5 Episode results for "Coronary Thrombosis"
S11: Infamous: Dr. Death Pt. 1
"He's the UK's most prolific serial killer. And he was a doctor. If you enjoy this episode on Fred Shipman Aka Dr, death subscribe to medical murders. So you don't Miss Pot to then join me every Wednesday for all new episodes where I dissect the formative years and motives of history's most infamous killer doctors listen free on spotify or wherever you get your podcasts. Listener discretion is advised this episode features discussions of murder medical malpractice, mental health conditions, addiction, and prescription drug abuse that may be upsetting. We advise extreme caution listeners under thirteen. At a certain point in life we accept death is inevitable. We even come to expect it in certain cases. When we lose someone elderly or very sick we grieve but we aren't surprised. We've prepared for the pain anticipated the event. When a grandmother dies of old age no one questions it. When her aging friend down the road dies from cancer, it's not a shock. And when over two hundred elderly citizens of Hyde England died within a twenty year span. Known. Imagined that they were the victims of the UK's most prolific serial killer. This is medical murders apart house original. For decades thousands of medical students have taken the hippocratic oath it boils down to do no home. But a closer look reveals a phrase much more interesting. I must not play. It's gone. However. Some doctors break. That's health choosing to play God with their patients, deciding who lives and who dies. Each week medical murders we'll investigate those who decided to kill. We explored the specifics of how they operate not just on their patience, but within their own minds examining the psychology and neurology behind heartless Lewis Medical Killers. I'm Alabama and I'm joined by Dr David Kipah Md. Hi everyone. It's a pleasure to be here to assist Alastair by providing medical information and insight into the killer's modus operandi I've been practiced for over three decades specializing an internal and addiction medicine, and I'm really thrilled to be part of this program because I'm a huge fan of crime stories and for me as a doctor solving a murder is much like sobbing difficult diagnosis you can find episodes of medical murders and all other podcast originals for free on spotify or wherever you listen to podcasts to medical murders for free on spotify just open the APP and type medical murders in the such bar. This is our first episode on Doctor Harold Frederick Shipman otherwise known as Fred the UK's most prolific serial killer. Between Nineteen, seventy, four and nineteen ninety-eight Shipman killed at least two hundred, eighteen people. Every one of them was a patient who had entrusted the doctor with that cash. Each victim's family believed they died of natural causes. Until the truth was revealed. Today we'll look at shipments, disturbing modus operandi, his early murders and likely motivations. Next time, we'll examine how shipman escalated his crimes within his private practice and how the subsequent inquiry into. Dr. Death. Forever changed the British medical field. All this and more coming up stay with us. Kathleen Grundy was late. Still, it was only a few minutes into her scheduled eleven am volunteer shift her friend John. Green figured she was merely distracted. But after forty five minutes green and his friend Ron Pickford grew concerned. It wasn't like Kathleen to be late though she was eighty-one. She stayed active volunteering five days a week. Still she was eighty one. So, green and Pickford, went to check on their friend around noon on June twenty-fourth Nineteen Ninety eight. They found have back door unlocked. It wasn't uncommon for hides elderly citizens to leave their doors open, but it still gave green pause. He shouted. With no response. Further inside he found Kathleen lying peacefully the settee fully dressed as if she'd fallen asleep with her shoes on. He tried to wake her but her skin was gray. And head body was code. Green Colden Pickford who called Kathleen Dr Fred Shipment. Twenty minutes later, Dr Shipman arrived checked Kathleen for a pulse and promptly declared she died of a heart attack. Green asked about Kathleen stuck disappointment that morning. Had she been sick Shipman. Replied that he'd stopped by only for a talk. Later that day Kathleen's daughter Angela called shipments inquire about ten mother. Shiffman told her what he told Green and Pickford that mother had died of cardiac arrest. In fact, she'd complained of chest pains her appointment that morning. However when he filed the death certificate with coroner. Dr Shipman wrote the Kathleen Grundy had died of old age not a heart attack. Old Age means that you have lived to a point where some of your illnesses and some of the chronic things that have gone on with you starting to catch up with you. So we don't really think about aging until we start feeling the effects of these chronic illnesses. Old Age has sort of a non discript answer and can be missed berry misleading to the coroner families rarely review a death certificate but the corner, it's very careful about what's written. These are legal documents and actually have life insurance implications and also reflect exactly in case people do have to go back for family reasons to know what their genetic history is. They'd like to be able to refer back to these death certificates to see if they're in trouble for anything that may be in their in their genetics. Kathleen Angela did question the death certificate she was a solicitor and to her it was clear. The listed cause of death did not line up with the facts. When we approach Dr Shipman, he claims the FIB was a favor to save for the stress of a postmortem exam and identification he was helping her Angela knew her mom love. Dr. Shipman and that his private practice was extremely popular with the citizens of hide. so she trusted him. Until things grew more suspicious. Law Firm reached out to Angela saying they had her mother's will. But that couldn't be possible Angelo already had her mother's will. Even stranger this second will left nothing to Angela and requested Kathleen be cremated despite the fact that she'd expressly told Angela to bury her. Not to mention, the will was typed in all caps with words missing letters. The low funds set their points of contact was John Smith, which Angela guest was a fake name. This will was a forgery and a Lazy Won. She wouldn't stand for it. Angela began an investigation starting with the law firm and then the police. Before Long Kathleen Grundy's body was exhumed and an autopsy revealed that she hadn't died of a heart attack or old age. She'd been murdered injected with a lethal dose of morphine. The evidence pointed straight to the wills beneficiary and perhaps the last person to see Kathleen. Grundy alive. Dr Fred Shipman. Angela didn't know it but her mother wasn't shipments first victim. She was at the very least his two hundred eighteenth. His murder spans twenty three years with his first confirmed kill back in nineteen seventy five. But his crime story began twelve years before that in nineteen, sixty three. The first time Fred Shipman saw a sick woman dying. When he was a teenager shipments mother, Vera was diagnosed with lung cancer. This news was made more devastating by reports that Fred was his mother's favourite. According to some accounts, she's spoiled rotten always telling him he was better than the other boys. Though they were working class, she pushed him to apply for a scholarship to an elite private school. Shipments soon learns that perception was everything. He loaded his tie in uniform over his family and the neighborhood kids displaying an early sense of arrogance on and off the playground. But he had no more time for that in nineteen sixty three. After his mother's diagnosis, he raced home from school to Comfort Vera as she waned away from cancer. At the time it was routine for doctors to make house calls to check on patients and administer drugs like morphine. Sometimes, doctors dropped by unannounced just to say hello or have a cup of tea. Fred Shipman. Got To know his mother's doctor and his work. Well. Fred recalled watching his mother struggled for breath then grow calm and peaceful as the doctor injected morphine into her veins. Morphing works in the brain by slowing down those reflexes in the brain to control breathing and heart rate. So as morphine comes into the brain though centers that normally regulate these functions starts slow down more interesting Alastair doctors prescribe morphine, not just for pain management, but we also use this at the end of much life in order to give them a very peaceful and comics Itt. Vera passed away in one, thousand, nine, hundred, sixty, three. It seems Shipman dedicated much of his life to reliving his last year with her. To that point by the age of seventeen, he had decided to become a doctor. And in nineteen seventy, he graduated from Leeds University Medical School later that year twenty, four year old Shipman began working as a pre registration officer at pontefract. General Infirmary. In retrospect Shipman's killing career may have started alongside his medical one. So some people attempt to process their traumas by reliving that trauma. This is not uncommon in his US constantly and therapeutic sessions, and this is called exposure therapy. Exposure therapy however, in someone that has murdering people is probably not such a good therapy. The trouble with investigating Dr Shipman is that every one of his murders was initially documented as a natural death meaning that the hard evidence was lost to time and the truth buried with the victims. Not much is known about his training, but the accounts we do have a concerning. Oneness Sandra Whitehead recalled that the infirmaries women's ward once saw three deaths in a single day that Shipman worked. And she often found empty injection packs left in deceased patients rooms. She presumes they will use to administer intravenous drugs like morphine. If any of these deaths were murders, they lined up with shipments later AMMO. And they wasn't just Sandra the infirmaries. Records show a higher than usual death rate during Shipman's training period. Perhaps because we're conditioned to trust on doctors, no one suspected shipment of anything at the time. Nurse Sandra Whitehead only came forward decades later after she heard about the government investigation into Shipman, it's also possible. Some of these deaths weren't premeditated murders but accidental overdoses. Shipman may of hoped to relieve a patient's pain remembering the miraculous relief morphing gave his suffering mother and overdone it. If so this periods may contain shipments second moments of revelation. Morphine had the power to take away pain. But. It also had the power to kill without consequence. Coming up shipman experiments with his murder weapon now back to the story. After watching his mother diet age seventeen fred shipments seemingly became obsessed with the event. He trained to become a doctor and developed a strong interest in morphine. The same painkiller he'd seen his mother's doctor administer on her deathbed. In his twenties Shipman tried morphine himself and claimed he didn't care for it but that didn't stop him from experimenting with opioids even as he began to treat his patients at pontefract general infirmary. By the early nineteen seventies Dr, Shipman had developed a pepperdine addiction. Pepperdine's effects a similar to those of morphine which is derived from the puppies, the source of heroin. Pepperdine is used primarily in labor and delivery for pain management shipment obviously became addicted to the drug, and after a certain point, as we discussed with receptors being dumbed down the patient needing more and more drug in order to get the same effect, this is called tolerance by the way at a certain point, people start taking their opiate drug not for the pleasure that they used to get. But in order to prevent withdrawal because after a certain point, those pleasurable symptoms from an opiate become less and less pleasurable and the withdrawal effects are more and more uncomfortable. So, that's how these drugs maintain their their addictive quality. So addiction is really a problem with mental health. So the signs you look for our mental health issues. So if people are depressed or anxious polar, have any other mental health issue that is untreated. Those are the people that are more likely to self medicate, and since self medicating is fairly easy these days they often turn to these substances that are not prescribed not monitored access to narcotics was certainly on shipments mind once he began working in nineteen, seventy four, he went out of his way to handle them. That's Year Shipman was hired as an Assistant General Practitioner at the Abraham Murad Center in Taught Madden. He quickly jumped into to undesirable tusks, reorganizing the records and disposing of outdated pharmaceuticals including pepperdine. On the outside, it seemed like a move to earn goodwill among his new coworkers. But secretly. Shipman abused his responsibilities. He learned all about how records were kept, who monitored them and how to forge medical documents. and. Once he confirmed no one was keeping tabs on the trash he stopped disposing of the pepperdine legally. Instead he injected the drug into his own body. When he made his way through the practices drugs Shipman over prescribing. To his patients. This way, there will always leftovers to be disposed of. He was essentially stealing drugs from his patients. And he was getting away with it. Over the next year shipments painkiller addiction only grew more dangerous. According to the Shipman inquiry. The official investigation into shipments crimes a normal dose of Pasadena to relieve pain is one hundred milligrams and for someone with no tolerance, a lethal dose is around five hundred milligrams. In one, thousand, nine, hundred, seventy, five shipman was using six hundred to seven hundred milligrams of caffeine a day. His patients and his colleagues were clueless. According to the Shipman inquiry he was viewed as keen and hard working around the practice and his patients felt he was their friend as well as their doctor. In hiding his addiction shipman was extremely thorough. He put all the prescriptions he used in his patients names, and some patients didn't even know they had an open pepperdine prescription. Shipman would pick up the medicine on the patient's behalf and never tell them about it. But he couldn't keep his secret forever. In June nineteen, seventy, five, a foam suits co company notes the absurd amount of. They was supplying taught Madden's boots pharmacy and contacted the case federal law enforcement known as the Home Office. The investigation led to Shipman and in July offices interviewed him about his prescription practices. All signs pointed to pharmaceutical abuse. It should have been a quick arrest. However the Home Office couldn't verify if the amount of pathogens supplied stacked up to the amount actually used by shipments patients. Shipman. Hadn't kept a record of it. And because it was his job to organize the practices records, no one had noticed. As we said Shipman always covered his bases and then he covered them again. When the Home Office pressed him Shipman claimed he wasn't aware he was legally required to keep those specific recode. With. No recourse they let shipment off with a warning. After that Shipman stopped keeping records of his pepperdine prescriptions altogether. He became increasingly unhinged Shipman began experiencing blackouts and seizures. He'd suddenly convulse lose consciousness at home in the car and even at the medical practice in front of patients. One SESIA even cost Shipman to fall in the bathroom at his home. He hit his head resulting in a bad concussion. In August nine, hundred, seventy, five shipman was diagnosed with idiopathic epilepsy or unexplained seizures. Eventually the seizures forced him to stop driving but despite all of this Dr Shipman continued to practice medicine including intravenous injections a skill that certainly requires a clear head and a steady hand. Someone that had one epileptic. Would not dangerous because that would more likely be treated. If someone had multiple episodes of epilepsy, it would mean either that they weren't being treated or that their form of epilepsy was resistant to treatment. So doctors will often try to mask any kind of subtle or minor problem that they're having with their health. If doctor recognizes that they are no longer capable of performing, they are obligated to step away. The reasons doctors might not step away as they might not recognize or admit that they are incapable or they are compromised. Capable Oh, not shipman would not be stopped from seeing his patients. He kept his symptoms hidden and his old fashioned manner and charming house calls continued to gain favor. He would do anything to help them recover from their pain and suffering. When he stumped driving his wife Primrose chauffeured him to appointments around Talk Madden. Primrose often helped her husband throughout his career and had no idea. She was actually putting Shipman's patients lives in danger. and. By this time they were in danger. In nineteen seventy, five, twenty, nine, year, old Shipman, committed his first confirmed mudder. Seventy year old EVA lions. Shipman visited at her home on the nights before her seventy first birthday. Seeing has suffering shipments said, he'd give a verse something to ease the pain. Aver suffered from cancer and a dose of painkillers wasn't unexpected. Sitting beside Avis husband Shipman pierced his needle into the back of EVA's. Hand. Opiates take effect quickly and keg is a sometimes able to stop the dose. When it's clear, the patient is no longer suffering. Shipman likely saw that aver had enough. But kept pressing the SYRINGE. Intentionally overdosing her. When he did stop the injection Shipman acted as if everything had gone normally. Eva's husband even invited shipment to have a cup of coffee downstairs. Eventually, Shipman went back into the bedroom to check on Eva. and. He returned. He told her husband. She's dead. Avis husband was upset but not surprised. Shipman left shortly after. Later he certified Avis death without an autopsy. Everyone believed it was natural caused by her struggle with cancer not any medication. Later Avis has been told his granddaughter Shipman was a Nice bloke. He didn't suspect a thing. The doctor had perfected his forgery skills and could now quite literally get away with murder. However, it didn't make shipments behavior less paranoid and he had every reason to be. Near the end of September nineteen, seventy, five shipments colleagues at taught button confronted him. They believed him guilty of theft forgery and drug abuse. Shipman admitted it. He abused pharmaceuticals. But. Then he made a request. Would they help pin covered up? If his. Over prescribed pepperdine well, he could avoid further suspicion from the Home Office and keep working at the practice. But the doctors wouldn't be fooled again. They forced shipments resign and check into Rehab. Then they alerted the authorities. The Home Office sent offices Makita and Macintosh to interrogate shipment at the Rehab Hospital. At first Shipman declined to speak with them, but he soon changed tack and began confessing. He spoke about how he acquired pepperdine how he forged prescriptions, falsified records and abused the drug. There was only one detail they doubted. Shipments said he began abusing pepperdine in nineteen, seventy four. But detective McKee eating noted all his veins had collapsed something. I would have expected to see on an addict of at least five years standing making me suspect that his habit was longer than he admitted. Even if he may have been lying about when he started using Pepperdine Shipman disclosed enough crimes in enough detail that authorities believed they had the full story. They didn't press him further. He was charged with eighty two criminal counts solely around unlawful drug possession and prescription forgery. He pled guilty to eight and was fined a some worth around seven thousand dollars today. The convictions was sent to Britain's general medical. Council which had the power to begin proceedings to revoke shipments license if they found him incompetent. But they too with wilted by shipments Kaffa cover-ups. Even. Though he'd confessed to possession and forgery those crimes were considered low level. There was no evidence. His patients had suffered due to shipments drug abuse. On top of that shipments seem to have made a full recovery after three months in Rehab and vowed to never abuse drugs again. He perfectly played the role of an upstanding citizen who'd made a mistake. So the General Medical Council gave him the benefit of the doubt. By May, nineteen seventy six shipments case was fully closed. He was cleared to resume medical practice. Given this fresh start he'd learned one important lesson. He would no longer abuse drugs on himself. He'd abused them. On other people. And much like opioids overdosing patients proved all too habit-forming for Dr Shipman. Up Next ship and replaces one addiction with another now back to the story. Dr Friendship Shipman left his first job with one confirmed murder and a series of suspicious deaths in his wake. But he was a medical con artist, a master of deceit. He passed his first murder off as a natural death. And it was only a matter of time before he killed again. In October one, thousand, nine, hundred, seventy, seven, thirty, one year old ship and landed a job as a general practitioner at Donnybrook. Medical Center in. Hyde. A village just southeast of Manchester England at Donnybrook. Shipman was open with his new colleagues about his checkered past just as being with the police, he used a partial admission of the truth to gain his new colleagues, trust. For the next year, he played it safe creating a fresh facade. Shipman charmed his new patients joined the PTA and ran a rugby club. He bought a nice suburban house for his family, which now included primrose and four children. From a distance Dr Shipman was an upstanding citizen. Before, long his new patients were raving that he was the best doctor in. Hyde. And he clearly agreed. Shipman was confident and proud of his work. Arrogant even. The sole remaining consequence of his crimes and Tottenham was that Shipman was not legally allowed to carry controlled substances on his person. This was intended to ensure he didn't abuse anymore opioids. But that ruling didn't keep shipment from encountering controlled substances. He continued to treat elderly and Tenley ill patients prescribing and during painkillers as any doctor would. In the Shipman Inquiry Dame Janet Smith proposed that Shipman was able to steal opioids left behind by his terminally ill patients after their deaths. Through nineteen seventy seven and nineteen, seventy eight he could have easily stockpiled more than diamorphine Pasaden- and chlorpromazine. He certainly had the knowledge and experience to do so. And he had a plan to use the drugs. About ten months after starting work at Donnybrook Shipman overdosed another patient, his second confirmed murder. On August seventh nineteen seventy eight, fifty, four year old Irene Chapman paid her mother ceremonies land a visit. It was just across the neighborhood both lived in a small village of hide. Irene sister CECILY had just died and Irene knew her mother was feeling low. Sarah had lived alone since she was widowed. So Irene was shocked to find a man leaning over her eighty six year old mother's bed. The shock turned to agony as she realized, her mother was dead. Then it turned to confusion as she processed that the man was the family doctor Fred Shipman. Shipman had a story immediately. He'd stumped by for an unplanned check in on Sarah. Of physical pain says she grieved. Shipman. Helped her move from the chats at the bed to make them more comfortable. But moments later she died. Shipman attempted to revive Sarah but couldn't save her. In her extreme shock and grief Irene accepted the story. Shipman listed ceremonies. Lens course if death as coronary thrombosis. In Reality Shipman likely injected Sarah with an overdose of opiates. Dumping a murder coronary thrombosis became a pattern for shipment though he also frequently documented his patients as dying of pneumonia respiratory failure and myocardial infarction, which is a heart attack. So I think that shipment picked this cause of death in a way to throw off the corner, and also as families rarely questioned a death certificate, he knew that he would not be scrutinized but people that die of a heart attack die in a very uncomfortable manner people that die of an opiate overdose die very peacefully. So the way people die is different in these two events. So there is a tremendous abuse of power in this, and it really is comes down to that question of our doctors allowed to make that decision about who's going to die weapon. Shipments pattern of forgery continued he weasel his way out of his second murder unnoticed. But that wasn't the last shipment would see of Sarah's daughter Irene Chapman. Irene remained his patient for the next twenty years. In that time her daughter-in-law Carol Chapman was even hired as shipments receptionist. Irene never suspected that her doctor may have killed her mother. She continued to see. Shipman. For routine care until nineteen ninety eight. That year. Dr Shipman Killed Her two. From Sarah Moslen through Irene Chapman Shipman followed a distinct modus operandi. Visit Patient at home, inject them with narcotics to stop that pain and suffering. Stay, for a few minutes as they die insure the death looks natural and peaceful. Each murder brought him back to his last days with his mother watching the morphine white the pain away. After he killed them, he usually turned on the fireplace and this actually makes a lot of sense ouster unlit fireplace would increase the temperature in the room speeding up the body's decomposition. This could create complications when it comes to establishing a time of death increased. Heat also speeds the onset of rigor. Mortis, which is of biochemical change in the body, the causes stiffening of the skeletal muscles and usually happens a few hours after we die. Increase temperatures hasten the arrival of Rigor Mortis, creating more productive environment for the bacteria to do their damage side from stiffening the skeletal muscles. Rigor mortis changes, composition of the tissues, making them more difficult to examine in an autopsy. This degraded tissue would make identifying the morphine levels of corpse all the more difficult. These combined effects likely made it even harder to connect shipment to its crimes. Even decades later, the British government was only able to tie shipman to full murders in nineteen, seventy eight. Just, three weeks after killing ceremonies lend Shipman Murder Mary Ellen Jordan the same way before Christmas he killed Harold Brown wool and Campbell. No one suspected a thing. There was virtually no way to stop him. Shipman. Made sure of it. He continued overdosing patients through one, thousand, nine, hundred, seventy, nine with two confirmed murders toward the end of the year. Still. He was careful. There were no confirmed killings in one, thousand, nine, hundred eighty, and only two in nine, hundred, eighty one and he apparently cooled off in one, thousand, nine, hundred, eighty two before killing twice more in nineteen, eighty three. But extremely likely Shipman killed more during this era because we know he took nine victims in one, thousand, nine, hundred, eighty, four. And from nineteen eighty, five to nineteen, ninety-one Fred Shipman killed a confirmed fifty two people. Psychologists consulted during the Shipman inquiry observed the doctor as obsessive with a need for control clearly evidenced in the way he covered up his crimes. I he was careful about his selection most victims terminally ill and patients he treated for some time. He built up trust as the family doctor before acting and he built up the records of illness. Their life expectancy wasn't guaranteed. It was whatever their doctor estimated. For talked to Shipman's patients, their life expectancy was only as long as he waited to kill them. Some victims ones even ill? Take More Fox she was seventy-seven and in generally good health. On June twenty-seventh Nineteen eighty-three Shipman roads in his appointment book that she was getting blood drawn the next day the seemed to be his code for administering a fatal dose of morphine. Dame Janet Smith suggested a blood sample was a clever ploy for the doctor to access veins while the victim wasn't looking. And that's likely what he did to Maura Fox. He asked her to lay in bed while he drew a blood sample. Minutes later. She was dead. Shipman updated his appointment book again, the next day merely writing Miss Fox bloods. Dead. However. Shipman told Mr Unsworth MOIR's retirement community cat tak- a very different tale. Shipman claimed Moore recalled him on the twenty eighth complaining that she didn't feel well. This was no shock to Unsworth more often complains about her aches and pains though he believed she was more of a hypochondriac. Shipment continued his story. He'd arrived to find more red dead on the floor out of respect he moved to the bed. But he didn't just inform the CAETAKER. Shipman insisted Mr Jones with come at Maura. UNSWORTH wasn't sure why Shipman required this, but he was a doctor and must have had some medical reason. Shipman had several patients in the retirement community and Unsworth hadn't heard a bad word about him. So he examined Mora and confirmed she was dead. He noted that she looked peaceful as if she'd had a painless death. With this Sherard Shipman was essentially creating a second witness solidifying his cover up. That cover up continued when Shipman documented Moore's death as coronary thrombosis. When he killed a healthy patient like this shipman often backdated his records falsifying evidence of lingering disease often months of heart problems. He also invented tales like the one he told the caretaker where a patient complained of an ailment they never had. Shipman relied on the fact that almost all of his victims were over sixty and most of them were over eighty. A peaceful death at home wasn't shocking. Like more Fox, most of Shipman's victims were found in the same tranquil state sitting in an armchair all lying in bed. They were always fully dressed as if they were taking a nice midday nap. For a single death, this wouldn't raise eyebrows. But looking at over two hundred deaths together. As extremely odd. Because they were overdosed with painkillers Shipman's victims were never found struggling to reach the phone collapsed in the kitchen or groaning on the toilet. They were never part way through tying their shoes or in the midst of cooking dinner. There was no blood, no goal or bruising. When they were found shipments, patients never looked like one imagines a murder victim, most causes of death or not peaceful because what's happening inside the body as it some part of that body is shutting down starving the brain and the lungs and the heart from their oxygen. The body reacts in Perry uncomfortable ways. When somebody dies, they exhibit a very unusual breathing pattern it's called stokes breathing. If somebody observes her level and going through a chain stokes breathing pattern, it's very uncomfortable and it appears that person is struggling. If somebody sees somebody that acutely dies of an overdose of morphine, they go very peacefully. They don't have that same reflex when someone dies of a sudden death, they are usually found in an awkward or compromising position. You can find somebody that has died on a treadmill. You can find somebody that has died on the toilet seat. These are people that when they die suddenly they fall, they land on the ground and they don't look like they're in a peaceful place. He actually post these patients before he injected the morphine and he did this because he used a blood draw to. Hide the fact that he was actually not taking blood but injecting morphine if you somewhat gets a rapid injection of morphine, they can die within a minute. It's very sudden. So his victims were already in a peaceful place. They were already in a peaceful position lying down and so when they were found dead, they look very much like they had died in their sleep. Shipman's victims families saw what they wanted to see. Their parents and grandparents were come in the final moments that death wasn't painful or drawn out. It's what we all wish for a loved one's. An end to this suffering. But even that cover wasn't enough Dr. Shipman. He remained studious in a racing evidence. The final key to his years of undetected Mata was hidden in plain sight. Cremation. He recommended or of his patients be cremated and many of them were. When the bodies burned. So did all the evidence of an overdose. Unlike many serial killers, there was no need for shipment to dispose of his victim's bodies. Their families did it for him. Shiffman himself is reported to have said. You can't exume ashes. Don't Fred Shipman's actions paint the picture of a man obsessive and paranoid a killer who more than anything feared being caught. He maintains a charming trusted face with his colleagues, his patients and the people of hide. Anyone who saw the true shipman only glimpsed him in the final moments. Dr. Shipman made every effort to ensure his victims never sought justice. For years it worked. But by Nineteen ninety-two, his tolerance for murder had risen. He taken on more and more patients serving much of the town of hide. He gave them his version of care. But his fear of being caught war on him. He couldn't escape his paranoia as long as he worked at Donnybrook Medical Center. To feed his addiction shipman needed more secrecy and more power. He needed to escape the oversight of his colleagues. He needed. A one man practice. Next. Time on medical matters, Dr Fred shipment launches his own practice. He remains a pillar of the community despite killing the parents, grandparents or friends of almost every residence of hide. His murders are so horrifying and so numerous. The British government's reaction hits the scope and scale of a natural disaster. Thanks for listening to medical murders and thanks again to Dr Kipah for joining me today. Thanks for having me I really look forward to the next episode for more information on Fred. Shipman. Among the many sources we used, we found the six volumes of the Ninety Kingdoms Shipman inquiry compiled by Dame Janet Smith extremely helpful to our research. You can find all episodes of medical murders and all other podcast originals for free on spotify not only to spotify already have all of your favorite music but now spotify is making it easy for you to enjoy all of your favorite podcast originals like medical murders, the free from your phone desktop or smart. Speaker. To stream medical murders on spotify just opening anti type medical murders in the search bar we'll see you next time. Medical murders was created by Max Cutler and his opoku studios original. It is executive produced by Max Cutler Sound designed by Ron Shapiro with production assistance by Kali Madden Kristen, Vado Jonathan Cohen, and Jonathan ratliff. This episode of medical murders was written by McKee via with writing assistance by drew cold and stars. David. Kipa and Alliston murden.
The Philadelphia Experiment Pt. 2
"When Ed Cameron opened his eyes. The world slowly fell into focus around him. For some reason, he was lying on a hospital bed. His Brother Duncan was unconscious in the caught beside him. Surgical tools and machinery surrounded the brothers on all sides alarmed. It's started tugging at the tubes connecting his body to one of the bazaar apparatuses. But as he did, ed felt a sharp searing pain. His body was covered in Burns Edward as an engineer for the navy in Philadelphia the last thing he remembered, he leapt off the naval destroyer he'd been stationed on. The rush of cold ocean water, encasing his body before he could piece together any more of his memories, neurologist entered the room. The doctor began questioning Ed. Did. He have any idea what year it was. When ed answered Nineteen forty-three in the doctor? KOCHTA's head squinted. His is in corrected him. The year was twenty, one thirty seven. He showed at a map of the United States. Florida was gone. The Western and southeastern coasts of America were underwater. It didn't represent the country that ED served, did it? Add in Dunkin spent several weeks at the hospital in one thirty seven. then. They travelled through time again to the year nineteen eighty three. When they arrived, the brothers found themselves face to face with us. Government officials threatening them to keep quiet. Welcome to conspiracy. Theories apart cast original. Every Monday and Wednesday we dig into the complicated stories behind the world's most controversial Vince and search for the truth I'm Carter Roy and I'm Molly Brandenburg and neither of us are conspiracy theorists, but we are open, minded, skeptical and curious. Don't get US wrong. Sometimes the official version is the truth, but sometimes it's not you can find episodes of conspiracy theories, and all other park cast originals for free on spotify, or wherever you listen to podcasts to stream conspiracy theories for free on spotify just open the APP and type conspiracy theories in the search bar. This is our second episode. On The Philadelphia Experiment, on Nineteen forty-three government experiment said to render a navy ship invisible to the naked eye. Last time we investigated the claims of Carlos and Lendvai Aka Carl Allen. Who allegedly bore witness to the experiment? We also examined the navy strange fascination with author and UFOLOGIST Morris K Jesup. Some believed his book held missing keys to the Philadelphia experiment, not long after being contacted by the Navy JESSOP committed suicide. Today we'll analyze the claims of a man who allegedly participated in the Philadelphia. Experiment Al Balic. His accounts have spawned a number of conspiracy. Theories will cover three of the most popular. Conspiracy Theory Number One. The Philadelphia experiment accidentally caused participants to time travel, and the government worked to cover up their mistake conspiracy theory number two. The experiment may have been the catalyst to other government programs and technologies like the Phoenix project the stealth bomber and Project M. K. Ultra. And conspiracy theory number three the Philadelphia experiment successfully rendered a invisible in order to infiltrate enemy waters. But accidentally teleported it to Virginia. We have all that and more coming up stay with us. In the nineteen forties, the United States Navy may have funded a top secret program that attempted to render the navy ship the US eldridge invisible. Allegedly, their experiment went horribly wrong. The flesh of sailors fuse to the metal of the ship. Others teleported. Some even time traveled the first report of the Philadelphia. Experiment came in Nineteen fifty-five from a sailor on board and neighboring vessel named Carlos Alendronate. Then in nineteen ninety, some aspects of Monday story work corroborated by Al Balic bail. It claimed he'd been not just a witness. A participant in the Philadelphia Experiment Balic, and his brother does. Were among the soldiers who were apparently transported to the future which brings us to our first conspiracy theory. The Philadelphia experiment accidentally created a portal that caused Alec and his brother to time travel. And government didn't want anyone to know about their error. Most of our evidence for this theory comes from Alex accounts. And after fifty different radio, Internet and television interviews and forty different convention Conferences Bailey story remained consistent. Why did bail wait fifty years to tell his story? Apparently, it would have disrupted the Space Time Continuum According to Balic he was born in Nineteen. Sixteen under the name Ed Cameron. For the sake of clarity will always refer to him as Balic. No matter what is given name would have been at the time. In one thousand, nine, hundred, thirty, two bail graduated from Princeton then earned a second degree at Harvard. During his studies, he met Dr John Von, Neumann mathematician, physicist and computer scientists who would later work on the Manhattan project developing the atomic bomb according to Balic. Von Neumann replaced scientists an innovator Nikola Tesla as of what Linda called The Philadelphia experiment. Basic said the program was officially called Project Rainbow by nineteen, thirty nine bail had received his PhD and Von, Neumann recruited him and his brother. Dunkin to the navy together. They underwent a mysterious ninety day training program. The specifics of the program are hazy, but Ed graduated the program as a lieutenant. Then in the nineteen forties, von Neumann recruited Balic. DUNCAN TO WORK ON PROJECT RAINBOW AKA THE PHILADELPHIA experiment. During a failed test. Balic and Dunkin jumped off the ship to save themselves. Balic describes what happened next. As lean suspended in time frozen in place, then everything went black. When Balic woke up, doctors told him it was the year twenty one thirty seven. He spent the next six weeks under the surveillance of medical professionals. Then basic inexplicably traveled forward in time again this time to the year twenty, seven, forty nine. He spent the next two years of his life in the twenty eighth century. Eventually Ballack worked as a tour guide to familiarize himself with his surroundings. According to his report, a synthetic computer system ran the world in the future. Artificial intelligence controlled human lives. All information was stored in a system similar to what we know as the cloud. People paid for goods and services through the eye and communicated telepathically. Humans had completely lost their autonomy and were running on autopilot. If all the dots don't connect, that's okay. Bail account is a bit vague, but apparently no one in the future could recall how or win. The AI took over. As if they're. Memories had been erased after two years and twenty, seven, forty, nine Baylock, returned to twenty, one, thirty, seven and reunited with his brother. Once again, they abruptly an inexplicably time traveled this time to the year nineteen eighty-three. When they came to a group of government officials wiped their memories to ensure that their journey never reached the general public. The officials then sent ballot back to nine, hundred, twenty, seven, where he was reborn as Al Bailiwick no longer Ed Cameron. Unfortunately Dunkin didn't make it to nineteen twenty seven. BILLICK assumes his brother died along the way. But at the time, he didn't think twice without his memories. He forgot he had a brother Duncan entirely. Then, in nineteen eighty eight albuque- watched a science fiction movie called The Philadelphia Experiment. The film triggered flashbacks and Bailey's started feeling an intense constant sensation akin to deja-vu billick saw therapists and psychics to discuss the waves of emotion and memory. Eventually through past life, regression, techniques and hypnosis ballots started to recall the memories that government officials tried to erase the story. We just told. How did the Philadelphia experiment allow Al Balic or Ed Cameron to travel through time. He claims it has something to do with what he called time locks and allegedly inventor Nikola Tesla discovered them. Essentially the idea is that every soul contains a time lock. Think of it as an IP. Address for a computer and identifier meant to aid security. The time lock exists to keep humans from slipping into another reality dimension or time line. The high voltage used in the Philadelphia experiment somehow ruptured Balic's time log Nikola, Tesla feared that might happen and to prevent it from happening in the future, Tesla's supposedly worked to build something called a zero time reference generator, according to an article from Guy Online the device supposedly locks to the earth's magnetic fields and acts as a cosmological reference with the electromagnetic fields at the center of the Galaxy. In other words, it's a fancy seatbelt for time locks. It keeps them safe and in place. According to Bailiwick in nineteen forty two tesla ended his work on the Philadelphia experiment without finishing the seat belt, and he took his unfinished plans with him. How much of that is true? Well it's no secret. Tesla worked on high-tech innovations for the American government. He advocated for electrically driven ships and tried to sell the US Navy on a vessel, called the teller automaton between nineteen, seventeen and eighteen twenty tesla frequently met with Assistant Secretary of the Navy Franklin Delano Roosevelt. which could mean that Tesla was involved in the Philadelphia experiment, except in the final years of his life Tesla lived in the Hotel New Yorker. He could barely afford to make rant. He spent his days roaming central park, trying to remedy failed equations in his head and befriending wild pigeons. Maybe bought before that Tesla worked on projects yearly. SIMILAR TO THE PHILADELPHIA experiment. In nineteen, thirty four Tesla told Time magazine he was developing four inventions which would make war unthinkable. One of which was a death ray, a concentrated beam particles that traveled at the speed of light. According to Tesla. It would be able to destroy armies, tanks, or even blow airplanes out of the sky. That may be, but there's no evidence to tie Tesla to the Philadelphia experiment, or as Bailey called it project, rainbow. In his lifetime, Tesla mostly sunk his fortune into one failed project after another. Today. His most recognizable invention is the Tesla Coil. It makes for some interesting lighting effects, but it's nothing compared to the technology required for time travel. At the end of nineteen, forty two, according to bail lack. The government replaced Tesla with John Von. Neumann. Maybe he was able to further Tesla's research. And we can't ignore. The Tesla died mysteriously in January of nineteen, forty, three from coronary thrombosis, which is usually associated with high cholesterol diets. Nikola Tesla was known in the hotel for his special vegetarian meals and his love for exercise. Well it's possible for him to develop the disease. It didn't match his lifestyle and that doesn't explain what happened after Tesla's death. According to the Federal Bureau of Investigation. The Alien Property Custodian Office seized all of Tesla's work and belongings after he died. Officials form the department during world. War One to seize the property of their enemies. Tesla's papers were classified as property of the United States government. It certainly suspicious, but Tesla was only mentioned in Balic's account. No one else not even Carlos Landay. Accused him of being involved. which could mean? Balic fabricated Tesla's involvement and his own experiences in time travel wild. Alex account his suspicious. There's another chapter to examine before we fully analyzed his credibility, so we'll save rating this theory for later. According to Bailiwick The Philadelphia experiment didn't end with the USA's Eldridge. It may have led to other secret programs involving mind, control and alien technologies. COMING UP THE GOVERNMENT GETS ITS HANDS ON A mind controlling supercomputer. Hi, it's molly. Navigating young adulthood can be a wild ride something Social Media Star Addison Ray couldn't do without her mom sharing a coal. In, their wonderful new podcast original series Mama knows best. Addison goes to her mom for advice on all things growing up here. They are to tell you more. Hey All I'm addison ray and her mom, Sherry and every Monday on our new show. Mom knows best. We're going to get real about all the ups and downs of growing up finding love and going viral, a bunch of topics signed up like living with your parents dating during a pandemic and so much more, and since I know Best Yano. I have some advice to share. Okay, but do you really know? Best is the name of the show all right? Well? I think we can let them be. The judge of that new episodes of mom knows best. Monday exclusively on spotify so follow, and you can listen for free. Now back to the story. In, one. Thousand Nine Hundred Ninety Alec announced that he participated in the top secret government project gone wrong. The Philadelphia Experiment Hey que project. Rainbow Bailey claimed the Philadelphia experiment didn't end in nineteen forty-three, instead project rainbow opened the doors for more classified projects on visibility time travel UFO's and mind control. which is our second conspiracy theory? Regardless of what it initially did. The Philadelphia experiment led to other programs like the Phoenix project. Stealth bomber research and project and K. Alterra. According to Al Balic sometime around nineteen, forty seven, the government resurrected the Philadelphia experiment as the Phoenix Project. Its headquarters were located in Long Island new. York at what is now Brookhaven national, laboratories. Today the Lab Conducts Research in Nuclear and particle physics to better understand quote, matter, energy, space and time. But in nineteen forty seven bail, it claimed mathematician John Von Neumann used this lab for the Phoenix. Project? The goal of the Phoenix project was to study what had gone wrong with the men aboard the USS Eldridge. It took ten years, but apparently von. Neumann discovered that the technology used in the Philadelphia experiment created some sort of alternate or artificial reality. Ballot called it a bottle effect that isolated the ship, and all of its crew from their reality and electromagnetic force field, surrounded the ship and made it untouchable. Like toy ship inside a glass bottle unable to collect the dust of time. Essentially the sailors on board, the USS Eldridge route biologically prepared to be suspended in space or time as Nikola. Tesla suggested due to their time locks. If von Neumann could disconnect humans from their time locks then maybe the horrors of the Philadelphia. Experiment could be prevented in future experiments. Maybe, the US military could travel between the fabric of space and time something that would prove useful in war to say the least. Mail. It claimed that in order to disconnect time locks on newman needed to design a computer that could calculate a person's time reference point. Basically he worked create something similar to Tesla's unfinished zero time reference generator this was in the nineteen forties when computers were in their infancy in nineteen forty three J, Presper, Eckert, and John, Moccoli of the University of Pennsylvania were building the very first. So it's hard to imagine find. The women could simultaneously create a computer capable of time travel and helped develop nuclear weapons, maybe but a nineteen forty-six proposal written by John, Von Neumann for the Institute for Advanced Study shows that he and his partners were absolutely working on an advanced computer system at the time. The, thirty three page document indicates that von Neumann plan to build some sort of computer. It's just not clear why or for what purpose? But it alludes to an inordinate amount of required storage space and the need for the machine to interact with a so called human component according to Bailiwick. This was the computer that would reprogram time locks. He also said that von Neumann had the help of alien technologies. In July nineteen forty seven United States government took swift action when a ufo crashed in Roswell New Mexico. The CIA and FBI. Event, but later claimed was downed weather balloon. Still many believe there's much more to the story either way. One of the men the CIA appointed to oversee the UFO investigation was Dr Venetia Bush the Director of the Office of Scientific Research and development under President Truman. Bush often dealt with some of these more unexplainable matters brought to the president. Hand Bush's former employees was none other than John, von Neumann. which could mean that? Von? Neumann really did have connections to alien technology if it was recovered at Roswell. Some believe that in nineteen fifty three. The Phoenix Project succeeded in what the Philadelphia Sherrod hadn't. They turned a navy ship invisible. The ship disappeared on radar and to the naked eye. The men came back alive and healthy. which could mean that the Phoenix project perfected? Similar advanced technology like the B. Two stealth plane In one, thousand, nine, hundred, Eighty, eight, the air force unveiled the very first northrop B. Two stealth bomber. The craft had been developed in absolute secrecy for nearly a decade. While the Stealth bomber does not become invisible to the naked eye, it can fly entirely undetected by radar systems. Just as the Philadelphia experiment tried to reflect light to make ships invisible. The stealth bomber deflects radio waves. It also conceals its own magnetic energy to help it go undetected, and in January of Twenty twenty CNN reported that the be two successor is on its way. The Be Twenty. One Raider is scheduled to take flight in twenty twenty five, but we don't know any more than that. The technology is shrouded in secrecy. Author Preston Nichols, an alleged former employees of the Brookhaven national laboratories believes the Philadelphia experiment the Phoenix. Project and government stealth planes may be connected. In, Nichols Book, the Montauk project which straddles the line between fiction and nonfiction. He claims that von. Neumann took his findings to Congress in Nineteen, sixty seven. He supposedly told them that he'd found a way to alter the consciousness of man through electromagnetics, his computer could send a person through space and time and also change how they think. It could control their mind. According to Nicholls, the concept terrified Congress. As a result, they ordered von Neumann to disband the project and hand over his equipment. During that same time. It's been confirmed that the United States Government worked on a project called. N Que Oltra. We covered it on this show previously, but the short version is. K. alturas studied drugs and other technologies that might be able to control the minds of war prisoners. It ran until the nineteen seventies if not longer. Knowing that the US government was running experiments on mind control. It's possible. They only acted like they were scared of von Neumann's research. So they could steal it, except there's one glaring issue with this theory and our first one. L. Balic. Preston, Nichols, relied heavily on his accounts to write his work. As, we mentioned bail at claim that he was born in a different body. Has Navy Officer Ed Cameron? Balic's website includes pictures of his supposed. Previous life is Ed. There are even photographs that are. Of The Philadelphia Experiment, but they've been debunked. The pictures are actually of a man named Alex Cameron. Alex was real and he did attend. Some of the same schools that basic claimed Ed Cameron had but Alex was never in the navy. He wasn't a scientist and he never participated in any government experiments. You can ask US children. They're alive and have confirmed that basic used their father's likeness to defend his outlandish claims. Balic also only remembered his past lives after he watched the nineteen eighty-four Movie The Philadelphia Experiment. A film about time travel time travel never played a role in any of the previous accounts of the Philadelphia experiment from Carlos, Lendvai or anyone else more likely than not, Alec watched the film, and then concocted a rather elaborate hoax. which is not to say that he doesn't believe his own lies, his brain could have invented the tail during his hypnosis, but due to the suggestive state. It may feel incredibly real. And as for those who believed Bailiwick well, he was charming and consistent. Sometimes, that's all it takes for people to believe did Alec Travel Through Time? was he a participant in the Philadelphia experiment? It's highly unlikely. We've confirmed that he made up a sizeable portion of his account, and there's no real evidence to support the rest. Which is why on a scale of one to ten with one meaning least likely and attend meaning most. I give our first theory two out of ten. Bailey at least did a little research before announcing his false claims to the world, but they're demonstrably false. As for theory, too, that the Philadelphia experiment led to further government projects I say it's more likely. Stealth bombers exist and at one time, so did and K. Ultra, so the government is interested in undetectable tools of war and has studied mind control, so did Philadelphia experiment or a future incarnation of it perfect time travel. Incredibly Unlikely, the brightest scientists today are still puzzled by the possibility. Stephen Hawking believed that humans could one day travel forward through time though. For those reasons I'll give our second theory a three out of ten. But one unreliable source doesn't mean all accounts of the Philadelphia experiment aren't true. After all the first claims about the program came out forty years before Al Balic. Author and UFOLOGIST Morris K Jesup met with the US Navy regarding claims of its existence. Not long after. He was found dead. Coming up, did the Philadelphia experiment actually exist now back to the story? Al Balic's accounted the Philadelphia. Experiment might not be true, but that doesn't mean the experiment itself wasn't real. The question becomes. Did bail build his lies on a foundation of truth? Whispers of the Philadelphia experiment began in nineteen fifty five when Carlos. Lindy reached out to you. Follow just K- Jessop with a fascinating story. That story is the basis for our final conspiracy theory. The Philadelphia experiment successfully rendered the US eldridge invisible. The ship, then accidentally teleported more than two hundred miles away to. Virginia. The Philadelphia experiment project in visibility, a book by William Moore and Charles Berlitz includes an account of the Englishman named Tony Wells. Claimed to know five British sailors. Who witnessed the US Eldridge's sudden? In Norfolk Virginia, the men allegedly saw a cloud form on the water. Then the naval destroyer miraculously materialized. The ship stayed for about ten minutes, then vanished into thin air again. Naval Security and shore patrol arrived later to investigate. Apparently the sailors were meant to return to England soon. To avoid delaying their departure, they kept quiet about quote. Whatever sort of projection or camouflage the yanks were up to. As far as we can tell, this is the only account of the ship's appearance in Norfolk, but the thing is. If ship did miraculously appear in the Norfolk Shipyard, it would have displaced nearly fifteen hundred tons of water, and it would have created enormous waves. So if that did happen, you think there'd be more than one report about that spectacle. According to Carlos, a Lendvai, the plans for the Philadelphia experiment were only meant to turn the ship invisible. The scientists never intended for it to teleport. That was a side effect. As we covered in part one, Olinda. The experiment utilized Einstein's unified field theory in equation that could potentially govern the laws of physics, and that would include things like time, travel and teleportation, but if the teleportation was an accident, how did the US eldridge conveniently end up in another shipyard? Why not on the White House lawn. Why not the rainforest? It's an awfully convenient place to land all. There have been some attempts to explain that essentially the ideas that if time is like pages in a book in the past, Present and future are already written, the ship can only go to a previous page or future page. The ship was docked Norfolk Virginia in the past, so it was sent back to that page in its story. Or it sailed there in a dense fog. If, the US eldredge took some shortcuts through inland channels. It could theoretically travel from Philadelphia to Norfolk in about six hours. Admittedly evidence to support the ships teleportation is thin. But it's tied to a more plausible theory that the government performed experiments in invisibility. In nineteen ninety four French astrophysicist Jock F. L. E. solicited information on the alleged government program. He received a letter from a former navy electrician named Edward Duggan. Dougan could explain all of the strange details surrounding the Philadelphia experiment. In the nineteen forties, he studied electronics at Iowa. State University. Unlike Bailiwick in nineteen, forty, two judge was actually recruited by the navy. He worked on a ship, called the USS Angstrom, which was docked in the Philadelphia shipyard at the same time as the eldridge. He explained that the indivisibility technology on the eldridge referred to something known as DeGaulle. The process of neutralizing magnetic fields. His own ship was equipped with similar technology. But dousing didn't make vessels disappear. It made them invisible to magnetized enemy torpedoes, according to the naval history and Heritage Command Degaulle housing requires a series of electrical cables attached to the ship. An electrical current is then sent through the wires to neutralize the vessels magnetic field. The technology could be turned on with the flip of a switch to make the vessel indetectable to magnetic mines and torpedoes. As it turned out. Judge outfitted ships with DIG Housing Technology. He knew many of the sailors on neighboring ships. None of them, mentioned anything unusual in October nineteen forty-three. The supposed time of the Philadelphia experiment. He believed Carlos Lendvai made everything up. Dejun also explained the green glow. Olinda said enveloped the ship. He believed. The mysterious aura could be caused by something as simple as an electrical storm or saint elmo's fire. Saint Elmo's fire is a weather phenomenon that can occur during thunderstorms. It causes a fluorescent glow similar to what you see around a neon light. duggan recalled witnessing the event before he wrote quote. I remember coming back from Bermuda with a convoy, and all the ships being engulfed in what looked like green fire. Unfortunately, Dungeon gave day too much credit. According to the meteorological website, wonder ground, there was zero percent precipitation in Philadelphia on October Twenty Eighth Nineteen forty-three. In other words, no saint elmo's fire. Maybe was right. Maybe Linda made it all up. It's been proven that day was on board. The USS Andrew Furious seth a neighboring vessel when he claimed the experiment happened sure, but as family admitted he was an attention seeker, who often fabricated elaborate stories sometimes even bought into his own allies. But in this case he didn't. He wrote a letter to one of his family members, admitting his stories about the Philadelphia experiment were the craziest pack of lies. He ever wrote today. The Office of Navel Research maintains that they've never conducted any investigations on in visibility. Not In nineteen, forty three or at any other time. In one, thousand, nine, hundred, ninety, nine, the Philadelphia Inquirer interviewed former sailors of the USS Eldridge at a reunion banquet in Atlantic City New Jersey. They balked at the ridiculousness of the claims. In fact, the sailor said the US eldridge never even dogged in the Philadelphia Chard, according to the ship's old logs on October twenty eighth nineteen forty-three. was docked in Brooklyn. In the end, we're left with two questions. Has the government run top secret naval experiments before. Probably. Was The Philadelphia experiment one of them. I don't think so that said I give our final theory three out of Tan. Sounds about right, but we can't forget that Morris. K Jesup died under mysterious circumstances after getting involved with Carlos. Day and the office of naval records true. Then I think it's just circumstantial Morris's death was separate tragedy. The. Origin of the Philadelphia experiment admitted it was a hoax. That's enough for me. But as we discussed last week, dozens of other sailors came forward after a lengthy to tell a similar tale. Nonetheless, I agree. We may never get the answers we're looking for. The US eldridge shipped off degrees in nineteen, fifty one in the nineteen nineties it was disassembled, and its parts were melted down for cash, which is maybe fitting. The various stories of the Philadelphia experiment almost work with compartmentalized and kept separate and like the Eldridge. People are still making money off of them. Thanks for tuning into conspiracy theories. We'll be back Monday with all new episode for more information on the Philadelphia experiment. We found the Philadelphia Experiment Project invisibility by Charles. Berlitz and William more helpful to our research. You can find all episodes of conspiracy theories and all other podcast originals free on spotify. Not, only to spotify already have all of your favorite music, but now spotify is making it easy for you to enjoy. All of your favorite park cast originals like conspiracy theories for free from your phone, desktop or smart. Speaker To stream conspiracy theories on spotify just open the APP tap, Browse and type conspiracy theories in the search bar until then remember the truth isn't always the best story and the officials. Story isn't always the truth. Conspiracy theories was created by Max Cutler and his a cast studios original executive producers include Max and Ron Cutler sound design by one Boorda with production assistance. Ira Shapiro Carleen Madden Joshua Kern. This episode of conspiracy theories was written by Lori Gottlieb with Writing Assistance by Kate Gallagher and stars Molly Brandenburg and Carter Roy. Listeners, don't forget to check out. The fantastic new park has original series. Mom knows best. Every Monday joined social media icon Addison Ray as she goes to her mom, sharing Nicole for advice on all things growing up. They're covering a lot of interesting topics, so be sure to follow. Mom knows best free and exclusively on spotify.
33. Cardiac MRI with Dr. Deborah Kwon
"Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter nerds. We've got a great topic to cover today. We have touched on incredible diagnostic power of Cardiac Marai during several episodes such as hypertrophic cardiomyopathy cardiac amyloid and our heart failure series. Well it's time to get down in nerdy with the subject so we can help start to develop an understanding and appreciation for this modality and how. It applies the cardiology and France for this journey into the world of protons and magnetism. We are incredibly honored to learn all about Arctic Mariah from a personal mentor and Director of Cmr. At the Cleveland Clinic. Docker Debbie Kwan for the technically inclined. The we begin real nerdy with some basic principles and physics of Cmr before getting into the strength and caveats for this powerful modality. Then about halfway through. We discuss some illustrative cases from the cards clinic to learn how cardiac. Mri can be helpful for specific pathologies hitting all of the main cardiac failures. We keep referring to coronary failure. Myocardial electrical end pericardial in short in this episode. We take you from the protons to the bedside. So buckle up for a tremendous discussion. It might get a little bumpy. Yayha. I am very excited before we jump in. I just wanted to plug a non cardiology. Podcasts called mental filter a great podcast that views all aspects of life through the Lens of mental health hosted by cognitive behavioral Therapists Schmo Fischler. I'd joined him for a two part episode series to discuss many aspects and coping mechanisms. That may be helpful to others. As one progresses through many stages of Medical Education from Pre Med to fellowship ambience will share the links to these episodes in the show description. Definitely worth a listen Dan. That sounds like such an incredible show with an important theme. Schmil wherever you are. Thanks for putting this together and cardiac nerds an episode on Kartik. Imaging would not be complete if we didn't talk about the brand new cardiac imaging education platform cardiac imaging are Gora taking the field by storm. It was founded and produced by Dr Alycia Jamali and a personal mentor. Docker Whale Jaber. They produce bite-sized videos with illustrative images to explain basic and advanced concepts in all imaging modalities useful for the beginner and advanced alike. Definitely check it out and see the link in the episodes description below. Lastly the show is growing beyond our wildest dreams. Thanks to all of you. If you haven't already police take a couple of seconds to rate and review us on your favorite podcast platforms and spread the word to your colleagues mentors proteges and help us spread the cartoon movement all over the World. And just remember this. Podcast is not meant to be used for medical advice vs express here do not necessarily reflect the opinions or policies of our employers. The goal is to simply enjoy learning more about cardiology from our favorite cardio experts. Welcome back Carter owners. We are so excited for today's episode. Because Dan Corinne and myself get to learn all about a tool that I don't think I ever really truly appreciated the cardiac. Mri and urine for a real treat. Because we will learn directly from an expert among experts. Dr Debbie Kwan the director of CARDIAC MRI here at the Cleveland Clinic. But before we dive in I'd like to introduce a very special guest who will be joining us in the fun. Docker NICOLE PRESSED ERA. Nicole completed medical school at Case Western and internal medicine residency at Duke. She is now in all star. First Year cardiology fellow. I have so many stories like to share about her. But I think it's more meaningful coming from two individuals who have had tremendous influence on her career. Dr Amy Sauce dukes famous residency program director said the following about Nicole. Nicole is a total superstar. I remember working with her when she was an intern. On general medicine she was so capable and always thinking a few steps ahead and could decisions with great clinical reasoning. She continued as an outstanding level resident and none of us were surprised when she had a choice. A fellowship programs our program director here. Dr Venu Menon said that I knew Nicole was special when we recruited her in the first place. That's become even more evident now. Nicole has been just a spectacular fellow and simply extraordinary in every way. I expect her to be a leader in cardiovascular medicine in the future Nicole. It's such a pleasure to have you on the show. Thank thank you for such a kind introduction. I have been so fortunate in my training to come across such incredible mentors with doctors us and now with Dr Menon and on that note. I'm very honored today to introduce Dr Debbie Quan. She attended medical school at the University of Michigan and Internal Medicine Residency at University of Pennsylvania. She then completed her general cardiology and cardiovascular imaging fellowships here at the Cleveland Clinic. Dr Congo is really our Goto for all things cardiac. Mri She is the director of Cardiac Mr and serves as the core lab director for NIH. More personally Dr Clan and are part of my coaching family. And I'm also very excited to be Dr Kwan's continuity fellow for the next two years Dr Klein welcome to the show. Thank you so much. I'm super excited to be part of the Cardio nerds podcast and also to be able to see sharing this time with both on it. Thank you so much for the invitation to Hang Stock Requ on Dr Pined. What actually pulled you towards the dark side to go into cardiac MRI. Yeah I think so. I just sing the Cardigan right images. I was A. I'm like Oh my gosh years ago and then here's so much but I I think it's just to be the ability to be able to see the disease As what really fascinated me the ability to see tissue characterization understand the properties of the myocardium and being able to help guide therapy from that aspect. It's what made my heart flutter like seeing the images is what made my heart flutter and then being able to describe that to the patients Is What really fascinated me. I'll thank you for sharing that. That was fantastic. You know when it comes to understanding hypertrophic cardiomyopathy. I feel like I'm a good bonafide Cardi innards level. Just listen to our episodes but when it comes to Kartik I feel like I met about a college level so maybe you can help us out and just give us a basic intro to cardiac MRI principles how you would explain it to Fellow Sir just to preface that to be honest I think it takes an entire lifetime to fully understand. Mr Principles and after being in the field for over ten years I still haven't fully grasped the concept. So this is Samar. Principles will always be a continuity of learning throughout the years but Just to begin. I thought maybe I would start off with a comparison with a echocardiogram since I think. That's very easily grasp bubble for most cardiology fellows. So if we think about a cardiac ultrasound It uses high frequency sound waves to create images. The ultrasound beam passes through fluid and less dense tissue but the sound waves bounce off or reverberate off of bones or dissertation like the myocardium and then the ultrasound machine uses these reverberated sounds to create the images however with cardiac MRI magnetism action and radio frequency signals are used to excite protons or hydrogen atoms. An images are created by the different signals that are produced by these protons. So to simplify things. You really need three components to produce a magnetic resonance image. I you need to have an object with lots of hydrogen atoms. And fortunately the human body is made up of about two thirds of water and that has high density of loss of protons or hydrogen atoms and then you also need a strong magnetic fields such as a MR scanner And then you need radiofrequency waves so to give a little background typical clinical cardiac. Mri scanners usually one point five. Tesla or three Tesla and to give you an idea of how strong those magnetic fields are. Let's put them in relation to a refrigerator. Magnet or the Earth's magnetic field so a refrigerator magnet is about one hundred Gos- and by the way one Tesla equals ten thousand Goss and the Earth's magnetic field is about half Goss so a one point five t magnet is fifteen thousand Goss or one hundred and fifty times the strength of a refrigerator magnet whereas a three t magnet is thirty thousand. Goss or three hundred times the strength of a refrigerator magnet so that helps to give a little bit of scope of how powerful these clinical Craig scanners are and then the third thing that you would need is a radio frequency waves which the cardiac. Mr Scanner provides to help develop some of these signals so I don't know if anyone listening to the podcast has ever seen an MRI scanner before. Probably you all have but for those who have in it looks like a giant elongated donut called the bore so the patient enters the bore through the opening of the Mr scanner or the yuan gated donut hole and inside. The bore are the main magnetic coils. And it's these coils that create the main magnetic field just off by the amount of science and technology that we utilize every day but take for granted. Yes yes it's pretty amazing. So how are the images created? As I mentioned you can think of a hydrogen atom as a Proton and photons all have certain spin properties and these spin properties can be manipulated. So you can think of a Proton as a spinning top and when you spin the top. It's been very fast In the right to left access and that Spinning motion keeps it upright but as it loses its Connecticut Energy and the frequency slows down. You can start to see it wobbling. Around the Vertical Access and that wobbling motion or rotation around the vertical axis can be referred to as procession and One of the main MRI principles is that the frequency of that recession. Or that wobbling is directly related to the strength of the magnetic field so with magnetic resonance imaging give the Oregon of interest as a lattice of many different spending protons and these protons are all oriented in all different directions hall together by different strengths of the bonds Based on their environment in different protein contracts and when the body enters the borough of an MRI scanner all of the spinning. Protons are magnetized such that their orientations mostly aligned with the direction of the magnet. So now we're ready to apply the radio. Frequency pulses to create the signal that can be transformed into an image So maybe I can make another analogy Think of the Protons. As soldiers an army barrack before bedtime some of the soldiers will be laying down and some of the other soldiers may be sitting on the side of their beds. Talking some other soldiers might be gathered in the corner playing a game of cards and then imagine that a trumpet is blown an all. The soldiers have to get in bed as lights are turned out. This is analogous to the protons entering into the bore of skin. They're all all. The soldiers are now horizontal in their bets. Now think of the magnetic expectation radio frequency. Pulse as sergeant walking into the barracks in the middle of the night so when the radio frequency pulse is applied or when the sergeant enters the room all the soldier suddenly come upright and to the further bread with our hands on up in salute. However once the sergeant leaves the barracks the soldiers will want to return to bed and the amount of energy that's expended for the soldiers returning to their ordinal position in bed is analogous to the t one relaxation time so the energy that's when the Proton relaxes from a high energy state That slipped into a certain orientation just like the upright soldier salute and as it relaxes down to its lower energy state. Which is the Soldier Lane? Back Down back in bed. This energy can be released a picked up by the receiver coil and transformed into an imaging signal. Does that make sense yet totally? I really love the analogies. Dr Quiet sounds like we can get three hundred. Refrigerators a bunch of spin offs already and an army or you can just go to the basement and Choosey upright. That's good yet. There's I felt like having some `lustration might be helpful instead of just thinking of protons spinning and just to make sure. I understand it right at baseline. Protons have all different sorts of spins. We apply a magnetic field and align them along the magnetic field that supplied from the bore. And then we give them radio frequency pulse and this energy is absorbed and as they absorbed the energy. They alter their spin cracks in the windows. Stop applying this energy force. The spin of the protons realign with the magnetic field from the bore and protons in different tissues will release energy and realigned with a magnetic field different rates and the speed at which they re aligned with the magnetic field in releasing this energy. Is that you in relation time correct and then there's something called the tea to relax ation and this is a again. We could go back to the analogy of a spinning top so How FAST? Protons ARE SPINNING As I mentioned earlier this processional the wobbling is directly proportional to the strength of the magnetic field so what an RS pulses Applied Energy absorbed and the wobbling rate or the procession of the protons are now exactly identical for most of the Protons are spinning at the same rate And then there a thought to be in face however when the pulse is removed the uniformity of the wobbling starts to decay such that each protons precession rate slightly differs from the others. Other Protons wobbling rates And this loss of uniformity of precession or wobbly nece is referred to as the t two relaxation. So we're flipping protons and the orientation of the Hotan and there'd be lactation of that orientation t one and then the relaxation or the decatur randomness of the precession. Rate is the t two decay interesting and so protons in different tissues will have different properties in terms of how their releases energies and the difference is what we use to develop the emery contrast to see the crashes correct so A lot of the tissue contrast that we see with cine imaging is without the use of contrast because there's different water content on the blood reduces the water content within the myocardium and that creates the differences in this contrast in signal between the blood the myocardium heart. That's very hopeful. Dr Klein now was an amazing summary. And thanks for a really shedding light on such a complex topic and also just like really highlighting. How Complex Kartik is so just taking us back to super basics with We know from medical school and everything that every task has risks and benefits and one of the things. Beautiful about it. Seems like there's not really a lot risk except the buzzword of an has nefer genyk systemic fibrosis which is a concern with renal disfunction and the Gadolinium. So do you mind talking a little bit about that? And what's the reality of that risk? And who should we really avoid gadolinium exposure? Sure sure yes so nefer. Genetic SCLEROSIS FIBROSIS A very important and dangerous potential adverse events that can happen with Gadolinium administration and because of that the FDA restricted the use of gadolinium patients with chronic and acute pinions disease with Jeff. Far Less than thirty two thousand six and since. Then there's been a drastic reduction in cases of NSF and we also have learned that prior cases of Anisa seemed to be highly related to the type of Gadolinium agent that was used and the vast majority of these previous NSF cases were associated with on the skin or ghetto denied and the second highest number were associated with magma this or ghetto Penn state and these to contrast agents are no longer will used in clinical practice so therefore the incidents of NSF has been extremely low and recent data have shown that You use a group to Gadolinium. Based contrast agent the rest of US Office extremely low and as a result American and the European Radiology guidelines have been recently updated to liberalize the use of Gadolinium agents based on renal function also recent Meta analysis published in Twenty Nineteen Jeremiah of close to five thousand patients suggested that the risk of NSF from group to gallon agents and patients with stage. Four and five chronic. Kidney disease is less than one percent so this Meta analysis help to support the recent change guidelines so if your hospital center is using a group to gotTa Liam. Based contrast agent we know function no longer needs to be Screened prior to Gadolinium administration and even patients. Who are on dialysis can get gadolinium. But they have to undergo dialysis as soon as possible preferably within twenty four hours so currently there is no strong indication to restrict Gadolinium for from patients with severe kidney disease. If you're going to be using a group to agent However a Gadolinium administration in a setting acute renal failure In patients whose renal function has not yet plateau does not recommended now in regards to concerns around Gadolinium. I think that concerned that recently become more of concern. Is this observation. That gadolinium can accumulate in the brain for patients. Who've had repeated contrast enhanced studies it appears that gadolinium accumulation is likely dose dependent and can start to accumulate after four contrast studies. It's not really known. What clinical implications are associated with Gadolinium accumulation? Because we've been doing gadolinium contrast enhanced. Mri's and patients for over thirty years and this is mostly seen in patients who have neurologic disease who undergo contrast rain is frequently but nonetheless because of this observation the FDA strongly advises league judicious use of Gadolinium and the field of CMR has been evolving to try to see if we can develop techniques that no longer require Gadolinium Administration particular Tissue Characterization and I do believe that we may be able to develop techniques that no longer you gotta let them potentially in the near future. That's incredible and so clinically relevant like the recommendation. There has changed so much since I started residency. Yeah it was just within the past I think twenty eighteen or twenty nineteen is when they changed the guidelines. It's incredible how much information you can actually get from a CARDIAC MRI. And it's a wonder why Cmr isn't really the imaging modality of choice for everyone. A what are some of the challenges are caveats to know about we talked a little bit about the renal function. But what else do you usually take into account? Yes a agreed that while. Cmr provides real treasure trove of information. There's definitely limitations so Kirkum is never going to replace echocardiographic my mind because echocardiogram has a real strength in the sense that it's bedside examination despite all of the technical advances. I'm not sure we'll ever be able to develop a bedside. Carney scanner and also the temporary resolution for cardiology is superior to cardiac currently. But there's also some misconceptions about Cardiac Yakamora so some people think that cardiac. Mri is extremely long. In terms of how long the exam takes and a focus could go critic enright scan really can take about thirty to forty minutes which is actually very similar to the length of a comprehensive echocardiogram. However there will be longer protocols as a congenital Siham are those typically take sixty minutes or even longer and the fact that. Cmr's usually available. Only in academic centers remained main hospital centers. A lot of these centers are also doing cardiac Mr Research and so some of these scans may be longer because they're also tacking on some research protocols on top of it but if you are doing purely focused conical Amar exam That could typically done in about thirty to forty minutes. Wow that's a really good point when you compare see Marta Echo. The canton really. Isn't that long? Especially for the more simpler protocols but after Kwan. What about getting the patient through the scan in terms of their comfort in regards to patient tolerability? The patient has to be able to hold their breath for about ten to twelve seconds at a time. They have to be able to hold still and they have to lay flat so this has important implications particularly in patients who are admitted for De Compensated. Heart failure so doing cardiac. Mr Scan and someone in decomposition heart failure will not provide great quality images because these patients obviously can't hold their breath very long on the flats and the also get tired. There breath holds. Start to become shallower as exam gets longer because there obviously failure So for inpatients advisable if the Siyam our needs to be done during that hospitalization because it's great to dictate their management. You should really wait to the line. Sentences optimized so that the patient can be able to lay flatten do good quality breath holding in regards to cost phobia about ten percent of patients referred for cardiac. Mr I have an issue with cost of phobia and analytic therapy with sub lingual. Highly effective. I would say that. Up to eighty percent of patients who have cluster phobia can successfully complete their seem our study if they're given some kind of therapy but it is important to ask patients before sending them for credit mar if they have cost her phobia and to ask patients if they're willing to proceed Because sometimes just the anxiety of coming down and not knowing that they were going to have to undergo the tests further exacerbates their costra phobia inside. So definitely it's visable to have that discussion with patients with forehand. Sounds like there are some real caveats to take patient down for Cardiac Mariah. But also a lot of misconceptions in that we may at times overplay our hesitation for ordering an indicated scan. What do you think about? Cmr in patients with implanted electrical devices like pacemakers in CD's in regards to ice CDs and Ace makers there are definitely certain Medical Devices Co. Clear. Implants or insulin pumps that have absolute contraindications for more. I am I tex very vigilant about making sure that patients don't have devices that are contra indicated for undergoing MRI however guards to implanted cardiac devices there are conditional devices and then there's non-conditional devices so non-conditional devices used to be absolute contraindications for Carney Kamar. But this recently has been revised There was recently. There was a recent New England Journal of Medicine. Paper that evaluated over fifteen hundred patients which was published in two thousand seventeen and a demonstrated really reassuring safety for performing cardiac. Mr In patients with non-conditional devices. None of them had any significant long term complications. Now that being said the comforts of the radiologist or cardiologist who are performing the Amar to allow us to be done in patients with non conditional devices is variable. Some centers will allow it to be done in. Some centers are not comfortable reforming them. Scanning patients with devices requires a significant amount of coordination efforts. Definitely those things have to be taken to coordination because it takes more scheduling to with these patients on our similar schedule. And then the other thing to also be cognizant of is even though we can do the Samar study safely the image quality. It's another thing to consider so patients who have devices that are directly on top of their hearts are more likely to have non diagnostic images because the device generator creates a lot of artifact which we call susceptibility artifact an basically looks like a big black hole so the farther away. The heart is from the device. The more likely you'll be able to have that are quality images. So it's important to look at the chest x ray to see how close the cardiac chambers are to the device but then there's also specialized sequences that can help minimize these artifacts and so it would be important to have local expertise to be able to optimize for calls for these patients okay so MRI scan time patient tolerability and the presence of devices are not prohibitive for obtaining occurred. Kim Roy Protector Quan. What about the cost in terms of cost? There's a lot of misconception. I think in terms of the fact that Sia Mars astronomically more expensive than Echocardiogram Easy. And it really depends on the insurance provider. So if you took Medicare for instance A recently looked up the comparative cost so Chance thrashing Cardiogram is reimbursed at a rate of two hundred and ten dollars Based on the twenty nineteen Medicare reimbursement rate and then a multi. Planner suspect is reimbursed at five hundred fifty nine dollars a cardiac. Mri within without contrast is reimbursed at four hundred thirty three dollars and a stress Kirk is reimbursed at five hundred thirteen dollars so if you actually compare struck Mariah with a stress nuclear stress. Mr Is cheaper. It is twice as expensive as a chance drastic echocardiogram but it's not astronomically expensive. So those are things that have to be taken into consideration obviously is that indication for cardiac Mr You really have to be able to say that. What you're wanting to see is beyond what echo can provide If an echo has already been acquired in has given us good quality images that you're happy with And then the other thing to take into consideration the heart rate and rhythm so the patient has to have a heart rate Regular and that's not too fast. So if a patient having frequent activity for instance that's GonNa make it very difficult to be able to gates and have a high quality study And if the patient's heart rate is too fast like above one hundred that's also GonNa get a difficult. We have been scanning some patients with atrial fibrillation as long as they're irregular rhythm is not significantly curricular When that happens again getting has issues in his not high quality. Dr Quan going back to safety for these patients who have cardiac devices and when we go to consent them to discuss the risks and benefits of MRI. Can you talk a little bit about what those specific risks are to the patient? What should we be discussing with them? Yes so there can be heating of the device that can cause some local injury. Recent studies have suggested that that local injury usually is not clinically impactful and that New England Journal of Medicine Paper Did look at effect on the device itself. Sometimes it can affect the programming note. One case was reset to be the I facing on could not be reprogrammed so the device to be replaced but in regards to the ability to sense And pace the thresholds on the sensitivity were not significantly impacted but as part of the consenting process. I think we still have to be able to relate to the patient that there's a small risk that these thresholds could be altered when the device is put into a high magnetic field. Thanks for going over the doctor. Quan I just WanNa give a shout out that 2017 practice changing energy and paper. That really made us much more comfortable in getting Emma is impatience with these implantable devices is out of grew from Hopkins with Pi Henry. Halprin who'll Dan is actually doing research wit. So it's very exciting to see that. Yeah I mean we've been citing hopkins on the time and saying well they're doing it and you know look at what they're able to do and the advance of the made so yeah. You guys have really been the pioneers. I'm actually going the resuscitation arm of the lab but they are working a lot on device. Therapy like ablation therapies with using cardiac. Mri real time. So that's what they're doing. Let's have a interventional Mr scanner. I believe yes. Yeah everything gets designed to be. Mri compatible like our chapter MRI compatible. It's like wow yeah that's awesome and uses that when Kanye West's pigs okay anyways. Yeah the Doctor Klein. This is like super valuable especially you know when we you know sometimes you get complacent you're in the clinic and you just like clicking boxes and you're like I'll get the CARDIAC MRI we realize. It's like it's a whole consultation process and one click. An epic and a signature is actually setting forth such a big you know scheduling events and also you have to go through all this with the patient so when when you're considering getting Marai specifically cardiac number I have always been thinking about you know you get. Anatomical data gets functional data and you get this beautiful buzzword that we call tissue characterization at seems to be a big benefit for cardiac. Mri over some of the other reality. Dr Quantity might recapping on these different aspects of CARDIAC MRI that we get to help our patients. Yes the basic clinical sequences for CARDIAC MRI include Anatomic or morphological assessment and this can typically be helpful for patients who have dilated. Boorda's and you want to be able to measure and quantify the size cine imaging can be used assessment cardio function and. That's really one of the main strengths of Cardiac Mr. Because it's the gold standard for quantifying the trickier size and function because it's able to assess it in a three dimensional acquisition. As opposed to making assumptions that echocardiographic does. When you do a to planet four plane assessment and then we can do perfusion imaging to assess for my Cardio Ski Mia and also to quantify myocardial blood flow Tissue Characterization as Dan mentioned is really one of the highlights of cardiac Mr it is able to assess tissue properties to identify presence of Myocardial Dima myocardial fibrosis infiltrative processes and assassin quantify the size of Myocardium Fart and some sequences require Eleni on for Tissue Kirk And some do not so t to imaging Helps to assess the presence of Inflammation in that does not require gadolinium administration to acquire that data flow. Last quantification is also extremely useful in. It's used to measure the amount of amount and direction of flow at which is typically performed at the proximal era and can also be performed at the main pulmonary artery. When you do both the proximal era and the pulmonary artery then you can quantify the coupon s slow velocity quantification can be used to quantify valvular dysfunction so you can quantify erotic regurgitation Pomona regurgitation. And then you can integrate that with the volume metric assessment from your cine imaging to drive and quantifying migrant volume infraction as false tricuspid regret vitamin fraction. If you've acquired poem onic slow Velocity Assessment And then the last major protocol is Three D. Ole Heart imaging emery imaging and that allows you to get a full buying set of data and then you can reconstruct. It can be useful for orders but also for congenital abnormalities. If you WANNA be able to look at different structures or difference shunts or surgical repairs and reconstruction enough three dimensional nature. So those are the the main components of Carrega Martin. It's also important to realize that we don't Perform all of these sequences and every patient. Because that would take an an exorbitant amount of time which would also be uncomfortable for the patient so cardiac. Mri studies are really tailored to the question. And the indication at andt and we have a standardized protocols based on these common indication. So for instance. If you have a patient where you just wanted to look at their era we would do the. Mri and the Three D. whole heart imaging but we wouldn't do tissue characterization if there was no concern for myocardial infarction or some kind of underlying cardiomyopathy and then on the flip side. If you're sending somebody for cardiomyopathy assessment we would not necessarily be doing three D. Whole heart imaging to look at the at because again that extra time and if it's not clinically useful. We don't do that so when you place a CARDIAC MRI. It's important to indicate what the clinical question is so that the study is. Puerto called correctly so public service announcement for everyone. What you write in comments really matters so thank you so much. This was such an incredible intro to cardiac MRI but let's get to the heart of cardiac MRI now by going. So maybe you can walk us through. How A CARDIAC? Mri could be helpful in some of the patients we saw in accordance clinic yesterday current. Absolutely so I'll start with the first first patient of Ruth Hanna. Who's a forty five year old? She one P one female with prior pre ECLAMPSIA anterior steny status post in. Led Stan three years ago. Who's now being seen for chest? Pain t t e shows an e f a forty five percent with mid April call anterior. Hypo Connie's as well as an epochal aneurysm. How does see Amar Delineate? A schemic heart disease. Yes that's a great question. A great case example so cardiac. Mr would be very useful for delineating. The junction fraction. And this patient. The sometimes with echocardiographic the epochal images can be were shortened to provide a fosler elevated ejection fraction and so impatience with schemic heart disease particularly are that are on the borderline of thirty five percent. If you're not sure if they might need to be referred for Primary Prevention Credit. Mars is really good for giving you a gold standard assessment of the ejection fraction in terms of risk stratification cardiac. Mr would be really important for also assessing the LV size. And if this was in the acute setting looking for micro-vascular obstruction can also help to identify high-risk patients And this particular patient. Who has an April aneurysm? Kirk Mars very helpful for also identifying the presence of an only thromboses which would be important to identify because obviously than this patient needs to be put on anti coagulation And then because this patient is now coming in for Chest pain if you opted to go for a non invasive way of assessing for my cardio ski MIA a stress could also be obtained to assess myocardial blood flow. Oh and then obviously the strength of Cardi Cameras. Also the ability that can assess the presence of myocardial infarction on the size of the infarct and underlying viability of the myocardium. What a powerful tool. And you know just thinking this case. I'm struck by how young she is. But then I remember the Doctor Martha. He taught us that adverse pregnancy outcomes are important. Atherosclerosis risk factor for women. This patient had history pre eclampsia speaking of which So she did have a stress summer. I showed an intro epochal perfusion defect and Ethical Andrews on with a middle thrombosis with associated late gadolinium enhancement corresponding to scar on further review. However her chest pains sharp so ridic- and worsens with competency. Ekg On follow up shows diffuse elevations and PR depression except in VR which showed St Depression NPR elevation USR and CRP are moderately elevated. Dr Quan. How is more helpful for disease? And that's a great question So CARDIAC MR is actually very useful for pericardial disease particularly with Pericarditis Creek Mark and provide assessment of pericardial inflammation and also can assess for the presence and size of pericardial fusion so on first images with cardiac Mr we can also look for pair creo thickness and that could be your I q to your cardio disease than we do. T to stir imaging which looks for our cardiology Edina and that helps us to discern at this is acute versus sub acute versus chronic So it's enhancing on the T to stir images that suggests that the pericarditis is more in the cute face and then we can also do free breathing sequence that helps to delineate if there's constrictive physiology so basically it's a another way to assess for. Inter ventricular dependence so we ask the patient to take deep breaths in and out and we can visualize simultaneous. Rv only filling so if the patient has constrictive physiology. You'll see the RV septum flattening or going to the left during inspiration to accommodate Venus. Return so impatient. To have released significant pericarditis with significant amount of her cardio inflammation they can also develop constrictive physiology which can resolve as inflammation resolves with anti inflammatory medication so it is important to assess for constrictive physiology and these patients with acute pericarditis and then the delayed enhancement assessment can be utilized also assess the degree amid severity of pericardial inflammation. So basically these patients with pericarditis can devout neo vascular pericardium. And that's how the Gadolinium gets into the pericardial tissue. Because got only is an extra sawyer. Agent the Gadolinium stays in the pericardium and that enhances when we do the delete imaging So this allows us to do tissue characterization of the Ricardian and this can be tracked with patients who have pretty complex pericarditis. That's not responding well to therapy. We've Sean from our center. That Kirk can help dictate the intensity of anti inflammatory medication that needs to be a utilized if the patient has severe concentric cardio enhancement on enhancement imaging than these patients probably should be treated with triple therapy gate with end sides colchicine and partner zone and this is because we've shown that people who have severe pericardial. Hanson more likely to have recurrence and we think it's probably because they were not adequately treated. Initially she address it degree of inflammation. No that's great. You mentioned that Nicole and I were just talking about the use of pseudo Cardigan. Dr Clients Clinic in Managing Complex patients with recrudescence pericarditis. Yes those are very challenging patients to manage Cook Kartika. Mark can be useful in those patients who are refractory to medication. They're definitely it's definitely fascinating to hear how you can use them or is almost a tie trading test to see if your doses adequate or inadequate you almost think prior to now now. I'm well informed but I think of like memory is like what do I have do. I have very you know some sort of like a snapshot in time and I won't get another MRI forever you know. This is quite interesting inside note We added I and green and Heather are dying to Parker is up. Cardio episode. It's on our. Yeah Yeah Yeah So. We'll return to this subject for sure. So Klein would be a great person for that. I'd cast it's been mentioned. It's mentioned on it. It's it's really like been on our list. We started. We keep like having back because of other things okay. Let's talk about Susan. Kids who is a thirty five year old woman athlete who is admitted after a F arrests that occurred during a tennis match thankfully. She received immediate bystanders. Cpr with early defibrillation imprompt. Rask she has had prior syncope during training and an uncle who died suddenly at the age of Forty Resting E C G Shows Incomplete Right Bundle branch block ripe. According t wave inversions and an Epsilon Wave v one through three on telly. She's had multiple runs of of a Bundle Branch Block. Morphology and echoes pretty impressive. Rv delegation a heart failure console is done to consider and micro biopsy requests the Amar beforehand. What are we thinking about here and how it Cardi Kamara help us? Yeah so based on the couldn't go impertinent findings I think at the top of the differential would be Air C. and see Amar definitely helps to provide further delineation of that by assessing the right ventricular size and function ability to assess for regional right ventricular wall motion abnormalities as well as areas of discomposure Karnik. Mark also look for areas of federal fibro infiltration of the RV and so you can assess for tissue characterization if you will of the RV to help delineate that entity over it should be mentioned that the task for criteria for Cmr's really For a VC is really just based on the presence of RV size and function and a regional wall motion abnormalities. They did take out the RV tissue characterization. I think it twenty ten because he thought that there's a lot of false positives that were being identified. It's really helpful to note. That Seymour is so useful in right sided disease especially for imaging the right ventricle. Which is such a complex three dimensional structure that is difficult to really understand on a echocardiographic by ECHOCARDIOGRAPHIC. We often call it the forgotten ventricle And we don't have as much dedicated assessment with Echo yes in in our show. We've talked about Kartik amyloid. We've done hypertrophic cardiomyopathy. And we did in general kind of evaluation of heart failure especially Karma these. We've definitely touched on the importance of this modality in in those conditions. So that's great. Yeah have right moving. On to our next case we have been Adams a twenty eight year old man with no past medical history who presents with progressive dismay during his routine morning runs. His exam is notable front. Early Diastolic G Crescendo Murmur. That is best hard and expiration. While dining forward. While concentrating on the Murmur you'll also notice a subtle rhythmic head bobbing his echo. Shows E centric erotic insufficiency and a dilated left ventricle but further characterization is limited Rector Klein? How IS CARDIAC? Mri helpful for the evaluation. Valvular heart disease. Yes that's a really great question. So cinemark can be extremely useful for the assessment of valvular heart disease particularly patients with Eric regurgitation. So CR can help to identify the Valve Morphology and in a young twenty eight year. Old Man you would be Suspecting that he has a by customer or Bid Erotic Valve And so the cardiac. Mr Can help you. Identify the presence of the by custom valve and then also to assess if there's concomitants. Arctic pathology such a dilated or annual small ascending aorta. So Sarah has great utility for those components but in addition to that erotic regurgitation can sometimes be somewhat difficult to accurately quantify echocardiographic when the judge is eccentric as in this case and so cardiac. Mr Can be helpful because it can provide quantitative measurement of both the Arctic regurgitate volume as well as the regurgitate fraction and similarly cardiac American assess for diastolic flow reversal as can be done with echocardiographic and this has been shown to help be a very useful arbitrator those with dynamically significant versus nonsignificant. Uric regurgitation in. Finally this patient. Who's a symptomatic who has sounds like six Regurgitation based on the physical exam the main question would be to see if he meets surgical criteria based on the Elvis size and function of the left ventricle. So again since cardiac. Mr Is the gold standard for Elvis size and function. It would be able to provide very robust measurements of the ejection fraction as well as Alvin diameters and the only volumes to help you discern. If this patient should be referred for surgical evaluation that was perfect so in our patient on his Credit Kamara he was actually found to have many of the features that you described. He has a by CUSS pedic. Valve a thoracic aneurysm. As well as moderate left Dilation so move referred surgery in the Hypothetical Cardi nerds hospital. I love Dr Daca. Rozelle is all over and over the next day so our next patient miss. Holly Massey is a fifty five year old woman with sub acute fevers chills. Night sweats. Who's now presenting with an acute ischemic left leg pain obstacle tation reveals a mild diastolic plop. An Echo is limited by poor sonographic windows. But there's a nondescript echo density in the left atrium what's the role of Cmr in the setting of cardiac masses. Yes another great question so Siham are can be helpful in the role of cardiac masses but certain features should be taken into consideration so if the cardiac masses small and if it's high frequency meaning that's it's moving around quite a bit then. She might be a better option so for patients who have suspected For Instance T. E. Spatial resolution zero point six to one millimeter whereas Cmr's two to three millimeter. So my rule of thumb usually is that. I don't really recommend see Amar must. The mass of in question is one centimeter larger. Because I'm not confident that we would be able to see the mass that well by market smaller than that and so such masses that are one-centimeter smaller should really be better. Evaluated with T. E. I'm hovering larger masses such as In this case which is highly suggestive for a Maxima. Ciumara can be helpful in terms of delineating is where it's attached. But it should be mentioned that while. Siham are can be helpful in terms of tissue characterization. It shouldn't be thought of to be diagnostic ideology of the mass. Histopathology will always be required for definitive diagnosis. Where I think SIA mark can be helpful as if you're worried about the mass potentially being a neoplasm and you wanted to see if the mass was infiltrating tissue planes or if there was in satellite lesions that are also in the within the cardiac structures than cardiac. Mr could be helpful but masses can sometimes be difficult to discern if you should get a t. e. or cat scan or cardiac Mr. And so sometimes. Having a discussion with a cardiac imaging would be very helpful to delineate the next best advanced imaging test rank darker on so we are actually in the middle of a myocarditis series. Were building out. Basically a whole structure for everyone to kind of get on the same page in terms of myocarditis and we had a real patient. Actually join US last week. Chaz Miller who's actually we did his case from the medical perspective in episode thirty one and then in thirty two. He came in his wife. Julie gave it just gave us a really really great appreciation for what they went through during their whole process so anyways he presented with Cartagena shock in heart block and was found to have Microsoft office. He was pretty when he came in and he really was not able to undergo cardiac Mariah. But how would Karak Mariah have helped in a case of Myocarditis? That's definitely GonNa have to listen to that those episodes so patients who are in. He dynamic extremists as you mentioned Obviously are not suitable for Cmr So patients who are in our block of a temporary pacemaker. Wire the go for SIA. Marco's are contra indicated but if the patient stabilized and you want to be able to further characterize the extent of their myocarditis I think seamark can be particularly helpful and I think it can be particularly helpful in patients who have positive cardiac enzymes. Ekg Changes Normal. Coronaries you're not yet. Sure if they have myocarditis because mark can delineate the presence of myocarditis pair Cardis Myo pericarditis or Takasu. Bows or differentiate that from myocardial infarction and the setting of EPA Cardio coronary thrombosis that has we catalyzed by the time of a corner and geography. That was thus not appreciated amend said that it was normal coronaries because like Eleni handsome it would be characteristic of a myocardial infarct. These patients would then realized that the had an ISCHEMIC event as opposed to Myocarditis but impatience. With proven myocarditis whether it's biopsy or whether it means I still think that are has an important role to play because it can help predict the prognosis of the patients. So it can assess the degree of left and right ventricular dysfunction and also the degree of late. Gadolinium enhancement has been shown in several studies to be associated with long-term rest. So there's been a couple of studies that demonstrated that people who have a lake gadolinium harassment basically doubles the risk of major adverse cardiovascular events during long term. Follow up and so. These patients should be followed more closely. Also only just the presence of late gallon enhancement but also the pattern and location of the gadolinium enhancement so mid while enhancement or patchy distribution Seemed to have an even higher than those patients had. Costa three fold increased risk in Mace. So I do think that During Marin these patients will help risk stratified patients help physicians discern optimization of their medical therapy and to turn the closeness of follow up basically. The patient has myocarditis and there have a normal. Cmr Exam obviously. Those patients are going to be much more low risk But I do want to highlight the fact that recently Sanmar has become much more quantitative. And so we're doing t one. And T two mapping and sometimes patients can have negatively gadolinium enhancement but t two times And these patients would be diagnosed by myocarditis based on t one and t two imaging As opposed to by leaked Enhancement alone Oh that was very helpful. Actually I had been reading that when we prepping for the microdyne series. We kind of knew definitely Saw that that has been a popping the literature this quantification so that is very very helpful. Older study goes a junk. Starting twelve her. It was over two hundred biopsy proven myocarditis patients and In that study about fifty percent of patients head League gadolinium enhancement so if you refer a patient for Cmr and they say the late gadolinium enhancement. Seen that doesn't rule out the presence of myocarditis she wanted t to mapping really should be performed that helps to improve the sensitivity of the assessment. I wonder if in the future this will also help to predict who will end up having a dilated cardiomyopathy apathy from the episode of micro notice. Yes yeah I think that's a great point would be a very strong hypothesis to suspect that those are the ones that are higher likelihood of developing daily. Cardi map the down the road quadrant with such a helpful discussion. I feel so much better about the role of cardiac. Mri The assessment of cardiovascular disease. Thank you so much for the opportunity. This is a lot of fun Dr Climate. We can't get enough for taking the time to teach us today and I also want to add that Dr Brian Griffin. Who is the section head of imaging here said the following? Debbie is the epitome of the triple threat physician scientists she has really enhanced cardiac MRI by developing a database and has spearheaded our use of machine learning in cardiac Mr Applications. She is a talented inventor and clinician and just submitted her first. Ro One as such an accomplished physician. Scientists Mentor Educator. And mother we have to ask. How do you do it all? Do you have any advice? We launch into our careers on. It's a great question I think that definitely it cannot be done alone So having a strong So Schaal an emotional network is definitely key and mentorship is the most impactful thing I would have to say I was lucky enough to have Dr Wilson Tang as my mentor in Fellowship and actually went to go into heart failure but then I was pulled to the dark side and went into cardiac but he has remained My mentor throughout the years. And he is I. I never thought I would submit. My own are one honestly But he kept pushing me on this past year. I actually looking back. Can't believe actually submitted might Retribution soccer on your wealth We'll see in revision mode but if it actually gets Funded it's going to be all things to to Wilson's I think my advice is to definitely Seek out supportive mentors. There's there's a ton of people out there and the other thing I think is that Mentorship is a very strong bidirectional relationship. I think sometimes we feel bad approaching mentors because we think we're taking away their time but I've been fortunate to now serve as a mentor to trainees in. It's it's really inspiring invigorating. It's IT'S A. It's definitely a BI directional process and really helps to get back to the vision of why we went into medicine and science. It's really to further understand disease and better serve our patients and then the other really important thing is to find very understanding and forgiving and serving spouse definitely could not have done what we can all relate to your such an example for us fellows and I really just want to thank you for one being you in also for letting US borrow a part of your vacation day a hundred Friday evening to spend time with cards and I highly enjoyed and I just wanted to say that what you guys are doing amazing as really so much fun and I see a phenomenal a future head from the Cardio nerds so thank you for touching so many lives thank you. Thank you got part splintering. That's the end of our show so it's time to make like an s two and split. You can follow us on twitter at cardiac nerds and police share. What made your heart flutter this week. Send us a clip. Two Cardi Innards G. DOT COM. You enjoy the show via nerd and spread the word and now aflutter moment high cardiac. My name is Urwah head. I'm an international medical graduate googly starting for us. Emily's my husband. And I listened to your podcast regularly. The very knowledgeable. So what makes my hotter so during one of my rotations. I remember recognizing of classic explicit in the area and that was the first time I was able to apply all my knowledge into Gio patient cure and that my heart flutter thank you so much for the show. Keep up the good for guys.
69. Case Report: Cardiac Allograft Vasculopathy (CAV) UCSD
"Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter exists other than Dan. Thanks for joining us as we toured fellowship programs across the country as part of Cardi nerds report series produced in collaboration with the American College of Cardiology fellows in training section, each episode will feature a cardiology fellowship program fellows from that program will present and teach about a fascinating case and share. What makes their hearts flutter. About their program, each case discussion is followed by an e CPR segment from a content expert and a message from the program director. Before we dive in just remember who we are an independent educational platform. This podcast is not meant to be used for medical advice. The views expressed you're doing to reflect the opinions or policies of employers the case you're about to. Hear is one hundred percent compliant. We thank you for subscribing to and supporting the cartoon hurts our mission is simple to democratize cardiovascular education, promote diversity and inclusion empower everyone to learn and teach from the basics to the advanced while fostering wellness and humanity. If you believe in the mission, consider supporting US ON PATRIOT DOT com forward slash nerds every little bit goes. A long way we're also excited to grow the platform by mentoring the next generation of Cardi nerds. We are establishing the cardiologists academy and are looking for residents and fellows to join as Cardi innards fellows. Please see the Lincoln, the episode description to submit an application, and now without further ado, let's continue on our tour with another fascinating case from Amazing Cardi nerds colleagues. We are just so excited to be visiting such a wonderful city San Diego in the Great State of California we are here with three amazing fellows, Dan. Her Pre Kwan guys, could you introduce yourselves? Hey there. Dan Thanks for having US Yeah I'm. One of the chief cardiology fellows earlier is here and excited to be here. Guys I'm harpreet. One of the other chief fellows banks for having us. Excited to do this in my name's quantum bouillon. One of the second your cardiology fellows at UCSD cited beers well, Dan her pre and Quan well come to the show. This is so incredible to have you guys on and the been. So excited about this episode about every episode. But really this episode in particular because I went to medical school at UCSD and felt every day I was learning medicine. On the very beginnings and every day felt like a vacation. It's such a great city. We'd love to hear about it from your eyes and your perspective. So take winning favorite spots. So we can all got together and I can rekindle my left for San Diego before we get started that of it. Yeah. I San Diego truly is one of the more beautiful cities and really a lot to appreciate about this area. I. Think for the purposes of this. And this conference, probably one of the more relaxing venues that we've done several times was fellows is on one of the fire pits on the La Hoya Beach. It's area where you can rent a firepit sometimes at night and just sit around there watching the waves crash. Very great weather. Very nice relaxing. I think for this conference if you can imagine your co fellows, colleagues sitting round firepit talking about interesting case sets the tone very nicely. I don't have to. Imagine I've been there I love it and I'm so glad you took me back there. Why do we do what we love doing? We're hanging out with friends talking cardiology sounded great. So let's dive into it. So I'm going to start with the case. This is a nine year old male with a history of prior or a topic heart transplant five years prior those complicated by rejection who had presented to our hospital with progressive dystopia rethought. Neha. In lower extremity of. So a little bit more about that history as stated, he had developed aggressive Disney on exertion of the time span of about one week that accelerated two days prior to his presentation. He added additionally endorse Abdominal distension bloating or top Neha as well as lower extremity and Dima previously his New York. Heart Association Functional Class was a class to symptoms meaning he was able to walk about one to two blocks without symptoms at baseline, and again, this is in the setting of a patient has a history of rejection and half wrath of his transplanted heart at that time which he presented to us, he had essentially had symptoms the dismay at rest in was markedly. Limited with any degree of functional exertion whatsoever, it's interesting when you bring up New York. Heart Association because what's conventionally taught in many medical schools and programs is a question of how many city blocks a patient can walk generally more than a blocker twos considered nyj classification to less than a block and white take classification three there obviously differences in blocks. One of our great thought leaders in the director of our heart transplant program. Dr Aller asked a great question when we're trying to decide how limited a patient is in their functional capacity and it's as simple as ask if a patient felt wended walking from their car to the office appointment in general fixation feels. Quite short of breath with just that degree of exertion. It's a marker of at least class three symptoms because as we know, there's a big difference with in New York City block in the boxster in San Diego. So it's one of the ways that tease that out our patient has stated had symptoms can even at rest on review assistance for our patient he denied computations or syncope he denied cough fever or your eye symptoms like sore throat Reinerio's ricky joints. He also denied chest pain nausea vomiting or bowel regularities. One important points in a patient that has a history of accord. Transplant is lack of innovation and the heart, and so the typical symptoms. Of Satan engine our scheme Ya may not present with chest pain. So that's why I wouldn't always be a reliable symptom in a patient such as this but some of the more atypical symptoms like nausea or fatigue would be important to ask with respect to compliance with medications. The patient up into this point had endorsed total compliance with all of his medications Dan I'm going to reflect on the case so far this is a very concerning history giving a young man with a heart transplant is coming in essentially with what sounds I. Don't WanNa Anchorage just yet. But what sounds like left sided heart failure symptoms with this Nia or Nia as well as right Extremity Dima the differential diagnosis for heart failure is essentially the same as any other patient with the addition of a few important features. Right. One is all the causes of heart failure in a heart transplant patient to are related with immunosuppression, right and credits for instance, and then three I. Think it's also useful to go back in the medical history and see what was the indication for heart transplant in the first place better understand our host. For example, there are some entities that result in end stage heart failure indication for transplant by can recur. For example, giants held myocarditis. There is a recurrence after transplant in this patient were a differential diagnosis going have to be essentially the same. As any other patient is going to have to ask all the things that can go wrong with heart transplant, a transplant heart itself, the features with Immunosuppression, as well as the original cause of heart failure that led to the transplant in with less exactly right and I think that's good cerebal perspective because it is important to take the initial indication for the heart transplant into consideration. As you stated, there are many disease processes Malcolm Diana's processes. sarcoidosis processes that can cause residual cardiac dysfunction and that would indeed an important aspect to pursue when you're trying to elicit etiologies forgiven compensation, and that actually brings us quite well into this patient's past medical history and he had actually received a heart. Transplant survivors prior at the age of twenty four, and this was for an easy call rhythmic genetic right ventricular cardiomyopathy, or a R V. C. for those who don't know this is a fibro fatty infiltration of the right ventricle ended about half the patients it can actually involve the left ventricles. Well, it's a progressive carton off the attends to be associated with a high ventricular Arrhythmia burden and does tend to cause quite severe heart failure oftentimes requiring a transplant, and this is the case for our patient following his diagnosis of a RV see as twenty year old or so he had developed several de compensations as well as cardiac arrest. Ultimately, he did eventually require that heart transplant which was. Pursued at outside institution, which unique about our patient is that he was a young man at the time of his heart transplant and that's a lot for a young adult to take on the process of being entwined with the medical system taking suppressive medications showing up for Echocardiogram and diagnostic cats that's not easy for anybody especially challenging for young adults I think that was part of why this patient particular had so many issues with non-appearance fortunately, there were four distinct episodes from the time of his transplantation up until he presented for this hospitalization in which he suffered from various forms of cardiac rejection, and these were invariably in the setting of sub therapeutic immunosuppression levels, not taking immunosuppressive medications. Dan these are some really great pearls and really great over viewpoints. I will say one thing that I really admire about folks that go into Carter map the really deal with these patients is how challenging it is. Let me rephrase it this way you have a patient with rb see which a young patient otherwise healthy may have been an athlete may have been very active and all of a sudden hit with this idea that their life is different forever. And and sometimes, they may not becoming an acute to compensated heart failure things are progressing slowly and you as the cardiologists see the writing on the wall and you know where things are headed and you really have to help them cope with these really drastic changes, Kartika transplantation. So complex and I'm not just speaking of the surgical aspects by making your patient, the most ideal in suitable candidate that they could possibly be to get the actual transplantation requires more than. A village, it's just an incredible amount of work that goes in to taking care of the patient with the patient. Again, being the captain of the ship and then transplantation is really almost the beginning of the process. It's really a lifelong condition that requires continuous support both from a psycho social and medical aspects, and that's really what you're describing over here, and the other thing is it takes more than village to preparation reputation for transplant, but it also takes. More than a village to keep the patient live post transplant, not just in the acute setting in the hospital. But even as they go outwards, obviously these programs that are high volume or even lower volume have the infrastructure set up to take care of these patients and so when somebody presents like this gentleman with a week of these changes that is very concerning, you know even if he has struggled with compliance issues and adherence issues to his regimen an aggressive. Modification excetera something happened in the last week, and that's making me nervous about this particular patient. Yeah. That's exactly right. Cardiac transplantation. It's a team effort. It's not just the patient. It's the patients families in loved one it's the entire physician, a nursing team that requires a constant communication to make sure all the steps are achieved timeline reasonable manner. So it definitely is a challenging lifestyle adjustment and major life change, and again for this patient particularly, his age I think that it's not a reasonable to give some a little bit of understanding in how challenging to keep up with all the care that's required for newly transplant. So going back a little bit more to these four episodes of rejection I will say that these were all acute episodes rejection in for those that may be interested in heart failure. I won't die too deeply into it, but there are essentially three types of acute rejection. There's a hyper acute rejection, which as we know is due to Abo incompatibility. That's a very rapid following transplantation to more common types of acute rejection that you're GonNa see acute cellular rejection do t cell mediated process in antibody rejection. Be So meted antibody process. These forms of rejection are routinely surveilled. These are diagnosed via endo. Mata Cornell biopsies, blood work to Ev- I wait for elevated PRA's or elevated percent antibodies, antigens, and these are forms of rejection that is present can cause quite significant cardiac de compensation in the case of our patient, he had actually dialogue recurrent heart failure as a result of these four episodes of rejection ends objection fraction at the time of presented to us was thirty five percent and several of his hospitalizations for these rejection episodes hideous required report as well. Fortunately he had. been weaned off of that with the appropriate medical therapy to treat the rejection, some of these therapies to treat the rejection high dose steroids plasma for recess I, the I G in retired Sam his laughs rejection Zach's about two years prior, and that again was antibody mediated rejection, and by the time he presented to us not only was his left rejection fraction depress at thirty five percent but he had by Hartsdale he had RV dysfunction as well with the mouth moderately dilated are you may be wondering about chronic rejection this Joan, the form of cardiac allographs ask allopathy. A coronary angiogram about four months prior to this, which showed non obstructive coronary arteries with respect to his social history had worked in retail. He attended a community college. He lived alone in an apartment whose monogamous with a girlfriend toxic habits he drank about one to two beverages per week up to three drinks given occasion he denied tobacco use illicit substance use he had no. Family history of significant cardiovascular disease aside from high pressure. Dan. Just quick question we mentioned that it's a toxic cabinet. So would you advise a patient with a heart transplantation that it's okay or not? Okay to drink this kind of alcoholic beverages like one to two per week I think in these beads healer to the individual patients, there's always going to be a balance like anything. With patient care in general given the amount of new suppressive medications the changes that this patient had been undergoing with his medications I probably would not. It was advised to avoid alcohol at that time. It's another contributing factor which may affect various levels, immune suppression absorption medications, and as we know sometimes, patients do tend to drink more whether it's intentional or unintentional, and those can. Ultimately affect drug absorption rates as well as contribute to as we know primary cardiomyopathy if done access. So with respect to the medications that the patient was taking to presentation or his reduced ejection fraction, he was on view bet night two milligrams twice daily as a standing diuretic. He was analysts a parole, ten milligrams daily and further attempts to titrate up this medication were limited by. Of adverse events notably, acute knee injuries in symptomatic hypertension with his patient, he was also ons furniture lactone twenty, five milligrams again, not on optimal dose. This is something that is concerned in because we know from prior registries the Champ H F registry in particular that less than twenty percent of all nations in particular aren't even on optimal doses of medications even if they do have the Blood pressure to support them. This was certainly the case for our patient. He was not optimal medical therapy and there are any number of reasons for that. But unfortunately, he was not what is unique also don't always include half off as a result of prior cardiac rejection. This is a sub population that is not well studied not well represented so we don't necessarily know if these. Optimal doses in this particular population, which has very strange in unique pathophysiology respected Innovation Renan. NGOs, entrances them. No. No medications will work as well although it is theorized in suspected the other medication half that he had been on I've Aberdeen. This is a medication that works on the funny channel and it is derived from data of the shift trial. He had not been put on A. Beta blocker as he had recently had or I would say maybe more remotely. De, compensations at required on Trumpet Support and general with Ortho topic heart transplant patients due to changes in dinner vacation there little more susceptible to the teague in exertion tolerance of a Beta blocker compared to a typical patient with not secondary thawing heart transplant for his immunosuppression the patient was taken to columnists. CERAMAHS and Prednisone, and the this was a new medication that had been introduced over the course of a series of rejections. Zarrella S has additional added benefit in the prevention of acute cellular rejection, as well as cardiac allographs philosophy, and lastly, for his prophylaxis remember all patients that are on immunosuppressive therapy and that have a history of heart transplant or at increased risk above atherosclerosis and CAV. Again Cardiac allographs ask allopathy. So he was on a baby dose aspirin, one milligrams for primary prevention, and then he was on Kravis stats in twenty milligrams do want to highlight this province staten. It's a well documented study. Medication is a staten as preferred or cardiac transplant patients because it avoids decided crump e for fifty pathway, which is involved with its columnists metabolism so it can hidden. Summarize where we are right now, this is a twenty nine year. Old Man was a history of Ortho topic heart transplant by years ago which the original indication for it was a R v C. which have been complicated by cardiac arrhythmias, cardiac arrest, as well as progressive by trickier this function and the patients coming in which supress with evidence of volume overload a patient who's had multiple. Prior episodes rejection, and so I think coming into the exam of this patient where we're concerned about heart failure and part of what we're going to be trying to figure out is differentiating their symptoms of heart failure from kind of other ideologies which could complicate the picture such infection as his patient had episodes of infection as well in the past and Dan trying to get to the. Of these symptoms if it does happen to be evidence of heartfelt, we need to figure out why does patients getting worse and why they're coming to the emergency room. Now that's Great Harpootlian. Let me just pose a question that will be relevant to a lot of our listeners from two different perspectives. Say this patient presents originally right now to emergency room that's their local point of care hospital that isn't a transplant capable facility doesn't have a heart failure advanced heart failure service doesn't have a mechanical circulatory support options and has an ICU, but not they critical care sort of capable facility. What is your level of concern for this patient at this point and either say you're the provider this patient? And or you're on call for the heart failure clinic and they call you and say, Hey, this patient's of the ED is your is your patient. Should we admit the patient to our medicine floor and diaries or should the patient actually be transported at this point to a hospital with advanced heart failure and cardiac critical care facilities as we've talked about because heart failure is in especially, heart transplant is such a multidisciplinary effort. We always want to get these patients back at our center if we can because it's not just us as cardiologists surgeons, it's he infectious disease specialists social work psychiatry nutrition involves are a whole group of people who take care of one patient so we can provide Approach to this patient that can always be provided everywhere in places that aren't set up for that. The answer is that we always want these patients transferred back to us again, going into the physical. Then we're going to be very concerned about the patient's vitals about their output status, the profusion of their end organs and. A big decision point even be on which oxygen or support this patient requires help us tree is this patient needs to come to the ICU tonight or this patient can stay in that hospital overnight and come to us when floors down at is available. Generally. We want these patients always come to us and we have to triage how quickly that needs to happen. That's awesome. Prayed and I'll just add that one of the considerations here especially for this patient who has had a storied past with rejection. Worry about rejection, there's an impetus to quickly in the very aggressively diagnosed that maybe even with micro biopsy, more on more of an urgent basis and what we can think about on the clinical picture syndrome to look out for our rejection essentially is a micro titus, right? It's a inflammatory infiltrate that's attacking the heart and like we talked about in our previous titus episodes, you can think of effecting any layer of the heart it can get pericarditis you can get myocarditis with pump failure shock. You can get affect the electrical system with V F and her heart block, and so if there's concern for any of these we we should look for any of these and in any circumstances I totally agree with you that they should probably come to a heart failure kit bull hospital with a multidisciplinary team who knows a patient well that medical home. But these are the features also keep an eye out for because they would indicate a more rapidly progressive chorus that requires a sort of emerging. Diagnostic, evaluation. Those are all excellent points and I think very pertinent tailored to this patient. I think one of the issues that of triage in particular that comes to play a pivotal role is GONNA be contingent physical exam in a patient. As you know, compromise with a history of a heart transplant is one of the more important exams as all central TRAUMAS and cardiology is in differentiating house sick help critically ill patients for this patient in particular when he presented to our emergency room he. Was Eighth Federal's temperature's ninety eight's is heart rate was ninety five beats per minute blood pressure was ninety, six over eighty five respiratory rate was eighteen breaths per minute his auctions adoration was one hundred percent on air. One feature that you may have raised. Your eyebrow would the narrow pulse pressure in general a pulse pressure the difference between systolic diastolic. Blood. Pressure less than twenty to thirty is generally considered narrow. That is a native prognostic sign and suggestive of features consistent with low output heart failure. From a general appearance. Wise. He looked to be a well-kept male he had anxious aspect, but he was responding appropriately to questions on obstacle tation. He had a regular rates no audible murmurs Noah's three was appreciated. His Jugular Venous pressure was around eleven centimeters water he had sustained how Juggler Lukewarm to touch in the kneecaps in the dislo extremities and he had one plus pinning deem bilaterally up to the level of amid shed respiratory. Wise. He had decreased breath sounds of the basis more towards the lower one third. He did have bilateral by Basler faint inventory crackles and he had a mild increase worker breathing. He was on room air domino. Wise it. Was Mildly, descended out demand. It was non tender. He had no peritoneal signs like rigidity or rebound there. Logically, he was alert oriented she had a normal speech grossly normal strength throughout his electrocardiogram on arrival demonstrated a Sinus Taka card yet one hundred, two beats per minute, and this is common as we had mentioned earlier for prior heart transplant patients because of the. Lack of Bagel innovation in general, these patients will have a heart rate between ninety to one ten, permit a resting heart rate. But as I had stated, the patient was on Aberdeen, which is aimed at lowering that resting heart rate he had a right bundle branch block. This is also common a heart transplant. It's the most common type of intrepid truckload conduction delay. And it does not affect on notice other findings of EKG, worried axis deviation or our way progression in. These were all stable findings from the patient's known prior Ekg, his chest x ray on arrival demonstrated large cargo style silhouette. He had mild bilateral interstitial Dima he had small bilateral fusions and there were no consolidations no masses that we could appreciate on his radiographs. So. We were pretty concerned about this patience when we initially saw him I think the physical exam confirms that. So this patient has mangles mentioned has evidence of narrow pulse pressure concern for low output heart failure. His exam is also concerning with elevate JP as well as lukewarm extremities emphasis. This is affected as well with a chest X ray showing evidence of volume overload with Pulmonary Dima on parole fusions so I think the things that are really important to look out for our marketers of hypo perfusion, and that's he mentioned before I think the physical exam is the best way to evaluate that the kantha extremities tobacco whether they're warm or cool. But also looking at urine output to as well as really. Important. I. Think going to the labs and vowing for markers of hypo perfusion include looking at the creating. Looking at lactate as well as looking at LSAT's the see if there's any evidence of that other things to give patients, history of rejection is to look at whether the tacrolimus immune suppression levels are within normal limits and so those would be the things I would look out for in this patient given the physical exam as well as the cardiac work that's been done so far Dan that was fantastic. Anquan that was a great assessment of we're now just to clarify for the listeners just because they're vaguely tone is removed doesn't mean higher heart rates shouldn't be considered a warning side say your patient. Did have signed a stack of cardiac to one forty would that be something concerning to you? I think relative changed from their baseline would be worrisome. So if they're basically intact Cardi, our heart rate is ninety two, low one hundred than a relative change. The one forties would be concerning I agree with that in that kind of goes along with the idea that they're Vega tone is removed, but there are sympathetic tone. Still Exist Dan, that's brilliant because this is what Madison is all about is tailoring the differential and the assessment to the individual patient is patients outpatient resting pulse was in the eighties. Can that's on I've Aberdeen He. He's presenting here ninety, one hundred. So that is a relative change. So even that change for this individual patient for this person is clinically significant future. If say his resting pulse was a hundred came at one, twenty, one, forty, obviously an additional relative increase adds more value to the assessment meaning of hurry. So just goes to show how you need to individualize all of your assessment care. Yet these are great tasting points and I love the way you are anticipating what was should be looking for in the lab work Dan. We have some information at this point we. Do Okay. So for his lab work, he had a sodium of one thirty five Tahseen was four point three Craton is one point four and that's from a baseline of one point zero he had elevated White Blood Cell Count of fifteen with a neutral Philip shifts of about eighty percents is mclovin was thirteen his platelets were two, five, six, his be MPP was elevated at Twenty, eight thousand and his octave Alina be MPP or BNP that we have when he has achieved they dry weight was about fifteen thousand. So is current BNP was almost fifteen thousand more than optimally Nick BNP wait opt for lameck. Tried Hammett so we've been using the term optical Lena to represent. The ideal volume on a patient to achieve maximal perfusion relief of symptoms. Historically, you've Lee Mc or you've Lena has assigned when patients at achieve that. But every patient requires a different amount of freeload depending on their cardiac physiology. Some require slightly higher CDP's or central venous pressures based on pre existing RV function or diastolic function. They may require differences in their resting volume status. Compared to the historically classic Yulia Nick Status. So we individualize optimistic sauce for each patient I'd never heard of the term optimistic but it makes so much sense and is probably more of a useful measure to gauge a new program peer BNP valley when the patient comes in suggests such tremendous teaching thanks have reached that, but it does come into play because you will find patients. With were that heart transplant that do tend to run a little higher with respect respected their optimal filling pressures and that's okay. So as long as you're avoiding readmissions and symptoms of pulmonary congestion will find patients that can run lower without the incidence of acute kidney injury or electrolyte abnormalities, and so that's why this term octave Alenia comes into play when you're individualizing the care forgive patient. After going over them additional labs show the fifth generation Tr- opponent level returned at thirteen hundred and the repeat level was in the thirteen hundred range as well, which was similar to his baseline trombone allegation and has gone had a alluded previously it is critical to assess for markers end organ hypo perfusion. These include not only the clinical markers like Olive Julia or output in mental status in the physical exam, but also laboratory markers like elevated bill. Rubin lsat's lactate. So forth, this patient's lactate returned at one point seven which was normal but again, lactate elevation, particularly encouraging shock or low. Output Heart failure is one of the last markers who become elevated. There is a delay in elevation lactate. His off tees were also within normal limits ails. He is t bill Rubin was mildly elevated Interestingly, his out meant was slow at two point three, which gives you some marker of his degree of underlying cardiac severity. Even coming into is oscillation is spot and I say not trump to chromosomes aramis level were about nine and his goal is generally around for the sex. But again, these were levels that were taken on mission not true troughs mister gently done just before consumption. These medications and in working up that leukocitis that mentioned, he added Bland urinalysis in with Immuno compromised patients important to get a full urine culture as you may not always now the white blood cell infiltrates within the retail system urine culture was collected a blue culture collected as well. So I have to say, I'm a little taken aback by the fifth generation of the high sensitivity proponent being thirteen hundred and I. Wonder if your ass as just different from what I'm used to amuse saying the normal is like less than ten or around that neighborhood. So thirteen hundred would be essentially. Like a couple orders of magnitude above are upper reference range. How differences from your reference? Range. I reference ranges at twenty, twenty, one or twenty six for the upper limit. Yes. So this is quite elevated is this something you expect in a heart transplant patient to have a baseline elevation that is so high because that makes me wonder is this one patient who's got some degree of injury right? Like everything patients with cardiac emily doses have chronic micro-vascular ischemia and injury in that way or is this a patient with some sort of assay interference with antibody to the opponent ask? Yeah. Also are these labs that were getting these quote. Baseline labs are they from his prior rejection? So are we basically just seeing what his opponents were prior presentations? That's right. Yeah. In general these baseline labs it not as an outpatient were done on prior hospitalizations he had other hostels ations before this. For Various Reasons I mentioned some AKA is or kidney injuries solicitor. Pro So those were when some of these other labs were taken but this elevated opponent is indeed concerning it is above the typical level that we see cardiac transplant patients and it is something that partic- native pornography value for this patient. At that point, we had assess parks reports on patient. These were not in the setting of Q Corner Syndrome or type to the. States. This was the patient's true outpatients or prior to discharge hospitalizations reported level, and again, there are any number of reasons for these crimes elevator opponents that aren't always acutest. And this patient, he had quite advanced heart failure that was like the reason for this chronic quote trope anemia to elevations I would just echo that the high level of proponent gen five or high censored opponent is just a marker of a negative. Value I think that it is somewhat higher agree with you on it that there can hundreds pretty high for a patient especially, a heart transplant patient even for a D. compensated hef ref patient that we typically see really I see above a couple hundred and so I think this does show that there is significant cardiac dysfunction going on and it's obviously worrisome for this patient. So our next step into values patient was an echocardiogram and we'll we're looking for where some of the manifestations of that you can see in a transplant, a patient such as haircut. fusions obvious vegetation's or Sassi's as well as changes to the wall motion or while function in general, the echocardiogram was overall stable from his prior echocardiogram. As stated demonstrated injection fraction thirty, five percents he did have restricted diastolic filling as well. The severely dilated left a trim on top of his global hippo can uses he had known existing ethical a consensus that again habit attributed of prior episodes of am are in a CR and he had mild tomorrow mild CR, Mitral regurgitation custer station reduced RV function with RV right ventricular systolic pressure third for millimeters of Mercury. All of these were stable. There were no new additional findings compared to last cardiogram and no Kirk Cardell fusion abscess or echo density. So with that in mind as had been summarized before, this is already painting the picture of a potentially, very critically ill patients who presenting with symptoms of volume overload, specifically pulmonary edema, peripheral diva, and features both clinically by physical exam, Zam, and by laboratory assessment of low output, his labs demonstrate a Lucas, toes and acute kidney injury chronically elevated opponent chronically elevated BNP that's higher than baseline and demonstrates pulmonary deem as well so. The diagnosis for us was quite clear that the patient had presented with acute on chronic heart failure with a high likelihood of low cardiac output heart failure. The question was what was the trigger or the ideology of this de compensation or deaths potentially new type of heart failure, and so some of the ideology touched on early in the case, include recruit rejection especially given his history of rejection in the past other things being myocarditis could also be infectious etiologies given his elevated White Blood Cell Count and we have infectious work ongoing. Another concern is an acute am. In this patient and the opponent while elevated is appears to be baseline, and so I think that the next steps going forward to evaluate this would be to make sure and rule out rejection especially given his history and I think that can start off with a right Heart Catheterization Swan Ganz Catheter and a mile cargo biopsy, and that would probably be my next step going forward and then that can help guide us what steps to go in terms of managing this patient. This is something that we see a lot in medicine patients with critically ill patients where we have to. Start treating them and start managing them before we know exactly what's going on and that's why things like physical examined vital signs, basic lab work that are readily available are so important as kind of markers of what's going on so that we can start treating the patients stabilizing the patient and hopefully getting better we make time for further tests to gather more information as mentioned, getting a a right heart cath getting invasive human annex and eventually pursuing an endo myocardial bossy. But these things sometimes take time to marshal the resources get everything together wolrd setting off the next steps were also. This patient at the bedside, and this is someone who are worried about this as someone who's sick and so this is someone who needs frequent assessments and that I'm table that we may have our minds for when we're going to do these things could quickly change I. think it goes back to what we learned as interns sick versus not sick I. Think we recognize that this patient is extremely sick and needs acute manage nets urgently, and so like Harpreet is saying we need to basically mashed patient and we can get some more information along the way and put the pieces. Together, and this is part of the reason why having this patient at our center, which is a highly accelerated in advance nas six there for transplant patients was important for this particular patient we had amid the patient directly issue and were able to get a right heart catheterization with into my colonel biopsy very quickly after a mission to get a lot of diagnostic data very quickly, and so that's what we able to accomplish. His right heart catheterization demonstrate a writer pressure of seventeen it opponent artery pressures a thirty four over twenty four with a mean pa of of twenty eight. Pulmonary capillary wedge pressure of twenty three the view as the twenty five. As you can tell by just these pressures alone within the cardiac chambers, the patients elevated by atrial filling pressures. This was already indicated by the physical exam by Fiqh calculation of cardiac index of two point zero generally less than two point two is conventionally considered a low cardiac output. Pulmonary, vascular resistance of one point, two nine, which is within normal range and transported grade, which is the difference between the mean pulmonary pressure in the wedge pressure of about five transplanted grants greater than eight generally indicate a non post Kappler healing process or some other intrinsic homer hypertension ideology to additional parameters I like to introduce or the poppy in the cardiac power. So the poppy is stands for pulmonary artery pulse until the index in this is essentially the difference between the pulmonary arteries is solid pressure and the diastolic pressure divided by the brighter pressure studies have shown that indexes less than two are highly consistent with right ventricular failure particularly after patient receives left ventricular support like L. that this patient's pappy calculate zero point, five eight, which is clearly quite depressed inconsistent with our dysfunction additionally, the patient's cardiac power. Caveat two, zero, point four, seven, cardiac power is increasingly utilized calculation in the assessment of a patient's predicted mortality cardiac power by constellation is mean arterial pressure time cardiac output divide by four, fifty nine, and we know through various studies particularly studies involving in Pella's which is a former mechanical circuits or that cardiac our values lessons or point six or ten day high in hospital mortality as Kwan harpreet had brought up, we did obtain the urgent ABC's these. Are expedited with our pathology department in generally be returned within twenty four to forty eight hours. But in the meantime we were faced with a critically ill patient with high by filling pressures, a low cardiac index, significant with his function low cardiac power. So as a pretext alluded to, we need medically Mansa patient as best as we could. John Effort to improve in Oregon perfusion the patient was started on Wtam. The patient and start a high dose ivy diuretics to relieve pulmonary in peripheral congestion, and importantly, this is something that again is going to be unique at. Center the patient was treated empirically for rejection he received a high dose of methylprednisolone one thousand milligrams. I think one thing I would add here is just going back to what we've been talking about triage Ian and assessing how sick the patient is in a patient like this you really be fooled because this patient came in with symptoms progressing over week or two, but they were on room air a were mentioning well at a stable bloodpressure, pretty stable vitals over all the labs were not dramatic lactates normal. You might think that this patient is not as thick as they are in that kind of goes back to these other assessments that we've talked about in in China's and trying to get more information and watch them closely. This patient is fine. We can discharge and haven't followed heartfully rich clinic, right? Exactly. Yeah guys. This is a really good point to point out that sometimes we initiate a treatment and we have certain expectations for the treatment. So for example, if you think your patient has low flow heart failure and you're pretty confident, that's the reality and you think the beauty means GonNa do the trick you start your therapy and you see what happens in a lot of times you could predict the response that you're GonNa see and when that response occurs, you feel very validated that you're on the right. Track and usually you are, and then you could use your other forms of parameters of your swan data labs to confirm that and the clinical course of course, with patients like this where we really haven't knocked out the diagnosis just yet we started a therapy what you typically expect from this kind of patient who comes in with rejection after rejection and basically is in heart failure and we assume that he's going to be rejection again potentially so much so that we start him on empirically Ivy. Metha-. What do we expect for his course if we write It, completely depends on accede the diagnosis because depending on the type of rejection that is going to dictate the individualized therapy media. Mata Rejection Selah rejection have unique municipal treatments that differ from one another for example, plasma for recess ran about immediate rejection and so depending on that biopsy of the heart in the staining for antibodies. That's was actually a difference soon as far. As specific treatment, four antibody mediator seller without knowing, which is which or potentially in alternative process we talked about maybe having a primary myocarditis or something else that would probably be a little too premature but the methylprednisolone in general is a strong suppressive agent. It will blunt the effects of ongoing process until you can get that biopsy back again, we expedite those biopsies twenty. Four, eight hours. So again, exactly this is not a case closed situation. This is not where you're like. All right. We'll check in next week and see how things are going. This is an active actively investigated case that I'm really interested to hear what happened next from a clinical basis. So we're not getting the optimally MC BNP discharging heart bridge clinic then as much as. We would like that was not the case for this patients following the Swan Ganz capitalization biopsy. The patient was Mitch Icu and he continued to worsen quite rapidly in front of us he developed a new auction environment to liters. Nasal Kanye is labs then began to show those markers of end organ hyper perfusion, elevated lactate, Lt, elevations. He had demonstrated inability to produce a robust amount. Of Urine with our high dose. Ib Diuretics for these folks. We really aim for at least three leaders of urine output with our directs within the first twenty four hours and he was essentially olive direct with about five hundred CC's of urine, and this is on a high dose diabetics and poorly we had a Swan Ganz Catheter, we had tools so we were trending the. Mix Venus oxygen saturation and this although it has been stable continue to support a thick that calculate to a low cardiac index in the setting of a positive ion trooping beauty. So clinically he was worsening, and then throughout that same day he developed in episode Ta or pulses of electrical activity nurse had been in the room and the patient lost consciousness she felt for Paul's. which he did not feel in CPR initiated at that time base our telemetry the was actually sinus Tack Cardio was not of the tea or the ask you can commonly see bTV off with acute rejection episodes that was not the case for this patient. This was the activity he received about a minute of CPR response arousal and Ross return of spontaneous circulation and afterwards. As one would expect after cardiac already in shock his vitals continue to look worse Asala in the nineties Haaretz, one tens twenties, and now the increase in oxygen requirement. So the patient overall Nali was clinically worse thing but he just had a p arrest in. So I would ask of my Qana Pre the differential for patient like this with p. a. arrests were thinking. Yeah. So typically what I think about a cardiac aetiology to arrest I think about either a ventricular arrhythmias ventricle attacker cardio, fibrillation. So it's unique to have a PA arrests think the differential we learned with this includes the five inches in five TV's, and so it's really good to go through all these possibilities. Can remind you guys the five h include hypoglycemia hypoglycemia hydrogen, which alludes to acidosis hypoc Alenia Hypothermia hyperglycemia, and the teas include toxins Tampa nod. Tension with or ex thrombosis, which can include coronary and pulmonary thrombosis and trauma. So who wants that are most crucial rule out in this case would be champion non especially since his patient had a recent right heart catheterization and intermodal cargo biopsy, which can lead to a complication like Karl Fusion. So grabbing that bedside echocardiogram is really important to do other things are really important are coronary thrombosis. Or pulmonary embolism. We know this patient has a history of RV dysfunction and so forming clot an RV is a possibility in that can lead to a Palmer leads his compensation. And those are things that would be really important to rule out. Out of a place of really ignorance I, think about the ways in which people with certain disease processes die people with again Gamla doses they may pass because electromechanical dissociation they may continue to have organised electrical activity, but essentially loser contract how function and so essentially, it'd be like a PA arrest is that something you could see in a raging. for example, in a patient with acute rejection. Yet p. a is a really interesting entity because it's try grab bag. It's almost like the heff cardiac arrest. If you think about it, there are so many things that go into all of these conditions. But one thing that is, as you pointed out, it's really like the end stage of so many other disease entities barring of the tea arrests. So many entities basically ends in hypotheses are end in hypothermia end in hyperglycemia and so on and so forth. He as the definition, there's really different ways to explain it. One is that you have troop ea where you actually. Zero, pulse you have no pressure. Your heart is just as this electrical activity that really does nothing no. At I I, remember this distinctly when I was on my shock trauma in medical school and unfortunately a patient was passing and but they're echo pro was don and you could just see the electrical activity was ongoing on the monitor but the heart was literally dislike vibrating and not doing anything and there was no pulse generated but you can also have sustained low blood pressures that's not detectable by noninvasive measurements. So for example, if your map Is Thirty consistently. So your heart is actually raising a blood pressure, but your blood pressure Goff is measuring that and that's not necessarily going to translate into a probable Paul's that would still be considered. PA, some people call that pseudo p but at the end of day, you're not refusing the brain or the vital organs. In this particular case, we can have electrical mechanical dissociation as you pointed out. But at the end of the day, you could also have just persistent pump failure and that could be what's going on as well and the other point. Is that you mentioned thrombosis and so you said pulmonary embolism and pointed out some of the risk factors for this particular patient pulmonary embolism of an acute p. e. causing obstructive physiology. So set the V can no longer pump into the LV and I actually found as a resident. We go all these codes and there'd be harassed and you'd be going through your T.'s. And consider, let's say, for example, the heart attack or am I as Europeans the French and then people would say he wasn't complaining of chest pain before this particular and immediately think about p. e.. But actually if you think about it when there's an acute blocked artery, the Sasol at this function occurs almost instantaneously and people who work with proximal allegiance and high risk. I appreciate this and sometimes that's why they're reaching in their toolkit for things like the impel us so that they can have the provided support when they inflate the balloon in the left main, they know the blood pressure's GonNa immediately plummet, and they need something to support them to get the patient through the procedure and so when a patient with such cardiac dysfunction at baseline and obviously his risk factors are a little bit different because he's transplantation but if coronary artery disease is of concern in acute. Could result in an immediate loss of blood pressure. Just some thoughts that I had on pulse selective differential I think that what Dan had is particularly compelling. You can have a pure pump failure you can have transient worsening in this assault function patient like this, and in a patient doesn't have an arterial line as this patient have up. Until this point, there may be a palpable pulse but may not be brisk for strong enough the nurse of help it. So it could just be very low blood pressure and as decouple that in that setting, but clinically, you have to treat the patient as if it is a truly complete loss of pulse but indeed pump failure low blood pressure definitely on the differential. Yet I would echo that I. Think with my reading of this case, sudden death transplant patients can occur in severe cardiac allographs Galapaththy as well as if graft dysfunction from rejection, and usually it results sincere rapidly developing pump bill with mechanical dissociation. So I think you're spot on it. When you when you bring that up I'm loving this conversation, but I'm at the edge of my seat. What happened next? Did you guys do? All right so as one mentioned, we evaluated this patient and for some of those potential causes, we obtain repeat labs his electrolytes were not suggestive of task issues. Huma Lomas normal as would be expected to lactic acid was elevated to five the. Craton up to to the L. were elevated with respect to with Rambault says, we had obtained a repeating CG, the Renault new st segment changes or t wave inversions. Metropolitan level is just slightly higher than what had been about twelve hours. Prior nothing that we would think of is aid acute myocardial infarction at that time chest x Ray also known for acts and in a bedside ultrasound was without a pair of Cardinal Fusion. Again, it's important to grab that apper. Someone's had a into micro biopsy. Those can be seen it. Yeah. At that time on that, that side ultrasound was even lower and this is common after a cardiac arrest, but the F. was about ten percent. And so this patient is clearly critically ill in carjack shock now with a PA arrest and he continued to only get worse despite our aggressive medical therapies, these did involve escalating doses of beauty mean and dopamine, as well as the introduction of Basil Press Therapies to elevate the blood pressure up nefyn bays oppressing. But even after these maneuvers attempts at controlling perfusion, he had continued to develop into organ marker dysfunction in hypertension. Additionally, he had two additional episodes of PA arrest. At this point, he did have arch you'll linemen and these were true pulse electrical activities events in which he did not have A. away form present we had actually had a t probe during one of these presents. So we had a continuous monitoring of the heart function and there truly was a lack of systolic activity that will generate a stroke volume wait for. So a sick patient with recurrent PA arrest in a patient like this, we have to think about escalating therapies and one of the most important tools that we have advanced transplant center is GonNa be temporary, mechanical circulatory support as either a stabilization mechanism or a bridge to something a bridge to transplant a bridge too bad reject assist device or potentially a bridge to recovery. In a patient like this, there are any number of risk stratification tools clinically, it's clear the patient already at a high in hospital mortality, but there is data from the stave trial which looks at the save score. It looks at different sort of variables like age blood, pressure, renal failure, and together, they can or attend a pornographic information about the likelihood of in hospital mortality. For a patient who is put on something like echo in particular in calculating this patient Shave score it came out to about a in hostile survival of forty two percent if the patient were put on something like Aetna and for two percent chance survival in a twenty nine year old is a relatively higher survival one that we will want to pursue as aggressively as possible. Compared to say percents revival closer to two or three percent giving us. Clinical worsening Andy. Compensation we had considered mechanical circulatory support this conversation. This juncture that we are in this patients chorus is just really helps contextualize the earlier conversation we had this patient was just having shortness of breath, Neha pnd and Laura extremity email with his heart transplant his rejections in the past it's. So useful that he's at a center where we can start having a conversation about temporary mechanical circulatory support at that hospital at that facility without having to transfer somewhere else. So it's just a reminder about the triage decision making that you would have in this in this context really glad that the patients under your care right now where you can have this conversation an activated. Yeah, I think having a high suspicion for something else going on for something worsening having careful monitoring are really important aspects of this case. So I, think we come to another big decision point here. It's clear that the patient is worsening despite escalating interventions from our standpoint multiple Linux tropes, base oppressors despite that the patient is developing worsening perfusion having multiple episodes of cardiac arrest as clear at this point, something else has to be done something new has to be try, and so the next step is mechanical. Circulatory support is Dan set, but that's a big area. There's a there's multiple things that can be done from Kenneth Circulatory support. We have to decide what's going to benefit the patient so it can start win. Something like a intra aortic Olin pump and impelling device, which could be both less cited support cited support tandem heart the biggest gun that we have and terms of mechanical circulatory support and the reason the act was chosen for this patient was they had evidence by failure they had both by clinical evidence by laboratory evidence by their echocardiogram, there's evidence of failure on both sides of the heart. So I'm going a little bit about ECM oh here but essentially what most extra corporeal membranous oxygenation but answer, and there's two components to it went via Akmal and via needs. Venus arterial. Extra Corporeal Gas Exchange. So doing the work of the lungs and oxygenating the blood, and then it has a component of temporary mechanical support as well. There's also the akmal which would be Vino Venous Act. which is just oxygenation. So does not augment or supplement cardiac output. Is Not for circulatory failure but as for pure oxygenation issues and this is something where actually saying we're seeing a lot more at the Akmal right now in the setting of Kobe nineteen, we've been having a lot of patients with nineteen ammonia been placed on the. And we've seen a lounge patients at UCSD unfortunately actually a lot of them have done pretty well, and that's a a shoutout to our owner critical care department user amazing job taking care of these really sick patients by going back to Akmola's a whole. I think Dan brought up the score and the reason we use that is ammo is akin to during transplant or doing. Elvis. Placement where it's a big effort requires a lot of resources and comes with a lot of complications and so you have to make sure you're choosing the. Haitian for it so he want choose a patient who has a good prognosis has an ability to cover. You want them to come off Akmal and as damage visit either GonNa be support them to allow them. I'm recover from the underlying ideology of their compensation or it's going to stabilize them long enough to get them to permanent support. Such leff introductions device or re transplant the a visa Venus Kanye, which is typically in the vein can also be internal jugular vein basically draining the oxygen needed blood from the body it goes through an Oxygen Nader? Oxygenated blood announced reinfusing into the body through arterial Kanye again typically Summerell and that blood actually travels retrograde. Awards. The upper extremities and the brain to provide oxygenated blood. Up with two organs, the times when we reach Fried Mo- would be people with Karnik shock with by ventricular failure, cardiorespiratory failure assistant, a refractory cardiac arrest. This patient basically meets all three of those categories in the different sort of from other types of mechanical supporters. The Injury Arctic balloon pump a standard left sided impel These only support the outputs from the left side of the heart so. If you have a week right ventricle. You can basically support the left side of the heart generate output to the body with any basically bring it back around to the right side the heart but it into a week right heart conscious make the right heart worse and increase the preloaded into the right heart. But if you're not supporting the right heart in a patient like this, they may not improve. contraindications would be getting to with earlier about how this patient has for recovery. So anyone who's Got good. The logic status before they had an. Arrest or non unknown downtime criminal illness and you're worried about putting them on, I will ever recover. So AKMAL. Can lead to bleeding issues and cargo apathy issues and so someone who already has evidence of bleeding already has a problem you're going to be concerned because you don't WanNa lasting to make someone worse, and then I also WanNa just touch. Under the physiology Iraq Akmal one thing that's important when managing these patients is that supplements at a cardiac output, you can get three, four, five leaders, cardiac output circulating. It does the work of the lungs oxygenating the blood, but it doesn't actually unload the left ventricle at what I mean by that is you're taking blood from the systemic circulation you're. Not Actually taking blood specifically out of left ankle. That's important in a patient like this because they're left ventricles week, you kinda blood pool there in the eventual in addition that could actually make lv dysfunction worse because at Mo increases their blood pressure, it increases the blood flow into the arterial circulation that last part CS more after load which lead to. Elevated left sided filling pressures increased distension of the left ventricle, which then can lead to increased myocardial oxygen consumption. Escambia can lead to bachelor blood in pulmonary, Chemo, enter stasis of blood and thrombosis, and so one of the major questions that comes up with someone who's put on Komo is if you need to support the left ventricle and something we call venting. benching is basically using an additional strategy to take blood essentially out of the left ventricle into the stomach circulation Savannah can flow through the circuit and so options for that ethically for us included in article. Or an device. The some of the major complications that can occur with at Komo include sirs inflammatory response. By damage and bleeding basketball complications in limb ischemia there's thrombosis and stroke risk as well as I kinda talked about worsening a LV function. Another management issue that comes up with these patients is the use of Profusion. Catheter is essentially if you picture the akmal circulation, you have at the arterial cannulation you've blood traveling retrograde from the lower extremities upwards you may not be providing for flow into the lower extremities, but just overfishing catheters another catheter that can be added on that provides Antara grape, slow to lower extremities to prevent or extremity scheme you. There's also potential issues with differential perfusion with upper and lower parts of the body, and we get concerned about ensuring that there's cerebral profusion but I think that the big tank on for va GMO is augmenting oxygenation aren't many. Output, you're supporting both sides of the circulation, the left side as well as the right side. It's sounds good for someone with by trigger failure it has to watch out for people with LV dysfunction. Make sure that you're not making the situation worse with hiding left after Logan were left killer billing pressures and Ben as mentioned, it comes with a number of other complications. So he got to choose the right to. Make sure that this is someone who's going to benefit from this big intervention and then make sure that you have an exit strategy and that's something that as soon as you put someone enact moat, we say we're trying to figure out how get them off. I just Want to say that this was such a terrific overview have nothing to add you over the fact that echo is a by ventricular as well as pulmonary support win over the access in the Kanye you end over the complications whenever over the north-south Syndrome, the Harley consider with mixing cloud you talked about the need and the strategies for LV unloading. This is a great overview and very relevant for patient. What did we do for our patient and Missouri Unloading Strategy Utilized in this case Yeah so this patient ended up having essentially three major interventions. So lawn was, of course, the Va Akmal cannulation artery vein. Can't was or the venting of the left center, all irreceivable impel US EP to again offload that ventricle to relieve the body of Pulmonary Dima, and then for the third interventionist accusing Cather to his Laszlo extremity to help refuse that this'll several artery all the way down. So those were the key interventions that redone these were done at expedited, very quick manner with their interventional team, who does that here UC San Diego and so now that we have placed this patient on Oh with continuing support, we had again continued our medical management which still consists of high dose steroids ongoing Presser Attribute titrate. But at this point, we need to discuss exit strategies and contingency plans given that this patient regardless of aetiology of the heart failure shock given that his patient was young critically ill, we had already started the workup for potential by that Ivan Chiklis support device as well as a Redo repeat or the topic heart transplant. This was a organization committee ad hoc joined on the spot with our surgeons are Dietitians are Tristesse, are psychologists are ID doctors wall get together at any given time throughout the day discuss a critically ill patient about what the next step should be. And for this patient, it was decided that in addition for approval for by. Mad, support a repeat heart transplant would also be indicated and beneficial. So the patient was actually listed quite quickly or a heart transplant as soon as we got into by a cordial biopsy back that biopsy actually ended up not showing antibody or cellular media rejection. So our premise of antibody mediated rejection which the patient had four times. Fire was not the case and as such, we were left with one last major differential, which was a chronic tapa rejection something that we discussed before cardiac allographs ask allopathy and as we discussed patient had. Relatively normal angiographic coronary arteries, four months prior but it is conceivable impossible that within those four months, the patient had an acceleration of his CAV. Cardiac allographs, klopp A to such a degree that caused his currently compensation, and it's also very conceivable that a lot of these harasser pump feelers were found these micro vascular events that caused temporary stunning as well. Pure pump failure. So after including this Cav again in some situations if there is an acute in mine acute myocardial function, you may pursue with an angiogram for the intent of. This patient was beyond that face this patient was to critically ill patient had already been to the point where he needed some contingency plan beyond this, a stand would have been unlikely to resuscitate as patient sufficient. Agree. So fortunately, the patient was listed the top of the list and so at this point, the patient had been in our hospital for about eight days or so been on the Mos for about six days and listed for about two days after which point he did receive his heart transplants he did exceedingly well after this was able to be weaned off on tropic support and reinitiated on suppression. The remainder of his hospitalization was relatively uncomplicated. Alternately required tracheostomy decaffeinated due to ventilator associate pneumonia, ultimately, the patient was able to walk our hospital about four weeks later with his second heart transplant this overall being his third heart. That's just amazing. Bravo. incredible outcome after such a pfeiffer, his life. And I love the idea that ad hoc meeting of the minds. How incredible is that? We really do have one of the more engaged and attentive surgical team that I've encountered in my training this far in. Asian you that team be available at any point during the day, and that's what we were able to provide for this patient that ad hoc meetings critical. Gang against speaks to making sure the patients these are into medical home capable facility that can provide such complicated and a high level of multidisciplinary care. So the ultimate diagnosis it sounds like really was advanced cardiac allographs, vascular apathy that was our conclusion and in supporting that the PAP dollar G. of the heart, actually end up showing. Near Complete Lumina would ration- of almost all the Parang Komo arteries. So the small arterials up refused the Mao car yet as well as diffuse intimacy thickening all EPA cargo arteries left main led left untreated descending agree as well as the right coronary artery and on top of this, the biopsy of the hartselle showed varying ages of myocardial infarction likely at least some form of small micro infarctions that had been occurring up until four months prior to his authorization. while. This really helps understand this chronic anemia. It's like something again, we would be see in patients parallel would be hard. micro-vascular infiltration with micro-vascular Ischemia, and you may not get an appreciation for that. In the coordinate geography. I think it really helps you understand the pathophysiology of Kartik allographs basketball up at the. So in summary It's admirable Basler fiber proliferation and results of Corner Infield inflammation typically affects both the microsurgical Tori Epoch Arial Assistant. There's actually a high incidence of cardiac allographs Ascalon. And some registry data suggests that forty percent at five years and one eight death beyond a year after heart transplant are due to see Avi and. It was singing the classic symptoms of Myocardial Ischemia usually absent. ALLOGRAPHS innovation related to heart transplant. And so these patients present very atypically with weakness dysplasia palpitations or even late with evidence of graph is functioning with heart failure arrhythmias or sudden debt, and as mentioned before sometimes see Avi can't progress very rapidly you should the slow process, but it can progress rapidly and unpredictably. And so a matter of months the ANDROID game can change from a relatively benign picture to diffuse occlusive pattern, which we saw our patient in such rapid progression can be associated with the currents of late antibody mediated rejection, which this patient had, and it's that kind of helps put everything together in terms of detection it's really important to tech early, and there's a couple of different ways we can do this. There's noninvasive techniques including stress. Echo Khariaga fee and myocardial perfusion imaging ca but the gold standard is coronary angiography and due to diffuse Longitudinal concentric nature of this analysis compared to the focal et cetera pattern that we're usually familiar with atherosclerosis coronary angiography can't really underestimate the presence and burden this process and what we've been doing is that we've been using ibis intra bathroom ultrasounds although there is no clear consensus on the diagnostic criteria for cardiac allographs asked the. But most of the clinical trials applied the criteria of a maximum thickness of zero point five millimeters in the left entered descending artery. One year after transplantation as being diagnostic of allographs. Ask allopathy. and. So once we've made the diagnosis, there's different ways to manage this. And apparently we've been using aspirin although there is no strong evidence for this use, we use it on a presumed benefit to help with micro thrown by formation at the sites of immune injury in the coronary and the. Other that we can do include practice then our Stan therapy and you should initiate two weeks after transplant and as Dan mentioned statins, the practice is preferred stand to use just because it is nonsense metabolize by the three four mechanism. And stance have been shown to reduce CAV as well as mortality and also severe rejections. So that's why we use it so much. The other management strategies actually to adjust immunosuppression, and so this includes our m. torn hitters, which stands for Mammalian target a Rapamycin, and that's of. And Ever Linus which inhibit the fastest muscle and fiberglass proliferation it's very similar to the drug alluding stance that we use for coronary atherosclerosis and Dan also mentioned the use of PCI although there have been no control studies that have been performed determine if it affects improves graft survival. But if there's a focal lesion one artery, it can be used more of a palliative measure. and. The only definitive approach for treating CAV CARDIAC ALLOGRAPHS ask allopathy is re transplantation and we usually reserve that for severe great three. Cardiac allographs ask allopathy and that grading is based on the data presented in the. International Society Heart Lung Transplant. In two thousand ten. So in summary I think Cardi allographs ask allopathy is a very common. Complication or causes morbidly mortality after heart transplant and it can present very atypically and so you have to have a high suspicion of. Surveillance for this is through corny geography and the use of Inter vascular ultrasound. A once we identify we can treat it with different medications, including Aspirin as wells adjustments of our immunosuppression. Yeah I think what made this case? So interesting is that he had an geographically normal coronary arteries four months. Prior this by the way was also what is on him was in that chronic elevated high range, and so this is a show how I think it is is playing a much more important rule in a surveillance of CNBC for these patients routinely. Now, we are doing drugs with itis for all of our transplant patients to look for accelerated. See. So ultimately, this was a case of a very rapid acceleration of C. A.? V. In a patient presented encouraged shock who we were able to resuscitate temporarily with Akmal in advance mechanical circulatory support as a bridge to a heart transplant, and ultimately he was able to walk out of the hospital in is doing quite well, I'm happy to say is in good spirits in his keeping up to date on all medications. So we had a good outcome for this. Patient guys this is just absolutely fantastic. Cussin' was critical. We learned so much and it really is a testament to capability Andy Importance of having multidisciplinary environment a whole heart team where people can come together and pull resources and put the patient front and center, and it's really it's making me very nostalgic because I'm remembering so much a how much I enjoy being a medical student learning from all the legends, mentors and educators at UCSD whether it was rounding in. The United Dr Shamma mood or learning from Dr. Lori Daniels or getting advice from Dr Blanchard. I mean it was just such a great place to learn as a medical student is one of the places that really helps me fall in love with cardiology to begin with. But I'd I'd love to hear your perspective. Now, what are the reasons that you decided to become cardiologists and what makes your heart splutter about training at the University of California at San Diego? So I can start without for me, I had attracted to cardiology from really medical school when I had begun learning about the basic physiology and pathophysiology of cardiovascular system is a great deal of logic in the way that this system works that just for some individuals like myself draws you more into it because you can work the different components of the system like the Ranan NGO tension system franc-sterling Kerr's different sort of. Physiological Assessments Gender Stan How derangement can act patient and the manipulation of logic in the flow of cardiology just became an intellectually engrossing experience for me. What's so unique about cardiology is that we have these very advanced tools and diagnostics intervention ranging from EP interventional to advance imaging to genetics that really helped patients they truly get better. They feel better, they have better outcomes and they are less likely to pass so for me. Become. Cardiologists was a no brainer effort to truly help patients UC San Diego is a very unique institution situated in southern California, and our goal is really to train academic editions. Physician scientists in physician leaders are hormones. Goal has always been to train individuals to be thoughtful physicians that provide exemplary outstanding patient care. We have a very rigorous program with massive breadth of exposure to all major sub specialty services and this includes adult. Congenital heart disease structural heart disease like Tavern Trans, Eric Replacement, or Mitral even try interventions as well as a electrophysiology arrhythmia departments. Obviously, we have advanced heart failure and transplant teens, genetic cardiomyopathy departments in very advanced imaging training as well and C.. T. Murai pet and so forth as a result of the exposure to all these events of specialties, fellows come out as training with exceptional competency co cats level to in. Almost every field within their part of Asir Training. So this is C. T. ECHO MRI nuclear t the number and amount of exposure and experiences that we get is truly outstanding. Every fellow I think incredibly confident and competent leaving UC San Diego Basser Medicine, training fellowship we do train independent leaders. We train people to be thoughtful critical thinkers those that can rely on the training of those that can work well with others. To provide very advanced clinical care for patients. So most of our fellows do tend to stay within academia, they do tend to pursue advanced officially training, but we do also have some fellas that are more geared towards community medicine as well, and then in addition to these advantages UC San Diego is a research institution period. We have some of the more robust research that I've encountered in my career thus far from a basic. Or Bench side research to ongoing clinical trials we are leaders in robotic detainees corier. Intervention. Tavern Inventions Mitra clip intervention structural heart disease, as well as many other uncle trials and so for fellows who are interested in research oriented tracks or continuing to make research large component of their careers. It is not challenging to find a good mentor in good launched project or project super soothing throughout your fellowship and it doesn't need to. Be. said that UC San Diego is incredibly collegial and friendly my colleagues coworkers from my fellow, sue the internal medicine residents to our sub specialists to our consultants. All friendly. We go on a first name basis. It is a very welcoming environment of very warm feeling to be a physician here. The city is obviously amazing and beautiful. There's so much to explore. It's hard not to like being fellow here at UC San Diego. So I was looking forward to this part of the segments, which is what makes your heart full herbs I listen to this podcast pretty frequently. And I can remember the day. became interested in cardiology, which was first year medical school drew my cardiology. I remember listening to this events heart failure Dr Larry. Allen. Approached him after class and he took me under his wing and invited me to the advanced Hartford unit in I rounded with him and I remember just falling in love and I think it comes down to mentorship is what? What brought me to cardiology and I formed such great mentorship at UCSD in Iowa Echo the same. It said from Dr Lori. Daniels to Dr Eric Adler to Dr how Tran and Dr Yuri I've had so many great mentors at UCSD and I'm just so happy to be where I am today I. Think you see us the overall a wonderful place to train. For me like Dan said my interest in cardiology started with the physiology and everything else really springs off of that. Everything. We learn in cardiology everything we do it all tracks back to physiology. It always seemed to make sense Senate. Would always find it really fascinating how the heart works. And then learning more about cardiology, I was amazed by the breath cardiology even as coming into fallish I learn more about really how big cardiology isn't the variety of aspects of cardiology all this specialties, all different imaging modalities in procedures that are unique to cardiology, and then there's the burden of disease. This is the biggest awesome mortality in the world, and so it's an important field in its field that has been impact. And you can have an impact in so many ways that we take care patients all the way from prevention to these end stage critically ill patients on maximum life support that science technology have provided us to this point cardiology is I think an amazing field it covers everything at allows us to be medicine doctors every day leave our medicine training behind, which is what I really love about cardiology is we were internists I, and now what what makes Meyer flutter is preventive cardiology and my passion is learning how to keep people from getting to this point inches to keep people healthy and to prevent the development of cardiovascular. Do that from a clinical research pointed out that as mentioned are able to find mentors, and in here at UCSD who helping me to get skills, I needed at the foundation for hopefully a career doing research in that area you guys these perspectives were absolutely beautiful. Thank you for sharing but you forget the best part the soccer planters still take people out for drinks and food and do aboard review every now and then Oh. Yeah. We we actually that up until cove it was it was. A memorable experiences but yeah, we would. have to renounce go to one of our local restaurants reserve the entire room at just questions at jet. Awesome experience like he was doing obviously Cova things have changed we've transitioned overt. So. EPIC. It's just it's really a testament to dedication to teaching and the investment into the fellows absorbing Dan Quine harpreet you guys are just absolutely amazing. Thanks for inviting US into World San. Diego is a fantastic place. We talked about a post transportation heart failure. PA. V discuss such a gamut and spectrum of. All things you need to know heart transplant all things you know, pa all things in you know resuscitation mechanical circulatory support ca and why people need to become cardiologists. This has been such a delightful conversation. We are just so impressed with your program and the collegiality between you three, and also just the breadth and depth of knowledge that you have part on us today. So thanks guys for joining us at things for being on the show. Of course this was an amazing experience in mid Dan Avenues. Yeah. Thank you so much. It's been so much fun. Is really enjoy this experience. Thank you everybody for listening. That was our case. So now, I'm going to hand it off to our experts faculty leader. One of our associate program directors he is a very wonderful physician. One of our most treasured mentors here at UC San Diego. Dr Tran He. Mechanical Circulatory an Eldad Program here at UC. Thanks guys. Hi, this is how we trend at the University of California San Diego I am heart failure MCS. Transplant cardiologist I also am the associate program director for the General Neurology Fellowship alongside the program director of the Advanced Heart Failure Fellowship, I am a certified ten Thank you very much. I'm Dan for providing this platform for fellows over the world it is my privilege to follow our superstar fellows, Dan Mongols Harpreet Bhatia and Kwambonambi. Thank you for honoring me as your CPR discussing. Now, if we were to be at the shore side Hoya I probably start off. This discussion with funny stories about my fellows or maybe even regale the audience to the last October thousand nineteen pre pandemic when we had our divisional fellows versus faculty softball game I won't chain these guys by sharing with you the final score but we did beat the fellow eighteen date. Nevertheless, we are task for a more important discussion as with all of our heart transplant patients. This gentleman involved in this case is near and dear to our hearts. Now, if the five you have already pointed out as we consider heart failure patients for cardiac transplantation, we are arriving at perhaps. Most life altering event in their lives and had our institution heart failure faculty finish soon, ward rounds, and always pull up a chair after is you more rounds to patients bedside along with their family members? We put our phones on silent and embark on an explanation of what had happened why they're at our center what therapies we are currently employing in what they're. of He's we are considering in the future to make matters even more complicated our patient. This situation is a young guy, and as you pointed out, these discussions must be met to delicately here at UC San. Diego are general cardiology fellows are an integral part of the advance failure team. They have front row seats to patients who transfer from local hospitals insecure genyk shot. Also, very complicated patients, needing MCS, transplantation and complications thereafter. Now Dan Harpreet Kwan performed wonderful engaging discussion about our patient support cardiac allographs, Ascalon the but let's further elaborate on the ladder. So early in the post transplant period, the first six months or so lives can be claimed by nonspecific graft failure, acute rejection infection however beyond the first year cardiac allographs vascular with your cardiac transplant vast klopp. The is among the top causes of death in according to the ICT or the International Society for Heart Lung Transplantation Registry report in two thousand, nineteen about a third of patients have angiographic disease, five years, fifty percent, ten years but there are studies involving cereal intra vascular ultrasound that reveal. Most immel thickening occurring within the first year transplantation. So what's going on the particular vascular? The is diffuse, concentric, Longitudinal, integral hyperplasia confined to the allographs, epithelial coronary arteries, and this remodeling lead to substantial luminol loss. As you saw this case, obviously the allographs micro-vascular church also involved. Now, this is in contrast to the traditional atherosclerotic plaque, which is focal non circumstantial usually in the proximal portion of the epithelial vessels houses happening we have illogic Anonima logic reasons immunologic events appear to be the most important factors though since CAV develops in the donors but not the recipients arteries number one number of episodes of moderate to severe cellular antibody mediated rejection appears to be clearly live with the development of. Number two development of donor specific antibodies denote development of anti, Hoa Class One or two number three mismatching in particular H. L. A. D. R. H. L. A. So it's probably a good time to talk a little bit about t cell activation at this point remember image C. Class. One of antigens are recognized by C. Eight cells, which forces secretions of cytokines and. Then ultimately activate coronary in the field cells and these activated endothelial cells express increase immediately class to antigens and activates CD four cells, and that's how you get some antibodies involved. So who's at risk now important predictors of see development include in the donor older h mail and hypertensive disease in the recipient H., A. Mismatches Younger Age schemic heart disease other risk factors include cytomegalovirus. Infection hyperglycemia and insulin resistance, hyper denia. So the five you spoke a little bit about the signs and symptoms. So let's turn to that for a bit and you're right patients typically do not have symptoms of Angina, and as the hardest enervate at the time of transplant. So it is not uncommon for patients with basketball to have silent myocardial infarction. So in death and. Progressive. Heart. Failure symptoms in some patients, sudden death may be the first symptom of CAV mechanisms. Other ventricular arrhythmias may include a rapidly solving pump failure with mechanical dissociation us. Both of you guys have pointed out because the nature of these silent symptoms we in practice screen patients for Peres, Disease Corner geographies, the most common screening approach in here at Uc San Diego we complete. Evaluation in tandem with Ivy's during the first five years. What we do for surveillance is a yearly coronary angiogram. If the EGFR is less than thirty or forty adobe, mean stress Echocardiogram is performed instead of an angiogram after five years for low risk patients I e normal angios annual dooby mean stress Echo is ordered for those with evidence of. An annual surveillance with corner and geographies performed renal function allows now we can get away with this surveillance protocol because CV typically progressive. Slowly however, there are occasions when lesions progress rapidly and unpredictably in this case, Ivester Intra Vascular ultrasonography is helpful to confirm the diagnosis of CSV but not all transplant centers employ ibis the criterion for diagnosis using. In. Clinical trials is an increase in maximal intimacy thickness or mit a greater than or equal to zero point five millimeters in the led at first detection or in comparison to the last ivory evaluation. So what do we do now once we have a patient with Cav quantock about stance, we put all of a heart transplant patients on aspirin and statin therapy during their hospitalization. After the transplant, some studies have shown statins to improve. CAV INCIDENCE, we initiate pravastatine milligrams a day up titrate to forty milligrams daily US Quantum Dan pointed out the CNI. Intact grow. INHIBITS CYP three, eight four and of not private is not completely metabolize by CYP three a four. That's why we use it initially into inhibitors like rolling this, never loomis have been shown to reduce the progression of MIT NCNB the reports of wound healing issues particularly in renal transplant literature. Therefore, at our institution, we do not use Roma in the early transplant. As much. But when we do find an MIT that is greater than royalties point five millimetres, we do what we can to keep the cashier inhibitor add on the immature inhibitor in lieu of the Anti metabolite like Michael, Bennett? That's a mammoth for salsa. We would then keep combined trough goal of CNN inhibitor closer at about ten favoring the CNI level that is to say a trough goal of about six to eight for the CNI and three to five for the tour inhibitor keeping in mind per patient level. Decisions regarding anemia thrombosis Pena tremors and renal insufficiency are all very important. Re Transplantation is the only definitive approach. So in summary when we take patient post transplant and evaluate their CAV risks, we'd take a look at vascular risks. We obviously avoid rejection. We have seen the prophylaxis replaceable on Aspirin stent therapy. We survey their coronary tree with an geography with ibis at about three months and yearly up to about five years once. We find cardiac allographs ask allopathy them will convert their anti metabolite, an tour inhibitor fairly early on again, re transplantation for those with severe is Great Three v with allographs function, we will consider for a re transplantation. So at our heart transplant program is unique and now you look into the latest RTR tr that's the scientific registry of transplant recipients are center challenges, the status quo, all the time we push harder particularly when we. Find patients who are sicker we were the first on the West to transplant Hep C. Net positive donors the first on the West performed DVD heart transplantation we transplant across positive cross matches, employing clues, Malvo Celera's we have the most experience in the nation with durable Bi ventricular support. So patients can late in Preab on their way towards transplantation this is all just supposed on one of the best survival in the nation for A. Transplant program our size and we couldn't do without our fellows. So Wonderful Job Dan or Preen Quan I look forward to your case discussion online I look forward to the bright future each of you have in cardiology and I look forward to the next fellow versus faculty sports outing maybe a different sport I'm Dan thanks again for providing this instrument of fellow education. Next time we will see the the Hoyas Sandiego so bye for now. Then now. Message from the provost record. Tucker. Daniel. Budget, who is just such a special ed remarkable person a very strong advocate for trains even when I was a medical student, he was always A. Source of guidance and mention docker flashes hello to everyone. I'm Dr Dan Blanchard on the program director for the Cardiology Fellowship program here at UC San Diego. This case is an example of the high acuity cases. We see here at UC San Diego very active and busy clinical program here with high volumes of. Patients, advanced heart failure mechanical support interventional cases, and electrophysiology if you want procedural volume. Here, we are the only academic center in the Santiago region. So we see lots of bread and butter cases, but also a lot of acute issue level cases. We match six general fellows to advanced heart failure fellows to interventional fellows in two EP follows each year. Also every year we take several of our graduating fellows on as faculty we have become the largest division in UC San, Diego Medicine we are second only to the Department of Medicine itself in size we're glad you could be here with us today. Wow what an amazing case a huge thanks to the fellows and faculty for enriching us with yet another terrific discussion and incredible addition to the Cardi nerds case reports earnings. Sure. To check out the show notes for all the case media available for key take home and discussion points and links to the program. If you'd like the Education Takeaways and graphics delivered directly to your email signed up for the heartbeat. Cardio nerds newsletter you can join the email list using link in the episode description as well as from our website www dot cardi nurse dot com. We've thank the ACC fit section chaired by Dr Notion Research for their support and collaborations, and of very special. Thanks to our incredible production team for elevating our platform called Blumenthal Tommy Dos. Dugan Rick, Ferraro, old songs, and given breeze. All internal medicine residents as Johns Hopkins Hospital as well as their phenomenal MED mental and University of Maryland. Radiology. Feld car. If you love the show as much as we can be sure to spread the word rate review on your favorite podcast platform and consider becoming Patriot with the show on Patriots Right. That's a wrap time to make like an s two and split.
"Get crafty while celebrating. The holidays at home with joanne from festive decor to holiday projects and inspiration. We have what you need for. Whatever you wanna create plus. We have plenty of videos on our youtube channel to help you master anything. You want to tackle ready to start creating texts podcast to five six two six to get twenty percents off your next purchase and have an opportunity to win a one hundred dollars gift card every week happy grafting melissa from michigan. I work an extra part time job serving lunch at my child's school but i still can't afford to put food on our table. Daniel california choosing whether to pay the rent or pay to fix the car to get to work doesn't leave us with much at all now. We can't even pay for meals. Hunger is a story we can end ended at feeding america. Dot org brought to you by feeding america and the ad council on the puck. Dr cast questions asked movies. Have women are all their discussions boyfriends and has been. do they have individualism. The patriarchy fast. Start changing with the del cash. Everybody welcome to the bechtel. Cast by name is jamie loftus. My name is caitlin durant and today we are Unlocking an episode from our patriot aka matron feed ever heard of it. And if you haven't it's time to get wise or not we won't know And and maybe you're like oh cool. They unlocked one now. I don't need to pay for it again. We won't now but you know don't do that. Don't do the also there's still like dozens and dozens and dozens of episodes that will never on lock. There's like almost a hundred at this point. this year has been on for you. Six hundred years at this point is true So we're unlocking the lolita episode from our patriot ak matriarch today which we will get to second but If you're interested in more episodes that are just caitlyn myself kind of having a loose This is not actually not a good example of that but but having normally though having a one on one discussion about a movie You can get two episodes on top of the regular feet there every month for simply five bucks a month. That's all and there's like there's like a seventy or eighty episodes in their if you've run out of main feed episodes. Yeah there's a lot we should probably though they we should. I guess we should say what the bechtel cast is because we are in the main feed. We're yes so this is your first episode tuning into lolita show. Go on and we'll tell you what the show. yes so. The cast is our podcast in which we discussed films through an intersectional feminist lens using the bechtel test merely as inspiration for a jumping off point to initiate larger more in depth conversations. And jamie what on earth is the bechtol test. The battle test is a media metric invented by queer cartoonist alison. Bechtel's subtypes called the bechtel. Wallace test that requires that for our purposes multiple interpretations of this damn thing but for our purposes requires that there be two characters with names of marginalized gender talking to each other about something other than a man for simply two lines of dialogue. It doesn't happen in movies quite a bit not enough and furthermore if it does happen it doesn't even mean that the is good to women. Sometimes it just happens by mistake accident. But it's are jumping off point for for a larger discussion and Today we are talking about lolita because well first of all. I guess we should say this. This episode was recorded about three months ago. It was recorded like towards the beginning of august. I think yes. It was one of your birthday month. Picks on the matriarch and normally you choose favorite movies for your birthday month than the maitree on but Does not the case here. The reason the reason we covered lolita as because throughout the summer and into the fall. And now it's winter. Just time cues continuing and things. Just don't get any better but We i've been working on a show that comes out Listening to this on the day of release starting november twenty third and working on a podcast that tracks the history of the story of lolita. So i say this story because the adaptations are just out of control. Bad and just misrepresenting. What the story is really about. Feel what you can listen to the show for for for nine hours of expansion on that but basically yeah this is the first attempt to adapt lolita by vladimir nabokov to a to a larger medium. and there's just it's so okay first of all plug lolita podcast comes out on november twenty third and then it's released every monday There's gonna be ten episodes. we're We're gonna be talking with. I keep saying it. So i keep saying we because i'm so used to like not being alone. Yeah i'm not involved in it is it's jamie it's say we and then also just like me and just all of My my friends that live inside of my brain but Yeah no. I'm i'm talking to a lot of people about just kind of like tracking this story and analyzing the book and then i talked to several psychologists who have worked with victims of child abuse. i talk with people who are involved in some of these adaptations. I talked to people who really liked the book. People who really don't like the book but as far as the movies go. It's a pretty uncontroversial opinion to feel that they all aggressively suck and push just really harmful messages. That are very of the time and also by of the time i mean still now this is still like you know our our Our calls you're still has a gigantic issue with sexualizing young girls specifically but also just young people in general. So that's what the show is about. It's a little heavier than the bechtel. Cast but If that's something you're interested in. I tried to really examine it from all perspectives and bringing a lot of different voices to discuss it and i hope you'll listen So that yeah Mondays starting november twenty third. And oh the reason. I was saying that is first of all because i should second of all because i think that a lot of my thoughts on this movie have like not changed entirely. I still think the movie absolutely sucks eggs but but for like way more specific reasons than i did for months ago. Sure so yeah. I don't necessarily stand by to the word everything i say in this episode but The movie is bad. Well that's that's the beauty of just being alive and being a person you can learn more things. Your mind can change in growth. You love to see. And that's what the bhakta cast is all about growing changing acknowledging faults from the past and moving forward and a healthy and productive way. So yes i was just really listening to the episode and we mentioned too i frankenstein. Why because it's the other the other episode. We did on the matron for your birthday month. So they'll be references to james birthday. And i frankenstein and whatnot. So if you're just like what that's why my birthday was in august. And i honestly think and this is like not even. I know that there's no way for me to say this in a non biased way. But the i frankenstein. Episode alone is enough reason to sign up for the matriarch in my opinion one of our best. It's not jamie. This is not opinion. This is fact. So yes if you if you. I mean just what this is all to say folks that you should get on. Get on the matron train. You know for i frankenstein alone. Among many other films that again will remain locked. Were not gonna just keep unlocking episodes. All willy nilly. Some of them are in the volt is is a rare occurrence. Yeah so yeah. Enjoy our lalita episode To the extent that you're able to podcast. I recommend and again i'm completely unbiased. It's just You know just a recommendation. And i haven't been sweating about this for half of the year we'll as someone who is again not involved in lowly podcast. I also recommend hell yeah Without further ado here is our unlocked. Matriarch episode about stanley. Kubrick's lolita hate that run of words and joey del high. Maitree jamie. it's your birthday. It's jamie's chaos month on the matriarch on and boy do. We have a chaotic month for you this year. We just made a last-minute adjustment to my birthday month. In a way that i really think makes the whole feed vibrate. It's it's so today. Obviously we're we're doing lalita a very heavy serious movie with a lot of heavy serious things to discuss. And then at the end of the month as a pallet cleanser. We're going to be doing i frankenstein. Which is a movie that you don't even need to watch because it's more fun for us to tell you about it than to watch it. You watch it. Because bill nye he only and i also feel like genuinely if it came down to it. Aaron eckhart would pay you human dollars to not watch it which is a reason to long. Yes it's a greedy frankenstein movie. But here's a twist it's about do you remember. I love this movie. So well i frankenstein markets itself as a movie about i frankenstein But it's actually about the war of demons versus gargoyles. I vaguely remember that. But all the gargoyles the gargoyles heroes. Which i also like keping like wheat gerke. Whales our heroes. They are in this movie. The animated series gargoyles. You know that they are having saw that. Everyone roasts me for not. I just didn't see it. I was watching. Power puff girls. I don't know what i was doing but for me i was like we. I thought gargoyles supposed to be mean to you but the in this one. They're the heroes and there are all royalty and they're dressed like they went to a party party. I frankenstein i e exactly. It's all connection so we're going to start with uh heavy episode or an end with the light episode. And that's going to be my birthday month because i contain multitudes but today we are talking about the nineteen sixty two adaptation of lolita by feminist icon stanley bread. We should just very top here. Since we're we're attempting to be better Given content warnings for yes the content of episodes there's obviously a content warning here for statutory rape child sexual abuse. Yeah there there's I mean general predatory behavior and also murder so there there is just the general Brutalization of women and children is going to come up in this episode And i guess if you weren't familiar with the content of lolita that that's about so if you'd rather skip this one we totally understand if you'd like to hang around. There's so much to talk about that. I think is very revealing about our culture. Yes so let's get started. I guess i'll contextualized a little bit by saying i chose this movie. I am very curious as to what compelled you do want to do this for your birthday of all times while i'm doing it for i mean i'm not doing it as a gift to myself. This is very painful material But i'm doing it. Because i've been thinking about it quite a bit lately because advertisement forthcoming. I am Writing and producing an entire podcast. That is about the cultural impact of the book lolita. Because that's something that i've always had a fixation on. I think it's very telling an in interesting if disturbing obviously but that it was a book that i because i guess we should just kind of talk about the property versus the movie because a movie that is not particularly remembered. But it's going to be the jumping off point for our discussion. In any case lilly was a book that i came across when i was twelve because right not good because it had been recommended to me by lemony snick. It in a magazine and like take a second with that So i came across this book really really early on because i was obsessed with lemonades ticket books. I thought they were the best in the world. I still pretty much. Do the author have some issues But the but. When i was twelve i i just wanted to read what he was reading and know what you know. I wanted to be liked him And so i read an interview in two thousand five. What his favorite book was and he said in a children's magazine lolita by vladimir nabokov is my favorite book and so i went to the library and i got the book and i read the book and i didn't understand the book and i took all wrong. S.'s away from the book and it's been a point of fascination for me ever since because now obviously I am an adult. And i have read the book many times i wouldn't say it is my favorite book by any stretch but i think it is a very good book and i reread it just recently to prepare for this podcast that i've been working on and what i find. Most interesting about lalita is that it seems like it's cultural legacy is just taken completely out of context. With what the story is about because you think like i guess when i was going back to reread it i was like i wonder if you don't just read it since college was like. Is there any ambiguity about what the nature of how hundred hundred is treating lolita is is there any way because i feel like our culture has either framed it as like doomed love story more kind of just like fashion aesthetic for young girls that you see pop up in a lot of Japanese fashion lines and also in. Lana del rey's music. Are the two main places you will find it. but that's like the lolita brand now is it's clothing and it's associated with this tragic love story which is how i think humbert. Lalita framed a no small part. Because of how this movie does it but in any case i went back to read the book and i was like i wonder if the book is contributing to this problem and i would say pretty firmly that it is not the book could not be more. I mean it is horrifying what you're reading and it and it does i i mean. I think that there's a lot of arguments to be had that i'm still working through my own feelings about if like well. What is this adding like what you know. And there's a lot to talk about what we'll talk about it. But i find it kind of. I guess it would be naive to find it shocking. But given the fact that i recently read the book and it is very explicitly while the narrative is manipulative. They you know it's humbert narrating his own story trying to get you to empathize with him and trying to get you on his side because it was you know in theory in written in during his court Like his trial sanctuary. So tim trying to manipulate a group of people to get on his side but he also very explicit about what is done. He refers to himself as a predator and a number of other terms to that effect many many times constantly. The book i feel like is very clear at while. Well it is a narrator trying to manipulate you into being like well. Maybe it's okay but it's regardless it's very clear. There's no ambiguity right. I think in the movies and the other adaptations there is. I don't even know ambiguity. The word it's like just interpret it completely differently and i feel like this movie. This is the first major adaptation of lalita and it just really gets us off to a horrible start and it gets weirder and worse from there. So i'm very yeah. I've been attached to this book for a long time. I think it is like an interesting case. Study at like how american culture specifically takes a story that is very explicit about being a story about the abuse of a child and turning it into a sexy story that there are fashioned lessons to learn from I find it fucking infuriating. But it's also like yeah. There's there's not a ton of things where i feel like you can trace that journey so directly so that is why i chose. It is because i had been thinking about it nonstop. Got it what about you. So i believe if my memory serves me correctly. I think i saw this movie before. I read the book I saw the movie for the first time. I think a freshman in college. It was one of those. You know mike. I'm a film student. I need to have seen lulu break. Right right yeah. I remember it making me uncomfortable when i saw it and Not feeling compelled to watch it again. then a few years later still in college i took an english class my senior year and it was like a banned books class that taught literature that had been banned in different capacities throughout history and lolita was one of the banned books that we studied. So i read the book then Yeah and then. I read the book a second time or at least i more skimmed it that time during a another class i took in grad school. I would hate to bring up that. I have a degree in screenwriting from boston university but we took a class specifically on adaptation so lolita got taught in that class. That's exciting and the kind of discussion around lolita. Being taught in this adaptation class was like hey maybe some shouldn't be adapted to film So yeah that was not. I've so many gap so that's of my history I the whole the property as a whole makes me very unsettled and uncomfortable for obvious reasons. I don't remember the book that well. I remember like i think the discussion we had in my english class around it was. Everyone's like oh it's so well written. It's such a well written book. And i remember being like. Yeah but why are we reading. A story from the point of view of a predator pedophile child molester. Like what's the value in that. And that's like still where i land on the entire property as a home so that's where i'm coming from. Yeah i mean. I think that we're not going to reach a conclusion. I mean there's never going to be. A conclusion reached on whether this is the sort of thing that should be written about at all and everyone. I mean it is like i think it. Everyone's gonna feel a slightly different way about it and it like depends on what your own experiences are. It depends on what your views are in in all this. I truly don't know where i fall. I do like. I think that there is in the same way that there are like red flag movies for guys to be like. I mean not necessarily always kinds but like nine times out of ten But but where people will be like. Yeah i know that it's problematic. But look there's good parts of it and i i am always kind of like my intent. Goes up for that. Yeah i agree that it's a beautifully written book. I don't i mean it's kind of i. Guess that's like the whole discussion of every banned books class right like. Is this a taboo. That we know happens in real life that should be discussed and if so who gets to be the narrator I think that every adaptation of lolita and now intimately familiar with all of them. There's been will all but one. I'm still trying to get my hands on the russian opera. But i've studied four of them pretty closely. I think that they're all failures to differing degrees in different ways. It's it's hard because it's like this this topic of an abusive relationship especially towards a child. It's never like it's never going to be a comfortable palatable subject for for everyone and that's just i mean because it shouldn't be at the fucking horrific thing to happen I've seen a lot of opinions on it. Obviously i've also seen Survivors of this type of abuse. Who have felt very scene. And have found the work to be sort of healing by an and i can direct you just some blogs that have found i've done deep dive into the lolita blogosphere but there are some people who feel as you do. Caitlyn that it's like. There's absolutely no value in giving the abuser voice. And i agree with that but then i also have read the perspectives of survivors of this abuse. Who feel seen through the character of lolita and appreciate who she is appreciate feeling like this is a topic that even being discussed at all and so while. I don't feel that. It is the best approach i think it is a bit of a not a bit like it's whatever the nineteen fifties version of edge lord.'. Bokov is doing a very edgy thing to try to do. And fortunately he's a great writer otherwise there we wouldn't even be having this discussion. No one would have adapted it. But that said i agree that certainly the predators point of view is not be priority. But i don't think it's a valueless work because so many people and especially a lot of young women have found value in it that relates to their own experiences of abuse. That abuse should be something that is discussed in art But this is a very imperfect and fucking complicated as hell way to do it. That there was clearly no way to do in nineteen sixty two. But there's i don't think that we've done it successfully yet. I think that it's i feel like if this movie was ever going to be. If this book was ever going to be adapted into film it would have to be animated. I don't think that there is a safe healthy way to adapt this work. That is live action is just they. It's been attempted so many times. I also think it's directly related to who is adapting the work. The people who have been chosen to adapt this work are just it. Blows my fucking mind like stanley kubrick. I like seriously the guy who's notorious for abusing his power as a director. I mean he wasn't at this time quite yet. This was his early one of his earlier movies. But but the fact that you would hand it off to a young man or like similar like not that far off from humber eight. It's just you repeatedly see this work. Put into someone who is going to inherently prioritize. Hundreds voice above lolitas. The first time. I've seen this work put into a woman's hand was literally last year like this movie was given to stanley kubrick first. We'll talk about that. Today it fails is given to adrian. Line in super-duper fails horrendous. It was given to edward albee. At one point. It fails it was given to Let me get the names right. Two of the most famous composers of all time in the nineteen seventies. They wrote a musical about it. Oh it was. By john. Carey and alan jay lerner so john. Barry wrote all the theme songs to james bond. Alan jay lerner broadway. Legend did gee-gee camel had an american in paris g. league. Even i'm i'm just like they were given lowly to all the wrong. People have been given this property to adapt. And so i feel like my personal opinion. Is that This this material has never been even given a chance to prioritize the character who should be prioritized because every person who is adapted. This material is going to. I'm certainly not implying that they agree with humbert but that is the perspective. They're able to plug into their men. Says men in their thirties or older. And so i i i. Yeah so so. Yeah well like just to backpedal a little bit about the People who have managed to find value in it particularly survivors. Who you know. Read the work and identify with the leader like that's great for them to be able to find comfort in that or find someone to identify with a character to identify with but imagine like how more effective that would be if it was a. It's like it's not helpful to be like well. What if the book was this instead but if there was a book out there that was written from the perspective of these survivor and was just as well written and was just as iconic in literature and just as influential as a literary work like. I think we do have a more books like that. Now and i agree that i mean. There has been fiction about survivors of assault and of prolonged. That have taken their place. And i think that lolita i mean it is not the perfect discussion of abuse. It just isn't It's not the only discussion of abuse that's out there. Fortunately for me and for everybody. But yeah i think i do think that there is a lot of pressure put on this singular work that was published seventy years ago to be the discussion of this topic Because i think it's the most and i don't mean this as a compliment but the most iconic one in american culture but i kinda fault that more to american culture than the book itself you know. Nabokov didn't go into this project. Thinking this is going to be the only discussion we have of this topic for half a century but in a lot of ways it was and so it's like i don't think you can really fault the author of the work to anticipate how their work is going to be taken out of context over and over and over. I think that that is like a cultural sure problem. Yeah while i do think that i don't think all of his writing is certainly not perfect and not responsible. And if i were writing the story i would fully center. Lalita and i know that survivors of assault have interpreted this book and a number of different ways and no interpretation of this work is invalid. It's just yeah it's a tricky fucking thing and it's you know it's almost seventy years old now and people are still trying to find what i mean. I don't i don't know if this could be successfully adopted. What we're talking about today was not successfully adopted and i think that. Oh it's so frustrating. I think it's so the pivot a little bit to the nineteen sixty two movie adaptation of this. I feel like the general consensus on this. That was made. That was like well. It's not good but it's just because production codes. I feel like this movie is definitely not good. It is so long boring so tedious is just because of the production. Could nothing happened but that is not why the movie is bad. I think there's a lot of reasons. Production code included. But i feel like it's letting kubrick get off a little easy to say that it's just because of the production code. I think it also is bad for other reasons. Yes and for any listeners. Who aren't familiar with what. The production code is Google it for more information but it's basically a set of censorship rules that applied to hollywood studio films. It was enforced from the mid nineteen thirties to the late sixties and it basically said that movies couldn't have graphic violence no sex or nudity or overt sexuality. No swearing things like that. The list goes on and on but It's worth checking out just to see like what the limitations were like. What filmmakers could and couldn't do what they did sort of to get around production code stipulations. There's like we saw in certain genres like screwball comedies. There would be like tundra innuendo type of dialogue and stuff like that but it is interesting but yeah like informs a whole generation of movies basically and then this movie kind of comes out at the towards the tail land that this movie had been made even a couple of years later. I mean it might have been quite different. I don't care to know What stanley kubrick would have done with this story at literally. Any point in time I think that truly just like among the worst working directors you could choose for this it's kind of astounding But that was kind of that really informed how this movie was marketed. Which the tagline for this movie was how did they ever make a movie of lolita and the short answer. A of people have said this but the shorter enter as that. They didn't And that's how they did not doing it. Given the production codes it would have been virtually impossible to even sort of tell the story which this i mean. I guess you could. I mean there's scenes in this movie that really lean on suggestion. And then it's just like peter sellars for forty five fucking minutes and you're like in various disguises like count. Olaf i'm just like this is a exhausting wonder. Lemony snick liked it so much. He's like i'm gonna base count olaf quilty. Oh but it's interesting. I mean. I think that he did do that in a number of ways. I guess that's a separate episode But technically technically vladimir nabokov wrote the screenplay to this movie once again we encounter something here that is technically true but isn't actually true. Because i have read the screenplay that vladimir nabokov wrote and albakov wrote a fairly faithful while obviously working around quite a bit but a fairly faithful adaptation of his book that i feel frames. The story appropriately or more appropriately. And there's been a number of interviews done with him and with basically everyone involved in this movie that be like almost. None of his script is used in this movie so even though his name is on it he thought very little of it and i also. I'm like. I'm not here to stand for vladimir nabokov hardcore. He's got some weird shit going on in his life and i don't mean criminally i. I don't mean anything approaching like stuff like that. But he's just. I mean look vladimir nabokov's family. They were famously executing other authors. So a lotta shit. Going on with nick rush. It's a whole thing like they're so nabokov's got his own thing going on right. He's just kind of a bizarre cultural figure but He didn't like this movie the draft. He wrote of this movie at least resembles his book. And for me for the movies specifically framing is everything and this movie and the nineteen ninety. Seven movie are framed not at all like basically not at all so yeah stanley kubrick hacked into the script. I'm sure he was also trying to get his movie to pass the production code so that it could still be made but like fuck stanley kubrick man like fuck him true. When has he ever successfully written a female character or treated. You know an actress with dignity fucking never is when so Fuck stanley kubrick. Particularly and i guess. Let's talk about what happens in the mood. We'll first let's take a quick break and then we'll come right back. I believe in having clean options when it comes to my hygiene products. I'm not trying to dirty up. The world i support companies innovate natural products. That break the norm and help clean up my daily routine. that's why i love native deodorant. My native deodorant doesn't just block odor better. It's made with goods stuff ingredients. You've heard of like coconut oil shea. Butter and tapioca starch and does not use the bad stuff like aluminum parabens sulfates or talk and it's never tested on animals. Plus it's vegan shadow to my vegans. I'm trying so hard to be one of you. So with over ten different sense including rotating seasonals native has something for everyone. We've got the classics like lavender and rose cucumber and mint citrus and herbal and my personal favorite coconut vanilla. You know sometimes. I'll get a whiff of something and i'm like Is that a delicious cookie as a delightful candle. Is that a refreshing beverage. And then i'm like wait a minute it's me it's my theory. That's how good native smells. Here's another thing. I love other deodorants. I've used dry the skin in my underarms out so much that makes them all flaky and itchy but native moisturizes my armpits and keeps them soft and silky. This is a true story. So dude i did and make the switch to native today by going to native. Do dot com slash t b c or use promo code tb see at checkout and get twenty percent off your first order. That's native d. e. o. Dot com slash. Tb c. for the bechtel cast or use promo code t bbc at checkout for twenty percent off your first order smell you later and by that i mean i'll smell. How good you smell. If you use native deodorant okay bye. Hey i'm joel. I'm at and where the hosts of how money a show. That's all about helping people save more money and that's why we love telling people about mint mobile and mint is introducing a new unlimited plan for only thirty bucks a month. How much is your soon to be ex carrier. Charging you yeah. The major carriers cannot compete with that price. Agila we've both been with mint mobile now for over a year. We love it by going online. Only and eliminating the traditional cost of retail mint mobile passes significant savings onto you all plans come with unlimited talk and text and high speed data delivered on the nation's largest five g network. Use your own phone with any mint mobile plan and keep your same phone number along with all your existing contacts and if you're not one hundred percent satisfied mint mobile. Has you covered with their seven day. Money back guarantee to get your new unlimited wireless plan for just thirty bucks a month and get the plane shipped to your door. Free go to mint mobile dot com slash perfect plan. That's mint mobile. Dot com slash. Perfect plan could your unlimited wireless bill to thirty bucks a month at mint mobile dot com slash. Perfect plan all right. So here's the recap we open on. Humbert humbert he shows up to a rundown mansion belonging to the sky clare quilty played by peter sellers. They have some kind of history. But it's not clear at this point what humbert mentions a girl named lolita and then he eventually shoots and kills quilty. Then we cut to four years earlier. Humbert is a recent european transplant to the us. He arrives at a house in new hampshire where he will be spending the summer before he off to beardsley college in. I think it's ohio. Yeah to Teach french literature now. The owner of this house. Charlotte haze shows him around played by shelley winters. My birthday twin. Ooh and today's your birthday. So that's amazing. So he's kind of on the fence about whether or not. He wants to live here but then she shows him out to the garden and out. There is charlotte's teenage daughter lolita. She is sunbathing in a bikini. And the lead is simply being there really helps humbert decide to move in mrs hayes. Charlotte becomes interested in humbert. Pretty much right away but humbert becomes interested in lolita. There's a scene where they all go to a community. I suppose it's all like does caesar so we're his. There is a lot of. I mean one thing that was done for this movie to allow it to be made was to age lowly up because in the book she is twelve. Am i right about that. He is twelve. Yeah and then the movie. She's fourteen or fifteen year not entirely. Sure the actor who plays lolita in this movie. Sue lyon or jane at the shooting oche fourteen at time shooting. Okay yeah got sixteen when it comes out got okay. Yeah yeah so. They ain't sure up slightly and they added in like a boyfriend character. I would guess to make her seem less innocent. I don't know really what the thing but this whole boyfriend thing. This is just like invented for the movie. Okay kenny kenny. Fake fake news. Fake news kenny. And then here at this dance we learn that charlotte has a of going after men who are not interested in her because she approaches quilty who is there and he doesn't really seem to remember who she is even though it's implied that they have had sex before this is also totally made up for the invented. Yeah okay good to know that he doesn't remember charlotte but he does remember charlotte's daughter lolita. So that's comes into play later now. Charlotte kind of goes back to throwing herself at humbert. Again only has eyes for a child and they go back to the house. After this dance lalita returns and makes humbert very happy. But charlotte is starting to get the sense that humbert is interested in lolita so charlotte can lashes out and she says go to bed. You little pest. And then she kind of has a little outburst she sure does then humber starts writing in a diary or maybe he has been already but he basically started. He's like writing in his diary about his affection for lolita who he starts to call his nymphet and barf Gross but charlotte reveals that she is sending lolita away for the summer to camp because she wants to keep needs a free up her schedule to be hitting on humbert all summer right. We are to believe and humbert very disappointed by this. There's a scene where lolita comes in the house and wishes him a farewell and says you know. Don't forget me then. Humbert gets a letter from charlotte professing her love for him. Saying one of my favorite lines in fiction. I saw that you had changed your twitter bio to this. It is such a fun lie. I mean in a very depressing work. It is a fun line. I'm passionate and lonely woman and you are the love of my life. Okay drama like i. Charlotte's letter is over dramatic. And i love it yes. She's basically like get outta my house. Because i love you unless you also love me and then you have to stay and be my lover forever. You're like her insurance like i. Just i mean we'll talk about but like that letter is always fun for me. I hate the new laughs at her. I'm like this is the best writing in the movie and charlotte's letter but i loved charlotte's letter. Yes so so. He reads this letter and then he marries her. And the implication here is that he marries her so that he will have the opportunity to see lolita again But then charlotte says that she has decided to send lolita from camp straight to boarding school and then straight to college from their meaning. That humber probably won't really ever see her again so he freaks out. He starts to premeditate him murdering charlotte loudly. And all the time like there. It's so like adds to it that it's james mason just like the most british person ever being like maybe kill killer like you're just like shot up man like what are you doing. This is also this is really deviated from what happens in the book assualt but anyways got it. Yeah don't remember it well enough but humber decides against killing his wife And we're supposed to be like wow awesome like hero cool but charlotte has just discovered humbert diary in which he has insulted her and expressed his love for lolita. So she is. Distraught runs out into the street and is killed. When she's hit by a car humbert is mostly unfazed by this. He then leaves to go. Pick lolita up from camp Telling her that her mother is sick in the hospital and they kind of have to their time before until she's well so they're just going to travel around a little bit until then so they check into a hotel and there's only one room with one bed quilty also happens to be there. There's a scene where he is acting. He's like very high strung he and humbert top for a little bit about lolita and humbert returns to the room where he tries to get into the bed with lowly too but then ends up sleeping on the cot that has been brought in rights. But the next morning it is implied that they do something sexual together. Offscreen aka a statutory rape happens. Yes then they set off a in the car Humbert finally tells lily that her mother is dead so lalita is very upset. But eventually humbert. Lalita settle into a life together. And by that i mean he's a predator and he regularly again and again. This is so wildly deviated from the book. Where they're they're still travelling together but she is constantly trying to escape and she is constantly trying to get away and devise different ways to get away from her abuser. Who's continually manipulating her. In the movie it is kind of betrayed as a mostly fun road trip when yeah. I have a lot to say about the tone of this movie which is horrible Okay so now. They're living in ohio and he starts his job. As a professor at beardsley college lolitas seems to be getting bored with their relationship. He doesn't like that. She hangs out with other boys at school. She wants to do the school play but he won't let her so then quilty comes in. He has written this play. He shows up pretending to be the school psychologist. And convinces humbert to let lowly to be in the play but humbert finds out that little lolita has been lying to him about where she's been in who she's been hanging out with they get in a big fight but eventually she's like okay humbert. Let's go away again. So they set off. There's a car that's been following them for a while. And then lolita gets sick and has to be hospitalized but when humbert picks her up from the hospital the staff says that another man has already picked her up so he freaks out. He doesn't know where she is. He loses contact with her for. I believe few years. Yeah and then humbert after some time receives a letter from lolita honey. So he goes to see her. She is married to a young man. She is greg knit with his baby and she reveals that she had been having a relationship with quilty during this time that she was in the school play and then i think also before because he follows her around wherever she goes. Yeah it seems yes And it was him who had picked her up from the hospital lowly to says that she was always in love with him but she did care about humbert humbert gets her to try to run away with him but she refuses so then he goes to quilt is mansion which is the scene we see in the beginning and then he murders him and then we find out that he dies of coronary thrombosis before the prison. Yeah so that is the end of the nineteen sixty two movie again. I mean we will continue to repeat. This is unequivocally a story of a child. Being repeatedly abused by a guardian. Like there is no ifs ands or buts about it and this movie however i don't know what this movie thinks is going on because it seems like it is mishandling everything at every turn and where it linked to start as a sort of like for shy not fortunate alluding to this a little earlier of the way that this story is framed. If you're going to attempt to tell it which. I agree you don't have to. It exists as a historical moment of this topic attempting to be discussed in the nineteen fifties. That is very worthy of criticism. And that's in one place. If you're trying to adapt this responsibly. I feel that the framing of the story is very important. Because for you know the book. I feel like i'm like the book but it is important for this when the way that the book frames humbert humbert is that he is narrating his own story. He is doing so From prison trying to convince a jury to let him get off from these crimes that he's committed a murder but also he is admitting that he is a rapist of an minor. So this is something. He's acknowledging over and over so he is perhaps not a his perhaps an unreliable narrator yes juice but not just that caitlyn there The book starts with a An introduction by different fictional character who basically tells you not to trust a word you're about to hear and so just based on my own research and experience with the like the book is intended to be an experiment of you're told very explicitly at the beginning of the story. Do not fall for this person. Shit they're lying and then the book becomes well. Will you fall for it anyways. Basically this is completely absent from every movie adaptation and it is so important in to like if you're going to adapt it this has to be included like it absolutely needs to be included. Another thing that humbert again. It's like he's a fucking liar. So you don't know really. I also think it's weird that it's commonly accepted that charlotte just happened to walk into traffic. I always on like. I think he's lying about that but whatever yeah he probably pushed her he probably killed her like why but even like literary scholars are like. Wow he really looked out there. I'm like i'm tired. I feel like he just free. Meditating her murder. I don't know if that is in the book. Well that doesn't happen in it. But but like all the on her way to report him for being a criminal of the highest degree. She happened to get hit by a car. I mean give me a fucking break but in any case this framing is so important and humber. This is included in the nineteen ninety-seven movie but also in the worst stupidest way possible. He also mentioned at the beginning of the book that he had loved and lost. A young woman was about lolitas age when he was that age and i and he uses that as a manipulative narrator to get you to say well. This is why i did this. Horrible crime is because something bad happened to me. When i was that age which is a very manipulative tactic that is used by a lot of abusers again. This is completely omitted from this. I feel like this movie. I mean told me if you. I feel like this movie. Pretty just presents hubbard's narrative as fact as this is what happened period. Like there is no yes. The movie does not question him at all at all. it's ridiculous. There's no implication that he might be an unreliable narrator. They're like these. Are the events of the story. This is exactly how they played out explicitly. He does voiceover. Like i guess he he is the narrator. But there's no. I mean like for your average viewer and unreliable narrator is like a concept that you need to make pretty fucking clear like you can't just be like here's james mason a very established movie star who you probably like. Don't believe him like that is a difficult. That's a difficult concept. You have to make that super-duper clear yeah and i won. I mean i've really tried to follow the threat of like well. Who thwarted this from happening. Because nabokov screenplay includes everything. I just talked about. It includes the character at the beginning. That is like don't believe anything you're about to hear it includes if you're gonna try to adapt it the things i think but an like well who does kubrick's say don't bother does the production code state like who is the person that says no it bothers me and it's just dooms the movie too. I mean any live. Action interpretation of that is translated faithfully. I think is not even worth trying and is just is irresponsible. But this one in particular. I mean it's like you're not even fucking trying. I know i know the code and like don't go in the comments about the code. We know about the code but in that case hats fighting outside there is no a bunch of cats that fight in the alley. Next to my house. I live in a cartoon. So what happens in this adaptation in the sixty. Two one is the story because there. There's no mention of like believe anything. This man says don't fall for his manipulation tactics. The movie gets framed as being like almost like a romcom. Like yeah there are. There's a lot of visual jokes about bow like his attraction to lolita the inclusion of peter sellars at all like a comic actor of this era. Take some way too much screen time in this movie but that aside that's a deceptive very specific decision. You're making by putting a famous comic actor like second build in this movie right. What are you saying lega. Yeah yeah so like the tone that this movie takes absolutely think is horrendous because it friends a lot of what happens as comedy and as jokes i can say some examples at some point but and while the movie ends tragically for humbert like he kind of gets his comeuppance. I guess to like the not degree that he should have but like he does. That is how they end his story in the book. But it omits. I mean the the one thing that this movie does that i think is at least interesting and not just like blanket. I hate it is that it gives lolita a happy ish ending Which is not how any other adaptation nor the source material and in the book economically. She dies in childbirth. And as i mean it's just a tra- like she has a tragic life and passes away very young which wo and i was reading it at the time like i i really loved lulita and i kind of like looked up to her in a way that was unhealthy because i was misinterpreting what was happening but i cared a lot about the character and like to know that she dies at the end at least helped me understand a little bit that she had been done this huge disservice in her life that her life had literally been taken from her This movie does not go this way. It kind of ends kind of optimistically for her. Which i would suspect has something to do with the code of like well. Don't kill are titular character. Who never did anything wrong. It's the only choice that's movie makes that is remotely interesting is not is allowing lowliest character to live on. Which i i you know. I don't know. I guess i don't feel one way or another about it. It's interesting it's different sure There are two things. I do remember from the book. It's been a while. It's been fifteen years since i've read the book so i don't remember it very well okay. Let me know if i'm remembering this correctly jamie since you've read it more. Recently is there a component of the book. Where humbert as he's like writing in his diary and describing his relationship with lolita. I feel like he's often saying that like she is coming onto him by like. She's he's always like she's a nymphet. She's like a nymphomaniac. she's always trying to initiate like sexual contact with me. he like. he's kind of blaming it on her. I remember a lot of the tone of and that's a lot of what his character does. In the book. I think intentionally by the author is that he oscillates between blaming his victims and a deep hatred of himself so it depends on what part in the book you were in at certain parts and he blames her wholesale and a way that reading it as an adult you know is not true And is him offloading all of his own baggage onto a child and saying i mean the thing that people have said about victims since the beginning of time of like they were asking for it. Basically what he's saying by inventing this vocabulary word at all and then in other sections of the book which we really don't see in any of these adaptations he kind of switches when lalita shows extreme like an example would be when she finds out that her mother is actually dead and not zing. She grieves her and is really upset and cries for days and days and this point in the narrative he starts to go to like step zero point one of introspection and starts to feel a lot of guilt and is like. Oh my god. I'm doing this horrible thing to this child. what am i doing. I'm i'm a monster. I'm a horrible person. He calls himself like a penta pod monster like he he. There's sections where he seems completely aware of what he's doing but continues to do it anyway. Which makes him even worse right. And then there's sections where he's just blaming his victims so it's different head spaces of just a wholesale abuser. This this it's not even say it doesn't cross james mason's mind that he's doing anything wrong and i. I think that that has a lot to do with setting code aside the view that hollywood has of women girls at this time of. I think men the the way that it's like. You're saying caitlyn so often framed as a joke that this man who's almost forty and james mason was over forty Is having a relationship with a child. A person who cannot consent to them and kind of joking around like you know which was a real culture and there was a real thing that happened in in mid century america and there's countless examples of it and certainly i mean we don't have time to recap the history of how hollywood has treated child stars and how and then legacy that continues to this day of abuse that happens to young people but it is. I feel like it's treated as a joke. Because in this time you could just treat it as a joke like it. You didn't even you explain where you were coming from. It was just culturally accepted as a joke. The movie frames again. His attraction to her as like isn't it so fun and cute that he's attracted to an underage girl like and she and she's also interested in him and all this stuff of yeah. It's so it and it does lead. I think i mean. I feel like i mean this is not a hot take. I wish to god. I had not found out about this property. When i was twelve years old when i was like me as age. Because you know it's it's for most twelve year olds at that time for most young people. You're just not going to have the frame of reference to understand what you're reading. I don't think it should be a book. That's banned outright. Like if you don't wanna read it definitely don't and i absolutely understand why you wouldn't want to but when it's presented to see like who is this movie four is my question like who the fuck is even for this also extends to i mean lolita is i think to an extent demonized and made to say well this was a very like sexual fourteen or fifteen year old so i think that the movie frames that have like well. How can you really blame him. And it's like right. Yeah you can and in a shortage and you've done. But but i think that this movie has such a nothing view of a low lita. She's she's barely written at all. And i'm sure that that again code code code right but i mean i. She's robbed of any element that made her a character. Because i mean a lot of what you encounter with her in the book and to some extent in other adaptations. Is it making it very clear that she's kid and she has the interest that a kid does and she's like a really She's like a twelve year old with a big personality who likes very rebellious and has a complicated relationship with their mom. And all this stuff like You know people didn't identify with his character. I didn't identify with her when i was twelve. For no reason she had a personality that you can recognize but this is This is just kind of another thing. That's taken from her in this movie. We don't really nothing about her right and the movie has no interest in getting to know her which is just going to make it that much harder for a viewer to empathize with what she's going through right Let's take another break and then we'll be right back for more discussion Hey caitlin swim stinky sometimes time. There is a solution. it's called deodorant. We've both us yes. dot Using it for many months and our stink factors gone way down. We also what i like about native is that it's safe. It's formulated without aluminum. Parabens tallec also vegan and never tested on animals very woke deodorant. It is and it works love. This theater and i had actually already made the switch to native a while ago. And i absolutely love it. I love the way it keeps me feeling and smelling fresh all. Dang day and native has a lot of great sense for everybody to enjoy like lavender rose cucumber mint various rotating seasonal sense as well as their most popular and my personal favorite coconut in vanilla. I just put some on in the morning or before a soccer game. And i am ready to conquer the day so for twenty percent off your first purchase visit native deodorant dot com and use promo code t bbc during checkout. That's native deodorant dot com and use promo code. Tb see during checkout for twenty percent off your first purchase finance mailing alexa does. Alexa makes our lives. Better by keeping us connected to what we care about like when you realize you haven't talked to your mom in a few days all you have to say is alexa call mom or when you need a reminder to drink water just say alexa. Remind me to drink water every hour with alexa of voices. All you need in the latest episode of law school. Theresa's matt bowen. Sit down with alexa to discuss all things mariah carey and her newest book alexa. What are mariah carey's nicknames. Mariah carey is known as mc mimi mirage queen of christmas songbird and the voice. Okay i didn't even know all those to be honest i think alexa might be a lamb for those of you who don't know lambs are mariah carey. Fans mariah carey calls her fans lambs because they are a bunch of little lambs that follow her lead. I really thought we knew it all after eating our book. But there's still so much to learn clearly for more tune into the latest episode of law. School theresa's available on iheartradio. Or wherever you get your podcast going back to the kind of use of visual comedy to set the tone of this movie like there's a scene where after humbert has moved in they all go to a drive in movie theater. And there's like a scary moment in the horror movie that they're watching and both charlotte and lolita each put a hand on one of humbert sneeze and he takes off charlotte's hand because he's not interested in her and he like put his hand on lolitas hand and then like charlotte realizes what's happening and he realizes that she realizes so then everyone kind of like retreats into themselves and like pull their hand away and it's like this this kind of l. and then the co- the whole kat seeing. There's like a three minutes slapstick comedy scene about like. Oh shucks for him that he doesn't get to sleep in a bed and he has to set up a car. It's like the fact that this is a predatory statutory rape is. It's joke it's a long and it's a long joke. And no matter like how fucking like brainless you were in nineteen sixty two. No one could laugh at this joke. It is not just horrible in every single it also another thing. That frustrates me in these adaptations. And this one is no different and no disrespect to shelley winters. She is not given really the tools to succeed here. Nor was melanie griffith. Who gives my favorite charlotte performance in the nineteen ninety-seven movie unless was really good. Having been given nothing right but again charlotte is just because these movies take humbert word as law. Charlotte is portrayed as this as this very shrewd real clueless like not particularly intelligent. Hyper sexualize monster. Yelich pathetic desperate hysterical jealous like every negative poultry child and yeah and again. This is taken as law. I n i. It's like you can't know also these people don't exist. I know that but there's just again in literary analysis this interpretation of charlotte is taken very wholesale of like. Yeah this annoying woman who You know presents herself as an obstacle in the first act of of this story she obstacle but again. It's like if you think about the fact that you're told at the beginning this person who's going to misrepresent everything to make himself look better. Would he not benefit by making her look like a horrible incompetent. Mother would he not gonna fit from portraying her this way like. I'm not claiming that this character would have been a perfect person. It sounds like from the jump. She and her daughter have very contentious relationship. Lots of twelve year olds do with their mothers. They also like she in in the book. This is i. Don't remember if this referenced in this movie. I've seen so many versions of this apologize if i'm getting this wrong but She has lost a husband that's reference She is not. she's very cruel about it. In this movie they really. They're like well he didn't have sex with me. Good so i hate them. And you're like that's not really anything that know in the movie in this movie. She was like she was obsessed with him. Yeah in the nineteen ninety-seven one. She says he didn't fuck me right. And so i don't care he died. And you're like that's not something people say either way she's like in mourning. There's also a long tangent. She goes on in the book of like. She had lost a baby when he was very young. And lalita had a brother and that he passed away very young and she had never quite fully aggrieved that and that that informed her relationship with her daughter was morning this other child and that was one of the things that made their relationship free complicated which is really interesting and not something that is often discussed of like this deep depression that she would have been in. How does that affect the child who lives on in like this is a real world problem. It's i'm not saying that. This is the best exploration of it. But it's just kind of like all of that is pushed aside even though. I think it's interesting in the book that you're giving that information to make of what you will and then he's like she's annoying and you're supposed to take that as law like that's whatever that's part of what the books trying to do but the movies just they're like nope cheese annoying. We hate her when she dies. It's better that that he gets lolita away from her. Like that's what the movie one-sided and it's like i get that like even the viewers of the movie are not gonna think that because they know that he is a bad person. But i feel like the way. Yeah the way he builds up her character is to make you not feel too bad when she mysteriously dies the second. She's about to report him. He kills her. I'm just like how all these fucking the literary geniuses are like no. She walked into traffic. She was confused. And i was like he killed her. Whatever right the also she. She's given like a gun like she's give it that whole thing. Like that was a whole weird. Yeah that doesn't have she she's like the gun isn't loaded and he's like it looks. It is loaded. So like every every way she characterized just makes her seem so the the movie frames that whole situation as like the movie wants you to root against humbert being with an adult woman charlotte because of the negative way that she's characterized and the movie once you to route four humber pursuing a child. The movie frames at horrifically. And yeah again. It goes back to the fact that it doesn't question. Hundreds interpretation of events at all right. There's no context as to why he's presenting this information this way and what he wants you to take away and again. Yeah in every adaptation. Charlotte is done a huge disservice. I people don't really talk about that. Because i mean obviously because lolita has done the biggest service of all where she is in most cases erased from her own story and her at any reference in the original work to her emotions and her grief and her confusion and her figuring out what is happening to her and repeated attempts to get herself out are essentially erased or severely condensed to make hurt just less important to the story right to just invalidate her feelings in her experience. It makes me so sad for. I really love her as a character and philly. There's a real opportunity here to examine a victim's story. Do i think that a you know. An older man is the person to do this. Of course. I don't. But i being that she is this. You know i- conic character in american literature. She's just never been given an opportunity to show. Even what's on the page much less explore deeper. Which is what a lot of good film. Adaptations of books are supposed to do is take the important character and then give you a deeper look at who they are and what their struggle is and what their grief is and and all of this through the performances and it's just not allowed to happen here which brings me to thing that i hate. The most about. This movie is a problem that follows through. Every adaptation of this as supersizing cleric quilters role in the narrative This is a creative choice. That made literally every time. And i hate it. He is present in the book. he's not wearing. Count olaf disguises in the book but there but it is implied that he and dolores had known each other like when she was very young and he had been grooming her and it's kind of left ambiguous in the book as to. What actually happens. Which i just of can't be to it. But he was certainly grooming her in in the book from a very young age and does follow them as he doesn't this and is killed at the end but this movie just i mean i think because as movie doesn't know what to do with its title character and has no interest in exploring the fact that the protagonist is a fucking criminal of the highest degree They just super size another male character right and try to deepen the history and their relationship with humbert and quilty. And i just couldn't think of like a relationship between two characters in this story that i care about less. I don't care about two predators. And how their enemies like. Who gives a fuck like it. Just i hate it. It's such a lazy choice. It's such a like of course you hand off this extremely difficult problematic story to a male director. They just kind of her. Like i don't know let's let's get other character in it more so i understand what we're talking about like i hate it. This happens in the nineteen ninety-seven movie happens in the musical. Happens in the headwear albee play. Which is it happens every single time. And i and i think that that choice especially has a lot to do with not the code. This is choice. Where i'm like. This is not the code. This is the filmmaker making a choice on how to handle. The code is like oh. I know what i'll do. I will make a like male predator character way bigger even though the lead character. This is a male predator. Why do that i just. I hate this choice so much. I think it's so lazy and bad. I hate it especially mad. So silly. why he's like. He's being peter sellars. He's like in every scene he's in. He's doing some kind of character right. He's like in disguise us pretending to be other people specter clues owing it through this horrifying dense narrative. It's just like that is not no that is not. He's to know what movie you're in. Who do you think you are bill. Nye he and i frankenstein. You just didn't read the script and you showed up and you're like i'm doing. What like it just easily. Dana carvey and master of disguise. He's like i can just remove yourself. You just need to go and read a book for one like just. It's so infuriating that this character is and it's always done in slightly different ways franklin. Gela plays him in nineteen ninety-seven use any plays the character very differently. Regardless it's still a huge part and it is not written as a huge part. I think it is just a choice. That lazy male creatives have made to handle the part of the story that they are ill equipped to handle. An ice is very clear. You know if you have agreed to adapt this work and you do not have experience as a survivor of abuse as a young person yourself. The first thing you do is research that and stupid to people and know what your fucking talking about and adapting like that's just like lodge like the one you like. Do you know what you're talking about in your work like it makes me so mad that these mediocre fucking. I don't care like about stanley kubrick. So whatever dragged me. I don't give a shit. He's terrible women. And i just i whatever i know. He's made good movies. I don't really care. I just think it's so irresponsible and so lazy and just the fact that people have even attempted to say like. Oh this is a this movie is bad because of reasons that have nothing to do with the filmmaker who also wrote most of the movie. It's like you can't. I mean i agree that the code is a big part of why this movie is never going to work. But it has a lot to do with stanley kubrick all whole loss it just so yeah because like because when he does decide to have lowly onscreen this okay. This is something. I'm kinda like figuring out in real time. So bear with me here but like even the way that she is introduced onscreen visually the first time. We meet her character in the movie. Yes she's lying on the lawn. She is in this kind of seductive pose or what the movie would have you think is that she like is wearing these sunglasses. She liked tilts them down in a very kind of like fem fatale way. I feel like she's like licking a lollipop. She's like well the thing is she is not actually doing that in the movie right. This is fascinating. And i think it's like okay. I know i'm like prepared to do this. Podcast and so. I'm like really in it but she doesn't actually do that in the movie. You remember it that way because that is what is on the poster and that is what happens in every like she is presented very sexualize and male gaze in her introductory scene. But this whole image. That is the i think. The most prevalent image that people have taken away from any version of this story as the young girl wearing heart shaped sunglasses and licking lollipop That exact image does not appear in the movie at all. It doesn't occur anywhere it is something that exists nowhere. Like it is fucking fascinating to me that it that that i mean. That's just marketing. That is literally just marketing designed to titillate a male. Viewer into thinking you know. And she's making eye contact with the camera and that image. It's strictly marketing. It has nothing to do with anything. But it's the thing that everyone took away from it including me. Apparently i wish is introducing. The movie is similar where she is lying on the lawn. She's wearing a bikini. There's a lot of people who have including the actress. Sue lyon who. I want to talk about a little bit as well Who she she implied and many people involved with its production implied that she was chosen because she was more developed than many girls her age and she's presented that way she's presented in a bikini She's you know hanging out. On the lawn she sunbathing. She looks at him very seductively and starts teasing him. Right away. This is a very hyper sexualization of how it's presented in the book the ninety seven movie you get a different hyper sexualization in the book. what it is is. It's a young girl laying out on the lawn reading a magazine and man everything else is like. It's a very ordinary image. But the way it's written by a narrator that you have been told not to trust is hyper sexualize and every movie kind of adapts. It whole this. It's the same problem is like the framing and the male gaze that comes with this is coming from the unreliable male gaze that is presented as in the book and just right. It's just these. Like i don't know like stanley kubrick. Never read a book. he doesn't he clearly. Hasn't been in grad school kaylynn. I mean he also made a movie. That i mean with the shining that stephen king hated. He's batted adaptations as it turns out. He's like he's i. I just don't like i know that. He's makers have i just don't care i don't care i don't have time sorry only so many so like what. My point is that. I'm still trying to figure out but i like the movie. Does frame a lot of what she does. As being seductive. Which i think kind of goes to happens in in the book where he's like. Oh this this nymphet is ten til ising me and like we see we see that in the movie where like she's right beside him like doing a hula hoop which is just a normal activity that a child would do but because he's a predator he is like living being is right in that shot. Like he's yeah. Do you see her. see him staring at her. But what we need. But because because this movie doesn't make it clear at all that he is an unreliable narrator the movie just makes it seem like she is deliberately tantalizing him so yeah i think what if we're landing her. It's blatant is in the same way humbert does by not framing it as like it blaming her. Yeah i think for that to be approached differently you okay remember the scene in fast times at ridgemont high. Where phoebe cates character is getting out of a swimming pool. And then you get judge. Reinhold 's point of view like fantasy version of what. He's seeing her in slow motion and she's being really sexy and seductive and she takes her top off. It's like male gaze for days and then it cuts to what actually is happening where she like jumps out of the pool. 'cause she's like choking on water and it's like she's got hair all interface and it's just like i so i totally agree like it is a very simple. I mean maybe goofy for thing but it makes it clear that what he's seeing. What is happening are two very different very different things. That's what needs to be established here and it never is never never is in any of these adaptations. It never is i- caitlyn need to send you a song that from this musical. Some people will say that the musical is the best this is ever been adapted which is just a look into how horrible the adaptations are their food. This is just so over the top that i had to laugh. But it's very fucked. This in the song goes like this. It's a lyric about humbert. The town's talking about hamburg. Something's not right with this guy. That's literally what the tone of the song and then towns person number five says who. Is this viper. That loves them post diaper. That's the line in the song that he sings. He's who loves them that and it is this kind of uncritical like bullshit like trying to acknowledge what is happening without with also while being completely ill-equipped. Do so yeah. I just that line really like i had to like. Throw my computer into the ocean. After i heard that that it's like if you want the soundtrack is on youtube. It's very bizarre. But for this. I think with the hula-hoop seen as a perfect example of like the movie is blaming her. For what eventually happens. It is setting the viewer up to say that she's quote unquote asking for it. That thing that we have heard and discussed so many different times that is like just a false narrative that has leveraged against victims And this movie is just like yup. We agreed which brings me to my last major thing for for this talking a little bit about sue lyon who played lolita in this movie. She passed away last year. And she's a very interesting figure in movie history. I've done quite a bit of research on her there's not actually a lot Because and this is a kind of continuing trend that young actresses who are cast as lalita historically don't tend to work for very long and i think that again it's everyone is different. I'm not trying to loop all of these people into the same narrative but there are similarities. That i think are worth mentioning which include the fact and i think it really speaks to hollywood issues. Not even issues with the story. It's more societal. Issues of sue lyon cast as an unknown. For this par- she's she later describes. What sounds like she she has like. Isn't this funny in the eighties. But what she described. I thought sounded very fucked up. She she went to this audition with stanley kubrick. And she frames us by being like and you know normally when you condition. They're like okay during this way this way Here's the line. Thanks for coming in cea. Whatever but she said this audition. He asked her very personal questions right when she got there and he said do you. Where do you go what do you do. What time do you come home. What does your mom think of you. Where did you get that dress. What what size is it like. Astro all these personal questions in order to get the roll rate so already. We're like okay if you didn't remember why you hated stanley kubrick. There's the fun reminder. But so she she's put into this movie. She wins a golden globe for playing his part And then goes on to really not have much of a career and then she retired from acting pretty young. She has a very tumultuous personal life. That is not really relevant to our discussion. But all that to say that. I do believe that. There is a stigma that comes with playing a role like lolita especially when it is written as air responsibly as it regularly is And he's adaptations. Where i mean. It's like peter sellars certainly didn't have a fucking problem getting work after being in this movie. James mason certainly didn't have problems shelley. Winters didn't have problems. But it is these actresses who are sexualize d- over sexualize playing a character that is in its essence misrepresenting and blaming them. For what is happening to them and then you see that they don't even really get to reap the benefits of having start in this huge movie. They're kind of discarded by hollywood and by the culture at large of. Yeah i mean. There's most sue lyon movies shoes after this. You wouldn't really know and a lot of the there's a similar line can be drawn for the actress. Who played lalita in one thousand nine hundred seven. It is like a common trend for this character and just extends my frustration. And my problems with this of like. I think with what she's given. I think sue lyon does an excellent job. And i feel the same of dominy explained in nineteen ninety-seven and the fact that they should have to in some ways it seems bear the brunt and the consequences of the people around them. Mismanaging story is so frustrating. To me. I mean it just truly no one else in these productions suffer except i mean. I don't want to say that. But like career-wise stanley kubrick's fucking fine adrian. Line i mean. At least you can argue that adrian. Line didn't make a move for lebron. Yeah but by and large reputation wise and typecasting wise. Jeremy irons went on to play a number of roles. And he's fucking the worst person have ver- Like i just. I just find that trend to also be frustrating because it just extends this blame onto the person playing the character. And that's just. I hate that so much. Yeah it's awful. It's also very telling of just were. We've been culturally where you know. We just blame women for everything abso i. It really frustrates me. I'm sorry for bringing this movie. But i do. I mean i'm very curious as to what our listeners think if if you Were listening to the episode. It's such a complicated work there so much to obviously talk about But also the ways that i mean. I i feel like of all the irresponsible adaptations. The adaptations of this book in particular have been egregiously terrible to the point. Where i'm like if this is how it's going to be remembered culturally. Do even want the book to have been written if it's just going to be given to people that can't get to stem market researching like so absurd to me because victims. I mean i think victims deserve better than lolita in general for sure but victims deserve better in these adaptations as well like. There's yeah. yeah so. This movie is upsetting and frustrating. And historically i guess i would say it's relevant and marks a very specific point in time but i also i'm just like if you're so out here being like it was just the code It wasn't it definitely wasn't there's a lot of other things at play here. None of them. Good no the one other thing. I remember pretty distinctly from the book. And i only remember this because i remember bringing it up in the class discussion. We had during the class. I took in college. Where in the book. A humbert is like obsessed with lolitas iq. He's always talking about how she has a high iq So let's start of course by saying and jamie. I don't have to tell you this. But like i'm in i q iq tests are like bullshit based on pseudoscience And you are in mensa. Yes that's what i meant to say. Yeah no it's it's Racist sexist you name it pseudoscience. Yeah he does. I mean i think he intentionally many points like tries to. I think what he's trying to do. There is try to make it sound. Like she is i. He's like well she's smart so that means that she's older than her age like just exactly trying to play that angle. Yeah because like i q stands for intelligence quotient. Which is a number that you get when you divide again in. This is all like bullshit since. But it's when you divide your mental age which is a number that you get from an intelligence test. Divide that by your actual chronological age. So if someone's scores a one hundred and fifty q. Test which is considered to be a high q. And you take that test when you're ten years old it means that your actual your chronological ages ten but your mental age is fifteen so i feel like humber is so obsessed with her. I q because he's like well she might be twelve chronologically but she's closer to eight clearly. I mean it's like it's it's so yeah he's he's just a fucking bullshit liar where yes. That's for like reading levels and math right. Nothing intelligibility to consent like it's just so. Yeah bad faith. Ridiculous but i do. Yeah that i. But i feel like that is like like four predators who tried to justify their behavior. They'll they'll cite like. Oh yeah. she was. Maybe technically underage but she was so mature. Yeah i feel like the very common tactic. Yeah yeah i. I mean humber. Humber certainly in in bodies a lot of common tactics of manipulative abuser. I mean yeah hell and that's something that could have been in the movie. Where like if we see him trying to justify his behavior through. You know the mental gymnastics. He's doing and then we see other characters be like wait a minute. That's another opportunity again if you're going to adapt this that's an opportunity to have as a filmmaker to present these things that he is saying in this very fancy flowery language in the book and then just having to have that character say as dialogue when it will sound predatory and ridiculous and will scare people. Because it's like you know he doesn't have the luxury of talking his way around the topic as he does in the book. That's an i mean. That's something that you could have explored of like. How does this person tried to justify himself in real time and of course it's going to catch up with him and Also a lot of what. The book deals with that. I think that the movies are successful in is society's failure of lolita not only are we. Seeing this predator succeed in taking her away again and again again we see. Her communities has failed her. Her school system has failed to her. Government has failed. Her law enforcement has failed her. She's been failed at every level and that partially due to this kind of extreme passiveness that existed in the nineteen fifties in the us and like That was very deliberate. Commentary that again. It's just like this movie has no interest or ability. I don't know which but like it just is like peter. Sellars is funny. It's like how is this where we are like. Yeah well wouldn't it be funny if the hotel is all booked up and they can only have one room because there's a police convention there and oh the irony of a pedophile. Who's you know breaking. The law has to be around a bunch of cops t he. What a funny obstacle. It's infuriating it's so like it yeah creating a comic situation out of it all of it. It's just it's it's a it's a waste of everybody's time and it's worse than always time. It's actively detrimental to telling a story. That could be of use to anybody to anybody. And i feel like that's i mean that's why nobody talks about. This movie is because the the book is very controversial but some people have found value in it. Which is why it's such a debate. Does movie no one is ever found value in so no one is like what about peter. Sellars like no one like. It's it's a useless useless movie. And i and i hate that. Sue lyon and shelley winters had to deal with any part of it Thank you for being willing to discuss this with me. I don't worry. I now i have. I'm i'll be using this as collateral. No what's the word no something to to yeah to because You know there's some some movies that. I know you don't wanna do that. I'm like we're fine. I did indiana jones. A let them but in any case. Yes i agree and i. Yeah i just might. Thoughts have been very consumed with this property recently and so wanted to bring it on the back deal cost and talk about it with you. It's yeah it's just Wow wow Yeah so feel free to leave your thoughts in the comments. Were very is always very interested in what you have to say. I did not honestly pay attention to if this booby past. If this movie passes the bechtel tests. I don't give any manner of fuck about that it does. I don't really care. Think it probably does leader and her mom. But i truly does. I just yeah. I don't really care it. Doesn't i don't think it matters for this movie. It doesn't matter no. It's not really relevant to this discussion. And i honestly don't know how to give this movie nipples either. I guess i would say zero. I'm going to give it negative one million nipple. Yeah i guess. I'll just say negative. I guess i'll say. I barely know that this even applies to this discussion. It is like the portrayal in this there. There wasn't even an attempt. It took a flawed attempt at portraying female characters and erased. Not just nabokov's problems but the entire character. Just turn the pencil over in or eerie. Like just it. Everyone deserves so much better than what this movie had to offer and fox stanley kubrick. And that's why the other adaptation the the other film one down is the station it adrian line. He shouldn't have worked for a long time. After that. i tell you what adrian linemen in particular. I just. I watched it today. And i feel terrible. You know what. I need to do as a pallet cleanser for having consumed all this little all these lolita movies as hard candy boo hard candy. Is everything these movies are not. It is a row and That was that was a fun episode to record. Yes yes i. And i feel like in a way you can view that movie. S kind of a response to movies like lalita. Yeah i think. Someone like saw stanley kubrick's lalita and they're like well I could adopt that better than this. And then they made hard candy. I just it still is so infuriating to me that the image that people take away from this movie doesn't even appear in the movie. That's as everything you need to know about this movie. It is tricked me to like i had mapped the poster onto that scene. I guess like almost everybody feels. Like i thought this until i built my life around it for no reason like it's so i mean manipulative like it's it's very effective marketing. That is doing bad things like yeah it it is a it is a very interesting case. Study it's very fucked up and i you know. Yeah we're done talking about it. And now we're done talking lizzy check out the podcast nine. Oh how we action with that. Thank you for listening again. We look forward to your perspectives. Or we'll see it. I frankenstein yes well that was our unlocked lolita episode and once again jamie tell people where and when and how they can listen to lolita podcast lalita. Podcast comes out on november. Twenty third and the new episodes are released every monday. Right here on iheart radio or wherever you get your podcast. And that's the official language But yeah i So as far as like there is one entire episode dedicated to like deep background on This movie in particular but it's ten episode series so we're taking a look at the book. Were taking a look at the author. Were taking a look. At the other adaptations. There is also entire episodes dedicated to talking to professionals in child. Psychiatry into other ways. That people have reclaimed this text over the years and It's an interesting right. I hope that People will listen. But yeah it's just It's just a podcast. That will come out on mondays soon. Excellent well speaking of plugs because this was an unlocked matriarch episode. We said at the beginning of the episode will repeat ourselves. Check out our matron and you can do that by going to patriae on dot com slash. Bhakta cast it. Gets you access to to brand new bonus episodes every single month plus access to the entire back catalogue of bonus episodes and like we mentioned there are upwards of eighty by now and if you're listening when this comes out in november twenty twenty we just The middle of mary kay nationally month on an in a horton moments in world. History you though. This episode was a critical discussion. Wait till you get to two different. Mary kit nationally movies too much discourse for one episode. So there's a lot of fun stuff we always cover Garbage holiday movie is it december. And it's just it's a fun ride so Meet us over. And the matriarch from more buy yes indeed and Yeah all the other stuff falls on. Social media at bechtel cast on twitter and instagram check out our merge on t public dot com slash. The bechtel cast the perfect time for a baby grinch merch or as i like chicago now. Green baby boy green baby boy you need to do a whole after lita is over. You need to do a separate podcast about your journey with green baby boy. I honestly will lead the relief after after we can literally for six months ago. Like okay this. This podcast is just about baby grinch. Let's just to chase and well if you'll allow me to plug something of mine. I have a still pretty new instagram. Live show that. I do every thursday on my instagram. Which you can find that at caitlyn durant i. It's called movie talk with caitlin and it's just me and a guest chatting abell movies. It's not the bechtel cast because i do know preparation. There's no specific movie that gets discussed is just a loose condo. Where my first guest. Ken oh what a what a blast only and and i think so far all friends of the cast have been on the so far. Yeah 'cause turns out. The only people i know are former guests on our show. Why well with the way. I was thinking of it is like we truly just bring our friends on our show. That's true But yeah. I think i'll i'll keep it pretty close to to tobacco cast friends on movie. Talk so check that out Again every thursday at six. pm. Pacific nine pm eastern. And that's again on my instagram at caitlyn. Devante and i think that does it right. I think so. Yeah have a have a great week. Everybody and We'll see next week with another episode. I don't know what i was gonna say with another episode goodbye. It's true by by you probably heard a lot of confusing things about portland on the news about the federal agents with snatch bands about the tear gas about the the anarchy in the fires. Would you probably haven't heard us the truth because the reality of the situation in portland is so much weirder and so much more incredible than what. The news was willing to show on november twenty third. You can hear the truth on my new show uprising. A guide from portland. Listen to uprising a guide from portland on the iheartradio app apple podcasts. Or wherever you listen to podcasts.