#158 - 🛩️ High-Stakes Missions: A Look into Military Neonatal Transports with Drs. Laura Borruso, Mike Guindon, and Liz Okonek

Ever wonder what it's like to transport a neonate across the globe in the high-stakes environment of military medicine? Three military neonatologists, Drs. Laura Borruso, Mike Guindon, and Liz Okonek, here to offer a rare glimpse into this challenging and vital aspect of their work. Transporting such fragile patients is far from easy, fraught with challenges around temperature regulation, resource allocation, and the use of equipment not approved for aircrafts. Listen in to learn how they overcome these hurdles while ensuring the safety and wellbeing of their young charges.

The distance between military and civilian transports is further than one might expect, not just geographically, but also in terms of the costs involved, the planning required, and the specialized expertise needed. Our expert guests share how they navigate these unique challenges, from the paradox of opportunity costs to the absolute necessity of bringing extra supplies. They also delve into the critical strategies for maintaining a baby's vitals during these intense journeys.

Lastly, join our neonatologists as they explore the daunting challenges of high-altitude medical transport, dealing with potential complications such as hypoxia and the crucial importance of communication and collaboration within their teams. Hear about the camaraderie they build during these missions and gain an appreciation for the extraordinary lengths the US military goes to ensure the safe transport of patients. This is a side of neonatology and military service that you won't want to miss.

As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

Enjoy!

Transcript

Ben: 1:26

Hello everybody, welcome back to the incubator podcast. It is Sunday. We are back with a new interview for you today. Daphna, how are you this morning?

Daphna: 1:35

I'm doing very well. We've had a lot of exciting interviews recently and I think this one is very much of interest, and we love having lots of people in the studio, so that's always fun.

Ben: 1:48

That's right. I mean, one of the things people have asked us sometimes in the past is like are you not afraid that you're going to run out of material right? And we keep telling them, like our field has tremendous depth.

Daphna: 2:01

Yeah, fortunately. Yeah, the community is so interesting, so varied.

Ben: 2:06

Everybody does something different. They all do some things that are super cool and today is a great reflection of that. We have three guests and we're going to talk and they're all members of the US military, but they're also neonatologists and they're going to talk to us about military transports and I think these guys are doing some of the most difficult transports very long, trans-specific stuff and have you done a lot of transport in your days? Daphna?

Daphna: 2:38

Some, not a lot, and it's always a high risk. It feels like a high risk procedure to transport.

Ben: 2:44

All right, let's see.

Daphna: 2:45

What's the longest? Is that what you're going?

Ben: 2:47

to ask me what's your street cred on transport?

Daphna: 2:51

No, I mean, ours were very short transports, very short transports.

Ben: 2:56

So when I joined Jackson Memorial they were like we do a lot of transports. I was like that sounds like fun. And then during orientation they took us to the airport and they have a company that they work with so they do fixed wing transports, and I was like this is the coolest, this is the best. So and then, as a fellow, they're like, if you are on trend, right you go. But they say if you are on transport call you get paid by the hour, like it's a moonlighting type of gig.

Ben: 3:24

I was like this is even better so.

Daphna: 3:27

I'm on all the time.

Ben: 3:29

Right, I signed up whenever I could. I was like this is so much fun and it was almost the same. You get a phone call and they're like oh, this sister hospital that's an hour away needs it. It's like ugh.

Ben: 3:38

But when they called you and they said, hey, there's a patient in the Bahamas that needs to get picked up, you're like this is fun. But then so I did these very short transports, even fixed wing. They would be like 30 minute flights, and it is very stressful. After a year I was like take me off the schedule. I am not doing this and it's funny because I think it's a theme All the fellows who would then join first year would be still.

Daphna: 4:03

Did the same thing. Yes.

Ben: 4:04

Exactly. But after a year I was like I'll go on an ambulance up the road. If you want, I'll go pick up a kid. That's right, I'm done. There are too many variables, there are too many things going on that are just it's too stressful. So when I hear stories of people like the guests that we have on that do these very long transports- we sometimes these yeah hats off, yeah, hats off.

Ben: 4:30

But also it's super interesting and I'm always curious to learn about the technique. How do they control for as many potential variables as possible? So very excited to hear what our guests are going to talk to us about today. I'm going to introduce our guests in alphabetical order. They have military ranks, so I just want to make sure that I'm not breaking any protocol. But that's right, I'm very clueless when it comes to military stuff.

Ben: 5:00

We have the pleasure of having on today first Dr Laura Borruso, who is a lieutenant in the US Navy. She is a neonatal perinatal medicine fellow at the Joint Program of the University of Hawaii and Tripler Army Medical Center. We are also having the pleasure of having on Dr Mike Guindon, who is a lieutenant colonel right Pronouncing in the US Air Force and he's a neonatal perinatal medicine fellow at Brook Army Medical Center in San Antonio, texas. And then, finally, we have Dr Liz Okonek, who's a major in the US Air Force and she graduated from the Uniformed Services University of Health Sciences in Bethesda, maryland, 2017. And she did her neonatology fellowship at Brook Army Medical Center in San Antonio, texas, where she is now finishing her third year. So a very star-studded lineup, and I was actually not in the studio when you guys recorded that. That was kind of bummed out, but I get to edit the podcast, so I got to listen. It's a great interview. Thank you, daphna, for manning the fort that day.

Daphna: 6:12

My pleasure.

Ben: 6:13

But without further ado, please join us in welcoming to the show Mike, liz and Laura.

Daphna: 6:24

OK, so, dr Liz Okonek, dr Mike Guindon and Dr Laura Borrusso, we're so honored to have you on today, welcome.

Michael Guindon: 6:34

Thanks, glad to be here. Thanks for having us.

Daphna: 6:36

Well, let's kind of jump right in First. I think a lot of people don't understand the role of pediatricians in general, but specifically neos in the military. Maybe you guys can kind of start us off by telling us a little bit about what this looks like.

Michael Guindon: 6:54

Yeah. So I think that's a really common question that I've had throughout my time in the military and in pediatrics is just why, when I tell other people in different careers what I do in the military, they're kind of surprised that that even exists. So one of our primary things is to support our active duty service members by taking care of their babies wherever they may be in the world, because we ask a lot of our military as a country. We ask them to live in remote places and to go places, and often we're allowing them to take their families with them, and that naturally includes having children, and sometimes those children aren't born as healthy as we'd like them to be, and that requires extra help and support. And often it's our active duty members who are having children, because it's not just men who serve. So making sure that we provide that service to them is a really important thing that our medical leadership in our country thinks is important that we do for them.

Michael Guindon: 7:48

So we as neonatologists in the military serve to support them wherever they may be.

Michael Guindon: 7:55

We also provide the biggest thing that I think is an amazing thing that we do as military neonatologists, which is this global transport capability we're able to fly anywhere in the world and pick up a critically ill baby and bring them back to more definitive care, whether that be a level four NICU in the US where they need support, or even just somewhere closer to them within the region that they can get help.

Michael Guindon: 8:23

And I think that Laura has a lot of experience with some of those types of missions, so I'll let her talk more on that. And then I think another important thing that we do, finally, is we ultimately serve as advisors to our military leadership. They don't know neonatology, they don't know pediatrics and a lot of them don't know medicine at all, so they don't have an understanding of why what we do is important, just like a lot of other folks don't understand why the military has neonatologists. So we advise them on what's important about what we do, what we need and what the impacts of decisions that they make may be, so that we can continue to provide that support and allow them to make the best decisions that they need to make.

Liz Okonek: 9:28

I think I would add to that. Mike had a great answer there. The only thing I would add is that, in addition to advising specialty leaders, we also advise general pediatricians, and so one of our other big roles is to help train the general pediatricians so that they may be at a base that is just them and they are the only pediatrician on that base, and so they need to know how to stabilize a baby, potentially for several hours to days, until, like Mike said, we can get there, depending on where they are in the world to help transport that baby to more definitive care.

Daphna: 9:58

Yeah, I guess when we think about supporting our local pediatricians here in the US, our response time is actually pretty quick compared to what response time it might look like for you guys. I guess how does telemedicine play a role in that in some of your kind of outreach? I guess less so in the states but overseas?

Laura Borruso: 10:23

Yeah, so actually Hawaii and the Pacific area has this PATH program where pediatricians or any other doctors, obis, can send over more complicated cases, for example from Guam or Japan that they want an extra set of eyes on, called PATH cases. So they could do that. And at Tripler we also have a program where we work with kind of more Pacific islands like Guam and we have a specific dedicated telemedicine video program setup that we could talk to them and help them.

Liz Okonek: 10:56

The military also has a system where pretty much any military provider anywhere in the world can reach back to a dedicated person in that subspecialty at any given point, and so our team here in San Antonio has field with calls from various places in the Middle East to help support a baby, both through those kind of logistical means through that system but also just kind of knowing different people. So military medical system it tends to be a small world and so you get to know people pretty well and so just kind of knowing where your contacts are. So people have reached back about babies that they've taken care of at kind of very remote areas and called back for help with how to manage that kiddo.

Laura Borruso: 11:42

The way the military assignments works, kind of, is, unfortunately, people fresh out of training get the short end of the stick and end up in places like Alaska and Guam, and I've had either texts from friends in Japan or phone calls to our unit asking for questions.

Daphna: 11:57

Yeah, I guess the learning curve is even extra steep as a new graduate, isn't it? So tell us a little bit what you know. This setting for a neonatal ICU looks like around the world.

Liz Okonek: 12:13

Mike, you wanna tackle that one with kind of what it looks like in the air.

Michael Guindon: 12:17

Yeah, in the air it looks a lot different than it does on the ground.

Michael Guindon: 12:23

So I have had the experience to be a general pediatrician in one of those places in Japan prior to coming back for fellowship, and so I got to see the transport process from the sending provider side as well as now from the receiving and from the fellow in the air with the babies.

Michael Guindon: 12:43

You know, not every NICU is the same and different countries provide different types of care, if that's kind of the question that you're asking and there are different things that are standard that we do that may not be the standard in other places. It doesn't make them wrong, it just makes them different. And that's part of the challenge that we face as military physicians is just understanding those different, both capabilities and norms of practice that there are in different places and trying to mitigate those things and help the patients through it and help the families through it also, because often these parents are facing this challenging situation where they're in a foreign country, their child is sick, they maybe have language barriers that are making things even more complicated and we know that medical English is already a different language than most people speak, so helping them through that becomes another challenging part of our job. But I don't know if that sort of gets to the question that you're asking or just said that it's.

Daphna: 13:43

Yeah, no, I think it's important that we realize especially most of our listeners are in the US, but not all of our listeners right that medicine and neonatology is practiced differently all over the world. And I think, specifically you know, when we think about our outreach to, say, general pediatrician or outreach to a rural area I mean, some of what you guys are making contact with may have really limited resources and I wonder how that impacts. You know what care you're able to provide, but also you know how that communication goes in planning for something like a transport.

Laura Borruso: 14:28

Usually the NICUs themselves. It's the standard of care in the US. They kind of make a mini US NICU in the local country that we're in and I could correct me if I'm wrong, but even for general pediatricians the same degree of early intervention is available in whatever country you are and any babies that born gets a newborn screen that is sent back to the US. I think it depends on where you are, what state it goes to, so if it's on a military base they get the same standard of care that everyone else in the US gets.

Daphna: 15:03

Before we get really into the meat of the conversation, which we really wanted to talk about, neonatal transports I did want to discuss a little bit about for people who are interested. What does the training look like? How is it different in the military? How does it kind of impact where you can train, what type of facilities and what kind of additional training is necessary?

Liz Okonek: 15:31

So really the fellowships are no different than any civilian fellowship. So to do a military fellowship you have to be a military medical provider, and so we have a different match than the regular match system. Our match happens during the summer and our residents and fellows match in December. That way, if there are people that are also looking to participate or join a civilian fellowship or residency, they basically match into a civilian spot and then participate in the regular match later in the year as well. As far as the fellowships for new unitology in the military, there's here at Brook Army Medical Center in San Antonio, there's the one in Washington DC at Walter Reed Medical Center in Bethesda, and then there's the one that Laura's at, which is in Hawaii, associated with Tripler Army Medical Center, and then each of the sites because of just kind of the numbers that we would see at our bases often have partnerships with the local civilian NICUs in the area for the fellows or residents to experience some additional training in a higher volume setting.

Daphna: 16:42

That's very helpful. I think that helps give us kind of the lay of the land. So we really wanted to talk about neonatal transport, since you know it's something that I think we get some experience with in fellowship. We sometimes don't even give a second thought to once. We're kind of doing them, but certainly when we think about triage and when we think about complications, you guys have a different perspective on what transports look like. So we wanted to talk about. You know, how does your approach differ between, like ground versus air, these kind of short transports versus really long transports, and how might a military transport look different than you know what we perceive in our quote unquote kind of civilian transports?

Michael Guindon: 17:32

Probably the biggest differences, which there are many.

Michael Guindon: 17:37

One of the biggest differences is that you know that that timeframe that you talk about, so civilian transport you get a call from your referral center and they say, hey, we have a baby that needs to come, and you say yep, and they send the baby or you send your team to go and get the baby and the turnaround time is usually hours before that baby has reached your NICU at the, you know, at kind of the outside.

Michael Guindon: 18:02

That's been my experience here in San Antonio where we do outreach to a lot of the the outlying areas, and usually the baby can be to us within a couple of hours. In the military there are a lot more moving pieces, so those acute transfers often don't happen. The fastest that the military transport system which is amazing allows us to move, based on all the, all the pieces that have to be put into place, is usually within like 48 hours. I was part of a transport where we were able to get everything organized and get halfway around the world and back in about 96 hours, which I think is pretty impressive, but overall I think that's that's not the norm. Usually the baby is in a more still critically ill, but less acutely ill, If that makes sense condition when we're going to go and transport them.

Liz Okonek: 18:57

To talk on that like so for one of the transports that I did, we knew about this baby who was at a country in the Middle East who was quite ill for several weeks, and so we knew about this kiddo pretty much the day that they were born but did not go get the kid until they were over 30 days old, just for stability sake.

Liz Okonek: 19:15

And then the coordination that went into trying to get a plane to that location, as well as the additional pieces. So I think Mike's probably going to mention here that when we fly it's not just us on the plane, that a lot of it includes a flight crew, it also includes an aeromedical evacuation crew or an AE crew, and a lot of times we also end up on planes that have other patients as well, and so that takes a lot of coordination with multiple different levels within the military and kind of the different regions of the military, kind of the different commands, to coordinate all those moving pieces and and like Mike mentioned, it's usually not very quick. It can be a couple hours if you're kind of in within the same region. So there are a lot of transports that go from Okinawa and Japan over to Guam, kind of in that Pacific region, but that still takes a couple hours to get things going, if not longer.

Michael Guindon: 20:08

Yeah. So, exactly like Liz said, those, all those different things have to be put into place. It's not like there's a transport team who's always standing by whose only job is to go and pick up patients. The military has, the Air Force has a lot of planes, but those planes are used for a lot of other reasons and, like we already kind of talked about, it's not foremost on most people's minds Like, oh yeah, going and picking up sick babies, that's why we have those planes. So those planes have to be reallocated, kind of from what they were going to do, to go and do that. And that requires a lot of money, both in terms of actually flying that plane to go and get there, having a whole crew that's going to do that, as well as that kind of opportunity cost of, okay, but what is that plane not doing while we do that? And then can we get the plane to do some of what we needed to do anyway while we do that too.

Michael Guindon: 20:59

So there's a lot of conversation that happens at levels much above us, often, I think, to our frustration and consternation of like, ah, we just want to go get the baby. That kind of has to happen for a lot of important reasons that we just don't always see from our level. So ultimately the meat of the process happens very similar to it does in the civilian world. The referring physician says, hey, I need to send you a baby. The accepting physician says, hey, okay, we can take the baby. Then the referring physician has to submit their request through this global system. That says, okay, we'll work on that.

Michael Guindon: 21:32

Those guys then try to find us a plane. They try to find us a team because that requires, you know, we have to have a plane, we have to have a team to fly the plane, which is our air crew, and then we have to have, like Liz already said, an air medical evacuation crew, which is a different thing than we have in civilian transport. For sure, civilian planes they have pilots, we have pilots, they help us out, they control the plane. They say we go, we don't go. They approve and disapprove of anything that comes onto the plane also. So some of our equipment, because it's not approved for going on military aircraft, is different than what we would use in the civilian world, particularly things like ventilators and some of the other equipment. We just can't use it on our military aircraft because it's not been approved. So they kind of control the plane.

Michael Guindon: 22:19

The air medical evacuation crew, which is that kind of different piece, is usually a flight nurse and some medical technicians, maybe a respiratory therapist. They are usually critical care trained. They are or have some critical care training, but they're specialized in flight nursing. They are there to take care of any other patients and then they kind of control the back of the aircraft where we work and help us set up our equipment, but they don't know babies so they really can't help us out with medical things that go on with our patients. The opposite is true. Sometimes if we're on a plane and they have an older patients or adult patients, they may ask for our help but they're not usually as helpful, even though they will try for sure with the specifics of taking care of babies.

Michael Guindon: 23:04

And then, of course, because these teams are not designed to take care of babies on the ground or in flight, we send a NICU team. So the transports that I've been on have had a neonatologist. We usually have a NICU nurse and a respiratory therapist who usually has some background in NICU, but we don't have NICU specific respiratory therapists really in the military, just because of the volume of those patients that we have, and it's not a highest level priority. We're going to have a lot more adult patients. We're going to have a lot more really old adolescent patients, if you want to think of it that way. That's kind of the main portion of our military population is those older adolescent age patients, so they have a lot of experience there, but they're not specific NICU respiratory therapists usually.

Michael Guindon: 23:54

So we go on a team. We take every one of these transports as an opportunity to learn and to train, so we'll often try to make sure a fellow is on that transport as well, which is wonderful. We've had residents go on transports with us, which is another amazing experience for them, whether they're interested in the NICU or not. I think it's changed a few minds over the years. And then we try to get additional like less experienced nurses and respiratory therapists to come with us also because you never know when that person is going to be the first line only person who can go. So we want them to get as many reps on these trips as we can. Our responsibility when we're there, like I said, is really only to take care of our patient, the neonatal patients, although, like I said, sometimes if things are happening with other patients on the plane. They may ask us to help out with that too.

Liz Okonek: 24:40

The other reason we end up taking a lot of people with is oftentimes our transports are not single day transports. They can be multi-day, and so if we're potentially having 16 to 24 hours of airtime flying with a baby, we need several different nurses or physicians that are there to kind of take turns as far as who's having actual eyes on the patient the whole time we're in flight and so making sure we're staffed appropriately to give that patient the care that they need, regardless of if we get delayed somewhere and our 16 hours of flight time turns into 30 hours of flight time.

Daphna: 25:16

Sure, so like creating shifts.

Michael Guindon: 25:19

Definitely yeah, and, like Liz said, not only the care for our patients but the care for ourselves, because this is a uniquely high stress environment where all those environmental factors that we appreciate for our patients when we're in the NICU are also having a big impact on us. You know, I think in the NICU we always think about temperature and noise and light and all these other stimuli that our babies are exposed to that we're really not exposed to in the NICU but in the back of an aircraft for 16 to 20 hours. You're definitely exposed to those things and they wear on you very differently than they do on the ground.

Daphna: 25:56

Gosh.

Laura Borruso: 25:57

I can't even imagine I don't think anyone mentioned yet that we have a couple different aircrafts to transport in. But what I've used is the C17, which is you've seen on the news a bunch of time. It opens from the back and you've seen kind of tanks coming out of it and very large equipment, so there's definitely a lot of room to pack as many people as your budget allows.

Daphna: 26:21

At least that, at least that.

Michael Guindon: 26:22

It has an actual functional toilet.

Laura Borruso: 26:24

Yes, but not very temperature controlled. You're kind of sitting right next to a bunch of wires and you get outlets dangling from the ceiling and see right out the window there. So a lot more noise, vibration and cold stress than a commercial flight.

Daphna: 26:44

Yeah, we think about some of these luxuries that we have right, that we learn about for, say, the boards, temperature regulation, water loss that because our technology in the developed world is so good for these babies we don't even really give a second thought to sometimes in the NICU. But it sounds like those are things that you guys are really having to take a kind of minute by minute account of. That again we just kind of take for granted.

Liz Okonek: 27:17

Yeah, and I think an example that I did a transport around Christmas time this last year and you know when we're in the unit.

Liz Okonek: 27:24

If an isolate or a warmer malfunction, you just get another one right, like you just switch them out.

Liz Okonek: 27:30

It's not a big deal, but we were, we had left the host country that we were in and we had our isolate malfunction and we lost temperature control of our isolate for our former 27 week baby, who is now about a month old, still intubated and pretty sick, and so we had to make the decision on how we manage this kiddos, temperature regulation in the air, and basically all we had left was thermal mattresses and we had brought in three width, and so we had to kind of strategically use those as well as wrapping the baby and then trying to figure out how we were going to maintain keeping an eye on our vitals, because we basically lost all all battery support to our isolate and had about a six hour flight until we could get to the nearest location to kind of exchange for a new isolate.

Liz Okonek: 28:23

So there's definitely things that you, you know, plan for that happen, and so it's one of those things that really taught me you got to bring all the extra supplies, even when you don't think you're going to need them. You know, two, two thermal mattresses might be enough, but really probably want it four or five, just in case something happens.

Daphna: 28:41

Yeah, that sounds absolutely terrifying and you know, and that's just if things don't go right. But you also mentioned that some of our equipment isn't even approved. So what does that look like if, say, you know, a ventilator that's been used, you know by a team in a facility can't come aboard? Like what does that look like?

Michael Guindon: 29:03

Yeah. So when we show up and have to take an intubated patient or you know we can't use really high flow on a on the aircraft, we can't. We don't have some of these modalities. So it's really a. They're fine in room air, they're fine on route, like basic nasal canula, a little bit of oxygen, or they need to be intubated for some of these transports. Laura does a lot of this where she is, where they. These are long range transports and there's not anywhere to stop and fix things along the way. You're, you're there's ocean, there's nothing there. Or, like Liz and I have had experiences with their countries that don't want us to land there, who will do bad things potentially if we land there, regardless of why we're landing.

Michael Guindon: 29:45

So with our equipment, when we arrive, we have our transport equipment, we have our ventilators. That are basic IMV. They are there is no. You know, we are titrating, we are adjusting our eye time and E time to set our rates and we are setting our pressures and that is it. We cannot, we don't have any ability to synchronize. It is just basic IMV. So we transfer the baby from the, the NICUs equipment to our equipment, make sure that the baby stabilized on that, check a blood gas, make sure that we're, our settings are okay, and then once we feel like we're in a, in a safe enough position, then we're okay to go. But that's just one of the limitations of our, of our transport ventilators that are approved for use in in our aircraft. We do have the capability to do high frequency if we need to. We have, I know, that we can do in flight if we need to, and I've been a part of one transport with I know, which was very interesting, and but it's just another one of those challenges that we face.

Michael Guindon: 30:54

So we we bring the baby into our equipment, we stabilize them, we check a blood gas, make sure we're good to go, and then we're on the way and then often just rechecking blood gases, fairly frequently along the way. Again, we lose all those senses in flight. We can't listen, we can't really even, you know, even checking measurements because the lighting is is a little bit more difficult. So we're relying on those vital signs in our monitors to give us the information about the patient status and then our blood gases to check. Because the ventilation is not synchronized.

Michael Guindon: 31:26

Often we're using more sedation, which also helps with all those other stimuli that the baby is being exposed to also just the noise and vibration and the different lighting that's there. So we have to do that to help keep them a little bit more in sync with the ventilator as well. Then we would otherwise on the ground and what we would probably on the ground feel happy about doing, but it's the safest thing that we can do for that patient where we're in that situation is to keep them sedated. Haven't had much experience with paralysis. I think we'd all prefer to avoid that in flight, if we can, just because of that risk of extubation. It's going to be very difficult to reintubate in flight, although I know of colleagues who have had to do that, where they've had babies extubate midway between Japan and Hawaii and had to reintubate them in flight, which sounds terrifying to me but also amazing once you're successful. So it's just again kind of challenges of the equipment.

Liz Okonek: 32:23

I think the other thing to mention too, is not only do we have to bring the equipment, but we also have to bring our own oxygen and medical air with. So that is not something that we can always get from the plane, and so we have to do the calculations ahead of time to figure out how much medical air we are going to need or oxygen for that baby, and figure out how many tanks we need to bring with us. And not only do we have all the equipment, the isolates and all of the crew stuff, but we also need to bring oftentimes several very large, very heavy tanks with us to get loaded on the plane and to make sure we have enough air and medical air and oxygen to make it back from wherever we're coming from.

Daphna: 33:02

Yeah, that makes memorizing like the AA gradients seem like child's play. Right, we have to think about how much oxygen, how much air are we going to need for an unexpected amount of time? Sometimes it sounds like and it I mean, so it really, and you guys have alluded to this and this is this is a bend question, but he loves this quote by, I think, the British military of the seven P's, that proper planning and preparation prevents his poor performance. Bless his daughter's heart. He uses this all the time at home. So you know, tell us a little bit about you know you have some lead time, it sounds like, but what is the actual preparation look like for these kinds of transports? You know on the on the front end, and what do you think we can all learn from you know these kind of extreme scenarios regarding transport or preparing for transport?

Laura Borruso: 34:05

I think it's a good exercise and thinking of everything that could possibly go wrong in a span of seven hours, because you have to take a ground ambulance to the airport, load up on the plane and then, once you get to the receiving state, take a ground ambulance to the other end.

Laura Borruso: 34:24

And each time you're transferring is a little bit tenuous, moving the baby and all the equipment, even if it's just from the ground ambulance onto the tarmac. But we have to. There's kind of standard code medicine and airway supplies in the kit, but we have to draw our own medicines from the pharmacy. So you have to say I want morphine, I want this TPN, I want these fluids, I want they're intubated. So please give me some sort of paralytic, just in case. And it's just a kind of a crazy amount of things you come up with in the pharmacist was always like oh, are you sure you want all this? Yes, you can always return it. But so I think even for transports that I ended up didn't end up going on because of my schedule. I got to think a lot about them and troubleshoot every scenario that could go wrong, and I learned a lot from those situations too.

Liz Okonek: 35:25

I think the other thing that is a little bit different sometimes, particularly on these long-range transports, is oftentimes we have a lot of communication with the physician who is currently managing the patient, and so there's a lot of callback and check-ins as far as, like, hey, are we still on this support? We were on this yesterday. What is the change to our medications today? Because sometimes once you leave to go get the kid, it takes 12 to 24 hours to get there, and so a lot can change, and once you've left, you can't change your mind and get different supplies or different medications. So I think there's a lot of communication ahead of time.

Liz Okonek: 36:05

My experience with local transports here is you get the call, you chat with the doc, you send your team, you maybe chat with them one more time, but a lot of times we're in communication with the host nation or whoever is managing the baby a lot more frequently to try and help mitigate some of these potential issues we could run into in the air or on the ground, like Laura was saying, and one of the things I've learned was to think about these babies as like what's the best case scenario? What do we need for that? What's one of the more common, or some of the more common, things that could go wrong. And then, worst case scenario, what would be like the absolute worst catastrophe that we could run into in the air with this kiddo, and how will we manage that at that point?

Daphna: 36:49

That sounds like a good paradigm. Even in our most well equipped unit right To think about those possible scenarios. So tell us kind of what sort of in transport complications do you encounter and how do you troubleshoot them, and kind of your advice for what to do when a transport goes unexpectedly.

Liz Okonek: 37:13

Yeah, I did a transport over Christmas that started with pretty much it was Murphy's law everything that could go wrong went wrong, and it started on the front end before we even got the patient. We were on our flight crossing the Atlantic and we lost cabin pressure and so we had the oxygen masks come out and deploy and we rapidly descended pretty quickly and that's for everybody right, Not just the patient.

Liz Okonek: 37:42

Yeah, we thankfully did not have a patient with us. We had several active duty or retired people that were also on the plane, including a child, who were kind of flying space available to go across the ocean, and so we all had to don the oxygen masks. Several of us did have symptoms of hypoxia before it happened. We actually had one of our nurses that NICU nurses that was traveling with us, who collapsed and had to have. One of the things I learned is, on military aircraft there's different forms of the oxygen masks, and one of them is basically a plastic bag that you can pull over your head that inflates with air, and so that had to be applied to her Like an oxy hood. Yeah, exactly, and so we had that experience, and then, when we were after we had picked up the patient in the host country and taken the ambulance back, we'd gotten on the plane.

Liz Okonek: 38:35

I had kind of already talked about this, but we got up in the air and we lost temperature control and basically the isolates stopped working, and then, shortly after that, we had concern that the battery had fried on our isolate, and so we had a brief moment of wondering if there was potentially going to be a fire risk on an airplane, which is another terrifying experience, and so having to figure out how to one keep this you know, 1500 gram former 27 week warm for a six hour flight. But then we also were running into battery issues as far as being able to check vitals. And so this is where the, the AE crew, comes into play. They were able to kind of work with us. They really looked at our equipment, even though it's something that they're not familiar with, and we were able to figure out that the, the battery pack for the vitals machine that they had is interchangeable with the one that was on our isolate, and so took some playing around with it, but we were able to find somebody who was able to get their hand behind our isolate and change out the battery pack so that we were able to maintain keeping vitals on our baby.

Liz Okonek: 39:42

And then the other thing that we had happen on that transport was, as we were landing, the baby had a bad Brady D-set and essentially put us into a code situation. And so what do you do when your baby is coding and you're about 2000 feet from the ground and actively descending, and so there are different safety mechanisms to have somebody kind of attached to the isolate. So we had our flight nurse strapped into the isolate trying to help get in there and unwrap the baby so we could get in a position to potentially start compressions and beg the baby. We had our RT who was quite experienced as a as a critical care air transport RT who was not strapped in and was able to kind of help with that situation while the AE crew helped brace different people that were around the isolate trying to manage this baby as we were actively landing.

Liz Okonek: 40:37

And then one of the other situations we came across was, once we landed, we determined that this baby was no longer safe for flight, and we were at that point in Germany, so we had to figure out what our options were to get this baby off the plane safely into a working isolate because we've now been about seven and a half hours without temperature support and get this baby to a local NICU in the area, and that took a lot of coordination that we were not anticipated, and so it was a lot of moving pieces with a lot of people above us trying to do a lot of this work so that we could get this baby stabilized and into a setting that was appropriate for the level of care that they needed.

Daphna: 41:15

Yeah, I mean I'm having palpitations and, having been a part of the team, that sounds absolutely terrifying. Yeah.

Liz Okonek: 41:23

So it was one of those, one of those experiences that I will not forget. But also it was. It was everything that could go wrong went wrong and even the baby was fairly stable when we left. But it just goes to show, like Mike was saying, there's a lot of things that can happen in flight that these babies we don't necessarily think that much about that they can really push them over the edge.

Daphna: 41:46

Yeah, my question is really about how do you prepare yourselves for this. Like I think this is a good when we talk about simulating for codes and simulating for the unexpected, like what is the what, what is the additional training to help you know, prepare the mind to, to troubleshoot things like this?

Liz Okonek: 42:09

Yeah, so our program here and our attendings here do a transport course and so that is for the fellows here as well as the residents, and then this last year we expanded it to fellows at the other military programs and so it's put on by several of our experienced NICU attendings and a lot of the time they have been over in Japan and been involved in multiple transports, as well as several of our most experienced either RTS or NICU nurses who have done a lot of transports as well, and really that's kind of the only additional experience you get other than you know when we come back a lot of debriefing and sharing with the, with the group here, as far as kind of sharing of experiences, so that hopefully somebody else can learn something that we didn't learn until we were up in the air and not have that same experience again.

Michael Guindon: 43:02

I'll add to that a little bit.

Michael Guindon: 43:03

So I think I think one piece of the experience that the training that we get is just that knowledge that we are military neonatologists, this is what we signed up to do, and just that knowledge of we're doing this so that this baby can come home and get the care that we think they need and be with their family in the best place for that whole baby, parent, dyad.

Michael Guindon: 43:28

And so I think that kind of puts us in a place, even before we leave, to say, hey, what we're doing is really important, we're the only ones who can do this, we have to have our stuff together and we have to be prepared. And I think that puts a little bit of that mental preparation in perspective for us too or it does for me at least like we're the ones who can do this and no one else is going to do this. And I can't think of any other countries that would expend the resources that our country does to make sure that we take care of our service members and their families, all the way down to the 1,500 grand babies, to make sure that they are where they need to be, so that we're taking care of them. So I think just knowing that for myself and being a parent myself, it gives me a lot of preparation for when these kind of things happen and for preparing to do a transport or mission like this.

Daphna: 44:18

We talked a little bit about stabilizing a patient before leaving or the fact that you may need to secure an airway because of the length of transport. But what about other special considerations for other types of patients in physiology? I think some you guys had mentioned are, say, the cardiac patient or a patient that needs bowel decompression, things like that.

Laura Borruso: 44:46

I've done a couple cardiac transports. The state of Hawaii recently got a dedicated cardiac surgeon. We used to have what's called Heart Week where someone from Stanford would come over and do a bunch of the surgeries, but now we're doing some simpler lesions like VSTs, asts, pdas, but anything more complicated than the shunts goes over to the West Coast to get repaired and then we fly them back to Hawaii. So I think one of the things that we all know is the partial pressure of oxygen drops when you get to altitude. So the little bit of oxygen they may or may not need will drop and, depending on what your set goals, that could be very scary as you're going up to altitude but just trusting it is the altitude and they aren't getting sicker. But we always double, triple, check again all those transfer points from either location to plane or that on the ground to altitude and then descending again. Usually we'll get a bunch of gases. Recheck our settings.

Laura Borruso: 45:53

I am lucky enough to have the opportunity. My fellowship is a joint fellowship, civilian and military, so I get to do civilian transports as well as military transports. So we get the smarter ventilator, not just the basic ventilator. So we do get to see some changes, but definitely the change in physiology. And then in the air. You want to keep them obviously as stable and optimize as possible, but you are not going to get the exact electrolyte goals that the CICU attendings are going to want. So I had this TET baby that was a little acidotic and when we got there I got asked why I didn't give them. We definitely don't have them in our transport bag.

Daphna: 46:40

We did what we could with what we had.

Laura Borruso: 46:41

Yeah, I was like well, I was either going to give a bowl list, but I think I don't know. The enemy of good is perfection, so I just didn't want to throw them over the edge. So the attending said fine, we'll correct it here. So I took that as a success.

Daphna: 47:00

Well, and I think it really speaks to kind of this frequent monitoring and the ongoing titrations that are needed that are totally different than what we see in a, I guess, stable ICU environment.

Liz Okonek: 47:17

And I think the other thing that Mike's going to maybe mention this too is the altitude, and so sometimes, depending on the severity of the infant and what's going on, we'll have to talk with our pilots about altitude restrictions and so flying at lower altitudes to make it safer for the patient. And so, considering what that does, if you're flying at a lower altitude, it's going to add some substantial time to your flight time, and so making sure that that's factored into all your calculations going back to how much oxygen and medical area you've brought with, but also, do you have enough drips or supplies for an extra two to four hours of flight time, because you've now restricted and you're only going to fly at 4000 or 5000 feet?

Michael Guindon: 47:59

Yeah. So, like Liz was saying, like all of those things, the typical cabin pressure in a commercial plane or what our military planes fly at, even if we're flying at 32,000 feet, is set at 8000. 8000 feet is what your cabin pressure is at, but we have the ability to say, hey, we need sea level cabin pressure. That's going to slow the jet down, that's going to increase the flight time, it helps us out potentially with the baby, but it comes with a lot of cost in all of those things. How much fuel is required? Can we do that? Where are we flying over? So, laura, does all these flying over the ocean? Liz and I have both flown over again like hostile, like literally combat zone countries to pick up babies. So there's not a lot of safe place to land or divert to if we have problems in flight. So all of those considerations happen outside of our new inatology perspective but are things that we have to keep in mind as we're making these requests and recommendations to the flight crew of hey, can we do this? And being understanding when they say, hey, we can't do that, what can you do otherwise? And then, just remembering you know Laura was talking about the physiology, so gas expansion and those other changes that happen with altitude. All of those different altitudes have impacts on that. They impact the oxygen and air requirements and how much goes how far in flight, as well as impacts on the baby. So, like you had mentioned, just ballady compression, basically every baby gets an OG or an NG so that we can relieve air because that gas expansion happens in all the spaces as we're flying. So things that we have to consider has this baby recently had surgery that we need to be extra cautious about? We try to avoid transporting too close to surgery for those kind of reasons, but sometimes situations require that we do things that we wouldn't maybe otherwise do. Making sure that, like, even like other things, like there's some debate over, do we need to, like, fill the Foley balloon with saline versus having air in there? And the same thing for if the baby needs a cuffed endotracheal tube. And just making sure that all of those things that have the potential to expand with altitude changes are assessed for. Just knowing all of those things Liz kind of mentioned, making sure you have enough supplies and equipment.

Michael Guindon: 50:13

So a transport that I did. We picked up a baby from the Middle East and from the host nation NICU and they did their drips very differently than what we would do. Everything was running at 1 ml per hour, just to make it simple, I guess. But if you're running dopamine and epinephrine or dopamine, norepinephrine and dobutamine at 1 ml per hour, those concentrations are not going to be standard concentrations to give you the doses that you think you're on, and for a transport that's taking you halfway around the world, that's, you're in the plane with the baby for over 20 hours those drips are going to run out. So we had the experience of myself and one of our flight nurses sitting in the back of the aircraft doing our calculations to make sure that we reconstitute our drips correctly so that we get the same dose going to the baby as what they had been on. So we weren't having a lot of swings in her blood pressure during that flight. So that was a pretty fun and unique experience and we got some good photos from that and then also just recalculating the fluids that they're on.

Michael Guindon: 51:19

So hey, we don't have enough TPN or fluids to run the entire time. We're going to have to transition somewhere in flight. How much sodium are we giving and how are we going to give that much or to make sure that we have what we need. All of that goes into the pre-mission planning that Liz was already talking about, like thinking about. You know, I think it was like Donald Rumsfeld, maybe, like in the early 2000s. You have the known knowns. You know what you know. You have the known unknowns. We know that we don't know this. You have the unknown unknowns, like we don't even know what we don't know. So we're trying to think about all of those things and just appreciating that those unknown unknowns may still come out and get us at some point, like the battery pack on the incubator drying in flight.

Daphna: 52:07

Yeah, you know we talk a lot, especially on the podcast, about how to manage our own. You know our burnout, our moral distress, our ongoing stress and anxiety about the work that we do, and it seems like I mean what you've described is certainly both additional you know, mental stress, but also physical stress. So how do you guys prepare yourselves, both kind of logistically but also kind of emotionally, for an experience like this and doing it over and over again?

Michael Guindon: 52:45

I get a lot of gratitude from the job that I get to do and the knowledge that we're the ones who can do this. We are the only people who can go and get this baby and bring them back from halfway around the world to Washington DC or North Carolina or Texas, or bring them from Hawaii to the West Coast of the US where they can get the care that they need in what is ultimately their home country. So I think that that helps me out a lot. I don't know that my family necessarily feels the same way when I'm gone for four days on one of these transports, that it's rewarding for them, but I think the fact that they see me happy with the job that I do and get a lot of internal intrinsic gratification from it, I think helps a lot. And then I think Liz already talked about it a little bit too just with respect to how we take care of each other on one of these teams.

Michael Guindon: 53:35

You know we're a pretty close-knit group already, like neonatology in the military is, I think there are 30-ish of us total.

Michael Guindon: 53:44

So we're a pretty close-knit group overall and when you break it down to we're going through these transports like this, you know like those bonds are definitely forged through fire and we get a lot closer with each other on these things.

Michael Guindon: 53:57

We look out for each other, we're keeping tabs on each other, we're making sure that we're getting snacks, we're making sure that we're getting hydrated, we're making sure that we're getting a nap whenever we can and really taking care of each other along the way and the teams that we encounter around the world along the way also. Like we stopped over in Germany on this mission to the Middle East that I went on and they asked us like what can we bring you guys? They were going out and getting us coffee. They brought us bags full of snacks and drinks and things like that, just to kind of keep us going, because you don't know when your next meal is going to be and you don't know when you're going to get an opportunity to do some of those things. So just the camaraderie that really comes out as you're, as you're close to these things, I think is pretty impressive and I think that gives me some energy to keep going.

Liz Okonek: 54:42

Yeah, I think Mike said that very nicely and I think not just a camaraderie within the military and unitologists but, like he mentioned, as well within the team. So you really get to know the nurses and the respiratory therapists that are with you and they, you know, they have your back and it is a in these environments it's not necessarily who is the highest rank or who is the physician. It sometimes comes down to who has had the most experience with what we're dealing with right now and that person stepping up as a leader. And, like Mike said, we also had the experience of stopping over in Germany and the AE crew that we were with was fabulous. They welcomed us into kind of their space and their people that were not actively out on missions made as a big meal, and so it really is a community people understanding kind of what you're going through and and how you know how difficult it can be. And one of the things we haven't talked about is the pilots and the flight crews and the AE crews. They have flight hour restrictions, so they have specific hours how much they can go, and that doesn't apply to the, to the medical team, so oftentimes we're in situations where the flight crew or the, the pilots may time out and we might just get another crew that comes onto that plane, or they may have a switch plane so that we can finish our mission of getting the patient back to where they need to go. And so sometimes those you know, 16 hour days are really 24, 30 hour days for us into taking care of each other, whether it's a physician to physician or nurse to physician or whatever that dynamic may be.

Liz Okonek: 56:06

And one of my experiences, both of my transports that I've done across the Atlantic, I was actively breastfeeding and pumping for. So not only did I have to take care of myself, but I was also pumping every three hours during those flights and trying to maintain a schedule with all the time zone changes and Storing milk, keeping milk cold, and I had the air crews and my team both times checking in every three hours If I had fallen asleep or things have gotten busy, them reminding me like, hey, you're still doing this. This is important to you. We're going to keep an eye on you and ask you to kind of take 5 minutes, 10 minutes, step away and do what I needed to do to maintain my supply so that I could come home.

Liz Okonek: 56:44

And you know, mike mentioned his his four, four day trip or transport. One of the other things I've learned is to to expect them expected, and a lot of times when we're traveling and having to take multiple planes, things get delayed and so a two day transport may end up being 5 or 6 days depending on where you are and what happens. And so having the resources and kind of the backup to To deal with that and then having the family support back home who can deal with you being gone an additional three or four, sometimes five days because this transport got delayed or something got added on and now you're bringing an additional kid somewhere.

Michael Guindon: 57:24

Yeah, I was going to just say I think was sort of alluded to, but I think that the, the, the pilots just talking about the, the crew reaction to it. I think that those guys also get a lot of Gratitude out of this is a pretty unique thing that they get to do. I have not been on a transport or around many pilots where they're. They're not fascinated by what we're doing. They take a very personal interest in coming back to see, hey, how's it going? What's going on, what, what do you guys need? Are we doing? Okay, I think that they take a lot of personal interest and get a lot of gratitude out of providing that support to us and to our patients also. So again, I think it's a very unique thing.

Michael Guindon: 58:00

Not that they don't take that gratitude, you know, get that, get that feeling from their other patients that they're transporting also in their other missions. But I think they have a a special feeling for this because a lot of them are parents also and and they appreciate how important what we do is. And again, like we've already kind of talked about, most people just don't realize that it's a thing that's needed. Until it's a thing that's needed or they're exposed to it. They just assume that it's fine and it happens, and so I think just letting people know that this is this is what we do and this is why it's important, is a it's a great thing. A theme that keeps popping up for me is how important communication is on your team, between multiple teams, lots of handoffs and transitions and coursework, Kind of sign out.

Daphna: 58:45

So so tell me, you know what role communication plays. What do you think we can all learn from that? Is there additional training specifically around communication? That's a great question. I don't think specific training. However, there's so many different ways that we can learn from that. Is there additional training specifically around communication?

Laura Borruso: 59:07

That's a great question. I don't think specific training. However, there's so many barriers to communication on the military aircraft, again, it's not, it's just metal and open and very noisy. So you either need noise canceling headphones, you put in foam earplugs or, if you're lucky enough, the flight crew will share with you the headset that works on their communication so you could talk with the flight crew and hear what the pilots are saying. But it's a lot of hand gesturing and motions and typing on your notes app on your phone or jotting down notes to each other. And then another challenge with communication too is you're usually with the families too. So I've had instances where my nurse was worried that her patient was seizing on. This was the private plane where I was like three feet from the mom, so trying to examine the baby without wearing her she. She ended up being OK, but trying to him quietly, trying to bring that up to me was definitely another level of communication.

Michael Guindon: 1:00:22

Yeah, and then I think Liz already had kind of mentioned you know, often we're we're in flight. So what was happening 12 hours ago when we left may not be what's happening when we land. We might be arriving to a different patient than we thought we were going to arrive to, and then the inverse is true too. You know, our teams back home or the team at the receiving hospital was may not be our hospital. We may not be taking the patient back to our hospital where we're going to continue caring for them. They may be wondering what's going on with this patient in flight. We may be delivering a very different patient than they thought they were getting when we left.

Michael Guindon: 1:00:56

So there's a few ways that we can try to try to get around that, but ultimately just trying to find those times to communicate. It's important we use a variety of asynchronous communication. There are some apps that we've had that are approved that we can use for communicating some of these things. We always have the capability, if needed, to use the aircrafts communication system and actually on one of the transports that I went on, they were trialing an in-flight Wi-Fi system, which is a novelty on a military aircraft. So we were able to maintain constant, just text communication back and forth with our teams on the ground so that they knew when we were planning to arrive, what the status of the patient was and things like that. So but yeah, to your point, just lots of communication all along the way.

Michael Guindon: 1:01:44

Liz already kind of mentioned you know like we were the military. So rank has meaning, but understanding that rank doesn't always determine everything, it's not the be all end all. We have to understand those different perspectives and respect where everybody's coming from in their own roles, and really understanding and appreciating everybody's level of training and what their expertise may be in a situation and just their different perspectives on things is really important. I think this kind of humbles you down a little bit in those ways to really understand the contributions that every member of the team can have If you listen and you talk clearly with them.

Daphna: 1:02:24

Yeah, well, I think that's a great lesson, even on our civilian medical hierarchy, right. One thing that you had mentioned that I was intrigued by is the families. I didn't even think that obviously many times they're along on the transport also, which makes plenty of sense, but I imagine sometimes they're not, and you know, how do you deal with families? How do you deal with the communication, like language barriers that you might encounter, things like discussing and consenting for the risk of a transport like this? What is the communication like with families?

Michael Guindon: 1:03:08

The most interesting transport that I went on was one where we were actually moving patients who are not American citizens. This was part of the Afghanistan evacuation that happened in 2001, where our Department of Homeland Security said, hey, these people have helped us out, they are at risk. The US government owes them because they've been supporting the US mission in Afghanistan for the last 20 years. We need to get them to safety because it's not safe there for them. So they were evacuated as quickly as possible to a variety of places around the Middle East. Of course, when you evacuate a lot of people, some of them are going to be pregnant, they're going to have babies due to the stress, due to just normal term pregnancies and things like that, and so on this transport we were bringing this critically ill baby back from the Middle East. We had a translator with us who was able to speak POSTION and was able to help us get that consent for both the transport as well as the care and just having those difficult conversations of your baby may not survive this transport, even though we think this is the best thing for them. We need you to understand that and then kind of continually having those conversations through the flight. So we had a translator who was able to provide that service for us. That was actually an active duty Navy language specialist, so it's his job to know languages, and he just got tagged and said, hey, you speak, postion, you get to go and was sent to help us out for this aspect of the mission to bring these children.

Michael Guindon: 1:04:39

It ultimately ended up being three babies that we brought back to Washington DC as part of this part of that Operation Allies Welcome mission, so we are able to communicate with the families, even through language barriers.

Michael Guindon: 1:04:51

Our team sets us up with that and again, that goes into that planning that we've already kind of talked about of who do we need? We need a translator. We actually had like spiritual advisors who were there who could help us out, like hey, if this baby dies or has a significant event in flight, this is what you should do, and religion wise, like this is what you should do for the baby if there's a bad event like that in flight, to honor the parents, religious and spiritual beliefs, and so a lot of those kind of things that we really hope to not have conversations about acutely anywhere, but that came up even as we're taxiing away from from this location. So, again, just super important many members of the team, lots of communication and all of those things that go into the, the, the planning ultimately. So I like Ben's quote that's perfect. Planning prevents this poor performance is definitely something I've heard in the past to. So I appreciate that that quote and just a lot of a lot of communication between our team are experienced people and and everybody who's involved.

Daphna: 1:06:04

Well, I really appreciate you guys coming on and sharing your stories. I think it helps give us a better understanding of what you guys are doing. I think it is a reminder to all of us to not take for granted some of the things that we we have at our disposal on a day to day basis. If people are interested in learning more about what you guys are doing, or might even have an interest in, you know, finding a position in the in the military as a physician, what are kind of the next steps? What should they do? Where should they go?

Michael Guindon: 1:06:44

I would say it depends on what level of training they're at. If they're a medical student, then the easiest way, I think I think the first thing to do would be to find what service you're interested in. Army, navy, air Force all have active duty physicians. Talking to someone who already does that is probably the first, best, first step to gain their firsthand experiences. And then there are a couple of different programs for helping people to join the military as a physician if they're interested in that. The ROTC program is one avenue. I went through the health profession scholarship program, which paid my medical school expenses and tuition and fees with the service commitment payback requirement. There are people I know who have done what's called the fee assistance program, which means you've finished medical school and sign a contract that will help pay back those student loans with a service commitment, but you're already a physician at that time. And then there are people who may just join later.

Michael Guindon: 1:07:43

I worked with a pediatrician when I was in Japan as a general pediatrician, who had been a civilian pediatrician for 14 years and just needed something different and really wanted to live in Japan. And so he went and found a recruiter and said, hey, I'll do this if you can get me to Japan and fortunately they did and he was one of the best people that I've ever worked with. It was phenomenal, as a brand new pediatrician coming out of residency, to have someone with that type of experience to serve as a mentor. And it's still a friend and somebody that I talked to today over gosh, how long has it been now. I left there in 2004-17 so somebody that I still keep in touch with, even though he's separated from the military now.

Michael Guindon: 1:08:21

So a few different avenues, but first thing I would do is just try to find one of us and ask those questions and see what we can tell you. We're often at conferences. I know that a couple of us were at PAS and I know that Liz and I think Laura also were just at the district gate meeting out in San Diego. So look around, find somebody presenting a poster, standing there in uniform. They will be happy to talk to you about what we do, why we think it's important, what we like about it, the challenges that we face, what's not so good about it or just those tradeoffs that we take between our practice and civilian practice, and see if it sounds right.

Daphna: 1:08:59

That's awesome, thank you, and we'll put on get some of those links on our kind of show page notes. Dr Zokanik, gwendolyn and Boroso, thank you so much for your time and for all of the work that you do protecting babies all over the world.

Laura Borruso: 1:09:15

Thank you so much for having us. Yeah, thanks for having us.