Episode 57: Stomachaches! How to think about them? w/ gastroenterologist Jonathan Matthew MD

On this weeks Ask Dr Jessica, she is joined by her uncle and Gastroenterologist Dr Jonathan Matthew. Children commonly get stomach pains, but how should parents approach them? How do they know what to do, and when to see a doctor?  We will  discuss common causes of stomachaches in children, including IBS, constipation, anxiety and even the "red flags" of appendicitis.  Dr Matthew has been a gastroenterologist for 40 years, and he is widely loved by his patients.  He trained at UCLA for medical school, residency and fellowship. He is an avid reader, golfer, UCLA sports fan, and proud father of 3 children and grandfather to 8 grandchildren. 

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

Do you have a future topic you'd like Dr Jessica Hochman to discuss?  Email your suggestion to: askdrjessicamd@gmail.com. 

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The information presented in Ask Dr Jessica is for general educational purposes only.  She does not diagnose medical conditions or formulate treatment plans for specific individuals.  If you have a concern about your child's health, be sure to call your child's health care provider.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

Follow her on Instagram: @AskDrJessica
Subscribe to her YouTube channel! Ask Dr Jessica
Subscribe to this podcast: Ask Dr Jessica
Subscribe to her mailing list: www.askdrjessicamd.com

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody welcome back to ask Dr. Jessica the podcast where I interview experts with a goal to help you worry less about parenting. I'm your host and paediatrician Dr. Jessica Hochman. Today we are interviewing my uncle Dr. Jonathan Matthew, who is a gastroenterologist. gastroenterologist, commonly referred to as gi specialists are doctors who treat digestive issues. Today, my uncle and I will discuss common causes of stomach aches. I love talking with my uncle. He's incredibly knowledgeable about practically everything, and he has a great sense of humour. I hope you enjoy. Hi, everybody. Welcome back to Ask Dr. Jessica, I have one of the most special guests I could ever dream of one of my favourite people on this planet. And that is my uncle John. Dr. John Matthew, how are you? Good. I've known you since you were born. I remember seeing you the day you were born 42 years ago. That's right. I went there. He saw you. Oh, my goodness, dad's brother, my uncle John. He is a gastroenterologist. And he is a wonderful, wonderful resource for me. I always pick his brain when it comes to gi illnesses. And so I'm excited to have him on here. Today we're going to talk all about different causes of stomach aches that teenagers or young adults may face. So how long have you been a GI doctor? So I started my fellowship in 1981, which was a two year fellowship back then we did not we had to do some research, but it isn't like today, you have to do a lot more bench research to be a fellow. And then I started practice 1983. So approximately 40 years. So what's the most common reason why patients come to see you and specifically maybe the young adults teenage teenage years. So in teenage years, the most common thing is abdominal pain, bloating, distension, bowel irregularity, or by belly regularity, it's going to be either too much or too little. Those are far and away the most common reasons for kids. So typically, it's pain distension bowel irregularity, they're uncomfortable. So if a patient comes to you with a typical abdominal discomfort, bloating, distension, what what's the first thing that you ask them? What's your, what's your approach to it, okay? Very often when kids come in, or teenagers come in, it's not just pain, but I'm bloated, my belly is blown up, it's out to here, it's very uncomfortable. So what I try to explain to them is, if you take a plain X ray of an abdomen, you'll see a gas bubble in the stomach. You'll see gas in the colon, okay, and they're different gases. Gas in the stomach stomach that you burp up is swallowed air, its room air, atmospheric air every time you eat, drink, swallow saliva, you shove some room air down there, that can distend the stomach can be uncomfortable, but you feel better when you burp. Yes. Now some people will swallow a lot of air. If they have bad reflux problems, ongoing heartburn, even if they're not aware of it. I'm just thinking if if someone's good at burping and they burp, often it might be a sign of reflux might be a sign of reflux, but sometimes it's just a nervous habit. People I'm going to have patients in my office will just sit there and burp continuously. And there's no other mechanism other than their swallowing hair. Are they coming in? Because of the birthday? Yes, but But what is that much? It's a nervous habit. And what am I partisan is not you can be a little rough on people. Sometimes he says, All right, open your mouth. It's very hard to swallow with an open mouth. Okay, and that just stops the burping cold and that kind of convinces them. That that's what that is. But often those. That's why those patients are saying he convinces them that it's a habit and drives. Now gas in the colon comes from the fermentation of food that you eat. That's not absorbed in the small intestine gets into the colon, and then bacteria chop it into gas and other particles. Yes. Okay. Now, a lot of times healthy foods make a lot of gas. I mean a lot of fibre that we eat fruits and vegetables. They're filled with dietary fibre, but dietary fibre you can't absorb. Right, right. So it gets into the colon, it gets fermented and boom, you start getting distension. And a lot of it can be exacerbated by how well the intestine squeezed if you have a sluggish colon, it doesn't squeeze well. It just kind of can sit there and blow people up and make them uncomfortable. Okay, so that can be helped by trying to be on low gas diets. I'm sure you put kids on what are called low FODMAP diets. Yes. Can you explain what that is? It is an acronym for the kind of carbohydrate that tends to be highly fermentable into gas and other particles. Okay. It's an acronym you could look it up. I honestly forget the exact wording, of course. And frankly, it's not important to know. Okay, the actual meaning I agree. Yeah, but it's but there's a lot of them. Okay. And, and there's lists, you can say, well, these are better than these and often that will make people feel better. I was always taught the first thing if someone is having problems is double check what they're eating because chances are they're making a mistake on their diet. Interesting. So celiac disease, undiagnosed parasites like Giardia that does crop up you had that one I had that one. I remember that doing Habitat for Humanity. I lost nine pounds in a week. How many years ago was that? I remember, oh, goodness, Kimberly, my, my daughter who's now I'm 37. She was a junior in high school. So over 20 years ago, it's a great diet. I'll tell you that. But, you know, it doesn't have to be as bad as I had. Again, that can cause problems. Yes. Okay. And then the thing you know, and just quickly say, how do you avoid getting giardia? Because it's avoidable? Well, it's basically grungy water. I mean, if you go camping and you drink out of a stream, you raise your risks, isn't it from animal poop? That makes sense. But you do look for it? Yeah. That's one thing. There's the concept of bacterial overgrowth in the small intestine SIBO, small intestinal bacterial overgrowth, people should be aware that there's bacteria in the gut, and some people think it was called bacterial overgrowth. And if there are too many bacteria in the small intestine, that can inhibit absorption. How do you treat SIBO SIBO or SIBO, however you want to pronounce it. You treat it with broad spectrum? Is it better to say SIBO? I don't think it's better at all. But if you treat it with broad spectrum, antibiotics, somebody to knock down the content to you and to so many times having to treat these patients intermittently every three, four months. Give them around again. So we talked about parasite we talked about bacterial overgrowth. Inflammatory Bowel Disease, is something that you have to make sure you don't miss in a kid because it's more common in teenagers. So inflammatory bowel disease, there's two basic types. One is ulcerative colitis. The other is Crohn's disease. Yes, they tend to be genetic and familial, but it can happen in any sort of population. And they're usually distinguishable. Sometimes they're not you get certain kinds of inflammation in the colon where there's a crossover, this features of both, okay, the Crohn's disease can affect the gut anywhere from the mouth to the anus, it's an idiopathic disease. That is to say nobody knows what, what the cause is. Certainly there's a genetic predisposition, familial predisposition, but I've seen it in just about every population there is, okay, every ethnicity, etc, etc. Although, as an aside, I remember as a fellow, It most commonly affects the end of the small bowel. Yes. Okay. So, what we call the terminal or end of the ileum, or the end of the small bowel that gets inflamed, stricture narrowed, can give cramps, obviously, with partial obstruction, bloating, distension, discomfort, loose stools, things like that. When I was a fellow, somebody came in with an X ray and narrowed terminal ileum and pain and we figured it was Crohn's disease. And it was a patient from Vietnam and the head of GI doctor Schwab at UCLA said, I've never seen a Vietnamese with Crohn's disease. I don't think that's what this is. And he was right. It turned out she swallowed a chicken bone, which had perforated the ilium caused an infection and an abscess. And that's why the ileum was narrow. Gosh. So it sounds to me like when people come in to see you with stomach aches, there's a lot you have to think about. There's a lot you have to think about. But you also have to, and particularly in teenagers, you don't want to abuse them with tests. I don't think No, I don't think that's a good thing to do. I agree. Okay. For example, I rarely put kids through and teenagers do endoscopy or colonoscopy, unless it's really under the gun and I've got to do it because they do not want to get prepped, meaning take a bunch of laxatives to clean up they do not want to come in and gets the data to knock down a good sculptor unless you absolutely have to do it. I appreciate that about you. Yeah, well, look maybe I'm wrong. I mean, I'm certain in in paediatric gastroenterologist I'm sure they scope a lot and I'm sure it's justified. But I feel like you would know when to worry and when when to justify it. Well, if they don't have real significant signs of colitis, um, chances are I'm not going to find anything in the colon. Okay, like I scoped a young woman today she was in her 20s. But I've known her for a long time. And at some point, I diagnosed her she both had Clostridium difficile a kind of C Diff infection, but you also had proctitis, which is an inflammation of the rectum. Okay, and she came in flaring, more diarrhoea, more bleeding, I treated the proctitis she wasn't getting better. I checked her precede difficile, there wasn't C. difficile. G. At some point, I've got to take a look. So I scoped it a day, and the rectum was mentally inflamed. Then it became normal. I kept going and boom. Your descending colon was badly inflamed. She was one of the I don't know 10 to 15% of people with rectal inflammation were finally moved north. Now she has full blown ulcerative colitis, although we have what we call skip areas, normal areas, she might have Crohn's disease, but the treatment will be the same as two children going on steroids short term, she doesn't get better. She go on what's called a biologic infusion or a monoclonal antibody to improve it. inflammation and we have those these days and they work really well. They all have potential side effects and complications, they do affect the immune system. So they raise the risk of infection, okay, and they raise the risks of certain tumours like lymphoproliferative disorders, lymphomas. Now the risk is still low. If I tell somebody this is going to triple your risk of getting a lymphoma, but your risk of lymphoma is two in 10,000, those will raise it to six and 10,000. Those are approximately the numbers is still pretty low. Yes. And if you say, well, we're not going to use it because of that. That means 10,000 People have miserable lives because of inflammatory bowel disease. So you're a fan of the monoclonal antibodies. I am too. Yes, because they make people their works better. Absolutely. I want to bring this back to diet and how to help someone with stomach aches and has that doesn't have the best diet. What do you see as the most helpful? I know, we talked about the FODMAP diet is would you say that's the most effective for stomach aches? One thing? Yes. And the other thing is making sure they empty their colon. Okay. Okay, because a lot of stomach aches are caused by backed up colons. So being constipated, being constipated, and different things happen when you're constipated. Because hormones are chemicals that work throughout the bloodstream, like thyroid, testosterone, oestrogen, right? Cortisone. There are a variety of intestinal hormones that most people don't think about. And they affect gut function. So for example, when you eat a meal, certain hormones get released that make the colon contract. We call it a gastro colic reflex. That is not a hammer reflex. But that's why people often move their bowels after a meal. It's not that the food is shoving it out. If there's a hormone effect on the colon to make a contract. Conversely, with a backup colon, hormones get released to slow the emptying of the stomach. Okay, so if you have a slow emptying stomach, it means you eat and food just sits there. And that's very uncomfortable. personal example. Yes, many years ago, Hillary, my wife and I went to Hawaii. And when you travelled people's bowels get mucked up. And one night we went out to dinner at a place called plantation gardens, a gorgeous restaurant. And I was young and always hungry. And I sat there at dinner looking at myself saying, I must be sick. I can't heat. I had no appetite. Well, what had happened was we've been there four or five days, I haven't gone to the bathroom. Horribly, I just couldn't eat. And I thought I was sick. We went back to the room that night, suddenly wish I cleared out like I was starving. And we all have that experience that we're much happier with an empty colon. Okay, so when kids if they get backed up or constipated, you got to get them to empty their colons because everything works better. everybody's happier with an empty colon. That is true. Do you think people should be going every day every other day? Which is what they're comfortable with? Yes. Okay. But it's the right we I was taught and gi school. Normal could be three times a day to once a week. Well, that may be true. But if somebody is comfortable at once a week Be my guest. Most people are not going to be comfortable at once a week. They're just not pressures going to build up, it's going to get uncomfortable. The stomach's not going to empty well, they're not going to be happier. Do you feel like diets the most common culprit? I don't know. Honestly, I think it's more. That's the nature of the patient, the value of food is holding on to fluid. So there's more lubrication in the colon to empty easier because I interesting patients that if you have a tight ring on your finger, how do you get it off, you either push real hard, which is uncomfortable or you lick your finger and you slide it off. So the value of food a lot of times is holding on to fluid bulking it up so it's easier for the squeeze that is there to shove things around. Is that why water is so important to or liquids are so important to consume yes to not be just drink liquid, right? Because if you just drink liquid need matzah, all you're gonna do is absorb the water and urinate a lot. So you need things that hold on to fluid and that's why fibre is helpful. The downside and fibre for some patients is sometimes fibre in addition to holding on to fluid is fermented into gas particles so then it's a race between do empty more or make gas more. So for example Metamucil which is a common fibre supplement we give people, some people swear by it, or the people said I was miserable on it. So just to just to clarify this so somebody has you diagnosed them with IBS? What is the basic advice that you give them? Okay, just to go through it. It's, first of all understand what I try to tell kids and I try to tell and until adults also is first it's real common. Okay. It's arguably the most common problem any gastric general gastroenterology sees anywhere. On the world, whatever continent you go to. So, if you if you, if you think you're unique or alone, I promise you, you are not. And if your friends aren't telling you about it, because they don't talk to strangers about their bowels, but they'll talk to me about their bowels, because sometimes misery loves company, realising they're not alone. Yes. Okay, absolutely. And realising I'm not strange, because I'm complaining about my bowels all the time. No, you're not. I remember once going back to the GI department at UCLA to visit some people. And I walked in the office of you remember, I'm not going to mention his name. He was a famous Dean of Admissions. And he was a gastroenterologist, and I hear him on the phone talking to some guy, well, you got to have her take fibre and you got to do this and she could use glycerin, suppositories. And he hangs up, and he probably shouldn't have said the name. But as the name of a very famous Miss America at the time, wouldn't mean anything to you, then suddenly be back then I went, Oh, okay. Well, it's just she can have it. Anyone can have it any is just real, real common. Okay. So you're not alone. That's first of all. So how to make you better, you got to keep pressure down in the bowels. That means get your colon moving, and try to reduce gas production. Those are the biggest things you can do for people, honestly, most of them. If they can keep enough fluid on their colon and empty their colon and keep the gas foods down. They're going to be okay. And when you talk just to clarify when he talks about the gas foods, if you Google FODMAP, fo DMAP. Right, you'll find the whole list and then there's a lot of good apps actually that a lot of patients use to track their Yes, high gas. You don't have to be a fundamentalist about it. No, you can avoid the biggest ones. Okay, it'd be living on broccoli, cabbage. And cauliflower is not a good idea. Yeah. I'll tell you an interesting gas producer diet sugars. Yes. Okay, because the reason they're dietetic is you can taste them, but not absorbed them. So when they get into the colon, they get fermented and we'll give symptoms so diet sugars, for example. So you get people. It's not common, but someone who choose certain diet gums all day long or sucks on diet candy all day long, may have problems. It's the sorbitol, right? So carbonation can be a problem and people. Okay, if you drink too much in the way of soda, now it's carbon dioxide. So theoretically, that gets absorbed pretty quickly and out of your system. But until it does, it can expand things out and give you a lot of Bloating and Discomfort. Okay, so there's dietary management. Like what's the most common regimen if someone comes in with IBS? When they leave your office? What's the most common advice that you give them? So there's going to be something to make sure their colons are emptying better. Okay, be it fibre supplements, stool softeners. If they're a tough constipation case, weirdly things like MiraLAX, or periodic use of magnesium, trying to avoid things that will slow down the colon, try to avoid the big gas producers. Now, if they have up top symptoms, nausea, a lot of indigestion will be called dyspepsia. I'll often give them an empiric trial of an acid blocker to see if they feel better. And do you find that these patients get better? It's just something that they're dealing with for four years on end. The irritable bowel tends to wax and wane, okay? Meaning it's what I but it's important to know that, for example, if you eat the wrong foods, you may get uncomfortable, but you're not going to damage yourself. Nothing bad is going to happen. They need to be warned when to come in, for example, fever, vomiting, hurts the walk, things like that, that are literally then you want to get checked because you don't want to miss acute appendicitis. Of course not. And just so everybody knows where, where, where on the stomach. Do we depend on Yes is the appendix where should parents be paying attention so the pet Well, here's the problem with that. The appendix is like a little warm like structure, little outpouching. It's in what's called the cecum, which is the first part of the colon which is in the right lower quadrant and most people so the right lower part of the steps however, with appendicitis, the initial discomfort can virtually appear anywhere in the gut. So it's most common, for example, around the belly button or up in the stomach area, with nausea and pain. And sometimes depending upon where the appendix tip is, it may fool you and be in the left side of the abdomen, the upper part of the abdomen. So if the appendix is in and you're worried about acute belly aches, I always worried about appendicitis. Okay, so really bad stomach aches hard, no walk fever. So hard to walk means you're jiggling the abdomen. When you jiggle the abdomen and it hurts. That's like what we call it. peritoneal sign of inflammation. Yes. Want to hear a story about that one. Of course many years ago, I was invited to a wedding of a guy gastroenterologist, he was at a temple over the hill. So I was young Hillary was young, our kids were babies. We had nurses as babysitters. This is pre cell phone. I'm sitting at a table with the chief of Gi Dr. Swaby. The Dean of Admissions Dr. Potts, who was a gastroenterologist and another gastroenterologist in private practice and Hillary and I, and the whole place is teeming with surgeons and gastroenterologists because the guy getting married was a prominent gastroenterologist. So Hillary goes to call the babysitter to see how the kids are. And she comes back to the table again, pre cell phone, she says, the kids are fine. Your brother Your dad called and he's having a lot of abdominal pain. So I got to go call my brother, everybody at the table kind of pays attention because all they care about in life is abdominal pain. So I sit down at the table and my chief Dr. Schwab. He looks at me says, so how's your brother said he's feeling a little bit better. He says, Oh, does he still have an appendix? I go, yes. Dr. Schwabe. He goes, Oh, I said, I know. So. As soon as I got home, I called Andy. He was feeling better the next morning, he wasn't feeling better. I walked him into the emergency room every time he put his right foot down. It hurt. So I said this is classic appendicitis question about probiotics, because so many people take probiotics are very in vogue. And my question is, when do you recommend them? Do you recommend them? Are they helpful? In some cases, for sure they're helpful. Okay. But not, but I can't prove it admit the most of the time that we use it. Okay. Meaning a lot of times people go on antibiotics, they take a probiotic to replenish their gut bacteria. A lot of times people say I have upset stomach, I have this I have that. I take a probiotic. I have nothing to measure in general. By measure. I mean, if you have high blood pressure, you have to tell me anything. I'll take your arm, take your blood pressure. If you have ulcerative colitis, it's pretty objective, the questions how many Valbonne today, how much blood are you seeing? I can look in there with a probiotic is does it make you feel better? I can't measure anything in particular. So if people take a probiotic, and they say, I feel better, I move my bowels better. Great. Keep at it. If they say, I don't think it's doing anything. I don't feel any different. I'm not sure what it's doing. So someone said to you, Doctor, what probiotic Should I take? I want to take a probiotic. Do you have a like a line LIG? And because it's pretty broad spectrum? I certainly don't like the ones and maybe it's not fair to say this. That's mixed with yoghurt. Because if you have somebody who's lactose intolerant and trying to take a probiotic, it's like, well, gee, maybe it's the problem is the yoghurt. But don't they always say that yoghurts have the live active cultures? And? Well, it's a probiotic, there's all live, I mean, don't you're not triggered and dead bacteria? Right. Hopefully, that doesn't do anything. But again, I think a lot of probiotic is empiric therapy. That is to say, Do you feel better, you know, are the result of the clinical outcomes better? Fortunately, I don't think it does any harm. Premium? No, no, sorry. Right. First, do no harm. So if you're taking something, it's not going to hurt you. But I certainly don't mind. That's different, for example, than taking antibiotics, which always have the potential to give problems, right? We're going to use other medications, and presenting the best stories always. Will stories are a great way to teach. Sometimes I have a question people always ask about, you know, pooping comes up a lot. And people want to know what's, what's the longest you can go without there being an emergency or problem? Well, everything is different. Because, for example, if if you can be backed up and go all the time, but there's just not enough, and it keeps building a building a building up, okay? So if somebody doesn't go for, say, two or three, you know, for three days or so you want to start thinking about it. Okay, bear in mind, the longer stool sits there, the more salt and water get absorbed by the wall of a colon makes it more difficult to get out. People will get what are called stair coral ulcerations. That is to say pressure sores from from the effect of stool on the wall of a colon. Those can be problems. They can get them in the rectum. Yes. Okay. So, like I said, you're not going to get into trouble with three days of constipation. But if somebody's barely going, because the problem is, the more they don't go, the more difficult it is to go, the more painful it is to go. Yes, you want to try to attack it earlier rather than later. I know we've we've we've kidded about some of these things. But honest to god, I had one mortality from constipation in my career. One One. It was it was a mentally disturbed gentleman. He was about 20 years old. He went to Tarzana emergency room with constipation. They gave him some stuff. And then he came to West Hills nine months later, and said to me, he said he hadn't had a bowel movement in nine months. Okay. Do you think that was true? Yeah. Because his belly was blown up like he was 12 I was pregnant. And it was like a rock. Okay, meaning now when people come in badly cause a terrible nine months, he was crazy. Because who stays at home like that? I told you he was mental. So patients who get badly constipated can get what's called a faecal impaction. That is to say where it's so stuck in the colon. They can't evacuate. So what do you do for that? I don't know if it happens a little kids, but in adults, it certainly happens. You have to literally disinfect them, do rectal exams, and break up the stool and yank it out of there. It's very uncomfortable. Yes. Okay. So I went to try it and this guy, and it was like concrete, and there was no way I was gonna be able to dig out that much stool. So I called a surgeon. And I said, he needs surgery. I can't get rid of this. Okay. Now, what happens is when you start descending, the bowel wall, okay, it gets very tense wall tension, physics lab, Laplace, what is it? Gonna remember, equals PR, while tension is proportional to pressure and radius, okay, so it got very distended. You can't get blood flow in there. So you get what's called ischemia. So the surgeon took him to surgery and at that point, he started having what's called ischemic bowel. Invariably, there was faecal spill, the abdominal cavity trying to evacuate all that he got diffuse peritonitis and died of sepsis. So you're saying that people understand that the poop broke into the stomach while where it shouldn't be right but stretching so that gutter stand I've seen one case like this and 40 years of Gi and I haven't seen anything close to that okay, that's that's kind of a winner. Meaning I wouldn't go at home thinking oh my god yeah, I'm gonna three days something's gonna happen. That's not what I'm talking about. So please don't go home freaking out about that was a was a problem of mentally disturbed situation. Bad problem. Lost in the system. How did you pick gi by the way? How did I How does one pick? One pick a gastroenterology? Yes. So when I was a resident, I did my residency at UCLA, which was a pretty high rent place for residency on the West Coast. I mean, there was UCLA there was Stanford, a Harvard General Washington, those are the big places you want to do a fellowship and something's that kind of residency what to do. The head of Cardiology at the time, I guess this is going over the airways. He retired now I'm not going to mention the name was and I could use epithets. He was not a nice human being. Okay, got it. Oncology was depressing. Okay. The head of Gi was a guy named arch Wabi, who was a great teacher. He went Golden Apple teaching awards. He knew everything about medicine. And he made it fun. Rounding with him gi with him was just fun. Okay, this is before endoscopy was really huge. I mean, he didn't go to it back. You know, today, they go into it like, Oh, I do a lot of industry make a lot of money back then. And dascomb. He was not that common. But I went to a Schwab, he just made it fun. He was a great professor. You'd watch him interact on rounds, and you'd watch him interact with professors, with big donors, with surgeons, with janitors, all the same. I remember once on rounds, where I was sitting there, leaning against the wall, and he's talking and a janitor was going down the hallway at UCLA and something fell off his cart. And Schwab is talking to us and He's looking at us and we're not making a move. He stops mid sentence runs over, picks up the stuff goes running down the hall to the janitor goes Excuse me, sir, this fell out of your cart, you dropped this comes back to us gives us a look like did I have to do that? And then just goes on. He was just a nice, nice man. At UCLA, if you remember, we used the old hospital, the new hospital, new hospital. Okay, well, the old hospital the top two floors were called the Wilson pavilion, where rich fancy people would go the ninth floor was I think surgery medicine was 10 or one of those things. And you'd go up there you'd see like somebody in the movie, somebody really rich big donors, whatever. They all wanted to be catered to. Okay. And Travi just treated everybody nicely. And he wasn't impressed by a movie star. And I mentioned this him to one day that he just didn't seem it was very blase about who he was meeting. He looks at me with a very serious space he says, from my end, they all look the same. That's a good that was sloppy. That's why I wanted to gi Chang, thank you so much for coming on. I always learn from you. I love you so much. Love you too, sweetie. And I appreciate appreciate you coming on. Well, this concludes this week's episode of Ask Dr. Jessica. I wanted to say a sincere thank you to all of you who are leaving reviews and spreading the Word last week's episode was downloaded in 10 Different countries which I find so exciting so thank you so much we'll see you next Monday