Episode 29: Anesthesia for Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

Hi everyone. We are here at another Tuesday. My name is Dr. Towfigh. Welcome to Hernia Talk Live. As you know every Tuesday we have this awesome session. It’s an hour with one of my favorite people and it’s currently being simulcast on Zoom and Facebook Live. You can also follow me on Twitter and Instagram at hernia doc, and once we are done, I will make sure that I post the entirety of this live session on my YouTube channel. Today’s guest is Dr. Edna Ma. Dr. Ma is a superstar. She is an board certified anesthesiologist. You can follow her on Facebook at Dr. Edna Ma, and if you do so, you’re going to find some really interesting things about her, which we will discuss towards the end of this hour. But first, I’d like to welcome Dr. Ma. Hi.

Speaker 2 (00:00:52):

Thank you, Dr. Towfigh for having me. It’s exciting to see you. I just

Speaker 1 (00:00:56):

Thanks so much for coming and giving me your time, and I just want to make sure that we’re very respectful of your time. Dr. Ma is an anesthesiologist. She’s married to a surgeon. She has two children who will probably, I don’t know, will they be doctors as well?

Speaker 2 (00:01:16):

Who knows? I did my little one. She seems to be interested in doing medicine was before the pandemic. She would wear one of the surgical masks around the house. And so who knows? She enjoys the whole doctoring thing and the stethoscope and everything.

Speaker 1 (00:01:32):

That’s very cute. Do you ever dress ’em up for Halloween?

Speaker 2 (00:01:36):

I do, and they’re very reluctant Halloween kids.

Speaker 1 (00:01:40):

It’s like the easiest thing. You just grabbed like a mask and cap and everything.

Speaker 2 (00:01:45):

Exactly. Pretty easy.

Speaker 1 (00:01:46):

So Dr. Anesthesiologist is our anesthesiologist. If you come and have surgery with me most likely you will meet her. She’s also a superstar. She’s had she’s entrepreneur. She’s a book writer. Author. She’s, you’re

Speaker 2 (00:02:03):

Embarrassing me. You’re embarrassing me now.

Speaker 1 (00:02:06):

<laugh> kind of survived on an island for a long time. For a while. We’ll get all onto that, but just really briefly, what got you involved in anesthesia and how much do you love my patients?

Speaker 2 (00:02:20):

Well, I need a whole Facebook live session just for how much I love working with you. Well, I always knew I wanted to be a physician and I thought I wanted to be an internal medicine doctor. But then as you rotate through medical school and you get exposed to different specialties, you realize how much more interactive it can be with in the operating room. And I really liked being the internal medicine doctor in the operating room. And we do procedures too in anesthesia. At the time I graduated, it was just the very, very beginning of ultrasound guided regional anesthesia was becoming more standard of care, now it’s become the mainstream in terms of adjuncts to general anesthesia and sedation anesthesia. There’s a lot of more involved procedures that we do in anesthesia now.

Speaker 1 (00:03:11):

So as you all of, I do hernia surgery, but I do open surgery, laparoscopic, robotic. I have patients that are totally healthy and have no problems, and I have patients with severe chronic pain and treating them from an anesthetic standpoint is very different. And the type of surgery I do requires different amounts and degrees of anesthesia. So it’s really great and helpful to have an anesthesiologist who’s aware of all that. In the United States, most hernia surgery is done under general anesthesia. It’s not common. It’s totally doable, but it’s not common to do hernia surgery under local anesthesia alone with IV sedation. And we’ll go into that a little bit, but maybe Dr. Ma, you can answer our first question which is what are the different types of anesthesia for hernia surgery?

Speaker 2 (00:04:06):

And I’ll kind of talk about types of anesthesia in general and then I’ll kind of narrow it down for hernia surgery. So anesthesia is, there’s just, I would say three broad categories, maybe four broad categories depending on how There’s a lot of overlap, like a Venn diagram. First there’s general anesthesia and you’re completely, usually that involves being completely unconscious and usually involves a breathing tube that’s placed after you’re asleep and comes out usually when you’re asleep. So you’re completely asleep. This is, I kind of compare it to consciousness to a light dimmer. So you’re completely awake, the lights are bright and fully on, and then there’s completely off where the switches off, but then you have a dimmer. So all that stuff in between kind of you’re awake but not really awake, and you’re kind of in that gray area. So general anesthesia’s completely asleep.

Speaker 2 (00:04:59):

Then you have what usually with the breathing tube, and then you have sedation anesthesia. Sometimes it’s referred to as twilight anesthesia or monitored anesthesia care, MAC anesthesia. And that even within MAC anesthesia can be completely aware sedation for cataract surgery where you need your cooperation to open your eyes and look at the light, and you need to be awake enough so your eye is facing forward. So that’s also considered twilight or mac anesthesia. But then you have kind of deeper anesthesia, which is still considered twilight mac anesthesia that’s given for a colonoscopy, but you’re still breathing on your own, no breathing tube, and you may be a lot more unconscious or unaware of what’s going on for that type of sedation. So that’s kind of the description for the consciousness level of control. Then we have regional anesthesia, and that can be divided into two subcategories, neuroaxial, which is like spinals and epidurals. And then you have regional anesthesia in terms of isolating a limb or part of the body for depositing local anesthesia. And specifically with hernia surgery a lot of regional anesthesia involving the abdominal wall is becoming more common, especially in Dr. Towfigh’s practice and there’s a lot of benefits for that. Do you want me to go into that?

Speaker 1 (00:06:18):


Speaker 2 (00:06:19):

Okay. So the regional blocks that are relative to hernia surgery, that includes truncal blocks that would be trans, they call it a tap block. I’m pushing myself back so I can kind of point to my body a tap block, which is transverse abdominous plane. I don’t know if I maybe can show you a picture. Everybody’s abdominal wall is consists of three layers of muscle, and I’m going to just pull up what I have. I have a little file inside my iPhone. I don’t know if you can see that. So it is,

Speaker 1 (00:06:58):

Yep, that’s good.

Speaker 2 (00:06:59):

It’s a schematic, a cross section of everybody’s body, and we use an ultrasound to identify the layers of the muscle and everybody’s nerve fibers kind of land in the certain layer. And with the ultrasound, we use just the same ultrasound that we use for identifying a gender of a baby. So it’s not harmful, it’s not invasive. Identify those layers and deposit local anesthesia. And this is even becoming so common that people having C-sections are having this type of anesthetic placed after their C-section.

Speaker 1 (00:07:33):


Speaker 2 (00:07:35):

The benefits of this is that you can avoid opioids or narcotics and opioids can be anything from tablets that you take a Vicodin, Percocet or IV morphine or cousins of morphine. And there’s a lot of benefits to avoiding those opioids, especially for hernia surgeries.

Speaker 1 (00:07:53):

Yeah, so I think in general, the way that I look at it, typically the laparoscopic or robotic surgery, you need some relaxation of the muscles to expand the abdomen. With the gas we put in the carbon dioxide, and that tends to be very uncomfortable for patients if they’re not complete put to sleep. So they get general anesthesia, although there have been reports of doing it under spinal or even sedation, but that’s not standard is general anesthesia for all the laparoscopic and robotic surgeries. And then for the open surgeries of the groin, not for the belly, for the groin, those can be done with any type of anesthesia, even no anesthesia. I have, I operate a lot of the transplant patients or the people that are waiting transplants. So Cedars is the number one heart transplant center in the world. That’s a hospital I work out of.

Speaker 1 (00:08:48):

And so there are a lot of patients waiting on the wait list to get their heart transplant, which means their heart’s currently not functioning well. And those are the worst patients to give anesthesia to <laugh>. And so I can do surgery with just local sedation, sorry, local anesthesia like lidocaine with no anesthesia or very minimal anesthesia. So that’s the other extreme. And then maybe a little belly button, hernia surgery, I can do that without general anesthesia because that’s not a lot of stress on the body. But the big abdominal wall reconstruction, you really need the muscle relaxation that you get with general anesthesia. So absolutely. There’s a question already up. I’m going to discuss that in a second once we talk a little bit more about general anesthesia, but what are the risks of general anesthesia? Because a lot of people are afraid of it, and many people don’t want surgery because they’re told they need to have general anesthesia, and so they’re actually more afraid of the anesthesia than the operation. So what are the real risks of general anesthesia in modern day medicine?

Speaker 2 (00:09:58):

Okay, so I would say that for most patients coming in for elective outpatient hernia surgery are at very, very, very low risk for any serious bad badness bad outcomes, I don’t, I just want to say that kind of general because anything from heart attack, death, stroke, those are the things that I would consider very bad. And for general, your type of surgeries, outpatient surgery for hernias, that is extremely, extremely low. And I found some statistics and everything is customized to the individual patient depending on their other comorbidities. Anesthesia these days is extremely safe. So statistically speaking, getting into your own car and driving to the hospital or the surgery center on the day of surgery is riskier to you than receiving general anesthesia. And as of 2020, the mortality in the United States for bad things like heart attack, death, stroke, that type of thing is 1.1 per one person in 1 million per year of anesthetics that are given less than 1.1 person.

Speaker 2 (00:11:13):

I don’t know how they divided 1.1 person per million per year. So that’s extremely, extremely low. And I think that anesthesia kind of got a bad reputation, if you will, maybe back in the seventies or eighties, before modern medicines were introduced, before modern monitoring was employed, it wasn’t until the 1980s, until the pulse oximeter became standard of care in the operating room. So this is relatively recent history, right? And so even back in the 1990s, it was the risk of having something seriously bad happen to you during under general anesthesia as one and 100,000. And that’s still

Speaker 1 (00:11:55):

10 times higher than now,

Speaker 2 (00:11:57):

10 times higher. But now we’re talking in basically one and 1 million per year. So it’s

Speaker 1 (00:12:04):

Not zero, but it’s very, very low.

Speaker 2 (00:12:06):

Very, very, very low. And every one of your patients, especially one of your patients, you are the most organized office. Dr. Towfigh, you have a checklist, this is your patient here, decision tree and labs, E K G, all the workup, internal medicine optimization, because we have everything teed up, we don’t want to try to figure out on the day of surgery and all those things reduce the patient’s risk for bad things happening.

Speaker 1 (00:12:37):

So one thing people are afraid of is that they’re going to wake up in the middle of surgery and either feel what’s happening or at least be aware of what’s happening. There have been stories that people seeing their surgery be done or being able to recount what the doctor was saying about their golf game or something during surgery.

Speaker 2 (00:12:56):

Yeah, well, that wouldn’t be us because we don’t golf, but I hear you

Speaker 1 (00:13:01):

Talk about our reality shows. But

Speaker 2 (00:13:04):

Yes, this is called awareness under anesthesia and that it’s all commerce, all commerce. In terms of awareness, anesthesia, it’s about one in 10,000. So that includes sedation, anesthesia, general anesthesia, cardiac patients. So the patients who are highest, highest risk for awareness under anesthesia are the people who you cannot give very much anesthesia to. So those are cardiac patients who cannot tolerate a lot of anesthesia. So maybe somebody who’s on bypass who are that heart transplant that you’re kind of referring to, patients who were in a traumatic injury like a trauma, a true trauma injury where any sort of anesthetic can compromise their blood pressure and perfusion to their vital organs, brain, heart, that type of thing. So those are the patients who are at highest risk patients coming on in day surgery, normal health, healthy, optimized, very, very, very, very unlikely.

Speaker 1 (00:14:02):

And they have these little stick EEG monitors nowadays where you can follow the brain waves.

Speaker 2 (00:14:07):

They do have those they’re called abyss monitor. There are some physicians, they use them more for neurosurgery cases where they’re trying to map or trace the eeg, the electro activity in your brain but that’s actually not considered the standard of care to use abyss monitor because they haven’t been shown to be reliable. And so the other standard of care monitors like heart rate, blood pressure is more predictive of awareness.

Speaker 1 (00:14:37):

So I don’t like to rely on general anesthesia if I don’t have to. What I understand is it’s actually easier for the anesthesiologist to maintain a patient under general because you have full control of everything and especially the airway. Whereas with IV sedation, you’re anesthesiologist’s much more involved to make sure that the patient’s breathing and the blood pressures are under good control, et cetera. But I do prefer sedation. I feel that after surgery the patients are a bit more awake and they kind of come out of anesthesia much quicker if they don’t get general anesthesia, if they just get sedation iv, which is propofol. Right. I also feel, cause we have a question about two questions actually about these risks. I feel that because of the more delicateness of IV sedation, the patients also don’t have as much narcotics used. They’re not as deep. And so urinary retention is less of a problem. And that’s something we actually discussed with Dr. David Josephson. He was on a couple weeks ago or maybe last week,

Speaker 2 (00:16:00):

Two weeks ago. Yes, he’s great

Speaker 1 (00:16:01):

And he’s great urologist. And we discussed the issue of urinary retention. So if anyone has questions about that that’s a great webinar to listen to hernia talk two weeks ago with Dr. David Josephson. But if you don’t give us much narcotics or as deep of general anesthesia then the risk of you having a weaker bladder or inability to urinate is also improved. Do you find that that’s true?

Speaker 2 (00:16:33):

I a hundred percent agree with everything that you say. It does require a level of more vigilance and diligence on the anesthesia provider’s part. When you’re providing sedation anesthesia because the airway is not secured you have to be constantly paying attention because any slight movement affects what you’re doing in the surgical field. And we would only give general anesthesia if it’s necessary for those procedures that you talked about. You need a large incision on the abdominal wall or optimizing the surgical field or view and keeping the patient safe. So in addition to terms of laparoscopic surgery, you have in laparoscopic surgery, you insufflate the abdomen with carbon dioxide and normal respiration, you cannot get rid of that carbon dioxide that quickly if you’re breathing spontaneously on your own. So that’s the reason why we give general anesthesia. But to your question regarding urinary tention, the medications that we used for general anesthesia have these anticholinergic side effects, which is the $5 word to save can cause urinary tension.

Speaker 2 (00:17:36):

Those medications just make urinary tension more likely. And when you’re giving deep IV sedation you basically avoid those medications that can cause the urinary tension. Got it. So I would say it’s a little bit in addition to, I know you always try to use every case is customized and in your preference, I definitely have noticed that it is you lean more towards sedation anesthesia if at all possible without compromising the patient’s safety. For patients who are having urinary retention kind of our approach for that would be if we have a patient that’s like a male patient who has most likely a prostate that might be enlarged just given the age for a hernia surgery or has a history of document BPH or benign prostatic or hypertrophy, we can pretreat them with a medication like Flomax that would relax the prostatic outlet or sphincter for that area. And during surgery, what we also do is minimize the IV fluids if they need to have general that further reduces their chance and avoid opioids.

Speaker 2 (00:18:52):

One thing that I didn’t really touch on yet, and you’re hinting at it and made me think of it with general anesthesia, that breathing tube goes in, the breathing toe comes out. And with hernia surgery and a lot of the cases that we do in the Beverly Hills area, you don’t want anybody to cough, you don’t want anybody cough, you don’t want anybody to test the integrity of your suture site. And so when you’re doing deep IV sedation, you don’t have that breathing tube. So you could still cough, but it’s just probably less likely with that. So especially with my care with Dr. Towfigh’s patient, I’d make extra. I take extra precautions to make sure that that patient is not coughing at the end of surgery or later.

Speaker 1 (00:19:36):

That’s a big piece of mind. And those of you, those with me know I cannot have my patient either cough or the other term we use is buck. When the tube is in your throat, it’s like you’re gagging on it. So it’s a fine line between waking up without the breathing tube in your mouth and breathing versus waking up earlier than that and feeling the breathing tube and then trying to gag against it. So coughing and anything like gagging or what we call bucking causes, exerts a lot of abdominal pressure. A lot more than any furniture you can lift or child you can lift or weightlifting, whatever. That’s nothing compared to really bad coughing, ratcheting vomiting, yes. Yeah. So one is that the coughing is a big deal, but this is another one question we just got, which is a live question, which is the issue with vomiting or nausea after anesthesia. How do you handle that?

Speaker 2 (00:20:44):

Okay just to close the loop on the coughing after surgery with your patients specifically, I do this with the majority of my patients, but with your patients, I make sure double check that we numb the back of the throat with what we called an LTA lidocaine tracheal anesthesia. And so during the, while the patient’s completely asleep and unconscious, as I’m inserting the breathing tube, I spray the back of the throat and into the trachea local anesthesia. So that breathing tube, you don’t feel it. And not all this facilities or not all centers have that lidocaine tracheal anesthesia. And then especially with your cases and a lot of other cases, we don’t want bucking such as neurosurgery cases or plastic surgery cases when you don’t want to increase the pressure eye surgery as well you usually run a propofol infusion that tends to be less irritating to the airway versus anesthetic gases.

Speaker 2 (00:21:43):

The volatile gases like fluoride and fluoride, those tend to be very irritating and provokes people to want to cough. So I take those extra precautions. The second pre-, oh, nausea and vomiting. So this is something it’s one of my most favorite areas to talk about, if you will. Yay. I’ll have to send you the article that it’s been a couple years since it’s been published in outpatient surgery magazine, but I wrote an article about that. I use a multi approach, a multi-prong approach for treating anesthesia. There are a lot of receptors in the brains that cause nausea, which means it kind of translates into a lot of triggers that cause nausea, which means a lot of medications can be used for treating nausea and also it means that nausea is very poorly understood. So for me, I and I have a personal story of having such bad nausea and vomiting that I ended up having a Mallory Weiss tear, which is a tear in esophagus and just from a local anesthesia, I had a little surgery on my arm when I was in high school.

Speaker 2 (00:22:49):

And so I have a very personal connection with this nausea and vomiting. I didn’t receive any anesthesia. It was all local, done at a dermatologist dermatologist’s office, and I received narcotics after the procedure and I got so bad, so much nausea that I ended up tearing my esophagus. So I take special care for the people who say they have nausea and vomiting. So in addition to your routine fasting minimum of eight hours fasting before surgery on the morning of admission, if you have a high risk, I usually put a motion sick passion on you. And that’s like what you see people wearing. It’s like a sticker or a size of a circular bandaid that’s worn behind the ear. It’s called a scopolamine patch. And it takes several hours for it to absorb into the skin, which is why we put on before surgery. Then I use, if it’s appropriate very generous IV hydration that helps kind of catch you up with a fluid deficit.

Speaker 2 (00:23:49):

Just being dehydrated in itself can cause you to be nausea. To think about the last time you were on a window seat on a long flight and you didn’t want to go into the toilet just like it gives you a headache, just makes you feel bad. So you just want to hydrate that person up as much as possible to get that going. Avoid an avoid narcotics, opioids, morphine specifically is really not so great for nausea and I use decadron, that’s been in the news lately due to COVID and reglan if that’s allowed or metoclopromide. And those are oh, you can give Pepcid Pepcid great for people who have reflux, doesn’t have a really strong antiemetic profile, but it’s an extra cocktail I include just to ward off evil spirits.

Speaker 1 (00:24:40):

That’s really important because I mean besides the fact that you feel sick, you definitely don’t want to be rushing or vomiting.

Speaker 2 (00:24:46):

Yes, that’s worse. I think that’s probably worse than that coughing after surgery because it, it’s more prolonged. You could be for hours or days and the studies have shown that patients would rather have pain than they would, they’d rather pay money to have pain rather than if they could avoid nausea and vomiting because it’s so uncomfortable.

Speaker 1 (00:25:04):

I’ve heard stories of people who come to me with a hernia recurrence and I always ask, how was your recovery? And they said, oh, I was rushing for three days.

Speaker 2 (00:25:16):

Oh, that’s terrible. People

Speaker 1 (00:25:17):

Got a sick a pneumonia after surgery and they ended up coughing. So all of these are factors for

Speaker 2 (00:25:25):


Speaker 1 (00:25:25):

Worst outcomes after hernia rec, hernia repair, which is why it’s important to factor all night.

Speaker 2 (00:25:31):

Oh, the other thing I didn’t say, but I should have said was you, I avoid volatile anesthetics for those high risk for nausea patients. Propofol IVs infusion has a lower risk for nausea and vomiting than the volatile anesthetics or even something like now people are giving precedex a lot and that’s the IV infusion.

Speaker 1 (00:25:55):

So I know that we’re saying how great IV sedation is, but I was told by an anesthesiologist that the IV sedation itself is not any less risky to the patient than general anesthesia. They consider the deep IV sedation that I require as opposed to the IV sedation you get for colonoscopy. They consider that pretty much general anesthesia. Do you agree with that?

Speaker 2 (00:26:19):

Okay. So I would say okay, I kind of got confused about what the question was. It would, okay, your question is IV sedation any less risky to the patient than, no. So it’s not less risky and I feel like I have this conversation or answer this question every other day. The research that have were from the seventies that people have lingering in their mind that sedation anesthesia is than general anesthesia. It’s so old and it’s been replaced with more modern studies that have shown with more modern anesthetics that are being used currently. And it, it’s just shown not to be true sedation, less sedation is not more safe than general anesthesia.

Speaker 1 (00:27:06):

So you’re not less likely to have a hard time.

Speaker 2 (00:27:09):

That’s you’re not less likely. You’re not less likely. And I would actually say that general anesthesia is safer than IV sedation in a lot of ways. So I don’t know if you know that I do cases for dental surgeries and stuff. This is a whole separate ballgame when it comes to sedation for dental stuff, but you don’t yet surgery in the airway. And you can think of people who’ve had procedures in the airway who have had a bad outcome like Joan Rives, so that she had sedation and she had laryngospasm and nobody made any intervention. When you do general anesthesia and anything regarding the airway, if you wanted, that’s any concern. You put a breathing tube then there at the very beginning of the procedure and that is your seatbelt that you’re wearing before driving into the Alps or whatever that is your safety belt. So in that regard, general anesthesia is much safer than IV sedation.

Speaker 1 (00:28:10):

Yeah. So I think to your life safety, to your life dying from it because you had a heart attack where there’s a stress on the heart, the stress is pretty much the same with sedation versus general anesthesia because you’re knocked out

Speaker 2 (00:28:28):

When somebody’s concerned about anesthesia, where the assumption is I sedation is safer than general anesthesia, I would kind of dig deeper. What is the actual concern? Is it that they have $20,000 worth of veneers in their teeth that they don’t want to have them damaged? Or is it something related to maybe even malignant hypothermia? They had a relative who had anesthesia. There’s usually something, but honestly besides the breathing tube, you can run a sedation, like a general anesthesia, like a sedation, you can put a breathing tube in, you put run propofol, but you just have that security of the seatbelt or the breathing tube in place. And other than that, it’s pretty much identical to sedation anesthesia if you’re talking about propofol only.

Speaker 1 (00:29:14):

Okay, cool. We have another live question, which is doing surgery in an outpatient surgery center versus a hospital. Is it relatively riskier to do one versus the other? What’s your thought on that? And I can give you my thought on that as

Speaker 2 (00:29:31):

Well. Okay. Have, okay. My thought right now for that is that surgery centers have been shown to be safer for patients receiving care that is appropriate for outpatient surgery center. If you’re in one of those patients who are much sicker that maybe require post-operative care in the I C U or some sort of additional monitoring, then the hospital would be safer for you. And I’m just talking about that in general, outside of COVID now in COVID times our patients are all tested for COVID before they come in and our staff are checked routinely to make sure that they’re healthy and you don’t cross paths with people who might be visiting a COVID patient or might be being admitted for a COVID patient. So I would say that’s that part of it. And also there have been studies that show that your risk of having a hospital acquired infection is much more reduced when you’re having surgery in a outpatient center. I would say that those are my thoughts in general.

Speaker 1 (00:30:43):

Yeah, you’re right. Wasn’t thinking of COVID from a COVID standpoint. You were safer in an outpatient surgery center for the same operation and you have less risk of surgical site infections usually in a lower volume surgery center than a higher volume hospital. That said, there are certain operations that must be done in a hospital setting. For example, you need right now robotic surgery is pretty much done at the hospitals. There’s no good robot in the surgery center. If I had one at the surgery center, I would do at the surgery

Speaker 2 (00:31:16):

Center. I think you guys are working on it though.

Speaker 1 (00:31:18):

We are.

Speaker 2 (00:31:20):

Oh, is that a <laugh> working on it stage? I

Speaker 1 (00:31:25):

Dunno. You heard about it already. Okay.

Speaker 2 (00:31:26):

I mean everybody’s talking about it.

Speaker 1 (00:31:29):

Yeah, we’re trying to pull some strings on that one. But my point is that so I personally, because I have such a close relationship with you all in my team, I personally prefer the surgery center for my patients. If it’s a good operation, good choice for them because I have the same team, I have the same anesthesiologist. They know exactly, I mean, I never have to tell you, oh, don’t give too much fluids. Oh, I need a tap block. Oh, make sure they don’t gag or cough when you remove that tube, it’s done. It’s automatic. My team is the same.

Speaker 2 (00:32:08):

It’s not reinventing the wheel within your team at the hospital.

Speaker 1 (00:32:13):

But if my patient has really bad chronic pain issues will need to be admitted overnight at least, or stay in the hospital, obviously I will do those in the hospital. My hospital of choice at Cedar Sinai, it’s like we’re in the top hospitals in the nation, but at the same time they’re really good at doing heart transplants and major cancers and so on. So what I say, let do this under sedation, they kind of look at me. Yeah. Are you sure We can just do general <laugh> like, no, I don’t want general, let me

Speaker 2 (00:32:49):

Get the level one transfuser here.

Speaker 1 (00:32:53):

It’s so overkill at the hospital. They’re so overqualified for so much of what I need that when I ask them for a much more kind of lower end, more delicate anesthesia, it is reinventing the wheel a little bit. And that’s among the top hospitals in the nation. So I love operating at Cedars, it’s just most of the operations I do tend to be outpatient. Now the big abdominal wall reconstructions have to be done in the hospital. Robotics currently are all done in the hospital for the most part and the chronic pain patients. So patient to patient, I think in some ways the outpatient surgery center is safer. Let me tell you, if your heart stops or if you lose an airway or have some dramatic allergic reaction to something, I think a hustle would be a safer place because you had more people to jump on you and figure it out. Right?

Speaker 2 (00:33:58):

Yeah. Well I would say that being said, Cedars does a very good job with putting people in teams. If you are going to be on the joint replacement team or the cardiac transplant team that you generally have a rotation of providers, tech, surgical techs, anesthesiologists that work on that team but that team is much bigger, let’s say 1520 anesthesiologists that you may be rotating for your team and they may be on a knee replacement that day. So it’s not like they’re totally unaware of your system and your needs, but it’s just more variables for a surgery like that. And of course you would never choose to have, you’d choose the appropriate patient for the appropriate setting for the best outcome.

Speaker 1 (00:34:51):

And more surgeries are done as an outpatient. We had Dr. Ali body several I think a month and a half ago, and she does hysterectomies as an outpatient. The stuff that we used to do before as an inpatient, even hernias used to stay in the hospital for a week. All of that has been turned into outpatient. So I think that’s kind of something that is evolving with time as well.

Speaker 2 (00:35:13):

And I think that that can be seen across the board with all specialties, medicine, cardiology, anesthesia, the medications all. And that makes, just echoing what you said, what we asked earlier regarding the safety of anesthesia, that just shows that, I mean think about how it was before taking out her a gallbladder at the beginning of your internship year versus now we just do a outpatient,

Speaker 1 (00:35:37):

I mean my chronic patients, chronic pain patients and the Mesh removals that I do, I used to do ’em all at the hospital, but once I have my own team at the surgery center, I do them all at the surgery center now. So that, that’s a nice kind of segue into this next question, which is about patients with chronic pain. So if you have someone who’s been on opioids or has some very bad chronic pain syndrome, has a lot of needs for nerve pain for example, is there a specific protocol you use during anesthesia to make sure they don’t wake up in too much pain?

Speaker 2 (00:36:14):

So for that patient, I would speak to them the day before surgery and maybe even speak to the chronic pain doctor to have an idea and have a clear plan and a surgeon to have a clear plan about what the anesthesia plan is. So we would try to avoid opioids and use other adjuncts like ketamine or precedex and we would use keep that patient free from or if this patient’s trying to become free from opioids, this is what I’m kind of assuming is that what we’re assuming or somebody who’s on chronic opioids,

Speaker 1 (00:36:52):

Really these are people that have coming in with already a very high level of pain so you don’t have that much of a leeway. So usually what we do is if they’re are a lot of narcotics or opioids

Speaker 2 (00:37:06):

We do and they’re not trying to decrease their DO dose, what they’re trying to do is disc. Okay. So probably in that situation we would definitely talk to the patient, have an extensive kind of understanding of their pain dosing because then you’re talking about somebody who is constipated afterwards and bearing down on their hernia repair. So we’d have to have a very good plan in terms of what their outpatient pain doctor, the prescribing physician, what their have regimen is, and in the operating room come up with a plan to make sure their pain is acute, pain is addressed. And we would do that by using nerve regional nerve blocks that we talked about, the ultrasound guided tap blocks and maybe even considered a indwelling catheter in that situation. So it would be a one-time shot to direct the tip of the catheter and then a tip of the needle and the catheter is threaded through a slow infusion, a local anesthetic is given there and we just don’t want that patient afterwards. You can do a most fantastic surgery anesthetic, but postoperatively if you’re super constipated, that reverses any of the good work that you’ve done. Is that answering? Answering the question?

Speaker 1 (00:38:16):

Yeah, absolutely. I heard about ketamine and magnesium. Are those also adjuncts?

Speaker 2 (00:38:22):

Yes. So those are adjuncts to provide an opioid sparing. Everybody’s talking about this pandemic that we’re having, the COVID pandemic, but there’s actually still this other opioid crisis, opioid crisis going on. And actually it’s getting worse given that people are having a lot of stress, physical, emotional, financial stress. So people are turning towards opioids just to get themselves through life. And so that epidemic is still going on. And so we’ve taken advances or taken, made certain protocols at our surgery center to do an opioid sparing approach whenever there’s regional anesthesia that can be done, we provide that. We’ve talked about specifically in your cases and ketamine specifically is one of them. And that was taking one’s taking center stage again in a lot of different treatment modalities and magnesium. Those are all adjuncts in, it’s in itself. And you just simple things like Tylenol as well, IV Tylenol and ketorolac other non-steroidal, all those things together come not just by itself are ways are tools that we have to administer an opioid sparing anesthetic. And it actually have a protocol too with your outpatient bromine and inflammation protocol. Those things have, I mean you have the research on that be very effective

Speaker 1 (00:39:52):

Of non-narcotic non-opioid based pain management for those who are eligible for it, which is most people. And the reason for that is constipation is a big side effect of opioids and is also a huge enemy of the hernia at the hernia routine.

Speaker 2 (00:40:09):

I like that <laugh>,

Speaker 1 (00:40:10):

The vomiting we work, so it’s vomiting, retching, coughing, straining, which includes constipation. And so I try not to give any constipating medications, but the anesthesia can constipate the patient. But I learned from you all about not, I didn’t know there was such thing as non-narcotic anesthesia. You’re the ones that tie it to me. No.

Speaker 2 (00:40:32):

Fascinating. Yeah, it’s like it’s all the rage right now. It is <laugh>,

Speaker 1 (00:40:37):

But that’s great. And I think it’s important for patients to under, one of the reasons why we do this hernia talk is I bring in people like you that are experts. I learn a lot, I change my practice from stuff that I learn from you all. And then the patients are empowered to go and talk to their anesthesiologists. Usually an anesthesiologist, if they don’t see you, if they don’t talk to you the night before, they will see you the day of surgery. And so these are questions to ask, what kind of anesthesia am I going to get? I don’t want to vomit or wretch I have a tendency towards constipation or do we have to use narcotics or opioids? So these are all really important topics to bring up and learn about and I really appreciate that you share all this with

Speaker 2 (00:41:27):

Us. One thing about the non-narcotic, I would say I have taken care of patients that I say this is our protocol. We do this opioid sparing non-opioid anesthetic. And they’re like, well that’s why I don’t get any. I’m like, no, no, no. If you want some, I mean you’d be like, you need it. It’s not, we’re not available to you. Right. It’s like the buffet at the in Vegas which don’t exist anymore. So it’s like if you want to have the dessert too, I mean whatever it is, if you, it’s not that you don’t get it at all, but if you wanted to have it, then certainly it’s there for you. So like some people you can have the non-opioid sparing if that’s what you prefer

Speaker 1 (00:42:02):

Because they still at the Tylenol, they still get the anti-inflammatory. Yes. You may not necessarily need the need. The opioids. Yes. They already review

Speaker 2 (00:42:09):

Opioids too. They may not need it. That’s the thing. But some people come in with anxiety of saying, you’re not going to give me any pain medicines. So that’s not what saying it is available if you need it and if you want it.

Speaker 1 (00:42:23):

But we already established opioids can cause constipation. Yes. Nausea, vomiting and urinary retention. So if you’re prone to any of those and it’s not an operation that absolutely needs narcotics, then there you go. Okay. So the biggest question that people get stumped on is like, okay, so you said nothing to eat or drink for eight hours, and what’s the purpose of that? Why do they say that?

Speaker 2 (00:42:47):

Okay, so this is fairly high risk of nausea and vomiting associated with anesthesia and we would rather have nothing in your stomach than your

Speaker 1 (00:42:57):


Speaker 2 (00:42:58):

Hamburgers, big Mac. Well now we don’t have Big Macs for breakfast. I mean what do you have at the international pancake house? The pancakes in your water or something like that. A McMuffin. That’s it. You can’t have a McMuffin in your lungs. That would be very dangerous. So that’s the main reason why we have people fasting.

Speaker 1 (00:43:15):

Yeah, because if you vomit and you’re like knocked out, it’ll go into your lungs.

Speaker 2 (00:43:19):

Yes. There’s only two places it could go over three places back into your stomach, which probably not going to happen into your lungs or out of your mouth. So because of that we don’t want you to end up with the aspiration pneumonia. So that’s the main reason why you have to fast.

Speaker 1 (00:43:36):

Can you talk about LMA? We have a question live about LMA, which stands for laryngeal mask airway. Is that safe and does it increase or decrease risk of pneumonia? Aspiration.

Speaker 2 (00:43:49):

Aspiration. So an LMA considered an advanced airway tool. It’s like a breathing tube, but it sits on top of the vocal cords and you don’t need as much muscle relaxant to have that. I would put that in the category if the surgery is appropriate for deep IV sedation and LMA can be in inserted. Most times when you are under deep anesthesia, most people can’t tolerate an oral airway being placed in their mouth. Their gag reflux is relatively blunted at that point. If you can tolerate that, you can probably tolerate a laryngeal mask airway. And

Speaker 1 (00:44:27):

Why would you ever use an LMA

Speaker 2 (00:44:29):

For your kind of surgeries or general,

Speaker 1 (00:44:32):

Let’s just talk about my surgeries. Why would you ever use it if you were, you’re either do I vaccination or the general endotracheal where it goes down your throat. Why would you choose the middle, which is LMA?

Speaker 2 (00:44:43):

I would choose it if it was somebody who was low aspiration risk. Let’s say for somebody who doesn’t, low aspiration, risk for anesthesia means you don’t have reflux gastro esophageal reflux disease. So if you don’t have that and you have sort of a higher risk for airway obstruction on your back, let’s say for example, somebody who has sleep apnea, he’s like, I always sleep on my side. So if you’re sleeping on your back and the way the shape of your face, the anatomy, your face or your tongue, it’s going to be obstructing it. Even with the oral airway in place, you would still be obstructing then those be that type of person would be an oral airway because even you basically would have to be doing a jaw thrust the whole time displacing the jaw anteriorly meaning forward on the face to relieve that obstruction and even loud snoring, it’s been, it causes to tug on your abdominal wall to get that breathing. So if somebody who slays on their has sleep apnea that doesn’t have reflux I would put in that that would be somebody I would put narrow airway and it for sedation case, not a general anesthetic case where you’re the abdomen for laparoscopic.

Speaker 1 (00:45:57):

Okay, so what are the medications that patients, so they’re told not to take anything after midnight, don’t eat or drink anything after midnight. But some people have pills they take in the morning, we usually tell ’em not to take pills except for usually right. Blood

Speaker 2 (00:46:14):

Pressure. Yes, that’s right. A hundred percent. What’s

Speaker 1 (00:46:16):

The recommendation that you give?

Speaker 2 (00:46:18):

Okay, this is my disclaimer. Always talk to your provider because everybody’s care is customized. But besides that, I could categorize if you take your blood pressure medicine in the morning, take it with a sip of water in the morning. There are few instances I think that the angiotensin receptor binding hormone drugs, there is now a trend that people are advised to hold that one. So the losartan for example, that’s a very common ARB that one can cause really low blood pressure during surgery with anesthesia. And I will say that this is just a trend because when I was in training at a medical school at that time it was hold your ACE inhibitors, but then they found out and this is then they found that didn’t make a difference. So that’s kind of the recommendation for blood pressure medicine. Take all your blood pressure medicines the morning of surgery if that is your usual routine with a sip of water

Speaker 1 (00:47:21):

Because the problem is some people don’t take it and they show up with a blood pressure of 200. Yes, and they have to cancel surgery because yes, that’s a dangerous pressure to go under anesthesia with,

Speaker 2 (00:47:30):

Right? Yes. We want to keep you the patient or keep you the same as much the same as you were if you were not going to have surgery and now we’re taking you from removing your, if you don’t take your blood pressure medicine, your blood pressure is now high, you’re taking, you have the anxiety of surgery and your blood pressure’s even more high and then you start to the surgery center and now you’re kind of in a critical situation where, okay, we cannot just maybe even send you home, not just postpone surgery, but we might even not even be able to send you home because your blood pressure is so dangerously high due to the compounding of the rebound blood pressure and anxiety of surgery. So definitely take your blood pressure medicine. Yeah,

Speaker 1 (00:48:12):

Just know if your blood pressure is super high at the day of surgery, it’s going to get canceled for elective surgery. It’s just not safe. So what about diabetes?

Speaker 2 (00:48:21):

Yes, for diabetes medicines, the recommendations are just to hold your blood pressure. Diabetes medicines, the morning of surgery, hold your diabetes medicines, morning of surgery, and this is presuming that your surgery is kind of in the morning. If your surgery is kind of later in the afternoon, your fasting guidelines, your medication guidelines probably should be modified to customize it to your care. That is because of similar to the blood pressure, you don’t want your sugars to be too low when you come into surgery because that can get you into a very critical state with low blood sugars.

Speaker 1 (00:48:55):

Yeah, it’s a reverse

Speaker 2 (00:48:56):


Speaker 1 (00:48:57):


Speaker 2 (00:48:57):

Blood pressure. It’s a reverse problem. And then also you can get

Speaker 1 (00:48:59):

With us if you’re on medication, not insulin, but if you’re on metformin or some pills, yes,

Speaker 2 (00:49:04):

Specifically metformin, you can get into this metabolic acidosis.

Speaker 1 (00:49:08):

So you should skip the morning, the morning dose. Now most of us try and be cognizant of diabetic patients and yes, put you earlier in the day so you’re not fasting for more than you need to because if you just stop eating at midnight and your surgery’s not till new the next day, that’s like way too long. Now if that has not happened and your diabetic, you should tell your surgeon, listen, I’m diabetic. We do my surgery early in the day and they should be able to accommodate for you. Very important detail.

Speaker 2 (00:49:37):

Yes, that is extremely because sugar control, it also kind of dovetails into wound healing. And so if your sugars are way too high and how you’re supposed to heal your wound, all those things are they work together. That being said Dr. Towfigh, I just want to make sure there are so many states in Cleveland State California have marijuana legalized and I wanted to make sure that while we’re talking about drugs, that patients feel that it’s safe to share with their surgeon and their anesthesia provider any of the medications are taking and mean. This is kind of leading into the supplements as well but we can talk about that next or we can talk about CHC and marijuana if you prefer.

Speaker 1 (00:50:21):

Let’s go to the next question, which is exactly that, which is because in California for sure, we are lovers of all types of supplements or supplements in addition to marijuana and also medications. Some things you should actually not take because it will negatively interact with your anesthetic.

Speaker 2 (00:50:43):

Yes. Okay. So one thing we didn’t talk about on the other slide, I’m so sorry before because I made a note to make sure when you talked to me about blood pressure and diabetes, the other things you kind of want to communicate very clearly with your doctors, any blood thinners that you’re taking, right? Either for cardiac stents, aspirin or any other NSAIDs, Advil, that type of thing. Because obviously those risks of bleeding has increased when you have surgery, but we want to make sure the cardiac stent that you might have is still working. So we need to have to coordinate care very, very carefully. That’s what I wanted to make sure I said

Speaker 1 (00:51:23):

Should be shared and there should be a plan by your surgeon and your cardiologist or medical doctor as to how to handle that during surgery and remember heart before hernia. So I

Speaker 2 (00:51:36):

Sure, I like that

Speaker 1 (00:51:39):

The hernia comes second so I’m okay operating on someone with aspirin to protect that. The heart again, I operate on heart transplant candidates, so that’s important and I’ll tolerate a little bit more bruising in your incision because of it. So just understand there’s compromises we can make based on what’s important to your health and the surgery that you need. Thank you for that.

Speaker 2 (00:52:08):

Okay, so the other supplements, basically anything that you can get at Whole Foods or this other supplements stores or that there’s a ton, Amazon, even hair supplements, nail supplements, all those things that should be stopped or should be disclosed to your surgeon before surgery. And the main reason for that is that they can have blood thinning effects and the ones that are categorized for blood thinning, blood thinning effects are all the ones with the G like ginkgo, garlic, gin, green tea, even saw palmetto can cause some thinning. Thinning of the blood issues like

Speaker 1 (00:52:53):

Fish oil.

Speaker 2 (00:52:54):

Yes, fish oil, sorry, those were not under the gs, but those <laugh> and including the vitamin E and all the vitamin supplements, those should be stopped before surgery and I would say at least two weeks to make sure it’s out of your system and your liver has a chance to recover from those.

Speaker 1 (00:53:12):

Right. Now, people who are daily marijuana users, I’ve noticed, aren’t they a little resistant to anesthesia?

Speaker 2 (00:53:22):

So now that there are some states that have legalized recreational marijuana more, the research is coming through to show that. And in one study that they looked at upper endoscopies, they found that patients required 220% more propofol than somebody who wasn’t using wow THC. And this is a study out of Colorado. And then in terms of fentanyls, like 15% verse said 20% more. But in my observation, just my casual giving propofol to somebody who is a recreational, I would say at least two to three times a week. Marijuana, not so much I would say CBD, but mostly the THC at least two to three times the induction dose and then slightly higher maintenance dose. So you have that one dose to get to sleep and then you have your cruise control level. So you’re at a higher requirement for both of those. Yeah.

Speaker 1 (00:54:25):

Well, okay, well I think we should go to the fun part of this hour, which is a superstar and Oh yeah, you played one on TV multiple times. So I was actually watching Shark Tank.

Speaker 2 (00:54:39):

Oh my God, it’s so embarrassing.

Speaker 1 (00:54:40):

And saw your episode on it where

Speaker 2 (00:54:42):

It’s so embarrassing

Speaker 1 (00:54:44):

The doctor that was promoting your product because you’re an entrepreneur called Berries, which is available I believe, for anyone to buy online or at your local pharmacy. So then I got to work with you and I’m like, I have this eerie feeling. I know this woman

Speaker 2 (00:55:02):

So embarrassing

Speaker 1 (00:55:03):

Told I watched that episode.

Speaker 2 (00:55:06):

So embarrassing. Hard to mean even doing something like this. Facebook Live is a little anxiety-provoking and I know it’s your weekly thing and it’s just kind of nerve wracking to see yourself back on Zoom and I’m like, oh goodness, I’m going to say something. It’s being recorded and people can rewind and it’s like, okay, gosh, I look, so whatever it is, people will, there’ll be trolls out there. So that’s kind of what I’m afraid of.

Speaker 1 (00:55:33):

But the fact you applied for it, went through the process and now have a product that’s widely available for everyone to use called Berries and you have, there’s two now, right? You have two products.

Speaker 2 (00:55:45):

They were sold kind of in conjunction with how we had the Tegaderm, the numbing medicine. You put the Tegaderm over. Yeah, I was kind of replicating that system. So it’s like the cream itself and then with the disposable underwear that keeps the cream from moving.

Speaker 1 (00:56:00):

Yeah, it’s like medical grade, an aesthetic available to anyone without a prescription.

Speaker 2 (00:56:07):

Right. Well, just making it more available to the areas that you need numbing. Yeah, that’s embarrassing.

Speaker 1 (00:56:12):

Which is great. Which is great. I love that you did that. And then what I didn’t know and I learned after I worked with you was that you, you’re married but you didn’t have your children yet, right?

Speaker 2 (00:56:25):

Yeah, that’s right. That’s right. Okay,

Speaker 1 (00:56:27):

So you know what? I’m going to do the survivor thing. I’m going to go and be, have

Speaker 2 (00:56:31):

A picture

Speaker 1 (00:56:32):

Actually trying and figure out how to survive on an island.

Speaker 2 (00:56:36):

Here’s my survivor picture.

Speaker 1 (00:56:39):

How ago was that?

Speaker 2 (00:56:41):

This was in 2011. So I was 36 at the time I got casted right now I’m my, I’m in my forties. And so at the time I was like, oh, okay, wouldn’t be great to try to get Ray some money for my entrepreneurial exercise and I’d like so that’s why I was on survivor first. But oh, it’s just like any other show. They’re trying to cast a variety of people and I’m sure if you wanted to go on a survivor, they would cast you immediately. If they were still doing the show,

Speaker 1 (00:57:11):

It would be the only way I could lose that much weight.

Speaker 2 (00:57:13):

No, the problem is that when you get back, they have a chef that’s been trained in this French School of culinary arts. He cooks you whatever he wants. And then, and one of the contestants of my season had Refeeding syndrome. She got pulmonary edema and she was swollen. She couldn’t, they almost medevaced her out. You go from starving and all those electrolyte shifts that you have and then you get back to your rice crispy treats and whatever pancake mix with your syrup and it’s just, you go from nothing to anything you want to eat. This guy, literally all he does is cook you whatever you want. Then so I got voted out on, I think I was out of the game day 33. I was sent to Redemption Island on 32. Spoiler alert, I’m sorry. And so I had one more day of Starvation Island and then basically I was ready to be out of there. So from those six days that I was on Survivor Island, I gained all my weight back, which is about 15 pounds.

Speaker 1 (00:58:15):

You lost 15 pounds. Yeah. I saw your pictures pretty devastating how much weight you lost.

Speaker 2 (00:58:21):

I was like, I could put my hand this around my arm like this. I could, I’m, I can’t even <laugh>

Speaker 1 (00:58:27):


Speaker 2 (00:58:28):

You. It was like, I was like, amen. For two months and I had my hair started falling out. It was really, really bad. I had some pictures of later in the season it was like I was day, so I was day because I got recruited very short. I had only two weeks to bulk up or carb bloat or whatever. But I had six eight pack abs, but I was like my hair was falling out.

Speaker 1 (00:58:53):

Oh wow. So did you make enough money to be able to help that spark your entrepreneurial endeavor?

Speaker 2 (00:59:01):

So was it worth I made what I would’ve made as anesthesiologist had I stayed at home cooking propofol, <laugh> because what you don’t know is you get reward, your reward or whatever your prize money is based on your elimination sequence. So the first person who gets eliminated is gets $2,500, but you’re gone the whole time. So they send you to the first six people that were eliminated. They were sent to Fiji and they were on vacation for a total of those 40 days but they didn’t want them to know the elimination sequence.

Speaker 1 (00:59:42):

Wow. Crazy.

Speaker 2 (00:59:45):

It was really rough. I would say that parenthood is more rough than survivor in some regards because it’s like relentless. Your can ever escape your children and at least Survivor, there’s only 39 days max. Your children are forever

Speaker 1 (01:00:03):

Too funny. And for those of you that want to follow her, she does have a fan page on, oh,

Speaker 2 (01:00:10):

That’s so funny. Totally forgot about that

Speaker 1 (01:00:13):

With hundreds and hundreds of members. So I am your fan, but not specifically for Survivor. I just

Speaker 2 (01:00:19):

Want to, I am your fan. I think you don’t realize how much I admire you and it’s like I’m fangirling you because you have really built an amazing practice and you have an amazing team. And I sound so hokey whenever I post about how much I like going to work, but it is so true. I like going to work because I get to work with people like you.

Speaker 1 (01:00:39):

I do have a fantastic team and until I opened up my own hernia center, I didn’t really have a team. I was a surgeon that works within a hospital setting and my team was the entire department of surgery, like residents and students. I didn’t have a dedicated clinical care team. And this is the first time that I can say I have a team and it’s like it’s worth a lot. On that note, my team, the daughters are playing tonight. I hope they win.

Speaker 2 (01:01:06):

Oh yes. This is getting close to the end.

Speaker 1 (01:01:09):

It is. Okay. Thank you for your time. We all have to go watch our World Series game.

Speaker 2 (01:01:17):

Well, Dr I appreciate the privilege.

Speaker 1 (01:01:20):

Thank you Dr. Ma. this is me, Dr. Shirin Towfigh signing out. You can follow me on at Hernia Doc on Twitter and Instagram and on Facebook at Dr. Towfigh. I will post this for all of you to share and rewatch on my YouTube channel. Please follow Dr. Edna Ma on Facebook and go watch her survivor. No,

Speaker 2 (01:01:41):

Don’t to much. It’s embarrassing. Thank you, Dr. Towfigh,

Speaker 1 (01:01:46):

<laugh>. You’re welcome. Thanks for your time. Appreciate everyone for logging in and participating. See you all next week. Bye.