Dr. Dave King, thank you for coming in today for Irregardless. And we were just talking about different things that we could talk about because you've got a lot that you've done. But being an orthopedic surgeon, who you specialize in, your hip specialist? Sports medicine. So, hip, knee and shoulder, basically. Okay. And I was just talking to you. And I like the ideas of like roads to success, like what you've had, like moments you've had along the way. And we were talking about the concept of every human is sun, some percentage squeamish. And I think those that aren't, I think they're some percent something else. And So I wanted to like talk to you about, were you squeamish before you went to med school? And then we want to walk into, you know, you've got med school, you're doing cadavers, but at some point you're on your own, you got the scalpel and you got to cut somebody. Yes, you do. Tell me, you kind of walk me through, were you squeamish? Yeah. So that's kind of the, I had said when I, since the time I was a little kid, I broke my arm when I was a little kid, and I remember having my cast on, and I said, "I thought the whole process was amazing," so I said, "This is what I'm gonna do. Okay, I'm set. I'm gonna be an orthopedic surgeon. I mean, I like a little kid." And my mom used to pat me on the back and say, "That's nice," you know, and then I couldn't get out of my head, so in high school, I remember I met an orthopedic surgeon and said, "I'm gonna, I would like to shadow you. Can I come see some surgeries?" And he said, "Oh yeah, great, come on, let's do this." Well, I passed out. I literally passed out, fell, hit my head. - Like you were in the room, kind of thing? - In the operating room, and when he, he was doing a shoulder surgery, and it was actually the team physician for the Atlanta Braves, where I'm my hometown, so yeah, he made a little portal site, little stab site on the shoulder, and shoved this big metal object into the shoulder for the scope to put the scope in, and I, boom, hit the ground. - Did you have like the aura or whatever that I'm gonna go? - I had the aura, I had the warm feeling, you know, I started getting days, but of course, my ego, I was like, I'm gonna be-- - I got this. - I was like, I'm gonna be an orthopedic surgeon. I can't, this can't bother me, and you can't fight it. Once you're going, you're gone, baby. - So you knew, like, okay, in about four or five seconds, lights out. - But somehow I thought, in my brain at the time, I thought I could win, I'm gonna win this war, I can beat this, but you can't. - So there is an autonomic nervous system. - Absolutely, absolutely. But it would be weird, I mean, I think probably everybody's had these experiences where you've had, sometimes blood would bother me, sometimes it wouldn't, you know what I mean? Buddy of mine smashes his bike when we're little kids and he's bleeding everywhere, but I had to get this I had to help them, you know, and all of a sudden you're like, that's okay You know and then and then another situation where you're watching something casually and there's a lot of blood on it And you just start feeling squeamish. So I mean, it's natural and even Even surgeons I think have some of that in them, but it just gets beaten out of you. Yeah You get desensitized to it. I put myself here. Yeah, - I gotta do this. - But I tell you another one, the scream is too. So I'm a full blown finishing, well, maybe I wasn't finishing. I was pretty close to the end of my residency. So I've, thousands and thousands of surgery had seen the craziest stuff you can imagine. Bloody, gory, everything. Saw somebody's leg get, you know, cut off by a propeller at the lake of the Ozarks or just dangling by, yeah, just dangling by the sadic nerve, you know, all those things, and didn't bother me at all. And then I remember when one of my children was being born by C -section. Um, my wife was awake and they were, you know, pulling and tugging. And she, she looks up and she's like, oh, I can feel them tugging and pulling. And I had to sit down. I was like, that made me, that made me like, okay, I don't like this. Let's, let's not talk about this. Yeah. I made it through that time and didn't hit. Okay. So I remember with Sarah had a C section. And I this is the first family that are the first C section that I'd ever seen. I'd never even seen a picture of it. And I was at a friend mutual friend of ours 50th birthday. And I was there. Yeah. And I mean, it just got away from me because Sarah It hit her OB appointment that day. And he's like, okay, great. C -section next week. So there's a Friday night. And I was like, Sarah, you know, things are probably gonna change in a meaningful way in a few days. So what are your thoughts on me just getting absolutely shit -faced tonight? She was like, do what you need to do. No, she was like, go for it, 'cause yeah, you're fucked on week. And 'cause I've been on for nine, and then you're going to be on. And so I get home. This funny thing is they knew you. I think I've told you the nurse knew you. And anyway, long, long night, we walk into-- we get home, and she's like, I'm going to labor. I was like, no, you're not. Like, not now. It's really a bad time for me. Anyway, end up at the hospital, walk in, the nurse goes, are you in manship? And I was like, well, yes, I am. You You know, anyway, so we get in there many hours later and Sarah starts having her C -section. I'm sort of coming back online at this point. And they cut her-- and they literally take all of your guts out, not mine, hers. And they put them next to her. And I literally was like, guys, we've got to stop the surgery. No bueno, no So I understand like having to sit down during a C -section and she has propensity, like all the anesthetic makes her nauseous. So she was actually gagging while they were doing that. And I was like, "Sir, you gotta stop." This is, you were making this so hard. So, but there's a part of me that was like trying to say, "This looks fake." I was trying to bring myself kind of down from it because it's pretty grisly. - Yeah, yeah, the belly stuff is especially grisly. - Yeah, it's like the opening scene of "Saving Private Ryan." It's just like, it's brutal. - Yeah, it's brutal. It's amazing though, how that, there's not sort of a single moment in the training that it flips, It's a process, you know? I mean, it's, you really, you, the max exposure does desensitize you to it over time. But you also take the emotion out of it, you know? I remember my older sister, she was a orthopedic OR nurse, you know, and she kind of counseled me on that and early on, and she said, "Listen, "when you're in the operating room, "it's a piece of meat, right? It doesn't feel pain, there's no, it's not a thing, right? They're anesthetized and you just look at that like you're doing carpentry and you don't even put the emotion into it. And that's pretty much what you have to do. - Okay, so when did she say that to you? - That was on the run up like during med school type thing? - Oh yeah, yeah, that's Shortly after that event in high school where I kind of passed out. Oh, I had I mean, how do you not have one of those? One of those moments you're like, whoa, I've been saying for the last 10 years I'm being an orthopedic surgeon and I just passed out in the operating room. What what am I gonna do in my life? You know, what do you recall specifically being like? Maybe I'm not cut out for this shit. Oh, yeah Oh, it was it was I remember sleepless nights, you know junior in high school and I'm like, hmm I got to get a new plan, you know, I hate - I hate, I don't really love business. I couldn't be a lawyer. I might learn to lay bricks right now 'cause I don't have another plan. - Wow, so that was actually a real moment. - Everybody else was gonna be a professional athlete and I was like, no, worth the exertion. - Yeah, you had the people who were gonna be professional athletes, lawyers or doctors or TBD, yeah or TBD. So yeah, it was funny, but then I I went back in I made myself go back in and kind of keep watching Surgery's and I got better at it there. So is there any I mean we're gonna get up into when you're doing a surgery by yourself But you've got cadavers at med school. What's it like the first time they're rolling? Rolling somebody out. Are you like that's somebody's mom somebody's dad like do you guys even go through your head or - Oh, are you kidding me? - I would think of what I would-- - And typically, I went to Emory School of Medicine in Atlanta, and you have partners, so you kind of have, you'll have a partner, you'll have your own cadaver, but then you'll kind of share things, like if you find some anomaly or something anatomy -wise, that's cool, you'll bring the other groups over and show them, and the Professor will take you around and be like, oh, we have this there, you know, but, but we, I mean, you, it's, it's just, you nickname your cadavers. - How long are you working on a given cadaver? - My cadaver had this massive schlong and had a penile implant. So we could, we could pump it up, you know what I mean? - Seriously, he was like a pair of Reeboks? (laughing) - Yeah, but I mean, it's, it's amazing. But then you're, you know, you also, you have a ceremony at at the end, so they bring the families of these people that donate to their bodies, you know, and you actually, yeah, you have kind of like a, you have like a special appreciation ceremony, and you are, I mean, there's two sides of it, it's you're, you are very appreciative. - Like, I wanted you to have this. (laughing) - We saw, I can't say, yeah, this is, I don't know who's gonna listen to this Yeah, but it was it was kind of amazing there, but you know, but yeah, so you that's it's it's super freaky I mean when you're the craziest thing I think was dissecting the eye and the hand those were the two things Besides the privates, but the those were the two things that you're just like holy shit You can't you can't help but look at your own hand and think about this and yeah, I and it's it's uh It's freakish, you know? It's what, we were just talking before we got on this though about the idea of, there's a reason why you can't spend too much time thinking about your death, right? And what is the meaning of all this? And that happens for the surgeons for sure, especially in orthopedics. But yeah, when you stare at your hand and you've done that dissection and you know what those little, what the pulleys are and what the flexor tendon looks like, it's-- There's a lot of stuff and make sure it makes your head start spinning and then you just have to kind of wash it out And get back to business. I mean we were talking about that. I had this you know partner did this hand surgery and The one surgery I've always wanted to not have is have someone put a scalpel through my palm And it's like, you know, I haven't had a lot of them But this is what I really didn't didn't want because that's like you're saying that there's something about the hand and I wouldn't go to med school but like this is there's a lot of shit going on in there and it'd be better if you didn't put a knife through it but it's just the way it worked out so when you're how long are you working on a given cadavers I like a semester long thing yeah yeah it's like it's like a full semester so you'll you'll have you know you'll you'll take essentially like a week you'll have a specifics we're gonna do the digestive system, we're going to do the heart, we're going to do the chest cavity. So you'll have a week sort of with a purpose and then you'll kind of have like a mini quiz and they label people's different cadavers and you walk around and you have to say what it is or what nerve route it supplies to this muscle or something like that. Yeah, so you'll do that in steps. You kind of work through the body there. - And And how far into med school are you when you're doing this? - This is right away. - This is right away. - So anatomy is year one, yeah. So that's one of the basic first year classes, yeah. - And there are horror stories of, that's a very difficult class. I mean, was that, or is it just, everyone who's at Emory, it's like everyone's gonna get through this and it's probably gonna be fine, I think. - Yeah, well, so it's one of those things, it's, I mean, it's just straight up memorization, right? I mean, you know, It's just put your blinders on and just trust them just just go, you know, I mean it's really I found that to be Very very interesting and then you also realize like This is the foundation, you know, I mean everything you talk about so pathophysiology is the big term you use for essentially how systems work, you know, like Your cardiovascular system, you know, the heart's pumping the arteries and the deoxygenated veins is coming through the veins, blood. So, I mean, the anatomy, you're constantly kind of going back to that and thinking about, oh man, I held that in my hand. Oh, I know what the mitral valve looks like and those kind of things there. So, I mean, that's where you started. I actually, I would encourage, my daughter's taken, she's about to start a nursing program, or a nurse practitioner program, but She's doing anatomy right now. It's not, it's not human anatomy, but I don't know why they don't offer that for non med school. - Well, it's so interesting. - It's fascinating. And now there probably are. I haven't even looked online. I'm sure there's crazy realistic AI generated stuff that you can get into it. But I think everybody should have, should have to take some human anatomy. I think the world should. You'd have so much more appreciation for the stuff, you know? - Well, it is a complex system that even, I mean, you know, I did a lot of apology stuff undergrad, so I've got some cursory understanding of the complexity and all the feedback loops and how the body, I mean, the majority of us, our body stays in balance and it's actually wild that you think like an internal combustion engine has a lot of fucking parts. You know, it's like, It is crazy, but was there anything in anatomy that you're just surprised you about us? - Yeah, it seems very fragile. You know, when you're holding the aorta, you know, which is the largest artery, essentially in your body, It's thin, you know, right, that's it, huh? You're using your your dad's garden hose you've run over so many times and you get a big split in it You're like, oh, I can't believe this sucker actually holds up, you know I mean, it's it's very very very fragile, you know, the nerves the cranial nerves that come out there You're like this is this tiny little frickin thing is is is giving us all this feedback and it's regenerating itself every night. - What? - And it blows my mind. - What do you mean? - Well, your body's constantly healing itself, you know? So there's something called the myelin sheath which covers these nerves. It's like a, it helps the electrical signal pass down the nerve, the neuron. But these things are constantly regenerating themselves. I mean, your mucosa in your mouth, I mean, it turns over daily, but when you actually open up the body and you're looking at the coronary arteries that are feeding oxygen to the heart to make it pump, they're incredibly delicate and fragile, and it's just, it's mind -boggling to me. That struck me more than anything else, you know? It's sort of like, you know, and then-- - Like how elastic are these things? - So you and I loved, we love smashing heads, playing football. - You love that? - That was That was our, you know, I'm like, the harder you hit, the more fun it was, but I, you do that. And then you think, and now I have, and I've seen, I've held a brain and now I have my kid putting a helmet on and it's like, wow, I can't believe we let our kids do this shit. Well, I'm, I'm like right on the cusp of really thinking about that. And I think that ultimately I'm coming down on the likelihood of them playing D one, D1, the likelihood of them playing the NFL, right? I mean, even if they're healthy, if they're good enough, just think burnout. Like, do they even really want to do it? Like, after a while, you've had so many concussions that you're kind of like, I'm kind of done getting hit in the head. But when you hear this stuff, to me, what you get out of it from a character perspective, and also, it's a source of strength. When you're doing stuff, you're like, well, I felt shittier than before you know and so you're like well I can get through that and you know the friends and all that stuff and then you look at the science and you're like well it's real and so where do you kind of come down or do you have or do you vacillate yeah well it's funny so I mean I've had to go deep dive on all the concussion stuff and we're it's just an evolving field by crazy but my ultimate take though is that some heads can take it and some heads can't and We haven't figured out which ones can, which ones can, you know, there's some that have probably had 20, 30 concussions and they're not going to develop CTE and these other bad issues. And then there's somebody that gets hit once and it's like lights out, you know, there's a kid that went to local high school here was a lacrosse stud and he'd had a lot of violent contact, but he went and played college and had a headshot and it took him out a semester, almost the entire semester it took for his brain to get back. He's now in med school, which is pretty awesome, but you know, it's crazy. It's crazy how some brains can tolerate that stuff and some don't, you know. - And there are people who not, some people don't even get their bell run. - Yeah. - Where-- - Yeah. - There's people-- - They might get a headache, but they don't actually get true concussion types. - I play with people that like, you see them get hit and they're like, yeah, fine. And you're like, there's no way you're fine. - That was one of the hardest hits I've ever seen. And I was watching on Luke Keagley, you know, who retired from the Carolina Panthers when he was like 28. I was listening to his interview. He had never had, from his memory, a single concussion till the first concussion he got in like his eighth or ninth year in the NFL. - That's fascinating, yeah. - And I was like, you're not hitting hard enough. That's one way to look at it. You've got to hustle, brother. But is that a phenomenon where some people, like they're craniums thicker or like their head just doesn't-- like the cerebral spinal fluid or whatever holds their brain is not as-- I mean, they're looking for that kind of-- ultimately, the best would be, yeah, is there some sort of screening test you can do that says they're prone to it, but right now they're in data collection mode. They're in massive data collection mode. And I've also heard, because I'm thinking through this stuff, I'm like, okay, let's say you have somebody who does get a major concussion. Who is it? Gronk and these others. You've gone through this barometric therapy, I think it was, to repair these cells. Is that a real thing? - I don't know, you know, I really don't know. - Developing science. - Yeah, I mean, right, what you have is you have some anecdotal type stuff that is now available to set up for long -term studies. But think about doing a real scientific, so in our world, we talk about levels of evidence when you're looking at, when you're reading a research article, right? And so, the highest level-- - Like the latest and greatest sort of thing? - Well, no, no, no, the quality of how much you can rely on the outcomes of the study, the conclusions of the study. And the ultimate in our world for a level one study, the highest, the best study, is you want a randomized double blind controlled study, right, whereas where the observer and the patient don't know which side of the study they're on. - And that's the blindness of the study. - Yeah, everybody's blind. Yeah, the guy that's recording the results, the participant who's in there, they're all blind, but you have to have, you know, you have to match the cohorts of patients. You have to have similar demographics and all these kinds of things. They have to be like, you know, you have to have apples and apples in these groups. - So there's an organizer that then backs away from it. - Right, right, right. So yeah, you're testing a medication on somebody, right? You have a placebo and you have a medication. And you have to basically screen all these people, try to create like -minded groups, and then you have to blindly give them one or the other, and then you study the effects of it, right? And you have to make sure that you have enough patients in it, they're called the power of the study. But think about concussion, you know, like you can't even remotely perform that, right? There's no way. There's so many, well, but there's so many confounding variables, you know what I mean? Everybody's genetics, you know? How do you find like groups and then did they take the same contact, you know? I mean, so, you know, a lot of these things are gonna never, we're never gonna have these like super conclusive because it's just, it's just too difficult and, you know, and you need too many participants. And I think you like testing for would make it maybe lethal. Like, you see how they test helmets at the helmet factory where they raise like the 50 pound weight up and just drop it like a guillotine on the helmet. Yeah. The bigger, the bigger thing that they study, the biggest focus I think right now is, is preventative, right? How, how, what is, what can we do, you know, training the neck muscles and What are the things that you can do to try to actually limit the numbers? I mean, you can do that study, right? You can, you could take all division, division one NCA football programs, right? And you set up where you're basically screening everybody that we now have, you know, pre -screening, um, tests that they do where they're, where they're, um, it's a cognitive test, right? And then that's how you sort of, you figure out what their baseline baseline scores. And then if they have what you think are a concussion or concussion symptoms, then you use that test to see when they cognitively come back, right? So, but they're constantly recording how many concussions they get and all that type of thing there. So you could, you, you can definitely implement, hey, we're going to implement, implement this neck program, or we're going to change this device or the helmet, right? We're going to, we're going to, we're going to introduce this new helmet to all of the programs and we're going to see, does the number of concussions come down, changing the rules. The big thing in the NFL was changing the kickoff, right? 'Cause the speed that they get and the violence that happens with that, you know, so. - It's insane. - So, you know, I don't think we're ever gonna really truly understand the concussion, physiologically what's happening in the brain or why it happens to this guy and not that guy. So the focus right now is just prevention. - Isn't the kind of an underlying problem that's to be hard to deal with is, let's say you make your your body stronger. It's like, it'd be the same issue if your car doesn't have crumple zones. Like you, ultimately, your brain is always going to be floating effectively, right, and fluid. And so the stiffer we make the rest of, like, it's just going to transfer that much more energy into, I'm thinking out loud, but like, it's going to put that much more energy into the movement of your, like, of your brain, I think. So we need crumple zone sort of in our craniums. Let's develop that. That'll be our next project. I'm just saying, it's tough stuff, because it's very real and back to kind of our world, which is, you know, I've got a rising fifth grader. Oh, yeah. And, you know, he's of a body type and mentality that going out and hitting It's like a really good time. - Oh yeah, and they're genetics. If they're coming from you, they're gonna be violent humans. Fast violent humans, which is fantastic. - The good kind, hopefully. - It's funny though, I was commenting. I was like, now that I've, having gone through med school, held a brain and now I'm seeing these, my kids, I have, you know, I'm like, I kind of don't want them to do it, right? I don't want them to hit like that. But it's funny how we don't, how certain things in ourselves, We don't, it doesn't translate. I remember we had a, we had a cadaver with bad cirrhosis of the liver, you know? And it's like, you see a healthy liver and a one that had been just abused your whole life. - Right, just boozing. - And I remember just thinking, wow, that's amazing. Well, I'm, I turn 50 next month and I'm a functioning alcoholic. You know, it's like, it didn't really stick on me, you know? - Right. And if I heard they're doing like a pick up tackle game. - Oh, I go right now. I go right now. - Fuck it, I don't need a helmet, I'll be good. Well, it's something that sticks. That I think of like, when I watch a hockey game and you and I used to play hockey, I'm looking at that headgear that they used and I'm like, it's probably changed since I last looked into a hockey helmet, I'm like, come on guys, there's gotta be more we can do here. - It's unbelievable. - From a helmet perspective. - Well, and the fact that they won't of cage you guys it's you continue to lose your teeth and shatter your jaws because you you don't want to wear the cage because your tradition it's it's amazing but it's there's a lot to impact there's a lot to unpack with that well also let's think about it from just like an ownership perspective like that's your investment skating around on the ice down there and sticks fly all the time and you know there's your surround you're in a room effectively, right, there are walls in that room. And so sooner or later, you know, you're gonna find the wrong side of something and your investment is now sitting on an operating table somewhere. - They're moving in the right direction. I mean, I think I saw the stat the other day that maybe there's only four or five guys still in the NHL that don't have a shield on their eyes at least, right? So, but to think there are guys out there who are literally putting their sight, you know, un -Jeopardy every time they step on the ice. What are their 80 games in a season? - You can't overstate how important it is to be able to see in hockey. - Like, hey man, yeah, okay, they can reconstruct your jaw and your teeth, but we don't have a fake eye, not one that actually sees yet. - Do you think it's sort of the push and pull between in hockey in particular, that violence is so inherent, like it's so important to the game. And that like the enforcer, they're thinking about, when enforcers need to be able to kick the shit out of somebody. So we can't cover people up too much. Or is that-- - I just think it's vanity. - You do. - I think it's tradition, it's tradition. Tough, you know, you're tough as nails. Same thing happened in football, you know when they went from leather helmets to face masks that people were making fun of them. But I think a lot of it's vanity to it would be it'd be there wouldn't be as much star -power coolness if every guy out there had it yeah had a cage on you know I mean you watch you sometimes you watch the frozen for college you know it's this the level of hockey is incredible it's not that far off of the NHL but the experience is different you know it is not seeing their face not recognizing who they are you know you're waiting to see their jersey number to figure out It has a different feel. Do you do you think that I mean we know hockey people and do you think that? NHL will ever actually migrate to I think they'll just keep making a better bubble, you know the boat the clear Shields, I think they're just they'll just keep making better stuff there But or guys until it's like a welding mask, but it's not a cage The thing though is is the NHL it still self -selects, you know kind of Certain brains, you know, so they may never evolve, you know Yeah, I mean it takes a certain person and I sure had hockey game recently. We're sitting You know close enough to to be able to gauge how big these guys are and it was mind -boggling. Yeah, how Big these guys are getting they used to be like when we were growing up a six footer You know, it's kind of maybe maybe on the tolerant, you know, you had the kind of small or really physical guys at 6 -4. It's like, that's not that big of a deal. No, not anymore. That's just straight up dangerous because those guys can move. They can move. So quickly, so back to, I want to get to this idea of like the first time you did your solo flight as a surgeon. So you guys are pulling these cadavres, you're dissecting these cadavers we're anatomy meanwhile taking how many other classes by that we got a full curriculum yeah it's it's a it's a job what do they do the curriculum with the cadavers at night they just oh they're embalmed you know so that it's just the rooms freezing so it's a super cold room yeah so they yeah you're they just stay on the table you just have a bag that kind of zips up it's pretty it's pretty gnarly they get a little funky by the end - There's no doubt about that. - Do they? - Yeah, oh yeah, yeah. - Wow, we gotta kind of keep 'em greased up. - They have a little PTSD. - Well, we can move on, which is, so they roll 'em away for the last time, you guys kind of have to have a ceremonial parting with them with the families. Do families attend that? - Yeah, yeah, yeah, it was pretty emotional, it was cool. - That is cool. - It means a lot to them, to know that their love one was part of the process. I'm sure it's creepy too, but it's special. - Should they see them? - No, no, no, no, no. - 'Cause they're like a pile of parts, right? - No, no, no, you're in like this nice auditorium, you know, it's very sweet. - And is that something that's specific to Emory or is that pretty much? - I don't know, I'm guessing, I'm guessing there's some form of ceremony pretty much everywhere, yeah. I can't imagine they wouldn't do that. It's probably a universal thing. - What's it like seeing that person's family is it kind of are you just it's so you're so immune to this whole situation by then it was it was surreal but it felt nice it felt right yeah you look like your dad I got to be offline comments but yeah no and no it actually at first I thought it's gonna be really weird and then it was like okay this is actually kind of nice. And then you sort of, you felt somewhat guilty for some of the nicknames and comments, just 'cause, but that's how you deal with something. It's so creepy, you have to kind of, you have to break the ice and, you know. - Did you guys ever talk about like, there being a reanimation moment? Like, what if this thing just like, what if this could average is sort of starting, I mean, there's so much to freak yourselves out. - Early on, yes, But then all of a sudden, once you've done all the dissection, it loses its personality pretty quick. And when you first have, like, when you first put your hand on that, it just must be such a moment. Oh. Like, when you first make contact, like. Yeah, it's, I can't even describe how awkward it is. But it's also beautiful. It's really cool. It is cool. and mom donated to school. - She did? - Yeah, yeah. - Yeah, it's more, I don't know if it was for science or more that she just, it's like I'm not a funeral home person and I just don't want to go into that world at all. I don't know, I never asked, it's what you want her to do. But so you leave med school and then you have a residency. Did you do that wash you or did you go straight to Steadman? - No, I went, I did my wash use where I did my residency, five -year residency, yeah. And is that when you were, like, for someone who didn't do a residency, what is a residency? Yeah, so in med school, you do two years of book work, basically. You take all your tests, you take your board exams, all that stuff. And then you do two years of what are called clinicals. So that's when you're actually, you know, shadowing and working for the real doctors. and you'll go through internal medicine, you'll go through general surgery, you'll go through ER, those kind of things, to kind of get a flavor of everything and they give you some responsibilities and then they kind of give you grades based on your abilities. And it helps you sort of figure out too what kind of path you want to go. Most, I went, I was-- - You had a clear vision. - I was dead set, right? But a lot of people are in there And they're kind of like, I don't really know what side of medicine I want to go on when I'm done. So you, but you have to do, you do those, you graduate and you do what's called the match. So when you, when you want to do a resident, when you want to get your residency, it's a pretty bizarre system, right? So, so there's residency programs are for the specialty training and that's it's internal medicine, orthopedics, general surgery, urology, all that, all those different ones, your nose and throat. So you, dermatology, so there's different level of competitions, so there's a certain number of residency spots, right? And obviously the more specialized it is, the fewer the spots there are. - When you say spots, lower, like United States, or you're talking, like how is this broken up? - In the United States, so you have to be awarded a residency program, and then they essentially award how many you can have like for example at Wash U they allow five residents there at a time I think when I was at Emory they were taking four maybe or some places only need three residents and some have six residents right so they're publishing availability yeah but but they you have to be accredited to do that you have to apply for these and it usually has to do with you know how many patient visits how many surges do you have can we support can can each guy get enough or girl get enough experience with it. But so there's a set number of residency spots in the country, right? And so when you're coming out, you're competing against all the med students that are graduating for those spots. And they're ranked, you know, there's a number one, there's a number one program, right? And there's top 10 programs for this specialty, and then there's the next to 20, and it's very, it's crazy competitive. And especially tends to be the more lucrative and better lifestyle careers have the most competition. So orthopedics, dermatology, those are super, super sought after ones because you get a, it's a pretty good life after you finish your training. But the match is crazy. So everybody is, all the fourth year med students kind of decide what field they wanna go into. Then they send out applications to the programs. If they like you, they'll interview you. And then what happens is they rank, the program ranks everybody One to 30 that they interviewed and then the the student ranks the programs they interviewed at double bond one to five Double, okay, and then a computer matches it up really. Mm -hmm. Yeah. Yeah, so so they could call it match day They literally call it match day. So you it's nerve -wracking. Yeah You all get together and they literally call your name out and they give you an envelope and you open it up And it's that's where your residency is can it be empty that envelope? It - Really? - You can not get a spot, yeah, yes. - You can fall through. - Mm -hmm, mm -hmm. And then there's other specialties, like internal medicine, where they don't actually fill all the spots. You know, there's certain programs that are so disastrous that they don't have enough people that want to go into it, you know? So it's a crazy thing. And let's think about it. If you're-- - And is that done to distribute doctors across specialties? Like you just said, like-- - It does have, yeah, it has a lot to do with need, right? So yeah, so they're like, yeah, I mean, we can't have everybody going into-- - I think it's great you want to be in dermatology. - You can't have everybody going to dermatology, like that this is not gonna work, that the system's not gonna work that way. So yeah, so they're definitely taking away spots and adding spots, trying to steer students into different things, you know? But I mean, if you're in the bottom third of your med school class, you can just check off all of these, you're never gonna get a look at all these programs, because your rank in your class is super, super important. - So what happens to this, no, from the jump when they're doing the match process, they're like, I'm just gonna go straight to whatever these-- - I'm gonna do family practice and just kinda, I'm gonna go, I'm just gonna do family practice and I'll just look around for a job and I'll get a job. I mean, there's always gonna be a job, but yeah, it might not be in what you wanna do. - And could you get more than one match? - No, that's the thing is you only get one match, yeah. And then it's basically binding. - Really, okay. - You'll get a choice, right? So it's not like, hey, these three programs all, these three programs all ranked me in the top five. I have a spot there, you can't pick. The computer matches you. - Oh, the computer does it, so it organizes the field so that you couldn't end up with options. - Correct, and they're supposed to, you're supposed to be no backdoor communication. The program's not allowed to tell you where you are in the rank, and you're not supposed to tell them if they're the top choice. - And if you come into this information, you probably keep it to yourself. - Yeah, yes, definitely keep it to yourself. But like ours was wild, So my first wife, we were, she was doing law school. She's from St. Louis, which is why I came back here, but we were in Atlanta. I was at Emory and she was in doing law school at the same time. We were both finishing at the same time, but I had planned to stay at Emory. There were definitely some winks and handshakes that I was gonna stay there. I had that. I had my, I had a job set up after I finished my residency. I knew who I was gonna join and all this stuff there. - Wow. - We're gonna live everything, the whole thing was set. And it was this, so we were, we were just, you get to kind of do, you can do a couple of externships when you're in your residency. You can go try out at a program, right? So you can go travel to a different place for six weeks and do orthopedics there, get a sense of if you like it before you actually sign up for all that stuff. - Okay. - Or Or before you apply seems awfully forgiving for this process. Yeah, well, it's well, they get a chance to look at you You know and the other way around so anyways I was set at Emory and the whole thing was done there and then we found out that her father was diagnosed with leukemia and It was in St. Louis and it was just like a We got to go to we got to get back to the non option Yeah, yeah, so I so I came back and did did a I did a you know rotation at Wash U and a slew and then kind of grease the skids for that. So that's why I ended up here. - Really? - And it was crazy. - How quickly did all that occur? - But I opened my envelope. Here I'm sitting there. I've got my wife's father's dying. She's mobile. She wants to come back to St. Louis desperately. I'm singing and dancing, pulling my hot top hat. I'll do anything. I mean, did a hand job to let me in the program. I'm your guy, call me. - Yeah, how many you need? - But I need, I gotta get in this place, but I'm at the mercy of the computer. I mean, it was like, my palms were dripping sweat when I pulled that envelope. I was like, motherfucker, I gotta get this, you know? And so on. - And did you get the one you wanted? - Yeah, yeah, that was my top 12. Well, yeah, I wanted to be back in St. Louis. It was a-- - God, that worked, the fuck. I mean, you worked for it. - It was a A great program is a great training thing, but it was, I always bitch and moan about it though, because at the time I did this, so this is 90, this is 2001 to 2006, '07, something like that. The Emory was a good old boys club. I mean, it was awesome, you know, your attending takes you to the play golf on Sunday and his wife brings you a sweetsy on the porch. - That's fun, I'm trying to go for it. - And It was, I mean, the residence room, there's like a residence room, it was all dudes. You walk into the residence room, it had like a gas station of dip. Like, you know the thing where all the cans are stacked up? - The logs. - Yeah, and then, you know, stack of the Newdy magazines everywhere. I mean, it was just like the most good old boys, everybody was friendly. Washu was coat and tie, buttoned up, dressed you down, You know belittle you military style. I mean it was it was not a fun place It was terrible in terms of just the collegiality. Yeah, it was the culture was nothing of what I wanted to do So so I got it. I was so happy at least have one dip. Oh my god. It was it was brutal. I Mean, I met some great like the residents were great And there's a couple of the guys that I that I trained with I love and our friends now But but it was The environment was so, it was so much more buttoned up professional, and I preferred the good old boys. Well, yeah. There's a lot easier life. Right? I mean, how are you supposed to keep up on your medical training if you don't have that? Yeah. You know, with all those playboys and dip, wouldn't be possible. But that was, that was, so getting to the kind of the point, you know, you, it is very, very military. The residency thing is very, so in med school, Everybody's telling you how smart you are. They're all patting you in the back. You're just doing a great job. You're doing so awesome. You're amazing. You're the best. You know how special you are? Then you show up at residency in your first year and you're a maggot. I mean, it's not as abusive as the military, but it's pretty close. And they break you down and you haven't slept in two days and they're quizzing you on some stupid article and making you feel stupid when you don't know the answer. I mean, that's kind of the mentality. But It just hardens you, it hardens you so much, you know, I mean, I would say though, you know, in a good way, but also to a fault, you know, I used to be way more warm, gentle, you know, ear, call me about anything, you know, I was like the go -to guy in high school for, if you have an issue, call me up, whatever like that. And, you know, you, I just got hardened. - Get over it. - Yeah, get over it. (laughing) Your phrase, just, yeah, everything now is kind of, and my kids, luckily I have a sense of humor and so my kids, we all laugh about it. You know what, when I have my harder side and I tell them to get over it, you know, they know it's out of love and, you know, there's plenty of hugs to go around. - And timing is everything. - Yeah, but it hardens you and then that prepares you, that prepares you for the day you pick up the scalpel. And no one else is around to bail you out. That's the day that you're like, that's where all of that comes in and you're just like, okay, I got this, you know? - When does that happen in this whole process? So you've got your, I mean, undergrad, you got four years of med, you've got your clinicals that are in med school and you have a residency. Your residency is a Presidencies at three to three year thing five five year thing Yeah, so you start you start out just doing all the grunt work and you might you know You might get to close an incision here or there you get you know, you're working on Simple skills then your second third year based on how good you are how good your hands are and how smart you are They'll start giving you a little part of the procedure. Hey, you can do this part of this You can do that there and then and then hopefully by your last two years they let you do quite a bit you know but you always have your boss backup you know you've always got that you always got somebody looking over your shoulder who's tweaking this changing that you know I talk about putting doing a hip replacement putting the cup socket in positioning that you know you get it you get it where you like it and then they come in and they tweak it a couple degrees and you're close but you know ultimately you've got somebody that's gonna take the responsibility and bail you out, you know, you get into something, you got a deep, you know, bleeder, and you can't get to it and your palm starts sweating, well, you got somebody to come in and, you know, you got the hand of God to come in and take care of you there. - Right. - And then you, and then your fellowship-- - That's happened, I assume every doctor on the planet where you have your learning process, you're like, oh fuck. - Yeah. - And like-- - Oh What was what was happening for one of your oh fuck moments like was it a deep leader or was it a it was a deep it was a deep leader it was a pelvic deep leader I had I Had I was somebody had a hip replacement that had failed and it become loose over like 18 years, right? So I was gonna go replace replace the socket well when I got in there There was all this terrible bone the bone had kind of disintegrated so we had to I had to put this augment piece in to kind of restructure the bone right well when you're when you're putting that piece in you have to put screws and things like that and you're working on an area where you're like I'm not usually over here like this isn't like a regular thing there you know and I remember I got a branch of like the gluteal artery which is come from the backside it's not easy to see in the field you know you're looking through this big giant hole and you're sitting there and it's And it's kind of bleeding, and I'm like, ugh, you know, I'll watch that, I'll pack it with a little pack. I'm like, maybe it'll just claw it off and be fine. Take it out. And now I start looking at it, and it's getting heavier and heavier and heavier, and I'm like, ooh, okay. So, finally I get, you know, I can put my finger behind the pelvis, and I can clamp it off, basically with my finger, but I'm like, how am I gonna get to that motherfucker, you know? - Do you have to - Do you have to make another incision? - I basically almost had to double the size of the incision and put retractors everywhere because that distal branch is coming off of a bigger artery and if you're like, if you just start blindly grabbing around there, all of a sudden you hit that and open that up and it's game over right there. So that was the worst, probably the worst moment that I was just, you know, you go back to the training. You just count to 10. I think I took a, I had my assistant hold his finger on there and I stepped back and just did a lot of breathing, said a couple of prayers, and we eventually-- - Had a couple of six in the OR. - Eventually got a clamp on it and tied it off with a vessel loop, but that was like a oh shit moment, you know. And there was no one to bail me out, you know what I mean? - That was okay, so you Yeah, there's a dude. There's a guy next door. There was a guy next door who was an ortho guy that kind of could have come led me a hand. But I mean, he wasn't it's not like he was some, you know, mastermind that was going to be able to get this bleeder. It's just it was like it sounds like the position was like a real issue and how well how well it's being fed. Yeah. You know, that's that is crazy because it's hard to train for that because it's one thing to do it in a controlled environment where you've got your mentor or what are you guys called them right there, you know, you can always reach over, do whatever. So we were talking about this before and I don't know if you've done this so many times now, I don't know if you can really take yourself back. But as a non -doctor, I think about how do you get to that point of making it like the first time you made an incision, you're on your own, you're like, and you just literally, those things are insanely, I've dissected a frog, I have some sense of how sharp those things are. It's insane how sharp, and it just opens right up. What is that like, like how can you, do you just not really notice it, you're so trained at that point? - Yeah, I think when you're, I think there's a, the actual making the incision, You know, you've already done 10 ,000 reps, right? You know, you're, you've already done your 10 ,000 reps. So I think it's more of the big picture right there, but you, the craziest thing is when you're actually making an incision on someone you know, you know? - Yes. - That's where it really changes, you know? And I was, before we were chatting about it, but you know, I've, I've replaced, I replaced the hip of literally man of my wedding. Um, and, uh, that there's a moment where you're doing a hippo placement where you're, when you put the socket in, you'll put us, it's a titanium shell that has a titanium, um, in growth surface on the back that the bone grows into it. So it becomes the, the titanium socket will affect and essentially grow into your pelvis. Right? Okay. But you need, you need some stability. There's a press fit. So it, so it's got a high fric coefficient of friction and you wedge it in to start, but a lot of times we'll put a screw or two screws to kind of just hold it in place, yeah, just to make sure it doesn't shift or rotate. And there's a specific screw when you're putting it in that if you put it into deep behind it, it lives a very, very, very big, large artery that feeds, and you can't see it. It's behind everything. It's behind your bladder and everything else, it's sitting in the inner portion of your pelvis. And, you know, I mean, it's the number, it's on every test, everybody knows where it is, there's safe zones to put the screws in, but there's always sort of that-- - Chance. - Yeah, you know, and I mean, it's, you hate to hear it as the public, but, you know, when you're doing it on somebody that you don't really know and you've done it so many times, you know, you're always using your best judgment and you do it, and you don't really don't think twice about it, you know, 'cause, but then he's doing it on my best friend. And we were doing it in an outpatient facility, right? So I'm not in a hospital 'cause he was young and super healthy and was gonna go home the same day kind of thing. Yeah, and that was the moment. I remember they, calling for the drill and just being like, oh, fuck. - You had like the moment of like, ah! - Yeah, that's like, this is, you know. It was one of the only times in recent times that I can think about actually kind of having nerves, you know You just get so deconditioned as a whole thing But that first day is crazy At first step the first scope you do and the first time the first time you get yourself into some sort of a little bit of Trouble that's that's when you're like, oh man, this is real our is human anatomy consistent enough that Like you you can count on the mapping of the human body you general, it's going to be really unlikely that if you put it in the same place, that something's going to be there that you weren't expecting. So I would say in orthopedics, yeah, I would say yes, you know, I think in some other stuff that abdominal cavity, you know, it's a, it's a big guessing game. I mean, yes, there's patterns, you know, you know, where the ascending colon and descending colon should live, but there's all sorts of anomalies, you know, so you have to be prepared for anomalies. So what is in this slightly, and I'm going to wrap us up, because I don't-- what time is it? I don't even know. 2 /17. But ligaments, sports, what's the latest and greatest on those repairs? That's the repair that I remember growing up. They do blowout as ACL. Lyman or something, they blowout as ACL. It's like a year. Yeah. We could do a whole 'nother podcast on ACL. That's the craziest thing ever, and there's only things so it sells on the back is that on the one of the cross yeah yeah so it crosses in the middle of your knee and so the ACL sits in front of the PCL okay and it it basically prevents the tibia the lower bone from coming forward and rotating against the femur right so it's a very specific motion that it blocks and that would be which which direction hit breaks so it's more of a it's more of a It's more of a plant and buckle kind of thing. - Okay. - Yeah, so it's a rotational torsion that's gonna cause that to tear there. But to your point, not much has changed really, honestly. We're still having to, if you're a young athlete, you still have to harvest their own tissue. So you're taking their patellar tendon, their hamstrings, or part of their quad tendon is kind of a newer design. - They're slicing off of these? - Yeah, you have to take a section of it off to reconstruct constructed. You can't repair the ligament. When it tears, it shreds like the end of a mop kind of thing. So you can't put it back. Yeah, you got to use new tissue. When it tears, is it coming off the bone or like in the middle or it could be anywhere? Two things. Yeah, most typically it tears from the femur, the top bone. That's the most common. But then it can pop off the bottom or tear in the middle, right? But either all of them, once the ligament tears, you basically it's gone. You got to put a new one in. So you like - You cut out the old one. - Yeah, take it, throw in the trash, yep. And then you either take their own tissue, or once you hit your 30s, you can start using cadaver tissue, right? So you can use-- - 'Cause we're basically slowly dying at that point? - Exactly, well, for some reason we just get stiffer, so the retail rates are lower when you get into your 30s. Even if you play sports, high -level sports, so it's crazy the date on that. But what's the future for the ACL stuff, right? We know how to position it, we know how to, the techniques for all of it is there's not a lot of rocket science, but the coolest thing that I think is going to come down the line is going to be how do we make that graft incorporate and become stronger? And so we're always looking at things like, can we wrap it in some sort of thing that has different growth factors that signal it to grow in faster, you know? meaning like attaching to the bone? - Yeah, to attach to the bone and then essentially it grows a new kind of nerve and blood supply to it. - Currently it does? - Yeah, so they've done, so it'll, so the cells that are in the tissue, even if you take your own, if you take your own potato tendon, right, and you put it in, there are cells in that tendon that the day one, those cells die and then they get repopulated from the femur, right? So cells actually, yeah, yeah. So it basically kind of grows this new blood supply and nerve supply. But how do we make that go faster? That's the whole thing is how do we speed this whole thing up? Why is this, you know, a lot of the college, college female athletes that play on turf, most schools have gone to nine months, you know, we used to be six months you can play, now they've taken that out to nine months because the retire rates are so high, you know. So our whole thing is, you know, how are we going to make those incorporate faster, how we make them stronger, there's all sorts of scientific stuff. Is there such a thing as it is, say you take somebody's, what's it called, Autologous, is that what it is? Autologous is your own, yeah, yeah, auto. When you donate to yourself. Yep. Is there such a thing as it not taking? Like, it doesn't innovate or it doesn't? Yeah, not so much anymore. I mean, I think we've got the techniques down so that they incorporate well. It's just, you tore the one God gave you, you know, you're gonna go back and play a sport. How do you think you're gonna be better than you were before so that the graft is still at risk of tearing, yeah. - Okay, 'cause I remember back in the high school, you know, maybe it's just the good news that people like to offset the bad news with. Oh, you're gonna come, I think it'd be stronger. - Yeah, lie, total lie. - It is a lie. - Yeah, it's a-- - Okay, now that makes sense. - Yeah, it's a total lie and it's meant to, it's just meant to give you Yeah, I mean because I have it all the time, you know, you do you do it and you're a young athlete and mom's just looking at you Are you sure they're ready to go back? You know, are you sure they're and you now the physical therapist has helped us a ton They did they develop all these tests, you know to try to make you feel good about it You're how you're the the landing angle of your knee when you jump and hop tests and all they're doing everything they can to try to See physically are you are you doing the right things that are gonna put you at the least amount of risk of re -tearing it. But ultimately, you know, I have this stud lacrosse player recently, you know, he's clearly like high level college material. Torres ACL, unfortunately his sophomore year. - Playing lacrosse. - Yeah, playing lacrosse, classic, you know, pivoted, was, you know, making a move and it just buckled and blew it out, it was just bad luck, right? You know. - Is ACL the most Terror that it's in those types of sports from a ligament standpoint. Yeah. Well, it's the one week I guess probably the most common is the MCL, but it heals itself. So nobody cares about it, right? Okay But the bit the ones that actually you have lost time with the most it's gonna be the ACL Okay, so this kid this kid we reconstruct reconstruct is a using bone patella tendon bone Which is a miserable recovery, but it's it's in my world It's the most it's the bestest to hold up for abuse, right? And the kid wants to play as long as he can play. Does everything right? I mean, this kid is, you know, he is diligent, everything like that, gets back, has his brace on, is in practice and is doing a drill, kind of showing some of the younger guys what to do. And some younger and experienced kid just loses his footing trips and falls and just lands so perfectly that he buckles his knee and blows the thing out again. - Same, same leg. - Same one, yeah. And they said it was just like the way this kid fell. He even had a brace on, but the way this kid fell, you know, this kid was just like, nothing was gonna save. - Yeah, like, did he have like a Don Joy style brace on? Like the heavy hinged stuff? - Yeah, that's like, the Don Joy, You brought that up. So total tangent, but here's one of my favorite stories. So so Don Joy It their their biggest competitor is breg Mm -hmm. Don Joy was the name of Donna and Jo and Joy were Where Greg and Brad's first wives that that divorced them They named the company after these two and then so they sat out there non -compete and then Brad and Greg started Break and now they compete against each other amazing I believe that's true if you are they still but is I mean even if it's not true it is now it's the greatest story of all time it doesn't matter the number one competitors break and just makes me die laughing is they're are they still like the only ones break in Don Joey there's a few other ones but the problem you know that business is hard because the reimbursement rates from insurance are so low that that there's no, it'd be, the margins are so terrible that no company really wants to get in the game anymore. There's no money in it. So those two will be there for forever. - So the, no, I love this, 'cause this is all very interesting. Like, we don't know, we hear about this and all we are, you guys are kind of, doctors are a little bit like athletes a little bit, where it's easy for us to sit here and say, you know, blue this or, You know the doctor did this the doctor that and I love hearing this because it's great reminder of This is such a science and with all the technology have around us and we're you know We have we're donating to ourselves a little sliver of epitel or tendon and you know, it's It's great to get a little bit of insight in that, you know, how much? Science is actually happening here and how much is still being discovered. Like CTE, I mean, brains have been around as long as we have, and we still have so much to learn. So it's really, it's not a tangent. I think it's all really interesting stuff. But too, I did cut you off on the future. So you're hoping that you're gonna have maybe a ligament repair that'll innovate, accelerate the innovation and getting a circulatory, like a vein and stuff going through it? - Yeah, really, well, it's really, how can we signal the cells around there to speed up the process? How can we manipulate the healing process to speed it up? That's what we're looking for, you know? - And is that part of that stems, like inject stem cell injection world sort of? - Yeah, correct. Regenerative medicine is really the world they talk about. But, so stem cells and other thing called PRP, platelet -rich plasma, which is your platelets are one of the three main cells in your blood. They have all the growth factors and everything. So platelets, if you cut your skin, the platelets aggregate together and clot. Okay. And as they clot, they release all these growth factors, which drive the healing response, right? Okay. So platelet -rich plasma is the idea is that you take your blood, you spin it down in a centrifuge and separate the platelets, concentrate them, and then you inject them into some sort of tissue to try to help them generate faster, right? Tennis elbow is a classic. So your tennis elbow, the PRP injections, healing tennis elbow is about as good as surgery. It's a really, really good question. Yeah, the stem cell thing is interesting, right? So stem cell injections have been shown, especially in joints, they have a lot of good properties. They block these nasty enzymes that cause inflammation, that they can help the environment of it. But they're not really growing, they're not really regenerating tissue at this point. And the reason-- - So it's not the sci -fi stuff. - Everybody thinks that it happens, right? So you have a cartilage defect in your knee and somebody wants to harvest stem cells from your pelvis and inject them into there. The steps that it has to, that stem cell has to be signaled along all these different pathways to make a cartilage cell. Then it has to adhere to the defect and solidify itself in there. The idea of just being able to blast this into your knee and it's magically going to do that is an absolute joke. Like, it doesn't, you know, if you have any kind-- Well, doesn't an undifferentiated cell need other undifferentiated cells? Well, yeah, you need other cells, which is not that hard. You can concentrate on the cells, but you have to figure out how to signal that to become that. So, it's, it's, regenerative medicine is here to stay, But we're but there's a lot of things that have to happen before it becomes before before we get rid of joint replacements You know, we need to have a lot of other science in there, but but AI AI is gonna take this So far so frickin far the science side of it, you know, think about just cancer, right? You're gonna have very few oncology Doctors in the end, you know, because they think they'll they can sequence your genome They can have massive databases that look at, "Hey, we found this cancer with these markers in this individual with these genetic characteristics. We did this regimen of radiation, whatever meds, and this was our healing rate without recurrence." You're going to be able to compute that data points. You may have a person in Thailand, in South Africa, and Venezuela who had a similar pattern, and this regiment of things healed this cancer, I mean, it's gonna be crazy what it can do for that. - And what is, I mean, something like, we think of orthopedics maybe as a little bit like carpentry, where you got your screws out and you're in stuff and you've got your drills, like you're talking about, are there implications for, It doesn't seem like AI is gonna be able to cut someone open and put a screw in their socket. - No, but what it's gonna do, so what it's gonna do, the algorithms right now are basically being built to feed the robot. - Okay. - Yeah, so we're using AI to create the brain to perform it for the robot, you know, so to, and you know, we're already using it in, basically when we put basically, when you put a knee, take a knee replacement. So the knee replacement, how you cut the bone, the angles, all these kind of things are gonna affect how well it functions and how long it lasts. So AI and the robot has already helped us tremendously in that sense. - How do you calculate that? - That's gonna get better, but you're eventually gonna, it's eventually gonna do, well, it's measurement. You're using reference points and And it's it's very visual as you're cutting that you're cutting like the top off right in the the femur and the shins Correct, and you want to you want to make that you know perfectly perpendicular to the tibia bone, right? So you're using right now. You're using reference guides You can use it either one goes down the bone or external and it's a lot of visual and it's tweaking And it's an art right now never even thought about there's sign There's plenty of science and tell you where you want to put it, but it's an art once you get into the surgery. Well, that's taking a lot of the heart out. - 'Cause you could theoretically have, end up with one, if they did double knee replacement, like one ends up being, one leg's not needed, one's not. - It's, trust me, I've seen everything. - Can you see it out on the street? - Oh yeah. - You can. - Yeah, yeah, yeah. - Like I had an knee surgery, it didn't go well. - Yeah, for sure. But the AI will help that, but ultimately to feed the robot to do bulk of the surgeries, yeah. - And are these big, I'm thinking robots, I'm thinking like the DaVinci or something like that. - Yeah, yeah, and DaVinci right now is, well, a lot of it is, you're doing macro movements over here and the robot is doing micro movements, like that's what's right now. Eventually though, the robot's just gonna do its thing. - Like, I'm thinking a car manufacturer. - With all of the assembly line and stuff. So is the DaVinci, the one now, is that still powered by a human though, like you're turning knobs or whatever? - Correct, correct, correct. - So you think that link is breaking, like the robot's just gonna, you're gonna program like a CNC table for metals or something, and it's just gonna go. - Yep, yep, and somebody will be kind of overseeing it. - Throw the shotgun over the robot. - I mean, think about the brain stuff, you know, going into isolate, going into a tumor. I mean, think about it. If you could take an MRI, right, and you can feed it into the brain, it knows exactly, you know, from a stereotactic standpoint, it knows exactly where it's going, you know, and I mean, it's incredible the precision that's going to have. Well, I guess at that point, if it gets that precise, it's like, can we just keep the head still enough for, so the destination is right where that robot expects it to be. Because now they use the Halo thing, I don't think, basically pull it in your head into a toilet seat kind of thing. So the ACEs of the repairs, and then the UCL, I told you, I've been on the Trevor Bauer Bender, and he's been talking about, and you've been around sports, I know that you've been with some pro teams and come on that if you want, but you've been around the sports. And do you think that there are mechanical true prevention to this sort of stuff? Or is there just, you only get, you know, sorry, you only get 50 ,000 pitches in that arm and that's... - Yeah, so there's definitely some anatomic things. I mean, some guys are, the way it's, the way they're structurally built and then their mechanics are just gonna keep them away from that, you know? Some guys, side armors, you know, guy that's with side arm, it doesn't put the same force on the UCL ligament to rupture it. But the crazy stat though, this isn't really answering your question, but the crazy stat though is, when a major leaguer throws a pitch, the physiologic force that the torque that's created should rupture the UCL every pitch. - Bullshit. - Yep, throw in a fastball. It should blow out, if you actually just take the tension, it should blow out What's going on there? That's it. It's like it's kind of like you just we don't know We don't know why but clearly guys certain mechanics are gonna put that at less of a risk But the volume it's all it's a volume game now. I think that thing just wears out the crate. Here's the craziest thing. Yeah Back in the day Not that long ago 20 15 20 years ago If you had it if you'd had a Tommy John surgery 'cause you blew out your UCL. It was a red flag. You know, when I worked, I was one of the, I helped with the Cardinals, one of the team physicians for several years. We would do exams on the minor leaguers and you'd look at, or a kid that's getting traded, you know, hey, we do a medical, what's they got? Ah, they had a meniscus tear, they've had this. They get stress fractures in their back, you know. Should we take this guy as it's a liability, right? 15 years ago, 10 years ago, if they'd had a Tommy John, that was a huge mark against them. You know, we're like, "Yeah, this guy's gotten borrowed time." Now, it's like, "Oh, you already had your Tommy John?" Cool, great, we're good, got that out of the way. - Got it out of the way, that's nuts. Now, is the UCL different? - They're like, "What?" I was like, "Can I have one in high - Yeah, they all get it. - Can the UCL repair strong? Like we were talking about the ACL, I know everything's different everywhere, but like can you come back as strong with the UCL repair? - So my theory is that the UCL reconstruction is never as tight as the original, and there's play in it, but they don't have pain with it. It's like it's kind of holding it together, but it's not doing a great job. And what happens is when you don't have a UCL and you keep throwing, you actually, you're creating arthritis, essentially on the other side of the joint, but that's not going to kick in till you're down the road. - So your arm's not just like floppy? - No, it just has a little extra play in it. It just has a little extra play in it. - Could you theoretically pitch through that? - Uh -huh, yeah, yeah. Usually people get-- - But you're trashing your elbow. - Correct, yeah. You're going to have long -term consequences by having its posterior rotary instability. It just causes this instability that is not going to cause you a necessary problem then. It's It's gonna be something that bites your ass down the road. - Interesting. - So my theory is that they just, unlike the ACL, which we can get tight, like a guitar string, I think the UCL starts that way and then it just kind of loosens up. And so the guys, it's good enough kind of thing, but they don't re -tear 'em and it doesn't hurt. - So there's a lower re -tear rate, but I don't necessarily think it's doing its full job. I think it's doing 50 % of the job, which is good enough. - And do people typically hit, I know you don't know all the stats, but based on what you know, do not just pitchers, but people who use their arms to throw, like short stops or whatever it may be, do they generally hit velocity again, or is there like, they go down two miles an hour or? - I haven't seen those numbers, I don't know, I don't know. I mean, clearly they get back to be effective, otherwise that would be a red mark you know I mean if they were if they never yeah guys come back and throw just as hard and for people who are listening I remember when so we all say Tommy John's like like pancake or something it's so tell us what it how you're actually repairing it because someone told me how it was repaired and that like with the wrist thing like in that some people have yep - some have one and what happens when you have one Well, so, no, so it's the, so think about the inside, the inside part of your elbow, right? So your funny bone, think about your funny bone, right? So that the ligament lives right in that zone, okay? When you tear it, just like the ACL, it rips apart. You can't, occasionally you can stitch a partial tear down, but for the most part, when it rips, it's gone. You gotta put a new one in. So the graph they usually use is called the pulmaris tendon, which is in your wrist, but it's kind of like a useless, we don't know why we have it, sort of like your appendix, like maybe it was important. - It's vest like this guy, right? - Yeah, if you pinch your finger, your thumb together and bring your wrist up, if you have one, so you either, some people just don't have one. - Literally like don't have that at all. - Yeah, they've like evolved out of it, right? So certain people don't have Paul Maris, but it doesn't have any real function. So harvesting it-- - So it doesn't help us pull our hand up. - No, no, they don't really know why we still have it. They think it's some evolutionary thing that's still hanging around that doesn't mean anything. So if you have one, they'll take that graft, or sometimes you'll have it on one side and not the other, so they'll take it. I forget what else they use. I don't really do that surgery, my partner doesn't. - Yeah, yeah, I understand, but So they yank do what they like how long is this going to play over they actually yeah Well, no because it's muscle. It's muscle in your forearm. It turns into a tendon, but they ready harvest It's pretty cool. They just make these tiny little necks. They don't open the whole thing up They make these little necks and they have a little device that That loops around it in it and you slide it under the skin and it shears it off. It's pretty cool Cool. Yeah, the worst the worst story though ever though is some some some super well -known guy who's taking care of a professional pitcher went to go harvest. They didn't have a Paul Maris and he harvested the median nerve. That is that power the whole hand thing? Like touch. Power is your thumb. Is it motor or sensor? It's motor and sensory. But it killed your pinch, all that kind of stuff there. Yeah, that was a bad one. And his throwing arm. That was a bad one. That's like an oh shit moment, because he probably knew it the moment he done it. Call your Med Mall insurance and just tell to give them the whole policy in your house. - So what, and I'm gonna wrap this up, but once they get this thing out, is that, like, what I'm feeling this, is that what a ligament feels like? - Yeah, that's the, no, no, sorry. - That's a tendon. - That's a tendon, yeah, yeah. So you're using a tendon to recreate a ligament. So ligaments connect bone to bone. Tendon connects muscle to bone. - And do they have the same sort of tensile properties? Like-- - Well, different ones have, no, no, no, the problem is is that, so we'd rather use a ligament because they tend to be stiffer and have less, they creep and all these other things that happen there. So the tendons aren't as good, but the pulmaris does a decent job. It does, but it can handle, it's ultimately may have more stretch flags or whatever, but it can hold the force. It can, but that's, that's my whole point on why I think it actually stretches out a little bit. Cause I don't, yeah. Cause if you put that sucker on tension and then just start hurling baseballs again, it's again, it's gonna loosen up, you know, attendance aren't that strong, right? They are, comparatively speaking. Compared to a ligament. So a ligament is, it's weird because can you like turn a ligament like that? Yeah, different ligaments. But you can't pull. Correct. Yes, that's a great way to think about it. Yeah, though you can twist it, you know, like in a circular motion, but yeah, you can't pull lengthwise. - And do you think there will be a time when somebody can think along the lines of like, okay, I'm gonna freeze an egg or have, is it possible? Do you think in your wildest dreams that athletes can somehow have spare parts made from themselves somewhere? - Of course they will. - You think that's like-- - Yeah. - I mean, how close, is that just a crazy, I know you guys think about these things, but how far away is that sense? - You're telling me you don't think in some Chinese labs somewhere they might be taking their best athletes and growing. - More of them? - Yeah. - But you think it's just a full clone and like, sorry, I got bad news here, the spare part container? - No, I think they'll clone different body parts. - Colonial and real thing? - Yeah, yeah, yeah. I think they're already decent work on that. There's a lot of data on that. I just, we don't hear about it much 'cause I think there's kind of the ethical dilemma. So I think that doesn't hit the papers very often. People want to keep that very close to the paper. - Yeah, I can't even, that's my head's about to explode. Just thinking about the implications of that, but redundant season was good. - I mean, just think about how killer that would be, is if you, yeah, if you had, again, if you had a, a lot of people have liver problems, liver cirrhosis that are not necessary 'cause Alcohol looks like me, but I mean, just think about being able to just regrow somebody's liver and transplant their own genetic makeup, you know, just, it'd be amazing. - You reach a certain age where it'd actually be easier just to take the brain out and put it in a new body. You know, just like a full upgrade. - Yeah, nothing's going to surprise me. I mean, put yourself, you're in 1855. - Yeah. - Think Think about what we're doing today, you know, it's just like you can't even fathom some of the stuff That would have been a horrible time to get fucked up by something awful awful. I mean, they're like and it's that you're like Oh shit. Yeah, what do they do? They just cut it that you're done. It's cut the leg. Let's go to shock You give it you give the you create the pain till they pass out Okay, yeah, that's a game All right, okay, I gotta wrap up man. Thanks so man. Thanks so much for coming in. I had no idea where this was going. I don't think either of us did. Well, no, you just kind of follow your nose, right? You're such an interesting guy. It's not going to take long. I appreciate you having me. All right, man. This is great. Talk to you. Thanks, buddy.