Hypermobility Problems with Anesthesiologist Dr. Linda Bluestein | Glaucomfleckens Bonus Episode

[01:48] Dr. Linda Bluestein: Hello everybody. Welcome to Knock Knock High with The Glockenfleckens. I am your host, Will Flannery, also known as Dr. Glockenflecken. I am also your host, Kristen Flannery, or Lady Glockenflecken. And we're excited for you to be here. We got a great episode for you.

[02:06] Yes. And one that's pertinent to our lives.

[02:07] That's right. I— Both to Kristen's life. Yeah. And so we'll get to that in a second. Well, before we get into that though, so we had this weekend, was the second to last week of our daughter's little spring soccer. And we're also in the middle of a heat wave though.

[02:31] Yeah. And so it was like a perfect storm of just unseasonably warm weather after we've had winter with a ton of rain in Portland.

[02:43] Yeah. And it was like a switch just flipped.

[02:43] Yeah. So we had the heat plus physical activity. Yep. Plus no shade, just direct sunshine. For 8-year-olds.

[02:55] Yeah. So you can imagine. They're going to run around. You can imagine how this went.

[03:00] Yep. There was a lot of complaining. There was a lot of just the world is ending. How could you make me do this? Right. My legs don't work anymore. Which does make it difficult to play soccer.

[03:21] Oh man, the histrionics, the exaggeration, the drama was out of control, especially from our child. And gee, I wonder where she gets that from. And the final score was like 2-1, which normally these games are like, you know, 10-8. So just not a lot of enthusiasm. And so it was a struggle. And as the assistant coach for the under-8-year-old girls team named the Jelly Bean Tigers, it was very challenging to get people motivated to play.

[03:58] Yeah, but we got through it. The Jelly Beans were not being very tiger-like.

[04:03] Yeah. And our team's pretty good.

[04:03] Yeah, they are. They've been together—what, when did they start? 3 years?

Yeah, 5-year-olds, and now they're 8-year-olds.

[04:12] Exactly. They're like pretty much the same team. They're a juggernaut. They're like the New York Yankees of 8-year-old rec soccer.

[04:24] Yeah, but it did, you know, the older they get, the more they're experimenting with different sports, and it's actually kind of relevant to our conversation today.

[04:37] Yeah, physical, because we talk a little bit about sports and performing arts, and in particular ballet and gymnastics, which is what Kristen did a lot of as a kid.

[04:49] I was a gymnast for 10 years when I retired at the ripe old age of 15, as gymnasts often do. And the reason we were talking about this is because we interviewed Dr. Linda Bluestein, who's a board-certified anesthesiologist who's now practicing as an integrative pain management specialist and does a ton of work on hypermobility, Ehlers-Danlos syndrome, and hypermobility spectrum disorders. And so that's how it kind of relates to sports.

[05:20] Yeah, so, you know, we talked about how I loved gymnastics and it was so fun, and I feel like, you know, I would still do it if I could, even knowing what I know. But it turned out that I have, you know, I'm somewhere on the hypermobility spectrum that's, you know, in the problematic end. And I think gymnastics ultimately didn't really do my body any favors in my middle age. But it was so fun. And so, you know, it's tricky thinking about, do you put your kids in something that they're interested in and are asking about, and that you did and was so fun, but also, you know, that it has the potential to mess up their body.

[06:03] Yeah. So we talk about that a little bit with Dr. Bluestein. It's just a tricky balance.

[06:10] Could put them in chess.

[06:11] In chess. Yeah. No, you know, if there's other parents out there wondering about that, right? What I have learned in my struggles is you want to look for things that foster strength and flexibility at the same time. And so things like martial arts are really good, things like swimming.

[06:26] Really good. But if you have a kid that's a little bit too flexible or has some party tricks, you might want to just think about what kind of sports you're putting them into.

[06:37] So I don't know, it's a different decision for—I don't know, but something good to think about and look into.

[06:44] Yeah. All I do know is don't put 8-year-olds on an 80-degree day. 80 degrees, that's all I know. It doesn't sound—but again, they're Oregon kids.

[06:56] Yeah, they're all Oregon people in the South are like, what? Yeah, you're gonna be making fun of us, and I get it because I grew up—we both grew up in Texas.

[07:03] Yeah, but now we can't take it anymore. I'd go and I'd play soccer as a kid where it's like 100% humidity, right? 100 degrees and whatever, like you just deal with it. But Oregon kids, they're—yeah, and us too, we've acclimated. We've gotten soft. We've gotten—

[07:20] I've gotten so soft.

[07:21] Yeah, like literally and figuratively.

[07:24] That's true. So anyway, let's get to our guest here. Again, this is Dr. Linda Bluestein. And so I hope you guys enjoy this one. Do I have anything else to add, or am I just like changing the topic?

[07:34] I think, you know, for people who might think hypermobility has got nothing to do with me, or I don't know, I could see how some people might think this is maybe not relevant to them, but actually, as it turns out, it is relevant to every specialty. And Dr. Bluestein tells us why. So be sure to stick around and hear how it might relate to yours.

[07:57] Well, let's get to Dr. Bluestein. Here she is.

[08:03] All right, we are here with Dr. Linda Bluestein. Linda, thank you so much for joining us. I can't tell you how excited Kristen in particular is to talk with you today.

[08:09] I am too, but she has just been like circling on the calendar, just so excited to talk with you.

[08:21] Papers. I've been listening to your podcast.

[08:25] Oh my goodness, that's so sweet. Yeah, and you have such a fascinating background and journey in medicine to where you came to be today. And something that I actually haven't heard of is performing arts medicine. So let's start there. How did you—and just give people the background of like how you got to that point where you're focused on, you know, performing arts as one of the many things that you do.

[08:54] Well, I have to confess, I've always wanted to be a ballet dancer. That was my number one goal, was to be a professional ballet dancer. But my body had other ideas at a fairly young age, so I had to come up with a plan B, which turned out to be medicine. But when I started really digging into hypermobility—and I didn't know that I was hypermobile or anything about any of these conditions until I was probably in my 40s, I guess. And like most people, I started reading and I was like, oh my gosh, this literally could explain my entire life, right? So many people have that same experience. So I quickly realized dancers must have this really commonly. And as I started to do more research, I realized that they might not all have some kind of connective tissue disorder, but a lot of them do have joint hypermobility in one or more joints. And so by supporting them at a young age, maybe, just maybe, we can help keep people more active. Because I'm sure both of you have heard of or seen people who are in their 20s or even younger who are really, really disabled. And so I just want to avoid as much of that as possible and try to not over-medicalize, but catch people at the earliest possible stage and let them know what to watch for, what kind of things they can do. And it was a way to merge my love of medicine and my love of dance in this phase of my career where my husband's retired, and he's like, come on, join me in the retirement.

[10:35] I'm not ready yet.

[10:35] I feel like I have more left to give.

[10:40] That was just such an easy marriage for me. I love what you just said about merging, you know, the two things you're very passionate about, you know, in science and medicine. And we love it when we have people who are both artists or creative in some way and really scientific and have become physicians.

[11:00] Well, I think most people in medicine are creative. I think most people in general have creativity. But medicine has a way of just stamping that out, like just removing that entirely from your life. And so it's such a great thing that you've been able to really focus in on combining those two things and keeping it alive. You know, we need more creativity in medicine, more people embracing that side of themselves.

[11:32] Definitely. So you're certified in anesthesia, is that right?

[11:36] Right, right. My training was very traditional. I went to UCLA Medical School, then I went to Mayo Clinic for residency, and I'm board certified in anesthesiology, and I practiced for many years in the operating room. And so now what I'm doing is such an interesting path because I'm so open to any kind of information and try to judge, is this something that I can incorporate into my clinical practice? Is this something that I want to share with my audience? Because to me, the most frustrating thing about hypermobility is that there is so much low-hanging fruit that most people are not aware of. And so many people, I truly believe, end up in a worse situation than really they needed to be in because their doctors didn't know this information, they didn't know this information, and we don't have enough data yet to be able to point to certain studies, but in the meantime, we can use anecdotal data, especially if it's something that's safe, you know. Of course we have to weigh the risks and benefits of everything, but if we're recommending something where the risks are pretty low, hey, why not try it?

[12:48] Yeah. Right. So how did you go from anesthesiology into integrative pain management? And what is integrative pain management?

[12:57] So I was practicing as an anesthesiologist and started getting more and more medical problems. I had a lot of medical problems as a teenager and then was doing quite well for quite a number of years and then started running into more problems again and basically ended up having some pretty major surgeries in my left upper extremity, which is my airway arm, and which is every anesthesiologist's airway arm.

[13:21] I think even if you're left-handed, I think you still hold the laryngoscope.

[13:26] Yeah, exactly. I think you still hold the laryngoscope with your left hand, come to think of it. So it became very, very challenging for me after my last surgery. I had CRPS, complex regional pain syndrome, and I thought I would be able to go back to work. My surgeons predicted 12 weeks, because I had bone grafting surgery, so that's a pretty big operation.

[13:45] Oh my gosh.

[13:45] And because of the CRPS, I wasn't able to return. And so that was really hard. That was really, really hard. But I'm such a curious person though, I still went to anesthesia conferences and met people. I met a woman who was the editor for a pain management journal. In fact, I literally have a copy of the most recent one that I wrote right here, but that was in 2017. And she asked if I would write an article for their journal, which I did. And I was like, "Oh, what should I write it on?" And I was in an Aqua Zumba class and I was like, "Oh, duh, I should write it on pain management for hypermobility because I had spent the last few years trying to improve my own quality of life, and I had a lot of pain. I mean, I had much more pain in my late 30s and 40s than I have now in my late 50s, which most of my patients are very happy to hear about that aspect of things. So I then wrote this article and people started asking me, where can I come see you? And I had to tell them I don't have a practice. And finally, my mentor, Pradeep Chopra, convinced me to open a practice. He's like, "You're an anesthesiologist, so you know about the cardiopulmonary system, you know about gastrointestinal to a certain extent, and a lot of different skill sets that would be very helpful to manage pain in this population. And as an anesthesiologist, you do some pain management." And in fact, I did have a pain management practice my first 2 years after residency. So I was just returning back to what I had done previously. But I also really felt very strongly that there were enough people that were doing interventional pain management. And even though I had done epidurals and stellate ganglion blocks and celiac ganglion blocks and things like that, I also was having enough issues with my hands. And I felt like there's a lot of people that are doing those things. I want to take the best of Western medicine and the best of Eastern medicine and be open to many different types of treatment approaches. And so integrative pain management just seemed like a really good way to go.

[16:00] Yeah. And there's just nothing—I mean, you know, speaking from experience, you know, I'm somewhere on the hypermobility spectrum, somewhere problematic. I don't know exactly where. But like you, I did not—I always knew that I was really flexible, right? And I always had the party tricks, you know, my elbows bend too far, and I could put my leg over my head still in my late 30s, things like that. But it wasn't until—and I had had pregnancies that just were so painful, and I didn't know why. And I knew—I did know though, after our second kid, I was—I knew somewhere in my body, this can't—I can't do it again. Like, my body will break if I tried to do that again. But I didn't know why. And of course, you know, all the medical tests and anytime I had been to a doctor about anything, there's no like, you know, obvious reason why any of this is happening. And even, you know, Will here, he's a physician, he's an ophthalmologist. So, you know, that's different. But she knows not to come to me with that. But even him, you know, the thing that I got so tired of hearing is, you are fine. Right. If I could just strike those words from the English language, I would, because I hate that phrase because no, I am not fine. You may not be able to tell what's wrong with me, but I am not fine, right? And we're not allowed to say that around the house.

[17:32] I'm not at all.

[17:33] Yeah. But you know, he would kind of poke fun, and I would too. I would laugh at myself of, you know, I'm always bumping into things, I'm always having bruises for reasons that I don't know why, and you know, just all these random—sometimes I have trouble swallowing. And he said, how have you not learned how to swallow in 35 years or whatever, right? Like, all these—you do it every day. I'm just saying, right? A lot of practice, but I still trip up on it sometimes. You know, I've got some—I mean, I could go on and on and on. The GI stuff that, you know, that I've only—in retrospect, it wasn't until my physical therapist told me, you are more—yeah, God love the physical therapist.

[18:16] Yeah. Oh my goodness.

[18:20] But she told me, I have never seen someone with your range of motion. And I knew I was flexible, but that got me thinking like, okay, that's interesting because you do this all day every day.

[18:32] Exactly. Lots of people for years now.

[18:36] And I had had a cervical disc replacement, and so I had physical therapy after that. And I have, um—okay, you're gonna have to help me with the words, both of you. It's antero—yes, on one of my—so like, I don't know, one of the upper two, right? They're anterolysis. And then a couple of the lower two are retro—retro—yeah, retrolisthesis—and then I got some other weird thing happening in my lower spine. And like, who even knows anymore, you know? And it's so frustrating.

[19:09] How often do you hear this type of story, Linda, about, you know, all these—all the constellation of symptoms?

[19:15] All the time. This constellation of symptoms. And yeah, the thing is, I feel like it's not even just a hypermobility problem. I took my son, who's very athletic, and he was playing Ultimate Frisbee and did a massive dive for the Frisbee, landed on his shoulder, and went in and got imaging because the kid never complains of pain, but he was complaining of pain. The PA came back in and said, "You're fine." And what I wish she would have said is, "There's nothing fractured, but if you're hurting, you have a soft tissue injury. So you probably should baby it until it stops hurting." That's what she should have told him.

[19:58] And my story, Kristen, is so similar to yours. I kept telling my internal medicine doctor, "Something is wrong with me. I get injured really easily. My tissues, I had tearing of certain tissues during things that should not have happened." I did have an ophthalmologic problem. I had a corneal ulcer at one point.

[20:17] So, ouch.

[20:19] Yeah, that was really painful. That was actually while I was writing that 2017 article. So then trying to write the post-production part was so painful.

[20:28] Oh God. While you have an eye infection?

[20:30] Yeah. Yeah, it was awful. That's when you need voice-to-text, just close your eyes.

[20:34] Exactly, exactly. But I hear this all the time. All the time. All the time. And what I wish people would realize is words matter. They matter so much. If we just instead said, I don't know exactly what the problem is, but I want to help you. And maybe they don't know at that visit how to help, but why don't you come back? We'll kind of, you know, they could have their staff look into some resources or something. It's so frustrating when people are given messages because the labs are normal and the imaging is quote unquote normal and they're told you're fine. It's like, well, wait a minute, aren't there limitations with our imaging and with our labs? And there's a lot—with our knowledge, right?

[21:23] Totally. Yeah. Yeah. And it's so, it hurts so much to be dismissed like that when you know something is wrong, but you can't articulate what it is and they can't find what it is. And then you're written off as it's all in your head, or you're seeking attention, or you're seeking drugs, or, you know, they have all these other explanations in their minds for why it is that you have these visits with them. But that's why I love so much what you're doing, because you educate, you know, in addition to your—to helping patients, you also educate physicians about hypermobility and the hypermobility spectrum disorder and Ehlers-Danlos syndromes and all of those things. And I think it's not—for whatever reason, it's not taught, but it seems so common. So I don't know why that is.

[22:14] Well, I'm just thinking about my education, and I was taught about Ehlers-Danlos, but I guess I never really thought of hypermobility as a spectrum, right?

[22:24] Well, that's newer, right?

[22:26] Oh, definitely. Yeah, that's definitely newer. And Kristen, like you, I could put my feet behind my head, I could do all these different things, but I wasn't the bendiest dancer in my class. So we're in a skewed population, right?

[22:40] Right, exactly. That was a question actually I had. It was, you talk about, you know, some maybe some patients not having an actual connective tissue disease, but is it—I'll use ballet for an example—is it the training that you go through that makes you hypermobile? Is there some part of that, or is it like, what's the chicken and the egg?

[23:03] Yeah, yeah, it's a fascinating question. And Professor Rodney Graham, Kristen, you probably know who he is. I don't know if you know who he is or not, but he's one of the grandfathers of Ehlers-Danlos and just an amazing man. But he published a study in 1972 comparing student nurses versus student ballet dancers. And he found that the fifth finger, how much it could extend and also with 10 pounds of pressure, how far it extended, he found that that joint was more hypermobile in the student ballet dancers as compared to the student nurses, which would suggest that at least part of it is that when people are hypermobile, they will stay in dance longer. They're more drawn to the profession because they can excel at it. But, Will, to answer your question, there's also a lot of additional factors that can be involved. For example, let's say you have hip dysplasia. So that's when you have a really, really shallow hip socket, right? So if you have hip dysplasia, you can have incredible range of motion of your hips, but you might not have any other excessive range of motion in other joints. So that can be very beneficial in something like ballet, but maybe you don't have a connective tissue disorder. And nowadays, I think we're also seeing a lot of forced hypermobility because dancers are doing things, crazy things, like putting their feet on chairs. I have patients who say, oh yeah, my teacher, my dance teacher put my feet on chairs and then pushed my body down in between the chairs in the splits. So going into the hyper splits.

[24:43] Yes, yes. You can imagine what that does to your knees and to your hips. So I believe that there are some people where they start out, they're hypermobile in a variety of joints, and so then they're drawn to ballet because they can excel at it and other forms of dance. But I think of ballet in particular just because of the aesthetics of ballet. And then in other cases, I think that maybe people didn't start out hypermobile, but because of the training, then they developed hypermobility in some of the joints.

Well, Kristen, were you—you grew up as a gymnast?

[25:18] Gymnast? Yeah, yeah, yeah. And I had no problem. It was great because, you know, course, all of this I've learned much later in life, but, you know, that really builds a lot of muscle as well. So, you know, I was hypermobile, but I didn't have any issues with it at the time. I was young still, and I had, you know, the strength, I think, to support it. But then, you know, once I went through my first pregnancy, it's like my body never recovered until I learned what I had and how to support it. And, you know, I'm even just now kind of figuring all of that out. But yeah, it did. It made it easier to be a gymnast. But then, you know, now I'm like, I've got two daughters. I don't know if I want to put them in gymnastics because, you know, they're interested. And it was so fun. And it was such—I mean, I love gymnastics to the point, like you, I'm sure that it's part of your identity, right?

[26:10] Totally. But it has also done a lot. I don't know, it and my hypermobility probably have done a lot of damage. So yeah, it's always tricky thinking about, do you want your kids to do that stuff or maybe try to get them in, I don't know, swimming?

[26:25] Yeah. Couldn't be better. I think the devil is really in the details. You know, if you are at a school where, whether it's a dance school or a gymnastics studio or gym where the teachers are really respectful of the students and they're really trying to train them in the healthiest possible way, I really think that those kinds of activities are hugely beneficial because they're good for our psyche, they're good for building muscle mass, as you pointed out, they're good for social engagement, which especially nowadays, you know, it's so easy to be disconnected from people, even for kids. So I think there's tremendous benefit that we can get from doing those kinds of activities. I think it's all in how we do them.

[27:10] Yeah, right. Well, I know whenever I met Kristen and I saw how flexible she was and knowing her gymnastics background, it made me realize just how inflexible I am. It's like, I mean, I thought I was like good being able to touch my toes and I was like 25. And like, here she is able to like put her palms on the floor. It's like—

[27:35] Well, I think the word you're looking for is normal. You were normal.

[27:38] Well, yeah, but I think that's an interesting point and something that I tell people all the time, you know, you only know what your own body is like.

[27:45] Exactly. I didn't know I was abnormal. You can probably relate to this. Like, you know, you just get in the habit of basically dislocating your shoulders every time when you're young and you're presymptomatic, you know, when you put on a little top, you know, or a sports bra or something, you're basically, you may dislocate almost your shoulders putting it on or taking it off, but you just do it because number one, if it doesn't hurt, it doesn't worry you. But yeah, my husband is the same way. He's, you know, a lot less flexible than I am. But yeah, we just don't know. And you're right, dealing with a skewed population, if you're training in ballet or something, then you—everyone around you is crazy flexible too, often. So it just seems normal. But yeah, that's why he ended up having to like do all the baths of our kids, you know, because you have to like lean over the tub, and I could not do that without just really having a lot of shoulder pain. And I mean, example after example after example. And I know you're familiar with them. But what can—so our audience is largely, you know, physicians or healthcare workers or people training to be one or people who know one. What can you look for as a medical professional? What should they be paying attention to? Or what should make the little bell go off in their head that says, oh, maybe this person is hypermobile? And then what do they do about it?

[29:03] Sure. So that's a fabulous question, and I will start out with the punchline and then we'll back up. There's a saying that was, I believe, first said by Dr. Heidi Collins: if you can't connect the issues, think connective tissues. And I think that summarizes it beautifully. Because, you know, someone comes into your office and they've got gastrointestinal complaints, they're dizzy when they stand up, they've got some musculoskeletal stuff that you can't explain. Tendinopathies.

[29:30] You know, it is interesting though, because I also see so often people thinking that everything is related. So, you know, it's having that balance of, you know, understanding connective tissue and what it does and that it is present everywhere in the body. And so, you know, a great example is if you have lax connective tissue in your gastrointestinal tract, it makes sense that you're going to have slower motility through the gastrointestinal tract, which could put you at risk for SIBO, small intestinal bacterial overgrowth, in the upper gastrointestinal tract. And then constipation is an extremely common problem for people in the lower gastrointestinal tract, and they can have evacuatory disorders, et cetera. Gastroparesis, or slow gastric emptying, is just extremely common. And so people get nausea, they get pain, abdominal pain after eating, and things like that. So it's incredibly important for people no matter what your specialty is, to just be aware that connective tissue is everywhere. So regardless of your specialty, you will see these patients. And so having it on your radar can just be so incredibly helpful.

[30:49] I saw an ENT doctor once—speaking of swallowing, I saw an ENT doctor once and I was having recurrent sore throat without infection, and I didn't understand what was going on. And of course, they scoped me. What do they always do? They scope you, you know, and basically told me, no, this couldn't be related to your EDS. I was like, hmm, well, okay, if you say so. But if you think about it, why would that part of the body be exempt? You know, there's a lot of connective tissue in the upper airway. And so I was having a vocal strain and I ended up actually ultimately going to speech therapy for my recurrent sore throat without infection. And that did help a lot. And a lot of my patients have swallowing difficulties and challenges of speech and cervical stability issues, various musculoskeletal issues, you know, it's pretty much any system that you can think of is something that we need to really be thinking about.

[31:54] Right. Yeah. I used to ask people, do you ever feel like your head is like too heavy for your neck? You know, and they would look at me funny and say no. And then I'd come to find out, oh, my head was too heavy for my neck because my neck was so weak. It had so many instability issues. So yeah, I love that. If you can't connect the issues, think connective tissues. Because I think what happens a lot right now is if you can't connect the issues, say you're fine, right?

[32:18] Right, exactly. So let's move away from that model into thinking about the connective tissues before you say you're fine. Let's just strike you're fine, in fact.

[32:33] Right. Yeah. Right. Totally. And, you know, I think it's so important for us as physicians to be able to say, I don't know. And for patients to not judge us for saying, I don't know. I feel like sometimes I see people say, I just want my doctor to say, I don't know. But then I also know that I've heard from patients who are talking about another physician and they'll say, they didn't know. It's like, yeah, you can't possibly know even everything within your own pretty narrow scope.

[33:03] My husband and I used to joke, especially for ophthalmologists, I—we have a cousin who's a retinal surgeon, and we would joke that ophthalmology has become so specialized that pretty soon you're going to specialize in either the right eye or the left eye.

[33:18] Yeah, or just a part of the right eye, right?

[33:20] Right. Yeah. We have like 7 different subspecialties where you will only be dealing with 3 square millimeters.

[33:29] Right, right. Well, one thing I wanted to ask you about is you talked a bit about transitioning from your job as an anesthesiologist, you know, leaving the operating room, which I assume was not because of, at least in part, dealing with the surgeon personalities. Was that—did that play into your decision at all? I know there's like some health issues, but I mean, let's be honest. It's okay. You can be truthful here.

[33:51] Okay. Well, if I'm going to be truthful, man, I would have left the operating room a long time ago. It wasn't the ophthalmologists that were the most guilty, but my husband is a surgeon. My husband is a urologist with a U. Yes. And I say with a U because urology and neurology, of course, sound similar. So that's why I clarify. But he used to say to me all the time, you have so many issues. Your issues have issues.

Yep.

[34:18] You know, because we didn't know what was wrong with me, like you guys, you know, we didn't know. Right. And it was hard for him, you know, to understand. And as a surgeon, you're very used to having more discrete problems and you have—yeah.

[34:39] And you're either—yeah, I love having just one problem to deal with.

[34:40] Yeah. Yeah. That's fantastic. But it's the same, right? It sets up this marital dynamic, right?

[34:49] Right, you're fine.

[34:52] Yeah. And it's a binary thing. You're going to operate on the person or you're not, pretty much, you know. Yeah. And then maybe, can I, can I just say, instead of saying you're fine, can I just say I'm an ophthalmologist? Is that, does that, is that better?

[35:05] You leave your profession out of it and be a sympathetic husband. Okay.

[35:08] But we can talk about that offline.

[35:09] I can do that. Yeah. Yeah. And that is a big challenge that a lot of people face. And I see people on all ends of that spectrum. I see patients where it's do you understand what your spouse is going through? Like, this is, you know, we all have to do our part, right? I mean, we all need to recognize that, of course, we have needs, but everyone else in our life, they have needs too. So it's trying to strike that balance. And it is really, it is hard. Marriage is hard. Life is hard. You know, striking that balance can be really hard. But my husband and I just celebrated our 31st wedding anniversary.

[35:46] So you guys probably aren't even that old.

[35:50] Sadly, we are. We feel like it. We're, well, not old enough to be married 31 years, but we're getting up there.

[35:56] Yeah. Well, let's take a quick break and then we'll come back here and talk some more with Dr. Linda Bluestein.

[36:07] All right, we are back with Dr. Linda Bluestein. So Linda, we are going to, as for all of our guests, ask you to bring a couple of stories. Stories, because we love stories on this podcast. And I have a couple of prompts that were from you to remind me to get you to talk about these stories. And I have to do it because one of them, all it says is eyes and nose, which is, I mean, you know how to really get me excited about something. Just put eye in there. And so please tell us. What do eyes and nose have to do with your history and your time as a physician?

[36:46] Okay. So for those that are just listening, you are missing me blushing like crazy right now because this was so embarrassing. I was a third-year medical student. And when you start your third year, you are brand new into the clinical rotations. I know now there is a little bit more in some schools anyway, there's a little bit more of a clinical introduction earlier on in the process. But at UCLA, back in the dark ages when we had stone tablets, the first 2 years were all in the classroom and then the 3rd year you're doing your clinical rotation. So anyway, I was on the ward at one of the hospitals and I was going around with my staff and the tiers, right? I was the medical student, then you have the junior resident, the senior resident, et cetera. And they asked me about this particular patient that I was taking care of. And they asked me, "Well, how are their eyes and nose?" And I was like, "What?" And they said, "Well, go ask the nurses," because they were in morning report. They said, "Go ask the nurses this question." I mean, they clearly didn't realize that I didn't know what they were talking about. So I go into this room full of nurses that are sitting there at their own morning report. And there were probably 20 of them sitting around the table discussing different patients and exchanging information and things like that. So I said, "On rooms 302, I need to know about their I's and O's." And they all looked at me like, "What?" And then one of them said, "Do you mean their I's and O's? Intake and output?"

[38:30] Oh my God.

[38:30] Not I's and O's. And I just like, oh, and they—

[38:37] Oh, you must have died.

[38:39] I was dying. I mean, they got such a good chuckle out of it.

[38:43] Oh, I'm sure.

[38:44] Yeah. And then of course, when I had to come back and, you know, with my head hanging and tell my staff, okay, so apparently you were asking for I's and O's and not I's and no's.

[38:53] You know, that misunderstanding actually, I think, might have saved you, because going into a room where a bunch of nurses are doing sign out and interrupting their sign out and asking a question, that's like another way to get disappeared in medicine. So yeah, exactly.

[39:18] I think instead you gave them a laugh, which I'm sure they probably needed that anyway. So right, right.

[39:26] I love it. Oh, that's funny. And then you gave it one more. This time as a—I love stories as whenever a physician can relate to or experiences as a patient as well. And so you also have one that involves a tennis ball at a wedding. I love—see, this is the way we need to do it. I want like 2 or 3 words. Yeah, yeah, really get me like, okay, what on earth is this gonna be about?

[39:49] As soon as you said that, I was like, you probably were wondering, what, a tennis ball at a wedding?

[39:54] Um, so this was when I was in a really dark time health-wise and had no idea what was going on, and my doctors didn't know what was going on, and I was undergoing all kinds of procedures. And they kept thinking that my problem, my main problem at that point was like radicular pain going down my left leg. So pain that was kind of shooting from my back down the back aspect of my left leg. And so I was going to a wedding of a cousin, another cousin story, and I was gonna go even though I was in a lot of pain. And I had figured out that by sitting on a tennis ball and kind of putting it underneath that hamstring insertion area probably just was painful enough that it kind of distracted me from my original pain. And that's how it was felt to be helpful. But anyway, I brought a tennis ball for this purpose, right? So you can probably already guess where this is going. So I'm sitting in my seat and I've got the tennis ball underneath my, you know, underneath my leg, right? Upper leg. And I'm sitting there with the tennis ball and it's the middle of the ceremony and somehow the tennis ball broke free and goes rolling down the aisle.

[41:09] Oh, no. Oh, my gosh.

[41:12] It was so embarrassing. Did you have to go chase after it?

[41:16] I did. I did go chase after it.

[41:18] Oh, no. I would have just let it go. You know?

[41:21] Who did that? Yeah. You know, I probably should have just let it go, but I did go chase after it.

[41:26] Yeah. And we were sitting, you know, pretty close to the front. Nobody missed me going and getting that ball. And I'm sure, I mean, you know, balance, balance.

[41:35] Yeah. Now everybody has a wonderful weird story about a time they, you know, someone was chasing a tennis ball at a wedding. So there you go.

[41:42] Exactly. If there's anyone that was in attendance that's listening to this, they're gonna be like, oh my gosh, I was there. Oh, that's why.

[41:50] Yeah. Well, let's, um, I want to get into this, because I'm really excited about this game. This is the first time we've played this little game.

[41:57] Okay. Um, it's called for me—

[41:59] Yeah, that's for you.

[42:01] It's called Backwards Medical Smret.

[42:03] Smret. Smret. Smret. Because what we're going to be doing is spelling.

[42:09] It's a spelling test.

[42:10] Oh no. Yes, yes it is. It's a—there are two different types of words that, that, um, actually Kristen has—I helped her put together the list, but I don't know which one she's going to ask. Um, there's hypermobility terms and there's also some ophthalmology terms in there.

[42:30] Oh boy. And it's called backwards medical smret because we're going to be spelling the words backwards.

[42:38] Oh boy. Okay. All right.

[42:38] Oh, smret is terms. It's terms spelled backwards.

[42:43] I see that. Yeah. Backwards medical smret. There you go.

[42:47] Oh boy. All right. So would you like to, let's have our guest go first.

[42:52] Okay. I was gonna say I'll try to start with an easy one for you, but I—all of these words are horrendous.

[42:59] Then don't give an ophthalmology term.

[43:01] Well, I was gonna say, given that it's in the hypermobility area—yeah, given that I was struggling with terms, I'm getting a little nervous right now and I'm getting out a pen.

[43:11] Okay, yeah, there you go. Um, okay, this—see, I think this might be the easiest one I have. I don't even know how to say these things, so apologies to the listeners. This is going to be so fun because Kristen has never—she actually—this is the first time she's seen this list. And I am not in medicine, so.

[43:28] Yeah, so we get to hear her pronounce these.

[43:30] Okay. Okay. Osteopenia.

[43:37] Penia? Osteopenia? Okay, osteopenia. That's good. Now am I supposed to spell that backwards?

[43:44] You got to spell it backwards. So you spell that backwards, yeah.

[43:46] Oh boy. Do I get to write this?

[43:50] You know what? Pineo—us—no, so you don't have to pronounce it. Yeah, yeah, just spell it.

[44:00] You just spell it backwards.

A-I-N-E-P-O-E-T-O-S-O.

[44:08] Yes, very nice. Nice. Well done, you got it.

[44:13] All right, give me— okay, give me one.

[44:14] Okay, one for you. What is osteopenia?

[44:18] Lack of, uh, low bone density.

[44:19] Low bone density. Yeah, something I'm getting evaluated for this week. Osteopenia, osteoporosis. So yeah, okay, is that more common in hypermobile patients or just—

[44:29] It is.

[44:30] Okay, yeah. Um, okay, I'll do the same. I'll start with an easier ophthalmology one for you and then I won't be nice anymore. So, um, aniridia.

[44:43] Aniridia. Yeah, lack of an iris.

[44:46] Oh my gosh. I didn't even know that was a thing.

[44:50] It is. It is a thing. Aniridia.

Wow. A-I-D-I-R-I-N-A.

[45:08] Yes. You got it. There's a lot of I's in there. What does ophthalmology say?

[45:12] Ophthalmology is so full of vowels.

[45:16] Yeah, you guys have—it's full of eyes.

[45:16] You have your own.

[45:16] Yeah, it's full of eyes. It's full of eyes. That's true. And you have so many acronyms.

[45:26] Oh my God, we do. Yes, we, we, we, we throw them at people.

[45:30] Yeah. And it just makes people more scared about eyeballs.

[45:32] Yeah. Yep.

[45:34] Okay, Dr. Bluestein, let's go with— oh, this is, um, you know, topical. Spondylolisthesis.

[45:38] Oh, okay. That's such a long—it is so long. Okay, S-I-S—if I could read my own handwriting, it would be easier. S-I-S-E-T-H-I-L-O—did I make a mistake?

L-Y-D-N-O-P-S.

[45:56] I think—okay, so there was somewhere you said T-H. Where I think it should have been HT. But other than that, other than that, I did okay.

[46:14] Yeah, pretty good.

[46:12] Okay, and spondylolisthesis is what?

[46:15] Spondylolisthesis is where the bones, instead of stacking nicely, where they slide forward. Sorry, the vertebral bodies. Yeah, yeah, vertebral bodies do it. Yeah.

[46:31] Okay. Sounds painful. It is, quite. So then there's the retrolisthesis and anterolisthesis, right? And I have both because I'm a lucky winner.

[46:40] Is that common? Does that—is it like, there's no—does it usually go one way or another way, or no?

[46:45] It's very common, and it's really important to know what the grading is. And it's so—again, this is where the words matter so much. I have patients who were literally told, you have the worst spine I've ever seen.

[46:58] Oh, that really, you know, does a lot psychologically.

[47:01] So, right. I really feel like we need to be so careful with those kinds of things. And I was offered once to have a free upright MRI of my neck, and I was like, I don't think so, because I'm not having problems. I don't want to know, like, you know.

[47:17] Yeah, it's not going to change what's happening. It's not actually going to change anything that I'm doing. So yeah.

[47:22] Yeah, that's smart.

[47:24] All right, don't give me—give me a—give me a hypermobility word.

[47:28] Oh, I spent all day with ophthalmology terms. Those words are harder.

[47:32] Okay, I'll give you— I'll give you a hypermobility, and then I'm coming back.

[47:35] Okay, um, kyphoscoliosis.

Kyphoscoliosis. Uh, S-I-S-O-I-L-O-C-S-O-H-P-Y-K.

[48:07] You got it. Woo. Does covering one eye help? You had your eye covered the whole time.

[48:13] That's my— I was trying to— I'm just smashing my head to hold my brain in place so that I can think better that way.

[48:20] I love it.

[48:23] Okay, what is kyphoscoliosis?

[48:34] Oh, um, yes, kyphoscoliosis is a curvature of the spine. Um, I guess I think of like lordosis as like a concave kind of, and then kypho is like the opposite.

[48:57] I think you did okay. How would you describe—yeah, what is the definition? Because I know we put that in there.

[49:03] Curvature of the spine, the upper spine, you know, being hunched. Kyphoscoliosis, I'm not sure if that refers specifically to the upper spine having a scoliotic curve. I'm not sure.

[49:14] Oh, it's like a sideways curve.

[49:17] Yeah, it says a curvature of the spine in both the lateral and posterior directions, which can be caused by EDS.

[49:22] Ah, okay, so it's like a—yeah, probably could be lumbar or thoracic.

[49:27] Okay, okay, um, a couple more. Dr. Bluestein, um, dysautonomia.

A-I-M-O-N-O-T-U-A-S-Y-D.

[49:52] Yay, you got it. Perfect. Pretty good. I'm impressed.

[49:56] Dysautonomia. Should we define what dysautonomia is?

[49:58] Please do, because I have these symptoms sometimes and have many a time been told by this man here, you're fine.

[50:05] Oh, come on. You're making me look bad.

[50:05] Oh my gosh. Do you know how many times I've been told? No, but they are. They're just like weird little things that all on their own, it's like, yeah, nothing burger, right? But then when you see the pattern of them together, it starts to become something. And it's so important because something like dysautonomia—again, most of these things are somewhat on a spectrum. So dysautonomia is dysfunction of the autonomic nervous system, which is the part of your nervous system that controls all of your automatic bodily functions. So you're basically—your gut motility, the size of your pupil, your temperature regulation, your heart rate, your blood pressure, all those kinds of things. And especially upright posture requires a lot of effort on the part of your autonomic nervous system. So it's very common for people with these conditions to experience problems with that. But if you have the flu and you're in bed for a week, you're going to have the same type of picture. So it's knowing how much is problematic also. So a lot of times people read some of these things and they think, oh, I have that, or I've had that. But it—again, it's, you know, if you—if it's happened to you a few times, that's one thing. But if it's something that you struggle with on a regular basis, that's a whole nother ballgame, right?

[51:22] Yeah, for me it's the dizziness and lightheadedness. You get dizzy all the time.

Yeah.

[51:25] Okay, well, one more. I can do it.

[51:25] Okay, you ready? Although I'm using a lot of brain power today. You got to get ready. Squeeze your head. All right, give me a word.

Cyclophotocoagulation.

[51:41] Oh, geez. You're the one that put it on this list. Why is ophthalmology so full of syllables?

Cyclophotocoagulation.

Coagulation. N-O-I-T-A-A-L-U-G-A-O-C-O-T-O-P-H-P-O-L-CYC.

[52:31] Yay, that's impressive. That is incredible.

[52:34] All right, really impressive.

Cyclophotocoagulation. That's 9 syllables. That word should not exist. That's way too long.

[52:42] What is it?

[52:43] Cyclophotocoagulation is a treatment that you typically, it's for glaucoma where you destroy some of the ciliary body, which is what produces aqueous fluid in the eye. So by destroying it, you can decrease the amount of fluid in the eye, you know, basically, and decrease the pressure.

[53:04] So, gotcha. Which is a treatment for glaucoma.

[53:06] Well, there you go. And I've never heard that word before in my life.

[53:09] Yeah. And you probably will never hear it again.

[53:09] Yeah. That's the last time. Unless you end up needing it, which hope you don't. Thank you for playing backwards medical smret with us.

[53:20] Oh man. Let's take another break and we'll come back.

[53:33] All right, we are back. Let's take a look at some of our favorite medical stories sent in by our listeners. And we have Dr. Linda Bluestein here to listen to these stories with us.

[53:38] Our first one is from an anonymous source. Hello, Dr. G and Lady G. I have an embarrassing mistake story from intern year. First, I was only a couple weeks into my general surgery intern year when all the best stories happen, like the first few weeks of intern year. You can attest, Linda.

[53:59] Oh yeah.

[54:01] Um, on a night float service—it's getting even better—so covering multiple teams. And you know, when you're on night float, yeah, you don't know the patients like super well. You just kind of like, you're aware of the issues, but you're just stepping in and trying to make sure everyone survives over the next few hours. And hopefully nothing bad happens.

[54:21] Yes, exactly.

[54:22] So I got a page from a nurse that a patient's blood sugar was 700, which is very high. I referred to my insulin sliding scale, gave the nurse an order to give a lot of insulin. Maybe an hour later, I got a page. Is this the intern on call? I said, yes. Said, this is Dr. C, the chief resident. Did you just give my wife insulin?

[54:41] My first thought was, of course not, but the patient from before was indeed his wife. So his patient's spouse is his chief resident?

[54:53] Yes. Oh dear. Yes. And so she said, yeah, well, yes, I did give insulin. Well, she is hypoglycemic now. It turns out the blood sugar value the nurse called me about was from the, not from a routine finger stick, but was blood drawn from a line just downstream from the TPN.

[55:11] Oh no. What is that?

[55:12] So TPN is when you're getting nutrition through a tube. An IV. So if you take up blood from—oh, right, where that's going in, right? Just taking the sugar that was going into her for her distribution around her entire body and just concentrating it.

[55:26] Exactly. Measuring.

[55:24] And so you can see how that could be a false number, that 700.

Yeah.

[55:32] Lesson, lesson learned here. Oh no. So this is the story. The person who sent this in says, lesson learned: if a lab value sounds crazy, confirm the source and/or repeat it yourself. Fortunately, she was okay, but it—but I was mortified and never made that mistake again.

[55:45] I bet. Yeah, that is—I mean, we all have things like that though, right? I mean, yeah, you know, you learn something like that and it's true, you never make a mistake like that again.

[55:54] And some of the decisions that the chief resident was involved, you know, that it wasn't just like an anonymous patient and their family.

[56:03] Exactly. Yeah. And some of the mistakes you just never make because you're now smarter, and some mistakes you never make again because, like, if you're like me, you just leave that part of medicine forever.

[56:13] That's another way to do it. Yeah, for sure.

[56:18] All right, our second story comes from Colby. The first time I felt like an actual doctor was as an August intern—again, intern year, beginning of intern year—during an emergency medicine rotation. A guy in his early 20s came in with intense lower abdominal pain so severe he was vomiting. After passing him through the donut of truth, which is another name for the CT scanner, he had a testicle in his inguinal canal. I don't know what that is, but I take it it does not belong there.

[56:47] Nope, it does not. It's too high, too high up. It's not in the scrotum, it's up in the body.

[56:53] Yep. So he either had 3 testicles or one had retracted back into his inguinal canal. The patient was unaware of any issues with his testicles, and when he checked on his boys, he started to panic as there was only one home.

Home.

[57:06] I was able to palpate and then reduce the testicle in the ED, and his pain immediately resolved. I was so excited. I went back to the workroom and said, I have ball skills like Steph Curry. I was subsequently called Steph for the remainder of my rotation.

[57:26] Oh my God, that's hilarious. Colby sounds like a party. I love those two stories because, like, the highs and lows of interning.

[57:33] That is classic training, right? You make some horrifying mistakes that you're just embarrassed by, but then you do like the most amazing things that'll just give you that high for like an entire—keeps you going.

[57:45] Yeah, keeps you going.

Totally. Um, so thank you guys for those stories. Send us your stories, [email protected].

[57:53] Dr. Linda Bluestein, thank you so much for joining us. Before we go though, tell us what you got going on. Anything you promote? Where can people find you? Find you all the things?

[58:04] Sure, sure. So a few years ago, I founded an organization called Bendy Bodies. So my medical practice is Hypermobility MD, and it was originally Wisconsin-based and I had a different name, but then I changed the name a few years ago. So that's my medical practice, and then the rest of my work is through Bendy Bodies, which is an organization designed to help people anywhere on the spectrum, regardless of where they are on the hypermobility spectrum, and supporting them in creating a better quality of life through educational resources like my free podcast. And I also do offer one-on-one sessions through Bendy Bodies, which allows people who cannot become a patient because they cannot travel to Colorado or Wisconsin, allows them to get a consultation and information that they can either enact on their own and/or take to their local healthcare professionals to take the next steps.

[59:02] That's amazing. I wish I had had something like that, you know, 10 years ago or something when I had no idea what was going on. And you've also posted a couple of articles, um, that are on your website, correct? That are really, really fascinating and have a lot of great information.

[59:20] Yeah, it sounds like they are—Hope for Hypermobility. They are directed mostly towards medical professionals too for some continuing education, right?

[59:30] So this is a continuing medical education journal, and they contacted me again after writing the 2017 article. They contacted me not too long ago and asked if I wanted to write an update, and I was fortunately able to pull together a team because back in 2017 I didn't have a practice. I was out on medical leave basically, and so I had like all the time in the world, really. So writing an article back then was a lot easier. So this time around, it was huge that I was able to pull together a team to write a two-part. It ended up being so long and they didn't want to cut anything out. They said, well, why don't we make this a two-part series? And it is a subscription CME journal. However, I think we did a nice job in really kind of outlining why clinicians need to know about these things. What are the things that you could expect to see in your clinical practice? What to watch for. And then part 2 is what are some treatment approaches that I have found successful in my practice?

[1:00:26] I love that. You don't just point out the problem, you actually like are providing at least, you know, something you can do to treat it while we are still learning more about it and working.

[1:00:38] Right. And one person, you know, so I don't know how often, Will, that you get trolls or whatever on social media because, you know, all the time. And my husband is constantly telling me, don't listen to them, don't listen to them. But sometimes it is, you know, they kind of make you think about things. But one person was like reading, they read part 2 and they're like, okay, so basically eat healthy and exercise. You're telling me nothing that I don't already know. But as Peter Attia talks about in his amazing book Outlive that just recently came out that I'm just devouring, he says for people to have these bonus years or bonus decades, it's not just the what but the how. So I feel like with people with hypermobility, the devil really is in the details and it's really the how is so much harder for people to accomplish. So by giving them some extra guidance in how they can actually achieve these things, I think is really important.

[1:01:33] Yeah, I mean, you have to learn—first of all, there's a whole like process of like acceptance, right? And this new identity that you have for yourself of, I don't have a normal body, I can't do easy normal things that people usually do, but I can do these other things to help me get there, or at least a little closer. So it's like learning how to move your body, not just that you should move your body, but how should you and how shouldn't and that differs from the, you know, quote unquote normal population. So, but definitely go grab those.

[1:02:04] Thank you so much for being here. It really was a pleasure to talk with you.

[1:02:07] Thank you so much for having me. Yeah, I love what you guys are doing.

[1:02:11] Oh, thank you. Vice versa. I just want to jump out of my seat and take you to lunch and talk to you.

[1:02:17] Me too. So, hey, I'm free. Let's go.

[1:02:20] All right. All right. Take care, Dr.

[1:02:22] Thank you so much. Bye-bye.

[1:02:25] Well, that was a lot of fun.

[1:02:30] Yes, so interesting. I could talk for days and days and days about that. She was really fascinating to listen to and her story. And I know you've been—it's like Christmas morning for you.

[1:02:40] I know. Well, when you go your whole life with this thing that no one can explain and everyone tells you is all in your head, and then you find an explanation for it, you know, you just want to shout it from the rooftops. So I love what she's doing. I hope everybody goes to check out her work for sure and learn more about hypermobility and Ehlers-Danlos syndromes. It's important things. And like she said, you all have them, and you are seeing these patients every day. You just may not be recognizing it yet. So definitely go check out how to recognize them.

[1:03:13] And thank you for everybody for sending your stories into us. We love those as well. And again, let us know what you thought of the episode, what you thought of our backwards medical smret.

Smret. Smret. Yeah, that's right. Smret. It's difficult to say. You should say it in that tone next time. There's lots of ways to hit us up to give us your thoughts. You can email us [email protected]. We're all over social media, all the platforms, or you can hang out with us on our—in our Human Content Podcast family on Instagram and TikTok at Human Content Pods. And thank you to all the great listeners leaving wonderful feedback and reviews, even after all my fumbles throughout all this episode. If you subscribe and comment on your favorite podcasting app or on YouTube, we can give you a shout out. Like today, we got @DorkyDoctorSongs on YouTube. I'm intrigued. I need to go look that up after this.

[1:04:10] Yeah. @DorkyDoctorSongs on YouTube said, you two have become my battling the traffic soundtrack on the days I drive into work at a very non-ophthalmologic hospital. Well, good. I'm glad. I'm glad I could help, especially with hospital work. I'm enjoying your podcast and it even entertains my non-medical husband.

[1:04:31] Oh, yay. I love that. We like that. That's some of my favorite feedback right there.

[1:04:34] Yes, awesome. Thank you, Dorky Doctor Songs. Absolutely. Keep sending us all of your guest ideas, your stories, your jokes. We'd love to hear all that stuff. And maybe send your songs over too.

[1:04:45] That's right, your dorky doctor songs.

[1:04:47] Yeah. Um, full video episodes of this podcast are up every week on my YouTube channel at D Glockenflecken. We also have a Patreon, lots of fun perks, bonus episodes, or react to medical shows and movies, hang out with other members of this community. We're there, we love seeing you, we love commenting, all the stuff. Early ad-free episode access, interactive Q&A livestream events, behind the scenes stuff, lots more. Patreon.com/glockenflecken or go to glockenflecken.com.

[1:05:16] Speaking of Patreon community perks, new member shout out to Shaban S. Hey Shaban, how you doing? Thanks joining. Shout out to all the Jonathans as always. We got Steven G, Abby H, Brianna Lee C, Shaver W, Dr. J, Edward K, Jonathan A, Jonathan F. Love having two Jonathans in the Jonathan Patreon tier. Caitlin C, K L Leah, Lucia C, Marian W, Mark, Mary H, Mr. Granddaddy, Omar, Patrick, Roskbox, and Sharon S. Patreon roulette time. All right, emergency medicine tier, random shout out to Kelly B. Hey Kelly, hi, thanks for being a patron.

[1:06:00] And thank you all for listening. We are your hosts, Will and Kristen Flannery, also known as the Glockenfleckens. And special thanks to our guest today, Dr. Linda Bluestein. Our executive producers are Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Shanti Booker. Editor and engineer Jason Fortese. Our music is by Omar Bensfi. To learn about our Knock Knock High's program disclaimer, ethics policy, submission verification, and licensing terms, HIPAA release terms, you can go to glockenflecken.com or reach out to us at [email protected] with any questions, concerns, or fun medical puns if you have to. Knock Knock High is a Human Content production. Knock knock, goodbye.