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Episode 109: PERSPECTIVES - Dr Matthew Fink

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Episode 109: PERSPECTIVES - Dr Matthew Fink

Contributors

  • Matthew Fink, MD

  • Nicholas A. Morris, MD

    Assistant Professor and Fellowship Director
    Division of Neurocritical Care and Emergency Neurology
    Department of Neurology
    University of Maryland School of Medicine Medicine

  1. 00:00:20
    Hi, welcome everyone to the Neuro
  2. 00:00:21
    Critical care Society Podcast. This is
  3. 00:00:24
    the perspective series. I'm your host,
  4. 00:00:26
    Dr. Nicholas Morris from University Of
  5. 00:00:27
    Maryland Shock Trauma Hospital, and
  6. 00:00:29
    today I have the absolute pleasure of
  7. 00:00:31
    interviewing Dr. Matthew E. Think. Dr.
  8. 00:00:34
    Fink is currently the Lewis and Gertrude
  9. 00:00:36
    Fail Professor and chairman of the
  10. 00:00:38
    Department of neurology, The Weil
  11. 00:00:39
    Cornell Medical College and neurologist
  12. 00:00:41
    in chief at New York Presbyterian
  13. 00:00:43
    Hospital, Weil Cornell Medical Center.
  14. 00:00:46
    He trained at the Neurological Institute
  15. 00:00:48
    of New York, Columbia Presbyterian
  16. 00:00:49
    Medical Center and served as chief
  17. 00:00:51
    resident under Dr. Lewis P Rolland.
  18. 00:00:53
    Subsequently he joined the faculty of
  19. 00:00:55
    Columbia University and became the
  20. 00:00:56
    founding director of the Neurology
  21. 00:00:58
    Neurosurgery intensive care unit at the
  22. 00:00:59
    New York Presbyterian Hospital, Dr.
  23. 00:01:02
    Fink was a founding member and chairman
  24. 00:01:03
    of the critical care section of the
  25. 00:01:05
    American Academy of Neurology and the
  26. 00:01:06
    research Section for Neuro critical care
  27. 00:01:09
    of the World Federation Rheology. He is
  28. 00:01:10
    board certified Internal medicine
  29. 00:01:12
    neurology Critical care medicine,
  30. 00:01:14
    vascular neurology and neuro critical
  31. 00:01:15
    care. It's been a pioneer in education
  32. 00:01:17
    and research within the field and
  33. 00:01:19
    welcome. Dr. Fink were very happy to
  34. 00:01:21
    have. Jan will thank you very much for
  35. 00:01:23
    inviting me. I am delighted to be able
  36. 00:01:26
    to share some of my experiences in this
  37. 00:01:31
    field with a wish. Those who are
  38. 00:01:33
    listening. It's been a fascinating ride
  39. 00:01:36
    for me and I'm happy to to talk to all
  40. 00:01:40
    of you about it. Great great. Oh what
  41. 00:01:42
    we'd we'd love to hear about it, so why
  42. 00:01:44
    don't you if you don't mind start by
  43. 00:01:45
    taking us back to Ah, You had trained
  44. 00:01:48
    at Columbia. You stayed on his faculty.
  45. 00:01:50
    There was no ice you narrow ice you back
  46. 00:01:53
    then, And what what were you doing at
  47. 00:01:56
    that time and and what led you to
  48. 00:01:58
    actually get this narrow ice you off the
  49. 00:02:00
    ground, And well it it, I'd like to go
  50. 00:02:02
    back actually earlier than that. If
  51. 00:02:05
    sure, if that that's alright with you,
  52. 00:02:08
    I decided in medical school that I was
  53. 00:02:12
    going to go to. Go into a field that
  54. 00:02:17
    had something to do with the nervous
  55. 00:02:19
    system. Many of us had those
  56. 00:02:22
    discussions. I didn't really know what
  57. 00:02:23
    I was going to do and there, so I took
  58. 00:02:27
    electives in neurology, psychiatry,
  59. 00:02:31
    Neurosurgery ruled out psychiatry ruled
  60. 00:02:35
    out neurosurgery and it's interesting,
  61. 00:02:38
    because later my career, I was actually
  62. 00:02:40
    invited to join the residency program in
  63. 00:02:43
    Neurosurgery Columbia. The chairman
  64. 00:02:45
    asked me to switch resident season, and
  65. 00:02:48
    I had to tell the chairman of
  66. 00:02:49
    neurosurgery that you know I actually
  67. 00:02:52
    find that very boring to be in the O R.
  68. 00:02:54
    For those hours. Not he looked at me
  69. 00:02:57
    like. Are you crazy? Yeah, I had the
  70. 00:03:00
    same experience. I remember. I tell
  71. 00:03:02
    residents this now, or as in the
  72. 00:03:04
    medical students that the first
  73. 00:03:05
    neurosurgical case I ever saw was one of
  74. 00:03:08
    the most incredible things I'd ever done
  75. 00:03:09
    the second one about four hours in. I
  76. 00:03:12
    was ready to move back to neurology.
  77. 00:03:14
    Exactly same experience, but when I was
  78. 00:03:17
    a medical school, I also did an
  79. 00:03:18
    anesthesiology an elective, and my
  80. 00:03:23
    mentor was someone I didn't know who he
  81. 00:03:25
    was. At the time. Some of you may know
  82. 00:03:27
    the name Peter Safir, Peter Safir
  83. 00:03:31
    really was the founder of the Critical
  84. 00:03:34
    care society, and and one of the
  85. 00:03:37
    leaders in the field, and I spent
  86. 00:03:38
    several weeks with him, one one the one
  87. 00:03:42
    t, as he taught me how to do
  88. 00:03:43
    innovations, and a whole lot of other
  89. 00:03:46
    critical care procedures that that he
  90. 00:03:49
    was an expert at, and I didn't even
  91. 00:03:51
    know I was being taught by the world's
  92. 00:03:53
    expert in this and a had an impact on me,
  93. 00:03:57
    so when I decided to apply for residency,
  94. 00:04:00
    and I know I was going to do neurology
  95. 00:04:03
    At that point, I came to neurology from
  96. 00:04:06
    what I consider to be a medical
  97. 00:04:08
    orientation, as opposed to a
  98. 00:04:10
    psychiatric orientation. I think people
  99. 00:04:13
    go into neurology. It's one of those
  100. 00:04:15
    two orientations. Either they're sort
  101. 00:04:18
    of entry by the behavior, and then
  102. 00:04:21
    that's the psychiatric orientation Mine
  103. 00:04:23
    was medical, so I decided to do more
  104. 00:04:26
    medicine before neurology, so I signed
  105. 00:04:29
    up to do two years of internal medicine
  106. 00:04:31
    first, but I ended up doing three years
  107. 00:04:33
    of internal medicine because I really
  108. 00:04:36
    loved it, but everything I did an
  109. 00:04:37
    internal medicine. I always referred
  110. 00:04:40
    back to what was going on in the brain.
  111. 00:04:43
    I saw patients with heart failure.
  112. 00:04:45
    How's that affecting the brain as of
  113. 00:04:47
    patients with pulmonary infections?
  114. 00:04:49
    How's that affecting the brain that was
  115. 00:04:51
    always my my orientation, so I came to
  116. 00:04:54
    Columbia as as a resident neurology and
  117. 00:04:57
    we had a huge inpatient service about
  118. 00:04:59
    one hundred and eighty beds, and
  119. 00:05:02
    everything that smelled like neurology
  120. 00:05:05
    from the emergency room got admitted to
  121. 00:05:07
    us, and we had an incredible variety of
  122. 00:05:10
    of stuff, Some of it probably not even
  123. 00:05:13
    appropriate, but. But so what and and
  124. 00:05:16
    and bud roll -in who is my chairman had
  125. 00:05:20
    a world reputation and neuromuscular
  126. 00:05:23
    disease, and so we had a huge number of
  127. 00:05:25
    patients who came to us with my cine,
  128. 00:05:27
    gravis, A L. S. Other kinds of
  129. 00:05:31
    neuropathies, My app, these and some
  130. 00:05:35
    of these patients, as you know, get
  131. 00:05:37
    really really sick, and they get
  132. 00:05:39
    intubated. They go on ventilators, and
  133. 00:05:42
    particular, My aesthetics are treatable
  134. 00:05:46
    conditions, and what happened to me as
  135. 00:05:50
    a resident, I was a second year
  136. 00:05:51
    resident. I was on call one night and I
  137. 00:05:56
    got paged a stat page in the days when
  138. 00:05:59
    we had pagers a sad page to see a
  139. 00:06:01
    patient who turned out to be a twenty
  140. 00:06:03
    four year old woman with generalized,
  141. 00:06:07
    my senior gravis intubated on a
  142. 00:06:09
    ventilator in a single room. On a
  143. 00:06:13
    regular patient care floor with a
  144. 00:06:17
    bedside monitor and the bedside monitor
  145. 00:06:21
    started beeping, and an excellent nurse
  146. 00:06:23
    got there as soon as possible and
  147. 00:06:26
    realize that the patient was not being
  148. 00:06:29
    ventilated properly, so I got stat.
  149. 00:06:31
    Paged went to see her realize that her
  150. 00:06:34
    and their tracheal tube was obstructed.
  151. 00:06:36
    We took out the eighty two re intubated
  152. 00:06:39
    her and and thought we had solved the
  153. 00:06:43
    problem, but she had been hypoxemia for
  154. 00:06:46
    prolonged period of time, and she ended
  155. 00:06:49
    up with secondary hypoxic ischemic brain
  156. 00:06:52
    injury from which he never recovered.
  157. 00:06:55
    I'm twenty four year old, healthy young
  158. 00:06:57
    woman with a treatable disease, and
  159. 00:07:00
    this in my view, this happened because
  160. 00:07:03
    she was not in a properly monitored
  161. 00:07:05
    setting. She needed to be in an icy you,
  162. 00:07:08
    so why was she not in an icy you because?
  163. 00:07:13
    At our hospital edit many hospitals
  164. 00:07:15
    throughout the United States,
  165. 00:07:16
    throughout the world. At that time,
  166. 00:07:19
    patients who had such severe
  167. 00:07:20
    neurological problems that they needed
  168. 00:07:23
    to be in an icy. You were simply
  169. 00:07:25
    rejected by the medical and surgical
  170. 00:07:28
    teams who were responsible for this,
  171. 00:07:31
    but and they would literally say to me
  172. 00:07:34
    if they're that sick, we're not going
  173. 00:07:36
    to be able to help 'em and you may as
  174. 00:07:37
    well just give up and in reality what
  175. 00:07:41
    happens to patients who had whether it
  176. 00:07:43
    was trauma, stroke, neuromuscular
  177. 00:07:46
    disease, severe infection, status
  178. 00:07:48
    epilepticus, All of those patients,
  179. 00:07:50
    when they were really critically ill,
  180. 00:07:52
    they were not treated in a proper
  181. 00:07:56
    intensive care unit, so for me, this
  182. 00:07:59
    was a pivotal moment. You know the
  183. 00:08:02
    light bulb goes on and I'm saved myself.
  184. 00:08:04
    We need our own. I see you to take care
  185. 00:08:08
    of these patients, so I went and talked
  186. 00:08:11
    to my chairman.
  187. 00:08:13
    To who had the same view of this and
  188. 00:08:17
    have been trying in his career to do the
  189. 00:08:19
    same thing, but was never able to get
  190. 00:08:22
    support from the hospitals that he
  191. 00:08:25
    worked at, and before he came the
  192. 00:08:26
    Columbia. He was the chairman of the
  193. 00:08:28
    University of Pennsylvania. He tried it.
  194. 00:08:30
    There. They nobody would support him at
  195. 00:08:32
    Columbia. Noack, Nobody would support
  196. 00:08:34
    him, so he said to me, I want you to
  197. 00:08:40
    give a presentation to the faculty at a
  198. 00:08:44
    departmental meeting. I was a I was
  199. 00:08:46
    chief resident at that time, but I
  200. 00:08:48
    still a resident. He said. I want you
  201. 00:08:50
    to give a presentation to the faculty.
  202. 00:08:53
    Then give that. Tell them what your
  203. 00:08:56
    concept is and what your plan is, and
  204. 00:08:59
    and I did that. I got in front of all
  205. 00:09:01
    the faculty and I presented the the
  206. 00:09:05
    argument for why we should have our own
  207. 00:09:07
    intensive care unit so we could take
  208. 00:09:09
    care of our patients. If our mission
  209. 00:09:12
    was to do the very best for our patients,
  210. 00:09:14
    then we needed to have a care of you and
  211. 00:09:17
    take care of them ourselves. Then I. I
  212. 00:09:19
    presented this, and then one by one,
  213. 00:09:23
    at least ten different faculty members
  214. 00:09:26
    stood up and attacked me and demolished
  215. 00:09:32
    me, said one after another, This is
  216. 00:09:35
    the worst idea I've ever heard this is
  217. 00:09:39
    stupid. This is terrible. Neurologists
  218. 00:09:41
    should not be doing this kind of thing
  219. 00:09:44
    where we're not going to support it,
  220. 00:09:46
    and there was universal rejection of the
  221. 00:09:51
    proposal. Not a single person stood up
  222. 00:09:54
    in support of what I was going into not
  223. 00:09:58
    a single person now, so I listened all
  224. 00:10:02
    of this and I, that. Fortunately I
  225. 00:10:04
    didn't take it personally. I just
  226. 00:10:05
    realized here's the problem. Here's the
  227. 00:10:09
    problem, so when the meeting was over.
  228. 00:10:11
    Bud Roland said okay Matt come into my
  229. 00:10:14
    Office Little I want to talk to you so
  230. 00:10:16
    he went to his office and he sat me down
  231. 00:10:19
    and he said ok he said what's your
  232. 00:10:23
    takeaway from that meeting we just had
  233. 00:10:28
    and I said my takeaway is everybody
  234. 00:10:31
    hates the idea nobody's going to support
  235. 00:10:34
    it and he said to me you're right that's
  236. 00:10:36
    exactly what we heard that he said but
  237. 00:10:40
    let me tell you something he said the
  238. 00:10:42
    best thing about being the department
  239. 00:10:45
    chairman is that I can ignore what
  240. 00:10:50
    everybody else says if I want to and I
  241. 00:10:54
    can just make an executive decision to
  242. 00:10:56
    do this and that's what we're Gonna do
  243. 00:10:59
    we're going to do it and I'm going to I
  244. 00:11:01
    said I'm going to hire you to do it you
  245. 00:11:03
    know July first this is going to be your
  246. 00:11:06
    job he said however it looks like you're
  247. 00:11:11
    doing it all by yourself. I don't hear
  248. 00:11:13
    that there's anybody in the department
  249. 00:11:14
    that's gonna help you with this. So
  250. 00:11:19
    that is how I got started. Now, so
  251. 00:11:21
    where did I do it? Well, we had a
  252. 00:11:24
    neurosurgical recovery room.
  253. 00:11:27
    Neurosurgents had a recovery room in the
  254. 00:11:28
    building. And that was the only place
  255. 00:11:30
    we could do this. We were gonna have to
  256. 00:11:32
    share it. Well, how was I gonna get
  257. 00:11:35
    the neurosurgeons to work with us on
  258. 00:11:38
    this? Because it needed to be a
  259. 00:11:40
    multi-disciplinary program. So I really
  260. 00:11:43
    didn't know. I had good relationships
  261. 00:11:46
    with the neurosurgeons 'cause I worked
  262. 00:11:48
    with all the residents closely. And as
  263. 00:11:49
    I said, when I was a second year
  264. 00:11:51
    resident, the chairman of neurosurgeon,
  265. 00:11:53
    Bennett Stein, who actually had just
  266. 00:11:55
    come to Columbia at that time, I took
  267. 00:11:58
    care of a lot of his patients. And he
  268. 00:12:01
    invited me at one point to switch
  269. 00:12:03
    residencies. And it's a been
  270. 00:12:06
    neurosurgeon have should you, Oh, says
  271. 00:12:06
    day this. to wife my 'cause funny of
  272. 00:12:06
    kind
  273. 00:12:10
    If you would have made a whole lot more
  274. 00:12:11
    money, Pena, and I'm like nah. That's
  275. 00:12:15
    okay. Not not that I made the right
  276. 00:12:17
    choice, so I got to know him very well,
  277. 00:12:20
    so so what do I do where I started just
  278. 00:12:22
    hanging out in the neurosurgical
  279. 00:12:24
    recovery room, getting to know the
  280. 00:12:27
    nurses going around seeing the patience,
  281. 00:12:31
    and just getting a sense of what we
  282. 00:12:35
    needed to do in that particular unit and
  283. 00:12:39
    the nurses were delighted to have me
  284. 00:12:41
    there, because there were no other
  285. 00:12:43
    physicians in that unit. The surgeons
  286. 00:12:46
    were in the O. R. There are no doctors
  287. 00:12:49
    around. It was the nurses, and if they
  288. 00:12:52
    ran into problems, they didn't know who
  289. 00:12:54
    to talk to, they couldn't surgeons in
  290. 00:12:55
    the O. R. So I was hanging around
  291. 00:12:58
    there, sir to helping out being ill
  292. 00:13:00
    available to help when they had
  293. 00:13:02
    questions, and while I was there at one
  294. 00:13:06
    of the postoperative patients, I
  295. 00:13:07
    believe was a post -op aneurysm clip.
  296. 00:13:11
    day after surgery for whatever reason
  297. 00:13:14
    had a sudden cardiac arrest
  298. 00:13:17
    never knew why I was there and with the
  299. 00:13:20
    nurses we pulled the team together and
  300. 00:13:24
    we resuscitated the patient got her back
  301. 00:13:27
    in perfect shape because we immediately
  302. 00:13:29
    started treatment immediately because he
  303. 00:13:31
    was you know the cardiac arrest was
  304. 00:13:33
    diagnosed instantly treated her got her
  305. 00:13:36
    back it turned out that this was one of
  306. 00:13:38
    dr. Stein's patients
  307. 00:13:42
    so later that night he came out of the
  308. 00:13:46
    OR and he came in to the ICU the nurses
  309. 00:13:48
    just briefed him told him what happened
  310. 00:13:50
    and he was like oh my god what happened
  311. 00:13:53
    but they said oh no we got we got her
  312. 00:13:55
    back we resuscitated her you know dr.
  313. 00:13:58
    Fink was here he helped us out he he
  314. 00:14:00
    organized the team it was went great
  315. 00:14:03
    your patients fine so the next day dr.
  316. 00:14:06
    Stein calls me in his office and And I
  317. 00:14:10
    didn't know exactly what he was going to
  318. 00:14:11
    say, and oddly enough, he didn't say
  319. 00:14:14
    thank you very much for saving my face.
  320. 00:14:17
    It. He didn't say that he looked at me
  321. 00:14:22
    very intently and said I get it. Now
  322. 00:14:28
    those were his exact words. He said I
  323. 00:14:31
    get it. I now understand what you're
  324. 00:14:35
    talking about what you wanna do and why
  325. 00:14:39
    it's important, and from that one
  326. 00:14:41
    incident, he became my greatest
  327. 00:14:45
    supporter through all of this and
  328. 00:14:49
    continued to be for all the years that I
  329. 00:14:51
    was there, migrant one of my greatest
  330. 00:14:53
    supporters, and if it wasn't for that,
  331. 00:14:56
    we would not have had a fully integrated
  332. 00:15:00
    discipline, or are you to, he
  333. 00:15:02
    understood the fact that we as
  334. 00:15:04
    neurologists being in the ice you all
  335. 00:15:06
    the time. Would make a huge difference
  336. 00:15:08
    taken care of not just our own neurology
  337. 00:15:10
    patients, which an obvious thing also
  338. 00:15:13
    the neurosurgery patients, So we from
  339. 00:15:15
    day one got involved in taking care of
  340. 00:15:18
    all of those patients. Now I had to do
  341. 00:15:22
    it myself, and I, I tell everyone you
  342. 00:15:24
    know, for the first three years, I was
  343. 00:15:28
    on call twenty four seven for three
  344. 00:15:30
    years, and literally I was I was in the
  345. 00:15:33
    hospital seven days a week of aid rounds,
  346. 00:15:36
    seven days a week, I was taking phone
  347. 00:15:38
    calls and until I could finally start to
  348. 00:15:42
    build my own team because none of the
  349. 00:15:45
    existing people wanted to work with me
  350. 00:15:48
    so so that was that was that was the
  351. 00:15:51
    start of it, so I had support from the
  352. 00:15:53
    two chairs, chairman of neurology,
  353. 00:15:55
    chairman or surgery, and and that was
  354. 00:15:58
    the start of it. That's that's an
  355. 00:16:00
    incredible story and I won't ask a
  356. 00:16:02
    little bit how you started the build
  357. 00:16:04
    your team, but before that. You'd
  358. 00:16:06
    mentioned sort of the the nihilism in
  359. 00:16:09
    the in the medical and surgical ice to
  360. 00:16:10
    use. Know what did they think of all
  361. 00:16:12
    this is you're you're coming up with
  362. 00:16:14
    this idea of a narrow ice you and
  363. 00:16:16
    getting support from the neurology and
  364. 00:16:18
    neurosurgery Chairman at work. How did
  365. 00:16:20
    how did that play in while I think that
  366. 00:16:24
    the their first reaction was. Oh great,
  367. 00:16:27
    you're not going to bother us any more
  368. 00:16:29
    about about trying to get your patients
  369. 00:16:32
    into the medical or surgical ic use. A
  370. 00:16:35
    really was that really was their initial
  371. 00:16:37
    attitude, but shortly afterwards they
  372. 00:16:41
    started to appreciate what we were doing,
  373. 00:16:44
    and within a relatively short period
  374. 00:16:46
    time I had a anesthesiologists who
  375. 00:16:50
    wanted to participate. That's how we
  376. 00:16:53
    build a team. I got it really good
  377. 00:16:55
    attending anesthesiologist who said
  378. 00:16:57
    while this is great, I'm really
  379. 00:16:58
    interested in this stuff. Can I you
  380. 00:17:00
    know join the team Internal medicine?
  381. 00:17:04
    Pulmonary medicine, people,
  382. 00:17:06
    cardiologists, we gradually develop the
  383. 00:17:09
    whole team of people who who were
  384. 00:17:11
    interested in neurological disorders,
  385. 00:17:15
    and and and it went from being a. We
  386. 00:17:18
    don't want to have anything to do with
  387. 00:17:19
    these patients. Too. Wow, This is
  388. 00:17:21
    really cool. We want to be involved. I
  389. 00:17:25
    ain't right and were you able to recruit
  390. 00:17:27
    in those early days, other neurologists
  391. 00:17:29
    and then her eyes, You, Yes, actually,
  392. 00:17:31
    the first person I recruited and his was
  393. 00:17:34
    Laura Lenihan, Who's had Columbia. She
  394. 00:17:38
    is the vice chair at Columbia, and
  395. 00:17:40
    Laura was a resident in Madison. At
  396. 00:17:44
    that years of Pennsylvania, did a
  397. 00:17:46
    residency in Neurological. Me, Then
  398. 00:17:48
    was a stroke fellow, but she was to be
  399. 00:17:52
    polite. She was and marginalized as a
  400. 00:17:58
    stroke fellow, and I attributed the
  401. 00:18:01
    fact that she was a woman and the stroke.
  402. 00:18:05
    Team was a you know was a bastion of
  403. 00:18:08
    males who you know like to make jokes
  404. 00:18:14
    that were inappropriate, and she was
  405. 00:18:17
    ostracized and and never felt part of
  406. 00:18:20
    that team and I observed it, and I knew
  407. 00:18:23
    that she was a brilliant well trained
  408. 00:18:26
    physician in both medicine or Oggi, So
  409. 00:18:29
    I, I spoke to her when she was
  410. 00:18:31
    finishing her fellowship. I knew she
  411. 00:18:33
    was miserable. Didn't know what to do
  412. 00:18:35
    and I said, Would you like to join me
  413. 00:18:37
    and be one of the attendings. I need
  414. 00:18:40
    the help. This is exactly what you're
  415. 00:18:43
    good at doing and she was delighted to
  416. 00:18:45
    do it, and so she was my first and
  417. 00:18:50
    attending who really helped and then we
  418. 00:18:53
    started developing a fellowship and then
  419. 00:18:55
    we started building the team. Really
  420. 00:18:57
    from the ground up, He also got an
  421. 00:18:59
    anesthesiologist who joined as the team
  422. 00:19:01
    as well as I said he's he, he
  423. 00:19:03
    volunteered, he said. He was a neuro
  424. 00:19:05
    anesthesia attending who wanted to do
  425. 00:19:08
    neuro ICU work.
  426. 00:19:12
    And Dr. Lenehan still remains very
  427. 00:19:14
    involved with the ICU now and how she
  428. 00:19:17
    has run the Graduate Service. They have
  429. 00:19:18
    there at Columbia. Absolutely.
  430. 00:19:20
    Absolutely. Yes. Yes.
  431. 00:19:23
    That's great. I just, I can't help but
  432. 00:19:26
    go back and talk to you a little bit
  433. 00:19:27
    about Peter Safer because we haven't
  434. 00:19:28
    talked about him on this podcast and I
  435. 00:19:30
    don't know that neuro-intensive,
  436. 00:19:33
    especially the young neuro-intensivists
  437. 00:19:35
    really know who Peter Safer is and how
  438. 00:19:37
    important he is in critical care. And
  439. 00:19:40
    to have someone who trained with him, I
  440. 00:19:42
    think he's inspired, gosh, dozens at
  441. 00:19:44
    least of intensivists. What was it
  442. 00:19:47
    about Dr. Safer that it sounds like
  443. 00:19:49
    from a very early point in your training
  444. 00:19:51
    really inspired you to follow this
  445. 00:19:54
    ambition? Yeah. Well, again, I
  446. 00:19:57
    didn't know anything about who he was I
  447. 00:20:00
    was simply assigned to him. For a
  448. 00:20:04
    period of several weeks and I, I worked
  449. 00:20:06
    with them every day. I went to the
  450. 00:20:08
    operating room with him every day, and
  451. 00:20:12
    he. He taught me to do all of the
  452. 00:20:14
    procedures to prepare a person for
  453. 00:20:18
    surgery, and that included putting in
  454. 00:20:20
    lines learning to do, and the tracheal
  455. 00:20:23
    intubation, to this day, I can still
  456. 00:20:27
    visualize doctors Safir telling me how
  457. 00:20:31
    to do and and the tracheal intubation,
  458. 00:20:34
    and I haven't actually done one myself
  459. 00:20:36
    in a number of years, but I could do it.
  460. 00:20:38
    You know you know at this moment and I
  461. 00:20:41
    can still visualize it and what was so
  462. 00:20:43
    remarkable about him is that and it's
  463. 00:20:47
    what I really love about Neuro Intensive
  464. 00:20:49
    care. As a specialty. He was very much
  465. 00:20:53
    oriented towards physiology, and
  466. 00:20:56
    everything he taught everything he
  467. 00:20:59
    taught was always based on. the
  468. 00:21:02
    physiology of why he was doing what he
  469. 00:21:05
    was doing. And to me, that was just
  470. 00:21:08
    the most amazing part of it. It was,
  471. 00:21:12
    he didn't do anything with the statement
  472. 00:21:15
    that some people, you know, say, Oh,
  473. 00:21:17
    that's just the way we do it. Remember
  474. 00:21:19
    that phrase? That's just the way we do
  475. 00:21:20
    it. He never said that. He always
  476. 00:21:22
    explained it based on what the
  477. 00:21:24
    physiology was about, you know, why he
  478. 00:21:26
    would, you know, do a particular
  479. 00:21:29
    technique during intubation. There's
  480. 00:21:31
    always a good reason for it. And I just
  481. 00:21:33
    love that. And I found that when things
  482. 00:21:36
    were explained based on physiology, I
  483. 00:21:39
    remembered them that way. I don't know
  484. 00:21:41
    how other people remember things, but
  485. 00:21:44
    for me, it was a great way to remember
  486. 00:21:46
    what was going on. And I didn't know he
  487. 00:21:48
    was such a prominent person. He
  488. 00:21:50
    developed in Pittsburgh, you know, he
  489. 00:21:52
    started a separate department, they
  490. 00:21:54
    have a department of critical care
  491. 00:21:55
    medicine, which is a very, very
  492. 00:21:59
    prominent prestigious department. He
  493. 00:22:01
    created Really created whole field and
  494. 00:22:03
    he was a lovely man. Just this really
  495. 00:22:05
    nice sky, and I was just fortunate to
  496. 00:22:10
    be assigned to him by chance, and I've
  497. 00:22:14
    been lucky enough to learn from those
  498. 00:22:16
    who learned from him and that's really
  499. 00:22:18
    been an honor and and for those of us
  500. 00:22:19
    who don't know and doctors offer, and
  501. 00:22:22
    what if he's really in many ways, the
  502. 00:22:24
    father resuscitation, and if if you
  503. 00:22:27
    have some time, you'd better youtube
  504. 00:22:28
    his videos, where he kind of shows us
  505. 00:22:30
    all how to ventilate patients, e n an
  506. 00:22:34
    estimated for are paralyzed and medical
  507. 00:22:36
    students in order to show the power of
  508. 00:22:39
    bag valve mask ventilation, and he is
  509. 00:22:41
    really really in many ways one of the
  510. 00:22:44
    the true pioneers of critical care, but
  511. 00:22:48
    then he had a. He had a difficult time
  512. 00:22:50
    in his own career. When he first came,
  513. 00:22:53
    I I believe he he immigrated to the U.
  514. 00:22:57
    S. He came from, I think he came from
  515. 00:23:00
    Eastern Europe, and and. I started out
  516. 00:23:03
    doing his research. It was then a
  517. 00:23:05
    Baltimore City hospital in Baltimore,
  518. 00:23:08
    where he was studying resuscitation in
  519. 00:23:11
    the best way to do Cpr on dogs and then
  520. 00:23:14
    Hopkins pick them up. I realized that
  521. 00:23:17
    he was a brilliant guide doing doing
  522. 00:23:19
    brilliant research and a wonderful man.
  523. 00:23:22
    Okay, so let's let's go back to the
  524. 00:23:24
    Columbia ice you there, and you, How
  525. 00:23:27
    how did you go from this imprint of this
  526. 00:23:29
    neurosurgical recovery area which I'm
  527. 00:23:32
    sure was not quite so large, developing,
  528. 00:23:35
    and what in many ways is one of the very
  529. 00:23:38
    first, like well established large
  530. 00:23:40
    neuro critical care units with the
  531. 00:23:42
    faculty and fellowship can, Can you
  532. 00:23:43
    take us a little bit more through of
  533. 00:23:45
    those earth? We worked with it this
  534. 00:23:47
    limited limited area in the old
  535. 00:23:49
    Neurological Institute building, which
  536. 00:23:51
    is still there, which by the way was
  537. 00:23:52
    built in nineteen thirty. I think
  538. 00:23:55
    nineteen thirty two, or something,
  539. 00:23:57
    It's an old decrepit building when I was
  540. 00:23:59
    working there didn't even have air
  541. 00:24:00
    conditioning. It was no air
  542. 00:24:02
    conditioning the plumbing that wasn't
  543. 00:24:05
    working at amazing that we are able to
  544. 00:24:07
    do anything there, and so we started
  545. 00:24:10
    working in this old recovery room,
  546. 00:24:13
    building a team of physicians working
  547. 00:24:17
    collaboratively with the neurosurgeons
  548. 00:24:19
    and and the one message I'll give to
  549. 00:24:21
    anyone who is interested in developing
  550. 00:24:24
    This is. It is critically important to
  551. 00:24:28
    have a strong positive working
  552. 00:24:31
    relationship with the neurosurgical
  553. 00:24:33
    department. It is essential if you
  554. 00:24:36
    don't you'll you will not be able to do
  555. 00:24:38
    this and I was lucky enough to have it
  556. 00:24:40
    happen in one fell swoop by
  557. 00:24:43
    resuscitating that one patient, and but
  558. 00:24:46
    you gotta do it. You have to work at it
  559. 00:24:48
    and you have to work at it because
  560. 00:24:50
    otherwise you can't succeed, and so we
  561. 00:24:53
    built a team and what happened was It
  562. 00:24:57
    became widely recognized throughout the
  563. 00:25:01
    new year. metropolitan area, and I say
  564. 00:25:03
    metropolitan area that's 100 miles
  565. 00:25:05
    around New York City, that we were able
  566. 00:25:09
    to take care of critically ill patients
  567. 00:25:12
    with terrible neurological diseases,
  568. 00:25:15
    patients with ruptured aneurysms,
  569. 00:25:18
    neuromuscular disease, status
  570. 00:25:19
    epilepticus, serious neurological
  571. 00:25:21
    infections, and the surrounding
  572. 00:25:24
    hospitals were unable to do that. They
  573. 00:25:27
    couldn't do it So pretty soon, we were
  574. 00:25:29
    flooded with referrals from all of the
  575. 00:25:34
    surrounding hospitals who didn't know
  576. 00:25:36
    what to do, didn't have the knowledge,
  577. 00:25:38
    didn't have the technology. For a long
  578. 00:25:41
    time, we were the only service that
  579. 00:25:44
    could do plasma foresis. Nobody else
  580. 00:25:47
    could do plasma foresis. So all of the
  581. 00:25:49
    patients with Guillain-Barre and
  582. 00:25:51
    Myosinia who needed plasma foresis got
  583. 00:25:53
    shipped into us and we were flooded and
  584. 00:25:56
    the hospital all of a sudden became very
  585. 00:26:00
    alert that Oh, look at this. We're yet.
  586. 00:26:03
    It will get all these new patients that
  587. 00:26:04
    are being transferred into us from all
  588. 00:26:06
    these other hospitals. They all of a
  589. 00:26:08
    sudden started to pay attention to this.
  590. 00:26:11
    Like everything else you know money
  591. 00:26:13
    talks, So the hospital saw this as a
  592. 00:26:16
    big rental revenue generator for them,
  593. 00:26:20
    and then when they planned to build a
  594. 00:26:23
    new hospital, Which is what they did.
  595. 00:26:26
    We were included, and part of that plan
  596. 00:26:28
    then became a brand new dedicated
  597. 00:26:34
    neurological. I see you in the new
  598. 00:26:36
    hospital and and and that's how we were
  599. 00:26:39
    able to then move from this old building
  600. 00:26:42
    into a brand new unit that I helped to
  601. 00:26:44
    design at the time, and we moved into
  602. 00:26:47
    that unit in nineteen ninety one. It
  603. 00:26:51
    was a Saturday when we were physically
  604. 00:26:54
    transporting patients from the old
  605. 00:26:56
    building across a bridge in. The new
  606. 00:26:59
    building I was in there. I had all of
  607. 00:27:01
    this all of my team and all the
  608. 00:27:03
    residents who are in their moving
  609. 00:27:05
    patients, and I still have a t -shirt
  610. 00:27:08
    from that day that I say everybody got t
  611. 00:27:11
    -shirts moving t -shirts and we moved
  612. 00:27:14
    into a brand new intensive care unit
  613. 00:27:16
    neuro, I see you, and in nineteen
  614. 00:27:18
    ninety one, that was a very big day for
  615. 00:27:21
    all of us and it was the only one of its
  616. 00:27:23
    kind in the whole region at the time now,
  617. 00:27:27
    and it's always struck me when I look
  618. 00:27:30
    back at the the early research that was
  619. 00:27:32
    coming out of the the neurologic, vice
  620. 00:27:34
    you a Columbia. That it really is a
  621. 00:27:35
    collaboration between neurosurgery and
  622. 00:27:38
    and the neurologists you you wouldn't
  623. 00:27:39
    really know in any given paper could be
  624. 00:27:41
    Robert Solomon, His the first author.
  625. 00:27:43
    It can be Laura Lenihan, I could be you,
  626. 00:27:45
    and and you are all sort of interested
  627. 00:27:47
    in the same things. Can you talk a
  628. 00:27:49
    little bit about the research mission
  629. 00:27:50
    And how important that was Is well it it
  630. 00:27:54
    was it was something that went. part
  631. 00:27:58
    and parcel with the treatment that we
  632. 00:28:01
    were trying to provide to patients and
  633. 00:28:04
    let me give you an example and a lot of
  634. 00:28:07
    it was never published. A lot of this
  635. 00:28:09
    stuff we just did and not published but
  636. 00:28:13
    for example early on we recognized that
  637. 00:28:15
    one of the greatest failures in aneurysm
  638. 00:28:18
    surgery was delay in surgery that the
  639. 00:28:23
    standard routine at the time was to wait
  640. 00:28:27
    several weeks until the patient was
  641. 00:28:30
    quote stabilized or the surgeons used to
  642. 00:28:33
    use the term until quote the brain
  643. 00:28:35
    cooled off whatever that means before
  644. 00:28:39
    they wanted to operate. Well what
  645. 00:28:41
    happened during those two to three weeks
  646. 00:28:43
    was about half those patients had their
  647. 00:28:46
    aneurysm re-rupture and they died and so
  648. 00:28:50
    we made a decision that we had to make a
  649. 00:28:55
    dramatic change. and how did we make
  650. 00:28:57
    that dramatic change will we pulled
  651. 00:28:59
    together all of the attending physicians
  652. 00:29:02
    in neurology neurosurgery who were
  653. 00:29:03
    involved aneurysm patients we got 'Em
  654. 00:29:05
    all together in a room and we all agreed
  655. 00:29:07
    let's sit down and come up with a new
  656. 00:29:11
    protocol that's going to change this we
  657. 00:29:14
    all recognize that what we're currently
  658. 00:29:15
    doing is not working it's not working
  659. 00:29:18
    and let's change it and we did it as it
  660. 00:29:21
    when in a consensus conference and then
  661. 00:29:24
    we literally on a one day and I think
  662. 00:29:27
    was a DJ july one of US forget which
  663. 00:29:29
    year it was everyone agreed that if a
  664. 00:29:33
    patient came in with a ruptured aneurysm
  665. 00:29:34
    unless there was a real contra
  666. 00:29:37
    indication if they were grade you know
  667. 00:29:39
    four or five they were going to go to
  668. 00:29:42
    the O R within twenty four hours to get
  669. 00:29:45
    there aneurysm secured and this is
  670. 00:29:47
    before the days of endovascular therapy
  671. 00:29:49
    this was all going to be open surgery
  672. 00:29:52
    open surgery and so the people who are
  673. 00:29:55
    doing it Solomon, you know was a new
  674. 00:29:58
    attending neurosurgeon and he was an
  675. 00:30:00
    expert an aneurysm surgery. He, he did
  676. 00:30:02
    the lion's share of these cases, and he
  677. 00:30:05
    was you know operating twenty four seven
  678. 00:30:08
    on these patients, but they all we all
  679. 00:30:10
    agreed that this is what we were going
  680. 00:30:12
    to do, and it it dramatically change
  681. 00:30:15
    the outcomes of these patients, and now
  682. 00:30:17
    as you know, within the vascular
  683. 00:30:19
    therapy, every patient gets treated as
  684. 00:30:21
    a immediately. Even if they're great
  685. 00:30:23
    for Raid five in their aneurysm gets
  686. 00:30:25
    coiled gets treated, you know with all
  687. 00:30:28
    that all of the new devices, so so we
  688. 00:30:31
    we were able to accomplish the research
  689. 00:30:34
    because we recognize there were so many
  690. 00:30:37
    problems that had no good answers and we
  691. 00:30:40
    did it as a team. We we always would
  692. 00:30:42
    get together as a team. It was always a
  693. 00:30:45
    collaborative team of both neurology
  694. 00:30:47
    neurosurgery. Always, we always did it
  695. 00:30:50
    together what so much of what we learned
  696. 00:30:53
    or what we have learned. In some rotten
  697. 00:30:55
    hemorrhage and beyond really did come
  698. 00:30:58
    from from the Columbia neurologic lies
  699. 00:31:00
    to you, And how did you go about
  700. 00:31:03
    building it the research infrastructure
  701. 00:31:05
    there Because I thought I was a fellow
  702. 00:31:07
    there, and I've always been impressed
  703. 00:31:09
    by fellow there. What you're there for
  704. 00:31:12
    an August two thousand and fourteen to
  705. 00:31:14
    two thousand and sixteen, Yup. Okay,
  706. 00:31:17
    So I was at Cornell, Cornell. There,
  707. 00:31:19
    Yeah, yup okay, but but but really
  708. 00:31:23
    it's it's turned out so much knowledge
  709. 00:31:26
    over time and and is not true across our
  710. 00:31:29
    field, and it really stands out as a
  711. 00:31:32
    beacon of research and has for a long
  712. 00:31:34
    time at a, It strikes me you were
  713. 00:31:36
    pivotal in building the infrastructure.
  714. 00:31:38
    So what what steps did you take to do
  715. 00:31:40
    that well at the time that this was
  716. 00:31:44
    going on? I had no strategic plan of
  717. 00:31:51
    what to do. Okay, I was. Really.
  718. 00:31:55
    Building things one day at a time one
  719. 00:31:58
    piece at a time as we needed it, and
  720. 00:32:02
    but the key was to get the right people
  721. 00:32:05
    together, who had the same mission and
  722. 00:32:10
    the same goals, and then we had a
  723. 00:32:13
    higher. There was no research
  724. 00:32:16
    infrastructure that we could rely on.
  725. 00:32:18
    There wasn't anything, so we just had
  726. 00:32:20
    the gradually start hiring people a
  727. 00:32:23
    piece by piece, begging for space and
  728. 00:32:27
    begging for support them to do that,
  729. 00:32:30
    and there It's I think it's a lot easier
  730. 00:32:34
    now because most departments of
  731. 00:32:36
    neurology have a strong research
  732. 00:32:39
    infrastructure, so the Cornell now
  733. 00:32:42
    we've I've got a whole team of of
  734. 00:32:45
    research coordinators supervised by A by
  735. 00:32:50
    Ea, the physician, who's an expert in
  736. 00:32:52
    doing these things, and so we can.
  737. 00:32:54
    Anyone who wants to do a clinical
  738. 00:32:56
    research can take advantage of this team
  739. 00:33:00
    to help them, but back then there was
  740. 00:33:02
    no such thing, and so we just had the
  741. 00:33:04
    gradually added on piece by piece until
  742. 00:33:08
    we had it, and it was done
  743. 00:33:09
    independently. It wasn't from any help
  744. 00:33:12
    from the department or from the medical
  745. 00:33:14
    school or from the hospital. We decide
  746. 00:33:17
    to do it ourselves and we we. We
  747. 00:33:20
    recognized that this was the future of
  748. 00:33:22
    our field, and we had to be innovative,
  749. 00:33:29
    and as I'm listening to you and it, I,
  750. 00:33:32
    I can't help but think that, and of
  751. 00:33:34
    course eat, you become a chairman, and
  752. 00:33:36
    and had gone into administration. As
  753. 00:33:37
    you were doing that from day one you are,
  754. 00:33:38
    and basically you've told the story of
  755. 00:33:40
    being a a founder of a startup company,
  756. 00:33:43
    and and can can you tell us a little bit
  757. 00:33:47
    about how your career has transitioned
  758. 00:33:49
    beyond kind of the twenty four seven
  759. 00:33:50
    clinical care to being a department
  760. 00:33:53
    chair? Well, let me just make a
  761. 00:33:55
    comment about the startup company. I
  762. 00:33:57
    think that's a good analogy. I love to
  763. 00:34:03
    take on new things that others have not
  764. 00:34:07
    done before. That's, it just, for me,
  765. 00:34:10
    it's an exciting thing to do. I've
  766. 00:34:12
    turned down job offers. I was offered a
  767. 00:34:15
    job in the early, in the 1990s,
  768. 00:34:18
    actually to go to one of the Harvard
  769. 00:34:21
    hospitals in Boston And I thought about
  770. 00:34:25
    it and considered it. And I rejected it
  771. 00:34:29
    primarily because the bottom line was
  772. 00:34:31
    the person trying to hire me said, oh,
  773. 00:34:33
    I want you to come to Boston and do the
  774. 00:34:36
    same thing that you did at Columbia,
  775. 00:34:37
    New York. And that was an immediate
  776. 00:34:41
    turn off. I don't need to go to another
  777. 00:34:45
    place to do the same thing. Right? Why
  778. 00:34:47
    would you want, why would I want to do
  779. 00:34:48
    that? I want to do something new,
  780. 00:34:51
    something new and different So after
  781. 00:34:54
    about Ten years ten or eleven years of
  782. 00:34:57
    of working in the I C you building the
  783. 00:35:00
    Ic program at Columbia,
  784. 00:35:03
    I was offered a new opportunity to build
  785. 00:35:08
    and create a multi -disciplinary
  786. 00:35:12
    neuroscience service at one of the other
  787. 00:35:15
    big hospitals in New York City, Beth
  788. 00:35:18
    Israel Medical Center Beth Israel, to
  789. 00:35:20
    time, this is in nineteen, ninety,
  790. 00:35:22
    four, ninety, ninety, ninety four,
  791. 00:35:25
    Beth Israel was actually the largest
  792. 00:35:27
    independent hospital New York, at at
  793. 00:35:29
    fourteen hundred beds. It was a beat
  794. 00:35:32
    behemoth, a huge place, not
  795. 00:35:35
    particularly academic. It was
  796. 00:35:38
    affiliated with Mount Sinai academically,
  797. 00:35:41
    but the leadership decided they wanted
  798. 00:35:45
    to create a neurological program that
  799. 00:35:48
    would compete with the other places in
  800. 00:35:51
    the city, and what that was they wanted
  801. 00:35:53
    to develop. Everything, neurology,
  802. 00:35:56
    neurosurgery, neuroradiology,
  803. 00:35:58
    interventional, I see everything, the
  804. 00:35:59
    whole thing. And they basically
  805. 00:36:02
    recruited me and hired me to do that,
  806. 00:36:05
    to build a completely new neurological
  807. 00:36:08
    service based on what I thought were the
  808. 00:36:12
    best things to do and recruit the best
  809. 00:36:13
    people. And that's what I did. I took
  810. 00:36:16
    the job and I started recruiting people
  811. 00:36:19
    from the whole region in all of these
  812. 00:36:22
    different areas And I got some of the
  813. 00:36:24
    best people, mostly from New York City.
  814. 00:36:28
    I sort of, you know, poached people
  815. 00:36:30
    from all of the big academic medical
  816. 00:36:32
    centers, brought them together. They
  817. 00:36:34
    built a brand new facility for everybody.
  818. 00:36:38
    And within three years, the volume of
  819. 00:36:44
    patients, we were bringing into that
  820. 00:36:46
    new center, I was only second to
  821. 00:36:50
    Columbia at that time I mean, we very
  822. 00:36:53
    rapidly increase. The volume of that
  823. 00:36:55
    and it was all based on bringing in
  824. 00:36:58
    excellent people who were all working
  825. 00:37:01
    together, and and so oddly enough,
  826. 00:37:05
    after three years and showing success
  827. 00:37:08
    that the the chairman of the board met
  828. 00:37:10
    with me over lunch, invited me to his
  829. 00:37:13
    office for lunch, and completely out of
  830. 00:37:17
    the blue, said to me, you know we're
  831. 00:37:22
    we're we're we're looking for a new ceo
  832. 00:37:26
    of the hospital and we think you would
  833. 00:37:28
    be great at doing that job, so they
  834. 00:37:32
    actually offered me the job to become
  835. 00:37:34
    ceo of this hospital, Anna, and again
  836. 00:37:37
    in In the way, I think about things, I
  837. 00:37:39
    saw it as another great opportunity to
  838. 00:37:41
    do all sorts of new things,
  839. 00:37:44
    so so as a complete shock to my, you
  840. 00:37:48
    know friends, family and and colleagues,
  841. 00:37:52
    I said. Alright, lug it let me give it
  842. 00:37:54
    a shot. Let me see what it's like to be
  843. 00:37:55
    a hospital ceo. So that was that was a
  844. 00:37:59
    never expected that, but it all grew
  845. 00:38:02
    out of the work that I did first first
  846. 00:38:05
    the icy work of Columbia, then building
  847. 00:38:08
    and or illogical service at Beth Israel,
  848. 00:38:10
    and then based on that, they asked me
  849. 00:38:13
    to be the Ceo, Saying, Look if you can
  850. 00:38:15
    do that with all the neurology programs,
  851. 00:38:18
    The neuro programs. Can you do that
  852. 00:38:19
    with all the other programs, and and I
  853. 00:38:22
    started to work on that, And now it
  854. 00:38:25
    didn't work out quite the same. I If
  855. 00:38:29
    you've kept up with us going on, You
  856. 00:38:30
    know who you know, Beth Israel was
  857. 00:38:32
    taken over completely taken over by
  858. 00:38:35
    Mount Sinai, Which is you know
  859. 00:38:37
    proceeded to to dismantle it piece by
  860. 00:38:40
    piece and it's the entire hustles going
  861. 00:38:43
    to close in another year, and, but
  862. 00:38:47
    that's the way it goes sometimes so,
  863. 00:38:50
    but. it was an extraordinary experience
  864. 00:38:54
    while I was in that position. But as
  865. 00:38:57
    you can see, it was not something I
  866. 00:38:59
    wanted to pursue. I could have gotten
  867. 00:39:02
    another job as another hospital CEO. I
  868. 00:39:05
    had no interest in doing that. I wanted
  869. 00:39:07
    to get back to my roots, really.
  870. 00:39:11
    So back to your roots, back to
  871. 00:39:20
    neurocritical care. As you look back
  872. 00:39:21
    over the last several decades, what
  873. 00:39:22
    really sticks out to you as the biggest
  874. 00:39:24
    breakthrough or the thing that's changed
  875. 00:39:27
    the field the most? Well, I think that
  876. 00:39:30
    a minimally invasive catheter
  877. 00:39:35
    interventions have been, in my view,
  878. 00:39:39
    the biggest breakthrough that we've had
  879. 00:39:42
    within our field. I think that has been
  880. 00:39:44
    huge It's been a huge area, and just as
  881. 00:39:49
    in a side. When I was in neurology
  882. 00:39:52
    resident, I kind of knew that was going
  883. 00:39:55
    to have happen. I tried to get into a I
  884. 00:39:57
    in our fellowship as a resident in. It
  885. 00:40:00
    was in nineteen,
  886. 00:40:03
    and was this nineteen seventy nine. I
  887. 00:40:06
    guess I could not get any place in the
  888. 00:40:11
    entire United States to accept me as a
  889. 00:40:13
    neurologist. Nobody would accept me
  890. 00:40:17
    which which is interesting, but so that
  891. 00:40:19
    turned out, I think to be one of the
  892. 00:40:21
    the greatest breakthroughs ever in terms
  893. 00:40:25
    of what we're doing and it's not just
  894. 00:40:26
    for stroke, and it's gonna apply to you
  895. 00:40:29
    know treatment of brain tumors,
  896. 00:40:31
    Disruption of the blood -brain barrier
  897. 00:40:33
    to treat a whole bunch of other things,
  898. 00:40:34
    so I consider that to be the the
  899. 00:40:36
    greatest breakthrough in our field, and
  900. 00:40:42
    I remember it My my time at Cornell and
  901. 00:40:44
    Columbia, The mobile stroke unit was
  902. 00:40:47
    just getting started, and and I think
  903. 00:40:49
    that was really your initiative. Can
  904. 00:40:51
    you talk? A little bit about the mobile
  905. 00:40:53
    stroke unit and what it's meant to
  906. 00:40:54
    Cornell, though absolutely absolutely,
  907. 00:40:57
    and I learned about the mobile stroke
  908. 00:41:00
    units on one of my annual trips to
  909. 00:41:06
    Europe, We run a course in Austria
  910. 00:41:09
    every year in Salzburg. Whenever I go
  911. 00:41:12
    there, You know all of the attendees
  912. 00:41:15
    are from the European countries, and I
  913. 00:41:17
    started hearing about what was going on
  914. 00:41:19
    in Germany and in in Hamburg, where it
  915. 00:41:25
    was really first started around two
  916. 00:41:27
    thousand and twelve, and when I came
  917. 00:41:30
    back to the U, S, I found that Jim
  918. 00:41:35
    Grata in Houston was starting a program
  919. 00:41:38
    in Houston, and I really thought this
  920. 00:41:40
    was a phenomenal idea that the concept
  921. 00:41:43
    of going out into the field and that
  922. 00:41:47
    diagnosing and treating a patient in the
  923. 00:41:49
    field was. way to do it because you
  924. 00:41:52
    were going to save a lot of time and you
  925. 00:41:54
    were going to definitely have a big
  926. 00:41:55
    impact. I presented this multiple times
  927. 00:41:59
    to our hospital leadership. They all
  928. 00:42:03
    looked at me and said, Yes, oh, this
  929. 00:42:06
    is a great idea. It's a great idea,
  930. 00:42:08
    but there are lots of great ideas. And
  931. 00:42:11
    this one's an expensive one, right?
  932. 00:42:13
    Yes, this is an expensive one, but
  933. 00:42:15
    who's going to pay for this? We don't
  934. 00:42:17
    have money in the budget to pay for this,
  935. 00:42:19
    even though it's a great idea. And it's
  936. 00:42:22
    also, it was unproven, too. I mean,
  937. 00:42:25
    it seemed like it was going to make a
  938. 00:42:27
    lot of sense, but it was unproven. So
  939. 00:42:29
    it meant somebody's going to have to
  940. 00:42:31
    take a chance. So I went back and forth
  941. 00:42:33
    multiple times, then finally, what did
  942. 00:42:37
    it was a donor, the donor, a member of
  943. 00:42:42
    the hospital board who heard about this
  944. 00:42:45
    and spoke to me about it,
  945. 00:42:48
    really also felt that This was a great
  946. 00:42:51
    idea and he supported he was going to
  947. 00:42:54
    support it, so he he made a gift of
  948. 00:42:56
    know several million dollars for us to
  949. 00:42:59
    get this program started and I spoke to
  950. 00:43:02
    Jim Grata about it. Jim came up as a
  951. 00:43:05
    sort of a consultant to help us with it,
  952. 00:43:07
    and then we went ahead and started a guy.
  953. 00:43:13
    Had the first unit built. The more
  954. 00:43:16
    difficult problem was getting the New
  955. 00:43:19
    York City emergency medical services to
  956. 00:43:23
    support it, because there's a a single
  957. 00:43:26
    E M S service run by the Fire Department
  958. 00:43:28
    in New York, and the political issues
  959. 00:43:33
    with that were quite difficult. I spent
  960. 00:43:35
    many many hours many meetings talking to
  961. 00:43:39
    them than to try to get them onboard,
  962. 00:43:41
    because the The The mobile stroke unit
  963. 00:43:44
    program had to be integrated with the E
  964. 00:43:47
    M 's services that were. Making non
  965. 00:43:51
    Mormon cause and triaging ambulances,
  966. 00:43:53
    and that was a very very difficult thing,
  967. 00:43:55
    but we finally were able to get it, and
  968. 00:43:58
    we got the first unit operating in two
  969. 00:44:01
    thousand and sixteen, and the first
  970. 00:44:05
    year we went out physically all of our
  971. 00:44:09
    stroke doctors, including myself, we
  972. 00:44:12
    went out on the ambulance runs in person,
  973. 00:44:15
    and for me it was one of the most eye
  974. 00:44:17
    -opening experiences I've ever had going
  975. 00:44:20
    out with the E M S workers. The first
  976. 00:44:22
    thing is I was impressed and amazed and
  977. 00:44:26
    impressed at how good they were. They
  978. 00:44:29
    were really really phenomenal. And you
  979. 00:44:32
    know, having to, you know, run up ten
  980. 00:44:34
    flights of stairs with a full backpack
  981. 00:44:38
    and an walk, go into somebody's
  982. 00:44:40
    apartment, which you know you don't
  983. 00:44:41
    know what you're walking into and having
  984. 00:44:44
    to address these acute emergencies. I,
  985. 00:44:46
    it was incredible and I've said to many
  986. 00:44:48
    people. If I have a heart attack and
  987. 00:44:51
    you know, need need emergency help. I
  988. 00:44:53
    want the E M S people. I don't want a
  989. 00:44:55
    doctor. The M S people know more than
  990. 00:44:58
    the doctors dohc know about what to do
  991. 00:45:00
    so. For the first year we went, I went
  992. 00:45:02
    out with others. We went out on the
  993. 00:45:04
    ambulance. An ambulance runs and it was
  994. 00:45:06
    an exhilarating experience. He will
  995. 00:45:08
    learned a lot, and then after we got
  996. 00:45:11
    the procedures down to be really really
  997. 00:45:16
    fast and efficient. After that one year,
  998. 00:45:19
    we converted the tele medicine, Because
  999. 00:45:22
    long term you can have a a stroke.
  1000. 00:45:25
    Neurologists are spending their time
  1001. 00:45:28
    riding round than an ambulance had just
  1002. 00:45:29
    doesn't work, so he converted the tele
  1003. 00:45:31
    medicine which work just as well. He
  1004. 00:45:33
    had a nurse on the ambulance, and then
  1005. 00:45:37
    we were fortunate to get additional
  1006. 00:45:39
    support, and we we as built two more
  1007. 00:45:42
    units, so he had one in Manhattan. We
  1008. 00:45:45
    had one in Queens, who had one in
  1009. 00:45:46
    Brooklyn, and as you know, we. We
  1010. 00:45:49
    incorporated the Columbia team as part
  1011. 00:45:52
    of it. I did that from day one. I felt
  1012. 00:45:55
    it should be a system-wide program that
  1013. 00:45:59
    it wasn't just a Cornell program. It
  1014. 00:46:01
    was a New York Presbyterian Hospital
  1015. 00:46:02
    program. I wanted everybody to
  1016. 00:46:04
    participate. That's always my mantra.
  1017. 00:46:08
    Get everybody under the tent to get
  1018. 00:46:12
    these things done. And it went
  1019. 00:46:14
    extremely well until the pandemic hit
  1020. 00:46:18
    And what happened, the effect of the
  1021. 00:46:21
    pandemic was that there was a critical
  1022. 00:46:24
    shortage of emergency medical texts of
  1023. 00:46:28
    EMTs. A lot of them got sick, a lot of
  1024. 00:46:31
    them quit. And we had to redeploy our
  1025. 00:46:36
    paramedics to regular ambulance runs.
  1026. 00:46:41
    So we put the program on a pause for
  1027. 00:46:43
    about, I guess it was about a year and
  1028. 00:46:45
    a half, Then we started back up again.
  1029. 00:46:48
    it's running again but we only have one
  1030. 00:46:50
    unit and and the results are being
  1031. 00:46:53
    published January you've seen the
  1032. 00:46:54
    results and and as a new paper that's
  1033. 00:46:56
    coming out very shortly and showing the
  1034. 00:47:01
    economics of it and and the program
  1035. 00:47:05
    overall saves money for the whole
  1036. 00:47:08
    healthcare system the the problem is the
  1037. 00:47:11
    way we are reimbursed the hospital we
  1038. 00:47:14
    have to provide the upfront pay the
  1039. 00:47:17
    upfront costs the the savings go to the
  1040. 00:47:21
    insurance companies and the medicare
  1041. 00:47:23
    program they save money the hospital has
  1042. 00:47:28
    to spend money to let the insurance so
  1043. 00:47:31
    they're happy to let us of course know
  1044. 00:47:34
    how that works I mean it's in Europe it
  1045. 00:47:37
    doesn't work that way in Europe the the
  1046. 00:47:39
    government is the single payer and so
  1047. 00:47:42
    they recognize that they are going to
  1048. 00:47:44
    save money so they say the government
  1049. 00:47:45
    their support So we're trying to get CMS
  1050. 00:47:48
    to change the rules and at least
  1051. 00:47:52
    reimburse us for the work that we're
  1052. 00:47:54
    doing. But I happen to think the mobile
  1053. 00:47:56
    stroke program is superb. I wouldn't
  1054. 00:47:59
    rank it up as the most important
  1055. 00:48:04
    success we've had because unfortunately
  1056. 00:48:08
    it hasn't been expanded It's been very
  1057. 00:48:11
    limited, it could be an incredible
  1058. 00:48:15
    benefit to society if we can roll it out
  1059. 00:48:19
    to all of the metropolitan areas. But
  1060. 00:48:23
    until we can do that, it's going to be
  1061. 00:48:25
    sort of a boutique kind of program. So
  1062. 00:48:29
    let me just mention one other thing,
  1063. 00:48:31
    because when I came to Cornell, we did
  1064. 00:48:34
    not have a neuro ICU program at Cornell,
  1065. 00:48:37
    it was very limited But one of my former
  1066. 00:48:41
    fellows, Stefan Mayer, was running the
  1067. 00:48:43
    program at Columbia at the time.
  1068. 00:48:47
    And I. I twisted his arm. Basically
  1069. 00:48:50
    they said Stefan. We were going to
  1070. 00:48:52
    build the program here. I'd like to do
  1071. 00:48:55
    it together. I want to do it together,
  1072. 00:48:58
    so let's expand the fellowship so that
  1073. 00:49:03
    Cornell and Columbia can do it together
  1074. 00:49:05
    and it. It was Rocky for the first few
  1075. 00:49:07
    years. I dunno If you experience any of
  1076. 00:49:10
    that yourself, an issue is rocky, but
  1077. 00:49:12
    it has turned out to be a phenomenal
  1078. 00:49:15
    success. Phenomenal success, and the
  1079. 00:49:17
    fellows have great experience at both
  1080. 00:49:20
    campuses, and and I think it's without
  1081. 00:49:24
    question the best fellowship program in
  1082. 00:49:26
    North America at this point, so I'm
  1083. 00:49:29
    very happy with the way that worked out
  1084. 00:49:31
    that was a great success. I certainly
  1085. 00:49:33
    had a fantastic experience, and I
  1086. 00:49:35
    thought was really valuable, and
  1087. 00:49:38
    because there there were actually
  1088. 00:49:39
    institutional differences between
  1089. 00:49:40
    Columbia and Cornell, and to to get
  1090. 00:49:42
    experience that as a fellow, I think
  1091. 00:49:44
    was really important. For my training
  1092. 00:49:47
    so I, I certainly appreciated that I,
  1093. 00:49:50
    I think we're coming up on time here,
  1094. 00:49:52
    and, but I, I've been impressed in
  1095. 00:49:55
    your career. You've really been an
  1096. 00:49:56
    early adopter and and kind of seeing
  1097. 00:50:00
    things before they happened. What what
  1098. 00:50:01
    are you seeing on the horizon that
  1099. 00:50:03
    excites you and neuro critical care or
  1100. 00:50:05
    emergency neurology. Yep, Shit, well,
  1101. 00:50:07
    I'll tell you the oddly enough the one
  1102. 00:50:10
    area that I am really hot on right now
  1103. 00:50:13
    and I'm trying to get our hospital to
  1104. 00:50:14
    buy into it. I think the concept of
  1105. 00:50:19
    hospital at home is the next big thing
  1106. 00:50:24
    that we should be pursuing that I would
  1107. 00:50:28
    say that you know half the patients that
  1108. 00:50:31
    we admit to the hospital from the
  1109. 00:50:32
    emergency department these days could be
  1110. 00:50:35
    cared for at home if we had the right
  1111. 00:50:38
    support services monitoring, and I
  1112. 00:50:40
    think all of the technology we have can
  1113. 00:50:42
    allow us to do that and. The hospitals
  1114. 00:50:47
    then are going to be essentially
  1115. 00:50:49
    intensive care units and operating rooms.
  1116. 00:50:53
    And virtually everything else should be
  1117. 00:50:56
    done at the person's home. And so I'm
  1118. 00:50:59
    very, very focused on trying to get
  1119. 00:51:02
    people to start looking at hospital at
  1120. 00:51:04
    home. And that applies to stroke
  1121. 00:51:05
    patients as well. I mean, yeah, they
  1122. 00:51:07
    have to come in, get thrombolytics or
  1123. 00:51:11
    thrombectomy But most of those people,
  1124. 00:51:15
    after 24 hours of observation, could go
  1125. 00:51:19
    right home and be, you know, managed
  1126. 00:51:21
    at home. And I think there are a lot of
  1127. 00:51:23
    similar situations like that. So that's
  1128. 00:51:25
    the area that I think is going to be the
  1129. 00:51:28
    next big area, hospital at home. That
  1130. 00:51:31
    would be very exciting. We were
  1131. 00:51:33
    rounding last week in the ICU. We had
  1132. 00:51:36
    an older woman with some cognitive
  1133. 00:51:37
    impairment who was admitted with a very
  1134. 00:51:39
    small I mean, minuscule. and sort of
  1135. 00:51:44
    not surprisingly became wildly delirious
  1136. 00:51:46
    in the ice to you and yes you know that
  1137. 00:51:49
    sooner or later she was a restrict you
  1138. 00:51:51
    know in restraints and oppose he
  1139. 00:51:53
    developed urinary retention every day
  1140. 00:51:58
    was kind of worse than the next and he
  1141. 00:51:59
    had part of me just thought maybe she
  1142. 00:52:01
    just would have been better if she never
  1143. 00:52:02
    came in and will let me give you an act
  1144. 00:52:06
    when I was in our resident Colombia we
  1145. 00:52:08
    used to rotate to Harlem Hospital okay
  1146. 00:52:11
    in those days nineteen seventies the
  1147. 00:52:13
    services at Harlem Hospital were so bad
  1148. 00:52:16
    so bad that when I was the consulting
  1149. 00:52:19
    resin I got called to see a stroke
  1150. 00:52:21
    patient in the emergency room I would
  1151. 00:52:22
    sit with the family and I would tell
  1152. 00:52:24
    them look this is not a C or bad stroke
  1153. 00:52:27
    I'm going to tell you what to do then I
  1154. 00:52:29
    wrote down this is what You're Gonna do
  1155. 00:52:31
    I want you to take your mother home take
  1156. 00:52:33
    care of her at home you're going to do
  1157. 00:52:35
    these things because if we admit her to
  1158. 00:52:37
    the hospital here she has a higher
  1159. 00:52:39
    probability of getting sick and dying in
  1160. 00:52:42
    the hospital than if you take care of
  1161. 00:52:44
    her at home. And I used to send all
  1162. 00:52:45
    these patients home with instructions in
  1163. 00:52:48
    the family about what to do. And I
  1164. 00:52:52
    think in many ways, we're gonna be
  1165. 00:52:54
    getting back to something like that.
  1166. 00:52:55
    Yeah, I sure hope so.
  1167. 00:52:58
    Just to finish up, we do a few kind of
  1168. 00:52:59
    quick hit questions with everyone on the
  1169. 00:53:01
    podcast. And these are sometimes fun.
  1170. 00:53:06
    What other passions or hobbies do you
  1171. 00:53:08
    have outside of neurology? Well,
  1172. 00:53:10
    before I got in the medical school, my
  1173. 00:53:13
    primary activity was, I had a rock band.
  1174. 00:53:17
    And I almost didn't go to college
  1175. 00:53:22
    because my band was gonna go on the road
  1176. 00:53:24
    and I wanted to go on the road with them.
  1177. 00:53:26
    I mean, so that was my primary. And I
  1178. 00:53:28
    still, I love music. Music is my
  1179. 00:53:31
    passion. I've got five guitars, five
  1180. 00:53:36
    or six guitars and bases sitting around,
  1181. 00:53:39
    unfortunately collecting dust that I
  1182. 00:53:40
    need to get back to to start playing.
  1183. 00:53:43
    And very into the, you share the name
  1184. 00:53:45
    with a famous musician, don't you? Oh,
  1185. 00:53:47
    Yeah, Dr. Dr. Matt Fink. Who is the
  1186. 00:53:50
    drummer for Prince. Yes, Yes, he was
  1187. 00:53:53
    the drummer for Prince at the time, and
  1188. 00:53:55
    and yeah, and and people. I've googled
  1189. 00:53:58
    my name and keep coming up with him, So
  1190. 00:54:02
    yup, Yup, It's funny. He goes by
  1191. 00:54:03
    doctor. As well. It is not at that,
  1192. 00:54:05
    but he wears scrubs. This event. They
  1193. 00:54:07
    wear scrubs when he plays and concerts
  1194. 00:54:09
    and stuff. Yeah, Yeah, I. I found
  1195. 00:54:11
    that pretty interesting. I don't know.
  1196. 00:54:13
    I'm curious to know why he'd develop
  1197. 00:54:15
    that that. Or maybe it's just to show
  1198. 00:54:19
    you your sliding doors experience. You
  1199. 00:54:21
    know that that could have been you, and
  1200. 00:54:25
    as I lose my voice, your what what
  1201. 00:54:26
    other specialty would you like to have
  1202. 00:54:27
    attempted or to attempt what other
  1203. 00:54:30
    specialty well as is and I are? Yeah,
  1204. 00:54:34
    Yeah, would I and our would have been
  1205. 00:54:36
    the other area that I was going to go
  1206. 00:54:38
    into the other air that I was extremely
  1207. 00:54:40
    interested in. I still am actually
  1208. 00:54:42
    where his movement disorders and I love
  1209. 00:54:44
    move, the just because of the, the,
  1210. 00:54:47
    the focus on you know, understanding
  1211. 00:54:49
    brain circuits and neurotransmitters and
  1212. 00:54:52
    things like that, and we had a in the I
  1213. 00:54:54
    you for awhile, we had a whole bunch of
  1214. 00:54:55
    patients with Parkinson's disease,
  1215. 00:54:59
    because there was a fad at the time of
  1216. 00:55:02
    abrupt a drug holiday, so all these
  1217. 00:55:06
    patients were taken off of there, leave
  1218. 00:55:08
    a dopa and and they all develop rigidity
  1219. 00:55:11
    that was so severe that many of them had
  1220. 00:55:13
    to be intubated and put on ventilator,
  1221. 00:55:15
    so that was a big mistake to do that in
  1222. 00:55:19
    an in with specialty. Would you not
  1223. 00:55:21
    like to do? Would I not like to do,
  1224. 00:55:24
    and
  1225. 00:55:27
    still I would not want to be a
  1226. 00:55:28
    psychiatrist there
  1227. 00:55:31
    at that as I haven't changed my mind
  1228. 00:55:32
    about that dinner. Is is there a sound
  1229. 00:55:36
    or smell on the ice? You That you
  1230. 00:55:37
    really like well? I lost. My sense of
  1231. 00:55:41
    smell is completely better in two
  1232. 00:55:44
    thousand and nine. I had a bad bicycle
  1233. 00:55:47
    accident. That's my other passion of a
  1234. 00:55:49
    big biker. I do a lot of biking had a
  1235. 00:55:51
    bad bicycle accident. A head injury. I
  1236. 00:55:53
    lost my sense of smell. You know
  1237. 00:55:55
    permanent, but I have memories of of
  1238. 00:56:00
    having some. I. I had my biggest
  1239. 00:56:02
    memory. Is I had a terrible allergic
  1240. 00:56:05
    response. Allergic reaction to a
  1241. 00:56:08
    perfume that one of the I U nurses use
  1242. 00:56:11
    the winner in the icy all the time and I
  1243. 00:56:14
    remember talking to her. I was very
  1244. 00:56:16
    embarrassed, but when I went up through
  1245. 00:56:19
    and I said I, I apologized for saying
  1246. 00:56:21
    this to you, but I'm having a terrible
  1247. 00:56:24
    allergic reactions of whatever kind of
  1248. 00:56:26
    perfume you're wearing every day, so I
  1249. 00:56:29
    don't want to take this the wrong way,
  1250. 00:56:31
    but could you try to not wear that
  1251. 00:56:33
    perfume because of alert? If you
  1252. 00:56:34
    pitched
  1253. 00:56:37
    and she was fine, actually, she was
  1254. 00:56:39
    like. Oh. That's why dory. I. That's
  1255. 00:56:41
    okay. I'm not. I'm not offended by it,
  1256. 00:56:43
    But you know you gotta be careful about
  1257. 00:56:45
    those things absolutely, and then add
  1258. 00:56:48
    to finish up. Though what advice would
  1259. 00:56:50
    you give to a fellow who's about to
  1260. 00:56:52
    graduate. Well, I, It's the same
  1261. 00:56:54
    thing I said it to to just about
  1262. 00:56:56
    everybody you need to follow your
  1263. 00:56:59
    passion of what you're really really
  1264. 00:57:02
    passionate and interested in doing and
  1265. 00:57:05
    don't worry about you know what then
  1266. 00:57:08
    what the next job is going to be Focus
  1267. 00:57:11
    on doing the absolutely best that you
  1268. 00:57:15
    can do with what you're doing right now
  1269. 00:57:17
    today and I can promise you that
  1270. 00:57:22
    fabulous jobs will come your way in the
  1271. 00:57:24
    future. If you do a great job today.
  1272. 00:57:27
    Don't worry about what you're going to
  1273. 00:57:29
    do next. There's too much anxiety about
  1274. 00:57:32
    around them. I was thank you so much Dr.
  1275. 00:57:35
    Fingers. Spending some time with us.
  1276. 00:57:36
    We really appreciate it for all the
  1277. 00:57:39
    listeners. Please check out the New
  1278. 00:57:41
    Yorker Clear Society Podcast available
  1279. 00:57:44
    Wherever you get your podcasts,
  1280. 00:57:46
    Including Spotify and Apple, See Emmy
  1281. 00:57:49
    are available and we hope you tune in
  1282. 00:57:51
    next time. Thanks again, Dr. Fink.
  1283. 00:57:53
    And we look forward to which we what you
  1284. 00:57:54
    do next to lead our field. Thanks for
  1285. 00:57:57
    the invitation. You'd be well, right.