going into anesthesiology. I think that only a couple of programs filled in the 1996, '97 timeframe. This was around '97. And I remember walking in and shaking Joe Rose's hand, my program director and he said, "Ah, warm body." That was my application process, really. I never turned in paperwork or anything. It was just simple as that. And now, I can say I graduated from UCLA, one of the premier programs in the country.

But I really didn't know what I wanted to do ultimately, but I did know that I had a short attention span. And I was kind of a—yeah, I had a short attention span. And so, I liked the idea of doing a project and then teaching this class and then going to the California Society of Anesthesiologist meetings. So, I got involved with the CSA, I got involved with research early on, teaching medical students early on, and I just liked it. I liked having something different to do every day. It was fun. And I had a friend who went into practice where he was sitting on his stool every day and he was kind of describing what his day looked like. And it sounded absolutely horrifying to me. And so, I was like, "I didn't want to do that." And then—can I curse on this podcast, by the way?

Host 1: You do anything you want, man.

Dr. Roy Soto: All right. So, I'm sure, I don't know if you had this at your residency program. So, we had a day where a private practitioner came in and told us how it was different. And I remember this guy came in and said, you know, all academics is turning bullshit into airplane tickets, you know? And I was like, "Wow, that sounds fantastic." And so, you know, again, got involved with ASA, early on with a resident section, the young physician section, a bunch of committee work, education with a bunch of different organizations, and then research. It's just fun. That's why I like it. It's just something different every day. This morning, it's 2:30 here Eastern time. And I've had two medical students on the phone talking about their research interests in anesthesia. I've had a resident who's not doing a great job that I've had a talking to this morning. I've worked on a research protocol.

And, yeah, it's just a lot of fun. That's why I do it. And hopefully, that's what we will churn out in the future. People always ask me, "What do I look for for residents?" I look for people who have a fire in their belly, meaning that they want to do more. And I don't know if this is me digressing from the original question. But, you know, in high school, these kids were on this huge upward trajectory, right? Doing more and more and more so that they can get into good colleges.

And when they're in college, they do more and more and all that extra stuff that helps them get into medical school. And then, when they're in medical school, they do all that extra stuff so they can get into a good residency. And then, not infrequently, you find residents who plateau and they don't want to do that extra stuff anymore because they figure they've made it.

Now, realistically, they're 30, they fall in love, they got a puppy, and the roof is leaking and you know, all that sort of stuff. But, you know, I think they're tired, stressed out, I don't know, but they turn off their fire. You know, some of them don't even have a pilot light anymore.

That's what I look for is people who have that fire in their belly with the hopes that they can graduate and continue to be exceptional, right? Because I don't ask about the complement cascade during residency interviews. And similarly, when people are applying for fellowships and for jobs, nobody's going to ask them how to intubate. They're going to ask them about the extra stuff they did. And so, that's what makes you an interesting guy or gal, and I think helps you to bring value to your group with diversity and excellence and things other than just anesthesiology.

Host 1: Wow. So Roy, I kind of noticed a paradox while I was sitting here, and this is more of a philosophical question. On the one hand, you have a background in aviation and Air Force. We've taken a lot in our specialty from them, and a lot of it is checklist, right? Checklist manifesto, Atul Gawande. And there's value in that, right? In doing the same things routinely. You mentioned the metrics that your group is held to. And so, there's that aspect.

But you're a creative dude, right? To write XenoAnesthesia took some creativity. And to me, those are kind of paradoxical things. What makes anesthesiologists really good at what they do? Is it their creativity? Is it their following of the routines and the checklists, or is there a balance that we can find somewhere in between?

Dr. Roy Soto: Yes. I think I'm giving you multilevel answers to simple questions. So, I think that it's a combination of everything, obviously, right? The answer to everything is somewhere in between. I think I have had people as residents who used to be engineers. And frequently, they can struggle because they have index cards and checklists, and they approach everything as a "this problem." And a lot of comparisons have been made between the aviation industry and anesthesia, right? The scary parts of the takeoff and the landing. And it should be nice and calm. And if anything goes wrong, everybody dies. But that's not really true because if the engine falls off of an airplane, the rest of that airplane is perfectly fine, and it's the same as every other 737 or whatever that's flying out there.

If a patient, something bad happens to that patient, it might be an old patient, a young patient, a big patient, a small patient, a patient who has a pheo, a patient who has hypertension, a patient who has diabetes. And so, checklists frequently don't work as well. And I know for a while the ASA and the SEA were pushing for kind of creating all these checklists for every conceivable thing that happened in anesthesia land. But the problem is there's so much variability, you never really can tell.

Now, Mitch, you hurt my feelings when you said we ran into each other in an Advanced meeting. I came out to you guys and I gave a grand rounds on ERAS back in the day when ERAS was just coming out. And that was, I think, a pretty good example of how you could standardize things, but still allow for wiggle room, right? It doesn't necessarily talk about how you intubate. It doesn't necessarily talk about when you give phenylephrine versus ephedrine or turn up or down the sevoflurane, but it talks about standardizing things that are evidence-based around the time of the procedure, right? NPO guidelines, preoperative hydration, medication reconciliation, glycemic control, multimodal analgesia, ambulation, physical therapy, all that other stuff. And so, I think that is a good structure around the anesthetic that you can standardize, and then you can still apply that art of medicine to taking care of your individual patient.

Host 2: So Roy, yes, I do remember the ASA advance, but then I did invite you to come speak at the University of Vermont, just like I saw and heard Dr. Sherrer speak at the ASA Advance meeting. And then, I invited him to the AACD. So, we shouldn't let it get out there that I find all the good speakers at the ASA Advanced meetings.

Host 1: That's where Mitch trolls. Everybody's going to start doing that. That's where he trolls.

Host 2: But no, I took my son to a 737 flight simulator over winter break, and he had to do the checklist. He had to go through the flight plan. And going back to this concept of teaming, we don't do that, right? I mean, what would anesthesiology look like if, at the beginning of the case, we discussed the flight plan with the surgical team, that this is where death level blood pressure—I don't even know what the factors we're going to look at, but that these are the things that we're going to shoot for and try to actually make it happen. I think it would change things. And if you scale it up to the broader system, right? The FAA knows across the airports where the airport delays are going to be, the weather problems and everything.

We don't do that as clinical directors, right? You start the day at 0700, take the schedule you were given yesterday, and then you pray. And you try to make everything work and as the day goes. So, I think there's definitely opportunities that we can actually still improve the specialty.

Dr. Roy Soto: You know, I have this vision of DeBakey back in the golden era of surgery, sitting down with his team and talking about how they're going to do this new weird thing and then, afterwards talk about what did and didn't work, and then massage it a little bit. So, the next time they do it, it's different. So, that's what we should do to your point. But it would slow everything down, right? So if we did a long debriefing and a long debriefing afterwards, and then an in-briefing if something weird happened during the procedure and we increased our team-based simulation and training, it would slow things up. And unfortunately, we're a numbers-based profession at this point, medicine as a whole. And so, it kind of limits how much of that we can do.

Host 1: So Roy, looking back, Mitch kind of touched on this earlier. Did you know what you want to do? I want to ask a different question, which is knowing what you know now, what would you do differently? Meaning what would you tell Roy Soto coming out of residency at UCLA based on what you've learned over the past however many years?

Dr. Roy Soto: I'm pretty happy with what I've done and how I've done it. You know, again, being involved with everything. I remember when I joined residency, I was like, you know, I'm just going to remember this whole summer of saying yes business. That came out a long time ago. I was like, "I'm going to say yes to everything." When the chairman or the program director sends an email, "Hey, who wants to get involved with this?" I'm just going to say, "Yeah." So, I think that's how my career got built. I just agreed to everything. And then, when I took my first job, there was this opportunity to get involved with ORG 25969 research, which churned into Sugammadex. And so, that's how I got involved with the research stuff and yes to medical school education. And I think it worked for me.

As far as what I would change you know, that's a good question that people ask all the time, but you wouldn't be where you were if you would've changed what you would have not done in the past and stuff. But you know what I mean?

Host 1:  Sugammadex, you mentioned it. It's the most ridiculous reversal agent I've ever seen in my life to the point that—like, I remember the first-time I gave it, just looking at people in the room like, "Are you freaking kidding me?" It's ludicrous. Nice work. Good job.

Dr. Roy Soto: Yeah, thanks. When we were doing the 16 per kilo reversal studies, we would have like a crowd of people in the operating room watching because it was wild. You'd give a 1.6 dose of roc. And three minutes later, you'd give the 16—and it was super concentrated at the time. So, it was 2 ccs of this yellow stuff. You'd squirt into someone and they suddenly became unparallyzed after a giant dose of rocuronium. It's as close to magic that I've seen. Yeah.

Host 1: I joke and say, "Hey, you give Sugammadex and pull the car around, because they can go home." I'm going on record and saying we are going to prove at some point in time that little cyclodextrin structure or whatever doesn't just pick up rocuronium, it picks up anesthesia, gas, and fentanyl. I think people wake up more. Am I making that up? Is that just totally anecdotal and you can say yes again, that's perfect.

Dr. Roy Soto: I think it's partially anecdotal. I think there is something to say for relaxed resting motor tone, that when you get your resting motor tone back, you get return of circulation to your central compartment. So, I bet you that there's something to do with that, I think you metabolize a little more quickly, because whether anesthetic sitting in your calf is going to get squirted up into your chest more quickly. But I might be making that up. And that's what motor pumping research at University of Florida as an undergrad was all about. It was a NASA study looking at return of circulation in gravity after being in zero gravity.

Host 1: And that's called bringing it full circle putting a bow on it. But did you see that, Mitchell? Did you see the way that just came all the way back around?

Host 2: I did not see that. I was trying to figure out how Sugammadex works in Wolverines. I apologize.

Dr. Roy Soto: Well, let me think about that. You've got the whole titanium infrastructure that you have to deal with. Yeah. Yeah.

Host 2: Adamantium, one of my favorite metals.

Dr. Roy Soto: Twitch monitoring would be more difficult. Yeah. We could do a superhero version of the book.

Host 1: Roy, you mentioned, before you came on the air, you know a couple of our prior guests, Gallagher, Corrado. I think Corrado even—did you say he called you out? Do you have anything to say back to him? Any volley back to Corrado?

Dr. Roy Soto: Tommy was a resident when I was at Stony Brook, and I am thrilled that he's an academically productive guy there now. I've heard through the grapevine, he's doing great things. I think it's fantastic, just like we talked about with a fire in the belly. Tommy had it then, he's still got it now, and gives you hope for the future, right? And then, Chris, Chris is as crazy in a good way as he ever has been. I talk to him every once in a while. He is a great guy. He was a great mentor.

Host 1: He's also hilarious.

Dr. Roy Soto: He was a program director before I was.

Host 1: Yeah, I don't know that I can ever forget Tommy Corrado doing breakaway suit pants at the last AACD meeting and literally ripping his pants off. And for those of you who hadn't listened to his episode, I'm not going to say anything more. I'm going to make you back and listen to it, just so you know what the heck I'm talking about.

Dr. Roy Soto: A good teaser.

Host 1: Yeah, it's a great teaser. All right. This has been fun. It's been awesome. Mitch, any last comments, man?

Host 2: No, thank you Roy. It's good to see you.

Dr. Roy Soto: Thank you, guys.

Host 1: Yeah, man. Good to have you on, man. Thank you for doing this for us and keep on doing what you're doing, man.

Dr. Roy Soto: All right. Thank you.

Host 1: All right. Thanks everybody. This has been another episode of The Fresh Flow Podcast. We'll catch you next time.