Surgical Angiology (VEINS & ARTERIES) with Sheila Blumberg

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Oh, hey, it's that guy who watched your stuff at the library.

So you could go to the bathroom, Allie Ward, and this is ologies.

And the lifeblood of the show is asking smart people, sometimes not smart questions.

So let's take a trip through your vascular system for phlebology, which you will learn in a few moments is not a good name for the episode because it does not totally encompass what this ologist does.

So we had to figure something else out.

And this guest is a vascular surgeon.

And from what I understand, that is a very difficult job.

And vascular surgeons have been called the surgeon's surgeon.

So if you're a surgeon who can impress surgeons, I'm going to want to come to your workplace and ask you all about it.

So this doctor is a clinical associate professor of vascular surgery at NYU Langone Hospital in Brooklyn, where she did her fellowship and residency after getting her MD from Boston University.

And has said that what inspired her was having grown up in Kenya, where she saw access to quality surgical care not readily accessible.

So helping people has always been important to her and she's very good at it.

So she's been on my list to help us learn about our circulation and we're going to get there in a minute.

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Okay, let's get into this episode.

Get your knitting, fire up the lawnmower, put your feet up for everything from vapin and vein health, why you can get a prescription for new socks, scary airplane blood clots, teenage movie tropes that are true, using science for cinema, how to tie a tourniquet in a pinch, spider veins, arterial health, atherosclerosis, stents, what is an aneurysm and how not to have one, COVID and clotting, and why your leg is asleep right now with NYU Langone, vascular surgeon, phlebologist, as well as surgical angiologist and general medical hero, Dr.

Sheila Blumberg.

You had an ice cream tone or you were doing karaoke.

Yeah.

If you were doing karaoke.

I do do karaoke.

Do you really?

I used to.

What's your attitude?

I have a good voice.

I would try to do Aretha Franklin

and tear the house down.

But the less I sing, the better.

The less I get good.

So I can't destroy her songs anymore.

I bet you're still so good at it.

If you could do Aretha Franklin one time, I feel like you're going to destroy it.

Sheila Blumberg, she, her, hers.

I've been wanting to talk to you for so long.

This is very exciting.

And would you say that lebitology, is there an analogy for this that you would phlebology?

Phlebology.

If that's specific for veins only, but then vascular also includes arteries.

So that would, I guess, arteriology, but that's why we just say peripheral vascular.

Okay, so vasculology has been used one time, but some countries refer to the study of blood vessels as angiology, meaning vessel in Greek.

But angiology sometimes deals with the lymphatic system, which we don't get into, and angiologists are not always surgeons like Dr.

Blumberg.

But since she is generously letting me ask her, a smart person, not smart questions, and giving us a lesson in all things blood vessels, we're going to go with that.

I mean, the first question I'm sure a lot of people don't know, including myself, veins, arteries, capillaries, what's going where?

Okay.

So those are all different sizes, first of all.

Okay.

Decides whether it's a vein or a capillary.

And then arteries are different pipes.

So they're all pipes.

Okay.

So I'm a fancy plumber.

And so arteries are the main way blood gets away from the heart.

Okay.

Those are the pipes that take blood away.

Veins bring blood back to the heart.

So arteries go away, A.

Veins, think V, Valentine heart.

And if the blood is leaving the heart, going away via artery, it's ready for the journey with a full tank of gas.

In this case, the gas is oxygen.

Now veins are heading back to the Valentine's heart on empty and they're returning home to the lungs for a resupply of oxygen and then into the heart and out through what are they going out through?

Arteries.

Nice, sexy.

Arteries carrying that oxygen-rich blood are typically bigger than veins.

Veins typically smaller.

Smaller still though?

Capillary bed is within the tissue and that's where veins and arteries meet and sort of form a web at a very microscopic level.

So we're talking microns And that's where the exchange of oxygen happens at the level of the tissue.

And so the arteries come into, let's say, your kidney and then go to the capillary bed, become smaller from arteries to arterioles and then capillaries.

And then the capillaries exchange into venules on the other end.

And then the venules become veins.

So the veins are the larger.

parts of things and that brings the blood back to the heart.

And so that's your circulatory system.

So arteries, arterioles, arterioles, capillaries, venules, and veins, they're all vessels or tubes that circulate blood.

Now, from biggest to smallest pipes, we got small venules branch toward the full-size veins as they come closer to your heart.

Veins have thinner walls, they're typically closer to the surface of the skin than arteries, and arteries are located deeper in the muscles, and arteries have thicker walls.

So, oxygenated blood leaves the heart via the arteries.

Artery literally means to keep air.

It's kind of like a train system that leads to major stops in the organs and the tissues of your body.

And then that goes down roads into smaller arterioles, which go into teeny capillaries, which are like little trails to the tissues.

And capillaries are around one-tenth the width of a human hair.

So tiny.

And while you're minding your own business, you're eating kettle corn, you casually have 40 billion capillaries.

You're magic.

Can you believe that?

40 billion?

You have that.

I hope you flirt using that fact.

Are there capillaries that are so small they're like single file in terms of blood cells?

How small do they get?

They have to be because at that level in order to exchange oxygen between the tissue, oxygen is just a molecule.

So it's got to be able to transfer itself across the bed of the cell layer to get to whichever organ it's perfusing.

So they're almost less than a cell layer thick at that level.

Yeah.

So extremely, extremely small.

Not visible to the human eye without

a microscope.

So it's been estimated that the human circulatory system would stretch out to be over 95,000 kilometers in order to pump more than 7,500 liters of your blood every day.

By the way, that's 60,000 miles and 2,000 gallons, America.

To exchange it that quickly, every second that we breathe.

and get blood through and the rate at which it's flowing, it has to happen just like that.

So it's miraculous in a way.

Do our veins and arteries, do they get less elastic or less robust?

Or

I guess hardening of the arteries is a situation.

Yeah.

What happens to us as we age?

Do we start off with amazing veins and arteries and then they get kind of shittier?

What happens?

Well, yes, I think the aging process, unfortunately for arteries, they tend to become harder.

And there's obviously lifestyle and environmental things that we can do to make that worse or at least better.

And so things like smoking and exposure to smoke and diabetes in general, those are the major factors in our environment and our lifestyle choices that end up hardening the arteries.

And so you get plaque formation and then calcium deposits.

And you can really see the calcium on imaging now, which they are doing more routinely for coronary arteries in the heart to see what level of disease you have.

You can scan and you can literally see the whiteness of the calcium that's deposited there.

So they get harder.

And that's not good because you want arteries and veins to function well when they're softer, more compliant, right?

So they can squeeze and open.

as the heart beats and relaxes.

The hardness, let's say, of the arteries is disease.

So that's unfortunate.

And a lot of that's not reversible once it happens.

Ouch.

What is the calcium deposits?

Where are those coming from?

They're coming from the bloodstream, essentially, right?

So most of it happens over time.

And the exposure to things like smoking, per se, makes that layer in between the inner layer and the outer layer thicker.

And so it essentially deposits in there, and the effect is calcification.

Yeah.

So I'm so sorry.

I'm sorry.

But smoking can swell those inner walls, choking the flow and making it easier to collect plaque, which contains cholesterol, cellular waste, clotting stuff called fibrin, and calcium that can cause atherosclerosis, which is a thickening or the hardening of the arteries.

But again, since this episode would have been easier to name phlebology, but phlebology is only about veins, let's get more into it.

What about veins and arteries?

Do they have different properties in terms of their structure?

Yeah, absolutely.

So veins, at any point in time, 75% of your blood is in your veins.

Oh, okay.

The 25% is your arteries.

So veins have to have a high capacitance.

They have to be able to hold that much volume at any amount of time.

So they're much more compliant.

They're much more relaxed.

And in order to get the blood back from your foot, right, back up to your heart, the way they do that is in a couple of mechanisms.

They have valves on the inside.

Arteries do not have valves.

Valves are kind of like gates.

They open, they let the blood go up, and they're supposed to shut tight so it doesn't drop back back down.

And so as blood goes up the column, it doesn't return distally.

Distilled, meaning back to the foot.

What else happens is when we breathe, that also changes the pressure gradient in the veins.

So that also moves the blood up.

So veins have to be compliant because part of their activity is by breathing.

So every time you breathe, you change the pressure in your chest.

That allows blood to come through and come up.

However, arteries.

So arteries are not based on that.

They're based on your heart, right?

Because that's where their blood's coming from.

So they have to be strong enough to take that pressure.

So like, for example, if you're exercising, right, and you're fairly young, your pressure can go up to 200 millimeters of mercury, right?

That's normal.

We're exerting ourselves.

And so arteries have to be tough enough to take that amount of blood pressure.

So they're much stronger vessels in general.

So they're thicker, more muscular.

And so every time the heart beats, beats, pumps blood through.

So they don't need valves or anything like that.

And in fact, valves would be a problem in the artery because they just got to get the blood down across to all of our organs, meeting a lot of resistance.

So the arteries have to be strong enough to do that.

And the heart provides that pumping action forward.

So very different.

And that upper number of your blood pressure is the force that your heart is beating that blood out or down to your organs.

And the bottom number represents the pressure when things relax in between the beats.

You don't faint at the sight of blood, I'm guessing.

No.

No.

And that's been from a young age.

So I'm in the right business.

When you were going through med school, was there a really big divide in terms of like who could deal with a lot of blood and who is like, you know what, I'm really going to be more of an outside doctor.

Or a radiologist or something.

No.

I think most people who go into medicine have a capacity to deal with injury and or blood.

So I don't think that's very common.

I've seen it in lay people who are not in the medical field so far.

But I think what sort of sorts people out is what kind of fluids they can tolerate.

So it's not just blood.

I think blood is pure, it's clean, it's sterile, it's red, it's pretty, I like red.

But some people, like phlegm, forget it.

Stool, forget it.

So, you know, there's some things that everyone can tolerate.

So I wouldn't do colorectal surgery because that's not for me and so I prefer blood and so I think that's what sorts people out is what fluid you can tolerate not necessarily an aversion to blood so much do you have to deal with that in your patients say if someone needs a blood draw I know for me I have to look away and I was getting a blood draw once and I looked away I just averted my eyes and I realized I was staring right into a reflective surface and so I accidentally was watching at the same time but I have fainted just cutting my finger and I don't know why it happens because I think my brain is like, you're going to die.

But do you see that in your patients at all?

Anyone just keeling over?

Oh, especially blood draws.

So even now, we have to be very good about making sure most people are seated just in case they do pass out.

They're already in a reclining position and we can sort of keep them safe from themselves.

But yeah, it does happen.

That's not uncommon, actually.

So we chatted with Dr.

Joy Reidenberg, who's a functional morphologist who does whale necropsies.

And the first time she witnessed a veterinary surgery, she was so excited.

But then she straight up fainted in the room with all these surgeons.

And she explained that she had what's called a vasovagal reaction, which is an autonomic discharge of your nervous system that no one can predict is going to happen.

And when that vagus nerve is stimulated, it causes a sudden drop in your heart rate.

And also maybe the dilation of blood vessels to your legs, which causes blood to pool there away from your brain, causing you to pass out.

And it can happen from standing too long or heat exposure, stress, the sight of blood in an anesthetized animal.

And in April of 2020, when the pandemic was very fresh and people were having things like hobbies, I tried whittling.

And within the first few minutes of attempting to craft a spoon, I cut my finger and I fainted into the kitchen sink.

So.

What about when you're watching movies and you see a pool of blood?

Are you ever like, that's not oxygenated?

That is too much for what they hit.

My commentary about movie blood is none of it looks really good.

Why is that?

I don't know what they use.

And I heard someone use paste of some sort.

I can't think of which movie had really good, maybe like Kill Bill.

Like Funti Tarantino has good blood, but the rest of them, and that's why I always like look at the characteristics of it.

And so I'm like, that's so fake like so you don't i don't particularly get gory about those kinds of things because it doesn't look realistic is it the viscosity or the color both okay yeah so the only thing that looks accurate most of the time is old dried blood like if it's an old crime scene that looks more realistic because it's congealed at that point right so i think the fresh blood of when they cut people and they're sort of like spurting i'm like really no i don't she's not wrong i researched this for way too long.

And according to a 2022 slash film article titled, Quentin Tarantino only wanted the best blood for Kill Bill Special Effects.

It says, it's really difficult to recreate blood digitally and Tarantino prefers practical, real-life goopy effects.

He also told a Time magazine reporter that, quote, I'm really particular about the blood.

So we're using a mixture depending on the scenes.

I don't want horror movie blood, all right?

I want samurai blood, he says.

You can't pour this raspberry pancake syrup on a sword and have it look good.

You have to have this special kind of blood that you only see in samurai movies.

Quote.

So that's his take on it.

And in yet another article, a 2015 Vulture Piece, there will be lots of blood.

One of his producers divulged that Tarantino films require a separate blood budget and blood of such a specific range of hues that no other filmmaker is allowed to use it.

And this range of bloods, plural, are under the label Tarantino Reds by the special effects effects house that furnishes his custom supply.

He has a custom blood supplier.

I hope this is a lesson.

People make art, make science, make stuff.

We're only here for a little bit.

Life is short.

Make stuff.

Also, I was having a discussion with my favorite cheesemonger today that French horror director Alexander Aha has superb blood, and I trust them.

But back to Tarantino.

Another one of his producers has described the director's blood use as different and balletic in the way that it moves and squirts and gushes.

Does that happen?

Because I always feel like you hear if you hit an artery, you're screwed.

Veins are less of a problem.

Is that true or is that complete nonsense?

Well that's to do with the pressure in the system.

So arteries are high pressure, right?

So when you cut an artery, the pressure at which it's coming out at you is high.

So you're going to lose more blood quickly.

Veins are low pressure systems.

So if you cut a vein and you bleed, it's going to be sort of a slow kind of ooze and more controllable.

And the second thing is because veins, like I told you, are very soft and compressible, you're more likely to be able to control it just with pressure alone.

You can cold pressure in arteries and get pretty decent control as well, but that becomes the other part of it, depending which part of the body it is.

You may not be able to compress it properly.

And that's why it can be more life-threatening, obviously, if you if you injure an arterial injury versus a venous injury.

Yeah.

So that's not flim flam.

It's not flim flam.

Okay, and remember, arteries tend to be deeper in the muscle, so they're harder to compress.

So imagine trying to stop the flow of a garden hose under a tarp, which is like a venous injury, versus crimping a fire hose under a mattress arterial.

Now, this is an exaggeration, but you get it.

What about your work?

What is a lot of your practice looking at?

What is the, what's your day like?

My day is, and this is why vascular surgery is injuring, it's varied.

I do a very large venous practice, so that's a lot of varicose veins and venous ulcers and those kinds of patients.

And then the other side of it with arterial disease, which is more sort of limb-threatening problems, right?

So you have peripheral arterial disease where they're not getting enough blood flow to their extremity, most commonly to the foot.

And this is why diabetics suffer from a lot of this.

And then obviously, like I mentioned, smokers as well.

And those patients who are at risk of limb loss, those are the ones who obviously I get involved in and try to revascularize them, try to improve the blood flow to that area.

For the venous patients, it's definitely not a limb-threatening problem, but it's definitely a lifestyle kind of issue, right?

Because people's legs do not function well if they have a lot of venous insufficiency where the veins and the valves have become destroyed for whatever reason.

We call them incompetent now and they're unable to get the blood out of the leg fast enough.

They can start off with things such as swelling to begin with and then progress to skin changes where they start darkening their skin because the blood's just pooling at the ankles.

And then the worst case scenario for a lot of those patients is getting skin ulcers at the ankle because their skin's been damaged over time.

So that is a spectrum of disease that we see in the venous space.

And each person's sort of treated a little bit differently with that.

So every day is a little bit.

different.

Every patient's a little bit different.

Every patient needs something a little different from the last patient.

And when it comes to surgery, if you're doing surgery, especially on an artery, which is high pressure, that I just learned that.

Are you having to clamp them off at either end?

How do you stop someone from just bleeding out if you cut into that thing?

Right.

So typically we have control.

So vascular surgeons, we love getting control of things.

So it's usually above and below where the hole is, regardless of where that is in the body.

And once you have control of it, you can actually take a beat and just repair what you need to.

And there's various ways to do that, whether or not it's patching it with a piece of vein of the patient.

You can use that.

You can take the vein as a graft and use that to replace the hole in the artery and or repair it just with sutures alone.

Put some stitches in it, and that should be enough to control it.

So as long as you can get control above and below the injury, most things can be fixed.

And then does blood find its way around other places?

Is it like a detour on the highway?

While you have it clamped down?

Yeah.

Yes, it can, depending on where the injury is.

So, for example, in the leg, commonly, if people get shot in the leg in trauma situations, and it happens to be in an artery in the thigh, which is a femoral artery, you can repair that.

There's another deep femoral artery that they can get blood supply around it, but you are having some time of ischemia.

There's some time you're not getting any blood flow, which is why the repair has to be somewhat expeditious because after,

you know, in the leg, it can probably tolerate at least four or five hours maybe of of ischemia before you start to get now death and muscle death and tissue death so that has to be taken into consideration for sure and ischemia is the term for not getting enough arterial blood because you've been shot in the leg in the femoral artery and thus not getting enough oxygen to those parts which can lead to very unhappy tissues and muscles

When you're doing surgery and they say, oh, we've got to get up to say a valve in the heart.

We're just going to pop into the femoral artery in your crotch.

I'm like, how do you get that far?

There's got to be twists and turns, right?

How do you do it?

How?

Well, thankfully, at least the first person who designed was a Sellinger technique of putting a...

needle and a wire and a catheter into a vessel.

That principle has been taken to make larger and bigger sheets and catheters and just devices basically that can transfer catheters and balloons and even valves directly into the heart.

So it's a straight shot because like I said, it's a pipe like any other pipe and you can go through the pipe with any sort of tool as long as it's a decent size and there's not a lot of clot or anything that would be obstructing.

That's medical advancement.

It's been probably one of the most remarkable things that we have done in the last 60 years or so is being able to do a lot of things minimally invasively because there's a Dirac route, so that's that's great.

The anatomy is consistent and well described.

So Swedish radiologist Sven Ivar Seldinger debuted this technique in 1953, which uses a hollow needle to get under the skin in which you can insert a thin wire as a guide through your blood plumbing, which then guides a catheter to quote previously unreachable vascular areas of the body.

And then you withdraw the guide wire.

What a revolution, right?

But no, he wasn't carried on people's shoulders through the town square.

No one threw confetti at him or gave him candy or named a day in his honor.

It wasn't until 30 years later that the field of angiography, which is mapping the circulatory system, gave him the credit that he deserved.

But still worth doing, even if it seems like people don't notice while you're alive.

But whatever your hobby or your passion, it doesn't have to involve vascular surgery, even though it's pretty tight.

It's so bonkers that that can even happen.

And when it comes to history and your history, how did of all of the winding, twisting roads one can take, how did you end up in this field?

I chose vascular surgery and it takes a while to become a vascular surgeon in terms of the route from medical school to surgery training.

At the time, seeing as I'm getting older now, there wasn't a direct route from medical school direct to vascular surgery.

So I actually did general surgery first, which is operating on every part of the body.

And then I while I was doing that, I had to make a decision about which specialty I was going to do within surgery so I think that part of my decision was based on the fact that vascular surgery is very delicate we deal with very also sick patients and the actual procedures themselves require sort of a very gentle hand which I think I have and I enjoy that delicacy of operating And also we have there's a lot of variety as well.

So like I said, one day I'll be doing veins, one day I'll be doing arteries.

And then I operate on various parts in the body, in the neck, in the leg, in the chest, in the abdomen.

So there's a lot of places where you have to be sort of facile with what's there and how to get to some areas because arteries and veins aren't just sitting waiting for you.

You got to find them.

And so that's always been very interesting to me.

And I just love that kind of surgery.

So that's how I ended up.

picking this specific specialty of all the other specialties.

And like I mentioned before, blood is a very nice looking fluid.

The other ones I don't have a lot of affinity for, so I was happy to pick vascular.

Does blood look different when it's leaving the heart versus when it's on its return trip?

Absolutely.

Yeah, when it leaves the heart, now it's been freshly oxygenated, so it's nice and bright red.

So arterial blood looks really red, like scarlet.

And then venous blood, when it's returning, is much darker because now it's quote-unquote deoxygenated.

There's not a lot of oxygen in it anymore.

And so it's darker, kind of violaceous, like a color that we can describe it.

So arterial oxygen-rich blood is bright red and venous blood is a little more purplish.

Arterial is the color of bright ketchup and venous blood looks a little more like a plum sauce or the color of raspberry jam.

I'm trying to make this appetizing.

So you can tell if you puncture a vein or puncture an artery sort of immediately in a healthy person, you can tell whether you're in an artery or a vein just by the quality of the blood you're looking at.

What about when we look at veins and they look blue from

they should, yeah.

Yeah, they should look blue.

Why are they looking blue?

Because the blood is dark now.

So they should look blue in a healthy vein.

That's its right color.

Yeah.

I remember hearing myths about that, that your blood is blue until it hits air.

I think they're probably referring to the oxygenation situation and the arteries being more red blood because it is oxygenated blood.

Yeah.

I mean, I heard all kinds of stuff when I was a kid.

I mean, I think we thought unicorns were real.

So, So, you know what I mean?

So I'm kind of.

And what happens when you blush or when you're embarrassed or when you get hives?

Is that blood just flooding capillaries?

Yeah, capillaries and very small arteries and veins in the face, really.

And they just dilate.

So it's a parasympathetic response and a sympathetic response.

And you get...

huge vasodilation and then it bursts and then it goes away.

So it's kind of like a big flash.

It's mysterious, really, why it's so specific to certain areas that we still don't understand.

I did find a 2020 paper titled, The Unique Contribution of Blushing to the Development of Social Anxiety Disorder Symptoms, results from a longitudinal study, the methodology of which involved making kids perform a song in front of a parent and a stranger, and then watching themselves back on video before a researcher aimed an infrared temperature gauge at their cheeks to determine if they would be prone to later developing what's known as sad social anxiety disorder.

Why blushing happens, I don't know, but what's valuable about this study is that it will be cited often in those kids' future therapy appointments.

Someone's making money off that.

Do you ever think about that stuff?

Are you aware of your own blood day to day?

No, thank God.

Like, I don't, I don't.

I don't really think about it that much, quite frankly, at least on my own day to day.

What I do think about is Venus health in in a way not necessarily the blood itself but for example like I wear compression stockings at work because I don't want to have swollen feet etc because it's more common in jobs where you're standing all the time

the second I knew about that in residency I started wearing them like right away I was like this is important and I feel like most more people should know that if they're in jobs where they stand all the time or when you get pregnant you should wear compression stockings as much as you can.

Yeah.

What about on airplanes?

Absolutely.

Yeah.

What's going on with that?

So the gravity, which is sitting down with your legs that way, and then the pressure changes in the air are more likely to make blood pool at the ankle and you get swollen, especially for long flights.

It's a game changer.

So I tell everybody who listened to me to wear them on the plane all the time.

But I think that's caught on.

I feel like a lot of people are doing that now.

You know, I have a friend who's a doctor who's also at NYU, Mike Natter, who got me a pair of compression socks.

Yeah.

And I should have packed it for my flight.

But what about varicose veins?

You said that you work on that.

Yeah.

How do those happen and

are we treating them, we, as if I help, treating them with lasers more?

Do you have to go in there and pluck them out?

Yeah.

So I think that's another part in which we've had a lot of advancements for the last 30 years.

So varicose veins.

And you'll hear a lot of terms used to describe it, like venous insufficiency, venous incompetence, varicose veins.

But ultimately, what it means is that part of the venous system is not doing its job correctly.

And this is all in the lower extremity for the most part.

So in the lower extremity, you have two systems of veins, two main ones.

You have the deep veins, which live in the muscle.

That's why we call them deep, because they're in the muscle layer.

And those are the most important veins.

They do about 90 plus percent of the work of getting the blood from your foot.

back up to your heart.

They also have a secondary system of veins, which is a superficial vein.

So the reason they're called superficial is because they're above the muscular layer and they're just surrounded by our skin and fat.

But it's connected to the deep system.

We call the connections between them sort of perforators.

And together, they're supposed to transfer the blood from your foot back up to your heart.

What happens to a lot of people over time, about probably 20 million people in this country suffer from this, the superficial system becomes incompetent.

And what that means is the valves in the inside of the superficial veins stop closing tight.

So these are the gates that I described that open, shut to let the blood go up.

They become incompetent.

They become weak so they don't close as much as it's supposed to.

And so blood takes longer to get out of that superficial vein.

So what happens if there are venous blood traffic jams because the gates and the valves went wonky and they can't merge from the superficial veins to the deeper ones and then back to the heart for more oxygen?

What happens?

Over time, your body's way of dealing with sort of, we call it this venous hypertension in the leg is to make varicose veins.

So you'll see these large sort of bulging little varicosities that come out of there.

They're not supposed to be there.

Your body made them to deal with the pressure in the system.

And so that's a sign that you have, quote-unquote, venous disease, right?

And the treatment pretty much for thousands of years is you get rid of it somehow.

Olden times, they used to have to strip it, right?

Which is basically make incisions in the groin and lower leg and then remove the vein entirely and that would be it what's my other option and then now thankfully we have lasers which is what you were describing before which essentially do the same thing but they do it through a catheter again like i told you a needle wire catheter through there and then seals the vein from the inside which essentially shuts it down so the technology is a lot better now and that's kind of like an outpatient in the office procedure takes half an hour patients do well we check on them probably a week later, and they can return back to work the next day.

So it's very, it's ambulatory, and their legs improve pretty remarkably, quite quickly.

So it's very rewarding.

And this is the part I was talking about.

It's in terms of lifestyle.

They're able to walk further, do whatever they need to do, less likely to get wounds in the future.

But their data about that is still soft because we don't really follow them for 40 years to see what they're going to look like, unfortunately.

But that's something that I think intuitively makes sense.

Are varicose veins just a cosmetic concern or are those a concern in terms of your actual vein health that like if you're making extra veins, you've got some issues down there we should solve anyway.

Yeah, so I think there's two camps about that.

There's certain patients who will start off with just varicose veins and may just stay like that for the next 40 years.

Okay.

They'll have probably some like swelling, some heaviness, fatigue, and they can tolerate that.

There's some patients who will start off with varicose veins and they'll end up, and I'll see them in their 60s and say, you know, know, this started when I was 30 and they told me it was just cosmetic and now they have horrible wounds and all sorts of problems.

And so the question is, had we started to treat them in their 30s, would they have been this miserable in their 60s?

And I think that I fall into that second camp of trying to make sure that their veins are as healthy as they can be throughout their lifetime.

So it's really a conversation with the person that you're treating about what it is.

that they're trying to accomplish, what their life goals are, what their functional status is, what they want to be able to do.

And that becomes more important to me than the other parts of it.

Do compression socks help your veins with that too?

So I think having compression is an assistive device, right?

Because it creates a higher pressure at the ankle so that the blood doesn't pull there.

So even if you do have vein problems, that will help at least boost some of the flow out of the leg.

So yes, I think that they're important.

I wear them, like I told you, even though I don't have anus disease, because I just want to make sure that they're as healthy as they can be.

What about crossing your legs?

Not bad, actually.

It's bad for your hips, and apparently I have to stop doing that.

I do it all the time.

I'm doing it right now.

Yeah.

And the compressing blood flow.

No, what that will do is mostly muscular and then nerve.

It can pinch your nerve in your popatial fossa, and that can cause, you know, when you've crossed for too long and you feel like your foot's numb and you can't feel it, that kind of thing.

But not, the blood flow will still be, it was fine.

So your foot fall asleep is not usually a blood issue, but it's a a neurological one.

The nerve.

And you mentioned deep veins, deep vein thrombosis.

Yeah.

I feel terrified of it.

I have a friend who went through it recently as well.

And luckily she's on the men, but has to be on blood thinners.

So when we hear about blood clots versus deep vein thrombosis, what's going on in there?

Yeah.

Deep vein thrombosis is the part of venous disease that can be life-threatening because a not insignificant number of people, around 600,000 people, die a year from a deep vein thrombosis.

And the reason they die isn't from the clot itself, it's from the clot traveling to their heart because, like I said, it's connected.

And then once it goes into the heart and then into the lung arteries, it's called a pulmonary embolus.

And that can kill you because if their heart has obstructed flow and it can't get blood out, you get a heart attack and then they die.

And it's a cause of sudden death.

And heads up.

So DVT or deep vein thrombosis happens when a blood clot or a delightfully named thrombus forms in the deeper veins and usually a leg, like at the side of those valves or gates.

And symptoms can include swelling, pain, fluid retention, some discoloration, and even fever.

Now if you have DVT, a doctor may put you on blood thinners to prevent that clot from detaching and just going on a walkabout to places you don't want it, like the lungs or the heart or your brain.

As for COVID and clotting, a 2023 study, Risk of Thrombosis During and After SARS-CoV-2 infection, pathogenesis, diagnostic approach and management in the journal Hematology Reports says that coronavirus disease, COVID-19, increases the risk of thromboembolytic events, especially in patients with severe infections requiring intensive care and cardiorespiratory support, and that COVID-19 patients with thromboembolitic complications have a higher risk of death.

And if they survive, these complications are expected to negatively affect these patients' quality of life.

So COVID increases the risk of blood clots.

And the worse your case of it, the more at risk you are for that.

It also says that recent data show that the risk of thromboembolism remains high months after the infection.

Now, why is this happening?

And there was another study, a 2023 study, SARS-CoV-infection triggers pro-atherogenic inflammatory responses in human coronary vessels in the journal Nature, and it presented data that established that SARS-CoV-2 infects coronary vessels, inducing plaque inflammation that could trigger acute cardiovascular complications and increase the long-term cardiovascular risk.

So COVID ups your chance of clots and data show that it can infect coronary vessels.

So how do you not get blood clots and thrombosis?

It's never a bad idea to avoid getting COVID.

Remember to get your boosters.

Don't be afraid to mask up because a blood clot is scarier than a weird look from a stranger, in my opinion and experience.

But other ways in general to prevent blood clots and deep vein thrombosis are to keep it moving, move your bod if you have the option.

So I think it's important for people to know about it and the ways to prevent it really are minimal.

A lot of it can happen in a hospitalized setting where you're immobilized for a long time or you've had orthopedic surgery, et cetera.

This is where compression becomes important.

Moving is important.

Also, if you have had a surgery or you have a family history of blood clots, then you may need to be on blood thinners to prevent that from happening.

But it is something that is a serious problem, right?

And can happen in an unrecognized fashion.

It's still rare.

We'll say that, like most people aren't going to have it.

Like I said, 20 male people have superficial vein disease, but not a lot of people get DVTs in general.

But that's something that should be recognized more, I think, in general in public health, because the people who tend to do worse from it tend to be minorities, underrepresented minorities specifically, especially after childbirth and women.

That's something that we've seen.

I think even Serena Williams had one and had a second one, I think, at her second pregnancy, and that wasn't recognized, but she knew what was happening, and she had to tell the doctors, this happened to me last time.

And so that's how when they recognized it and treated her appropriately.

So it is something that should be announced widely.

People should be concerned about.

What do you look for?

Dr.

Blumberg explains.

Typically, it will start with some swelling and pain in the leg.

And it's usually not both legs.

It's usually just one leg that's asymmetrically, for some reason, feels swollen.

It's more painful.

They should get checked out.

This is a very simple test to look for it.

It's an ultrasound that's cheap, effective, and highly diagnostic for that if you get it.

Do you find that, especially with people who are going through childbirth or is it a fact of certain people just not being listened to or more predisposed or I imagine a combination of both?

I think a combination of both.

There are people who are hypercoagulable, right?

That's what we call them.

They're blood clots for some reason.

Pregnancy by itself is a hypercoagulable state.

So women who are pregnant can form more clots because that's kind of the coagulation pathway of carrying a child.

So there's a heightened risk and assessment in those patients and OBGONs, I think, are very cognizant of that and do a good job of that.

I think in our medical community, there are people whose pain and or concerns aren't addressed as they should be.

And I think that's hopefully changing, especially as the workforce that takes care of them changes, right?

So if you're more aware.

that this happens to minorities and there are certain minority doctors, that helps to move that that forward and so I think that's improving but it has been an issue historically.

When it comes to getting the word out about fetus health too and arterial health what are things that you wish people knew before something becomes a problem?

Yeah so I think we'll start with arterial disease first.

I'll say simply smoking is bad.

It's always been bad.

It's going to continue to be bad.

And I don't think, and I know that now New York State has ads about people losing their fingers and their toes to in their quit smoking campaigns.

And that's important because they've previously never addressed the fact that that's actually a risk factor of smoking.

So I think that's the one thing.

If you can just not start smoking, because it's extremely hard to quit, and we talk to patients about this all the time, don't do that.

The second thing is diabetes.

That's still today, now is the number one cause of amputations in this country after trauma.

So if you're not an accident where you lose your leg, diabetes is the number one cause of you losing your limb in this country.

And that's a big problem.

So diabetes control, which also stems now from obesity.

So we've mentioned this in previous episodes as recently as last week, but some people object to the word obesity to refer to certain body compositions that could potentially impact health negatively.

But it is the current medical terminology that doctors use.

And while some doctors have overlooked actual causation of illnesses by wrongfully blaming body composition, most, like Dr.

Blumberg, are relying on years of research to keep us all living longer and healthier with fewer complications.

So it all starts there.

So those are the things.

So health and wellness.

I'm sort of an end-stage doctor.

By the time you get to me, a lot of things have happened along the way that hopefully could have been reversed.

So I think weight control, obesity management, diabetes management, smoking, those are sort of the pillars of arterial health and also venous health because we'll now switch to veins.

Remember, veins return blood to your valentine heart.

Function of veins is dependent on returning flow from a foot up to the heart.

Weight plays a big role in that.

If you're overweight, that's just a harder job for your veins to do.

And that contributes to the development of the disease and also the outcomes after you start treating the disease.

It's not just lasering everything, right?

Those are the things I wish people knew beforehand, and then also wearing compression socks, if you stand for too long at any job, because I see a lot of people, mostly women who did factory jobs, machinists, nurses, doctors, and they're all like, yeah, my legs have been killing me for years.

And I think we used to have a fair once a year at NYU where we would just give out compression socks and you could sign scripts for people just so that the workforce could have it because we knew that this is this is the thing.

So that's important, I think.

You mentioned smoking too.

And I have been in New York for just this past week and I'm from California and I have walked through absolute fogs of weed and I feel like more people smoke not just cigarettes, but just in general.

People who don't smoke cigarettes are maybe smoking more weed and vaping.

Do those have any impact on your venous health?

You ready for this?

Yeah, I think the data on vaping is that it's pretty much as bad as tobacco.

And also the particulates in vaping may actually be worse, at least for lungs in general, but that's a different ballgame altogether.

The marijuana smoke and the legalization of marijuana has actually opened up a huge can of worms, I think, for people regarding public health because you'll have conversations where people think it's natural.

Me and Mother Nature.

And therefore, it's not going to harm them.

We don't have enough data on long-term use of marijuana and how that affects the RTO system.

I can say our suspicions from the early reports now are that it's quite damaging to your circulatory system.

And unfortunately, with the widespread use, I think we're going to start seeing that in younger people who are consuming it at these high rates.

And that's a big concern to me because I think this concept of it's a plant.

And if I smoke it, it's not tobacco, so it's not going to hurt me is a problem there's other things that are natural that occur in a plant well it's just heroin comes from a flower that's not necessarily good for you now that it's legal it can actually be studied right and the natural population natural studies will start to come out and I'm not optimistic that it's going to be good news so let's stick to gummies maybe yeah

if you need it yeah okay smoking weed definitely not without its bodily consequences from a vascular biology standpoint.

Sorry to say.

And for more on this, you can see the 2019 paper, Harmful Effects of Smoking Cannabis, a Cerebrovascular, a Neurological Perspective.

And also, news came out in 2022 that if you're an adult who has a bleeding stroke and you have enjoyed the gancha in the last month, you're twice as likely to die or have serious injury from that stroke.

But it's really hard to determine what's caused by the smoking or the vaping factor, right?

So I did this deep dive on edibles and you don't want to hear this.

Neither do I, but I have a responsibility to tell us that a 2019 Annals of Internal Medicine paper, Acute Illness Associated with Cannabis Use by Route of Exposure, did find that according to the Colorado Behavioral Risk Factor Surveillance System, about half of THC users just smoke and about 4% just do edibles.

And the rest are kind of a combo of both.

But edible cannabis did account for more ER visits for acute psychiatric symptoms.

So don't let your mom eat the whole brownie.

And visits for cardiovascular symptoms.

So that's concerning.

Does it have to do with all the snacks you like to eat when you're cooked?

Jury's still very much out.

And more research needs to be done.

And doctors and scientists still need more questions answered.

As do you.

Can I ask you a couple questions from listeners?

Do we, is your heart out nine?

Just checking.

No, we also have time.

Okay.

No.

Okay, sweet.

So let's lob your questions to her about bruises, cold feet, why you should get an ottoman, how to make a phlebotomist's day, barbers, gossip about royal families, and much more.

But first, let's toss some money down the pipes to a good cause.

And this week, Dr.

Blumberg selected Breaking Ground, which enables people to forever escape the trauma of homelessness.

And their wraparound services include benefits assistance, primary medical care, mental health care, substance use referrals, and skills building to help each person get and stay on the path to permanent security.

And each year, Breaking Ground serves more than 10,000 vulnerable New Yorkers.

And to find out more about Breaking Ground, head to breakingground.org.

And that donation in honor of Dr.

Sheila Blumberg was made possible by sponsors of the show.

Okay, finally, finally, we put out episodes about OCD.

And by now, you know, OCD is not just about liking things organized or liking things in color order.

It is a serious, it's a highly misunderstood condition.

It can show up in so many sneaky ways.

In the episode, we talk about how OCD can be managed and treated with the right kind of therapy, which is why I want to talk about no CD.

So with with the right kind of help, a specialized therapist who gets what you're experiencing, it's trained to treat it, OCD can become so much more manageable.

At No CD, every therapist deeply understands OCD.

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Putting out the OCD episodes were really important for me because a few years ago I was diagnosed with it after years of thinking it was just anxiety and getting the right therapy has helped so much.

And it's been really heartening to hear how much these episodes have already helped people with OCD and people who know others who are suffering from it.

So if you're ready to start getting help from therapists who truly understands OCD, visit nocd.com to book a free call.

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This first topic was a curiosity of patrons, Sheepin, Perry Wilson, who just got their first old lady bruise, the very clumsy Atticus Atlas, Etta Rose, First Timer, Madeline Ash, Key Lime Pye Clark Bennett, Mouse Paxton, Vanessa Adams, Mark Rubin, Anna Dillon, Olivia, Anna Thompson, Barb Miller, Greg Lewis, Audrey Hudak, and Valbi Listenen.

Yeah.

A lot of them.

Want to know.

Audrey Hudak asked, bruises.

What are they exactly?

Why do some people, in Sheepin's words, why do I bruise so badly?

Is it because I'm vampirically pale?

Perry Wilson said, I just got my first old lady bruise with broken capillaries.

What is happening with bruising?

So bruising is at the very superficial level at the skin where the, I guess we can say, capillaries slash veins burst just from injury, right?

So it's very localized.

You're obviously going to see it more if you're pale.

Some people are more prone to bruising because they have either some platelet dysfunction where they don't clot fast enough.

Because if they're able to clot fast enough, it shouldn't bruise as much or it shouldn't have as much spread of blood in that area.

And so people who are prone to easy bruising, they should just have a simple blood test just to make sure they don't have an issue with cloning clotting disorder or bleeding disorder.

Other factors that can cause easy bruising are taking medications like ibuprofen or Advil, naproxen like a leave, blood thinners, antidepressants, and antibiotics.

Now another cause of easy bruising is not having died yet.

And as we continue to age, our skin gets thinner and has less cushion for that blood tubin we've got.

And I asked the Mayo Clinic how not to have purple legs and it offered the following solutions.

Use good lighting in your home.

Have your vision tested.

Arrange furniture and electrical cords so that they're not in your way when you walk.

Avoid clutter.

So doctors say lovingly, either check your meds or get your shit together.

I was getting a ton of bruises and then I realized it was because I was eating too many baby aspirin.

I'd get a headache and be like, ooh, baby aspirin is delicious.

And then I was like, you chilling.

Have one more.

And then I thought I had leukemia.

Turned out I was just eating too many.

What about circulation?

So many people wanted to know, why are my hands and feet so cold?

Diana Burchess, Rosalind Hesby, Bennett Venderbosch, Anastasia Press, Mary, Anne Sienna, Rick T., Kyla Frett, Jackie Chi.

Is it poor circulation or is that just a myth, Dr.

Casey asks.

So the cold hands, cold feet.

There's some people who have perfect circulation.

and have cold hands and cold feet and they'll come in and there's not much we can do for them because there's no blockages right there are some people who have a phenomenon called renaults where essentially they spasm they're very very tiny arteries in their hands, and especially it gets worse in the winter time.

What we recommend is just warming for those kinds of people because it's usually related to underlying rheumatologic problems that they may also have.

So with Renodes, your blood vessels may kind of slam shut.

And my friend Mackenzie has this, and a few of her fingers can just suddenly turn white.

I think it looks cool.

But as an equestrian who's outside a lot, she's got to keep those fingies warm.

But if you start to notice that you're just developing cold hands or feet and you haven't just moved to Canada, it could indicate a new issue like peripheral artery disease, which is when plaques form in the arteries of your limbs, or something like an autoimmune disease like lupus or rheumatoid arthritis, or maybe a thyroid issue.

And yes, we do have an episode on thyroids coming up.

Also, in terms of chickening out on something, the origin of the phrase cold feet is hotly debated.

But in 2005, Slate published the article, When Did We Get Cold Feet?

The Germans had them first, which is accusatory, but it traces the popularization back to German soldiers' apprehensions in getting killed in World War I.

They were like, I can't get out of this trench.

My feet are too cold.

But centuries earlier, an Italian proverb involved being cold in the feet to mean being shoeless, to mean being broke, which then meant that a gambler was too belly up.

So they backed out of a bet, which if you're broke, backing out sounds like a great idea.

Like 10 out of 10 would bail ASAP.

But if your actual feet and hands and nose are cold and it's been like this for a while, that's kind of your brand.

Docs say that it's healthy for your body to say, hey, I'm cold.

I'm just going to hoard more blood in our organs, if that's cool, because you can't put a beanie on your liver, babies.

It's very, very rarely a limb-threatening or digit-threatening problem, but there are some people who just have peripherally cold hands and cold feet.

And my daughter is one of them.

There's nothing to do about it.

So it's she's not like, mom, fix it.

Yeah, yeah.

She's like freezing hands the day she was born.

So pockets.

Yeah.

A few people, Bjorn Fredberg, Miranda Panda, Sadie Vipand, wanted to ask about hemophilia.

What is it?

What is it in Bjorn's words that hinders the blood from clotting or

lack thereof?

Yeah, that's taking me back to sort of med school.

That's more in the hematologic sort of realm as opposed to circulation.

genetically inherited at least the most famous one is from mothers to sons sons because it's on the X chromosome so it tends to be more profound in boys because at least girls have two X's whereas boy has one X and one Y so if they tend to present in boys because they're the ones who will manifest it whereas the girls will have protection from the second X and those are the ones who can't make that factor and then they they bleed and I think one of the czars sons had it, Nicholas, back in the Russian Revolution, and he was basically contained in a bubble as long as he could until the revolution and they killed his whole family and his well.

But yeah, and that was passed from, I think, the Tsarina's line with families.

But yeah, so it's a coagulation pathway problem where one of the factors is missing.

And

those are still quite rare in hemophiliacs.

Okay, so this side quest of info dumping kind of warrants its own three-part episode.

So I'm just going to give you some broad strokes, if you will, and move on.

So there was this mysterious blood and bleeding disease among European royal families, and it all traced back to a blood disorder transmitted to various European royals by Queen Victoria, who also went by the title, Her Majesty Victoria, by the grace of God of the United Kingdom of Great Britain and Ireland, Queen, Defender of the Faith, Empress of India.

And yes, one of her descendants among royals was Alexei, the great-grandson of Queen Victoria.

And he was a chunk of a baby, 11 pounds of butterball baby.

But he had this royal disease, It was found out when his umbilical cord bled for hours and hours.

His royal family was freaked out, but they didn't disclose his health problems to the public.

Now, over the course of his childhood, he nearly bled out externally or internally from events as slight as a bump to the leg or a nosebleed.

And there was this peasant monk who came along named Rasputin, and he was said to have the powers to cure Alexei by just pushing aside doctor's care and healing him through hypnosis and spells and just Riz in general.

But medical historians are now like, it may have just helped that he told the doctors to stop giving him aspirin because the aspirin thinned his blood.

Also, placebos, they don't not work.

Science knows that.

But sadly, Alexei's fate was sealed by execution in a cellar at age 13 during the February Revolution in 1917.

Now, the family's remains were discovered 90 years later.

And finally, in 2009, the paper Genotype Analysis Identifies the Cause of the Royal Disease revealed that the royal disease was hemophilia B, a blood clotting disorder, which can be carried by females but can manifest in male descendants, or it can just arise spontaneously in a family line, especially by mutations resulting from older dads' spermies.

But speaking of history and shady medical treatments, I do want to let you know that yes, bloodletting was a thing up until like the 1700s.

And back in the day, barbers, they were the only ones with sharp tools in town.

So they were tasked with all kinds of things like opening veins up and extracting teeth, applying leeches and setting bone fractures.

They were the original med spas.

Barbershop surgeons also cut hair and stuff.

And that striped barber pole that you see outside modern day establishments.

So legend has it that it descended from the shape of a basin of leeches at the top and the stick that patients would grip to encourage the little suckers to do their business faster.

Now, others say that the red stripes are reminiscent of stained bloody strips of gauze.

They would hang outside to dry.

Either way, next time you have any medical procedure done, be glad that you're not surrounded by stray beard hairs and a weirdo with a leech and that you have a nice person in a clean lab coat in front of you.

When it comes to drawing blood.

Yeah.

People asked, Bulky Keeple says, when I'm getting blood drawn, I'm always told I have good veins.

What does that actually mean?

Bart Miller asked, why do phlebotomists always have a hard time finding my veins?

When it comes to bloodletting, why do some people don't do as well as others?

Well, we're hopefully we're not bloodletting anybody anymore.

Drawing blood, if you have good veins, it basically means that you've made everyone's job easier because you're plump veins and hydrated.

And there's some, when you put the tourniquet up in order to see the veins, when they're drawing blood, some people become more prominent than others depends on the state of hydration sometimes if they dehydrate etc

and their veins are not visible or you can't touch them you can't feel them when you touch them that makes it more challenging so people who have more prominent veins who may have you know probably thinner arms etc may be easier for us to to get blood from There's some people who, for whatever reason, and it's usually most difficult in hospitalized patients who've had multiple blood draws or who need blood repeatedly.

At some point the vein's been touched and injured too many times that it can't be accessed we call them quote-unquote tough sticks like we can't find a good vein

in there right and most of those people you want to try to find places where the skin is kind of the thinnest so that's why a lot of people end up getting blood drawn in the not armpit but here in the elbow pit in the elbow pit where your anticubital fossa is what we call it because it's probably the thinnest place where the veins come up to the skin at a level which most people can access.

So you could make a phlebotomist day by hydrating a bottle.

If you're able to, because sometimes they make you either fast for a blood test or something like that, depending on what it is.

But ideally,

chug a bunch of water beforehand.

If you know you're a tough stick, that will help.

I just love the idea of behind the scenes.

Someone's saying, oh, yeah, room 14.

It's tough stick, man.

Tough stick.

What about rolling veins?

A ton of people asked about, Gabrielle Heiss asked, said fantastic about the topic.

Excited for the topic.

Why are some veins rollier?

I've never heard the term roly veins.

Also on the minds of Kay Lucas, Gabrielle Heiss, Deth Nell Kieran, Nehemiah Miles, Miranda Panda, and first-time question asker Bethany Schulz, who has rolly veins.

And after seeing them via a nurse using a laser vein finder, asked, why hasn't the goth clothing industry capitalized on vein pattern arm sleeved?

Asking as a goth scientist, Bethany says.

Bethany, you're living in the future, but you still have roly veins.

What's up with that?

I think that's more common in a way in very thin people because if you have less fat surrounding the vein, when you try to come after it, it just moves along the skin.

And you'll see it.

And it's like, oh gosh.

So you have to kind of stabilize it a little bit as you're trying to access it.

You got to chase them, kind of, going side to side.

You have to kind of

anticipate where it's going to go next and find it there.

That's how I do it when the veins are rolling.

Sean Thomas Kane and R.P.

Bergman wanted to know in Sean's words, is there a scientifically proven best practice for stopping nosebleeds?

Is that a vein?

Is that an artery?

I mean, everything at some point is a vein or artery.

But if you're having a nosebleed periodically, I mean, it's now head down and compress it.

Even with like a tampon, actually, in the nose, and just let it hold pressure and it'll stop.

But don't do this.

Don't put the head back.

You don't want to swallow the blood into your mouth.

So head down.

Head down.

And put some tampons in it, in one nostril.

Or if not, a cotton ball, something that you can actually pull out easily.

You don't want to get anything stuck there either.

Head down.

That's new information to me.

Non-menstruating people, keep a tampon in the glove box.

You never know who, you never know what hole might need it.

Now, this one was on the minds and in the bodies of patrons Storm, Addie Capello, First Timer, Jasmine Psy, and Maureen Flood, which is a great name for a blood episode.

Collapsed veins.

People have asked when they've donated blood, a vein collapsed.

Does that have to do with the musculature?

I think when they tell you your vein has collapsed, it basically,

for whatever reason, at the point at which they've drawn blood, it's just kind of spasmed.

Okay, so that's usually temporary.

So don't freak out if your vein collapsed.

No, it's still there.

If you're in vein collapse, that's terrifying.

And you're like, I need that.

Yeah.

Okay.

It's still there.

It'll be back.

It just needs a break.

It's had enough.

Just give me a minute.

Carlos De La Rosa and the Severinos asked about chemotherapy and vascular health.

Is there a way to recover or heal the veins from the back of your hands or anything during chemotherapy that you would recommend?

So chemotherapy is tough because it really does destroy the cells within the lining of the veins just because of the nature of the drugs that are going through, which is why they prefer to put it sort of directly through a port as opposed to peripherally although sometimes now they are using the veins in the arms directly for chemotherapy.

Unfortunately, we don't have good reversal for that once that happens to it or protection for that.

Where does the port go?

It goes in the, depending on where they, either the subclavian vein, which is up here by the clavicle, or in the neck IJ, the internal jugular vein.

And then the port sits at the chest level here because it's a clean area, less likely to get infected.

and they can then access it repeatedly, especially if you need multiple rounds, as opposed to trying to access a vein multiple times in the hand.

Like we said, it can collapse, it can spasm, and then just tolerating the toxic chemicals, it's kind of easier because here's a direct shot into the heart, so they get the medication sort of straight centrally and then that gets distributed throughout the body.

And you mentioned the jugular vein, which is the scariest sounding vein in the body, just because it's like, oh, going for the jugular.

Why is that jugular so important?

I think the jugular vein has sort of been mythologized as like the one that will murder you if somebody cuts you.

But I think what people forget is what was causing death wasn't the jugular vein.

It was the carotid artery that was next to it.

Okay.

So when, you know, for example, in Crunchy Tarantina, when they cut somebody's neck and all that blood and everyone's like, oh, it's the jugular vein.

That's the carotid artery that's been injured.

So the jugular vein is famous, but it's not really earned its place in our mythology.

But I think it's mostly carotid injuries are the ones that are the life-threatening, scary things as opposed to the jugular vein.

So we've been lied to.

And in case if it ever comes up over dinner, maybe with extended family, someone mentions a stent, no one else knows what that is, you now are about to know that stents are these little mesh tubes that vascular surgeons might use to open up a blocked or collapsed vein.

And they can be made out of metal or biodegradable materials.

They can have medication embedded in them.

Although the metal stents can become overgrown with scar tissue, which is why there are some newer options.

So I hope that answers some stent questions.

Brooke Dombroski, Amber McIntyre, and Mark Hewlett.

Now, patron Rebecca Fitchett issued a command, a polite command.

Please talk about aneurysms.

And that was echoed by Kelly Shaver and Stephanie McKechni.

And the quick FYI is that an aneurysm, it means dilation in Greek, and it's when a blood vessel, like a vein or an artery, weakens or bulges outward, like a little balloon.

And that can cause symptoms, especially neurological ones, if it presses on structures in the brain and can even lead to strokes or insufficient blood supply to parts of the body.

So managing high blood pressure can prevent aneurysms because then the pressure inside the veins is lower and it pushes outward less.

And Stephanie, I hope your dad's okay.

And everyone else, I hope this helps you understand episodes of Gray's Anatomy.

Now, most most of my familiarity with the term aneurysm is from movies like in the 90s where someone has a house party and they're like, well, my mom sees this carpet, she's going to have an aneurysm or something.

And I thought, that's kind of insensitive.

But it turns out that yes, a sudden burst of anger or physical strain or untreated high blood pressure or just ongoing stress can cause an aneurysm or an existing one to rupture.

So please chill for your own survival.

And now other patrons, Jackie G, first timer Sean Cavanaugh, Haley Kirby, and EDM asked about vascular surgery in general.

Like,

what, when you're going in there as a surgeon and you're working on veins and arteries, how are you sewing them up?

Is it the tiniest thread you've ever seen?

Or are there glues?

What's happening?

It's sutures.

They're pretty small.

We grade them on most sutures in a level of zero to like 14 and the 14 being very tiny, tiny, almost less than even a hair, quite frankly.

But we use microscopes, so we have loops to magnify what we're doing.

But it does need to be a fine suture, which is why I was telling you about the delicacy of it, which is why I like it.

Do you do crafts as well?

I used to knit a lot when I was younger, and now I don't do anything fun like that.

Like the enough embroidery at work.

Yeah, sure.

Knitting and crocheting were my go-tos when I was younger.

Can you not drink coffee before a surgery like that?

No, I drink coffee.

And your hands don't shake.

Yeah.

Okay.

I'm good.

Some Some people had to stop.

Apparently, when I get older, I might have to stop, but for now, it's so good.

Steady hands.

You mentioned tourniquets earlier.

My husband is a big safety nerd and has like a tourniquet on him in his fanny packet all the time.

Oh my gosh.

He took like a stop the bleed course just in case.

Good for him.

Go figure.

Yeah.

I guess CPR is next.

We should both probably know CPR.

But when tying a tourniquet, what's the protocol?

So the tourniquets that are available now have their own.

Each can be a little bit different,

right?

But depending on where you're putting it, you're going to go above the injury, right?

So if it's in the calf, you want to go in the thigh.

If it's in the lower leg, then you want to go upper in the thigh.

And when you place it, you have to try to turn the tourniquet so that it's tight enough that it's occlusive.

And the point is once you see that the bleeding has stopped, right?

That's the perfect point at which you can stop sort of turning the tourniquet.

Because that's usually just a life-saving measure that should be, you know, limited time, right?

Because anytime the tourniquet's up, you have to start counting down the extremity that you're treating, whether it's the arm or the leg, is not getting any blood flow.

So, once it's up, you start the clock on the tourniquet.

I think that's the important part people forget because once you stop the bleeding, you will stop blood flow.

And then, depending on the situation, I don't want lay people getting too crazy about it, but you can also elevate the leg as you're putting the tourniquet on just to decompress the venous system

and then put it on.

Just put it on, turn it till the bleeding stops, and then someone's already calling for help.

Please call an ambulance.

Call an ambulance.

Don't just rely on someone with a fanny pack tourniquet, but it's good to have.

Yeah.

I'm surprised.

I know now that civilians have a lot of things which are pretty amazing.

I mean, I suppose he likes to be

disaster preparedness.

Yeah.

Okay, on to some more chill stuff.

Alex Vangelatos said, I've always wondered if there was a difference between what would be clinically considered varicose veins and just having very prominent veins, especially in lower legs and feet and hands, that really show off aka bulge and pulse after exercising, Alex says.

And Alex, I found you the article, Lifting Made My Veins Stick Out, but Here's Why I Love Them Anyway, in which a fellow vascular biologist and surgical angiologist, Dr.

Jonathan Levison, explains that strength training causes the muscles to engorge and swell with plasma, which pushes the veins closer to the surface, making them be like, hey, especially if you happen to have thinner skin.

And whether or not you got a pump today, just kick back a little.

Putting your legs up at the end of the day when your feet hurt, good idea?

Yes.

Good for the veins?

Yes.

Yoga, upside down, inversions.

Yes.

Good for you.

Take some time.

Go upside down.

Get the blood out of your feet.

Yeah.

Okay.

Be in a different position, elevation.

I tell a lot of patients who have vein problems.

Elevate the legs as much as you can.

The worst positions you can be in are sitting for too long and standing for too long.

Moving, exercising is great, and then upside down if you can, as much as you can, or just elevate to whatever degree, you know, if you're older and it's harder.

I'm not saying to go a standing, you know, inversion, but yeah.

Acro yoga.

Yeah.

Yeah.

I mean, maybe.

Yeah.

The last two questions I always ask, what is the hardest part about surgery for you?

What's the hardest part about your job?

The most challenging part?

Most challenging part is when I can potentially fix the acute problem, but I know that the patient's not going to make it.

For example, this past week had a patient who clotted his leg.

I can fix that, but if his heart is so damaged, me doing that's not going to change his ultimate outcome.

And I think that for me is still the most challenging part.

Like I can do the best thing that I can, but you're still not going to survive for whatever other reason so that's that's still a challenge and that will always be a challenge with this job well you know I you mentioned that you're you sometimes see people when they're more advanced yeah in pathology any other advice that you you want people to know to take care of that vascular health yeah find a vascular specialist.

There's not a lot of us.

We're lucky in New York City, there's a lot of everybody.

But just speaking around the country, there may not be a lot of people especially if you're in rural areas etc who are specialists in this and this is where telemedicine can be helpful because you can always connect with someone who's not necessarily regionally close but can at least give you advice on how to get to the help that you need a lot of patients don't have good access so please find somebody who's a specialist in vascular care because it's a very sub-specialized specialty and when done well can be very helpful so that that's something i wish people knew more yeah We're kind of like an under dog specialty.

Do we need more of you?

We do.

We're going to have a shortage in the next probably 10 years of us.

But yes, we need more of pretty much most doctors, but yes, definitely we do need more of us.

So folks in med school have a rotation.

in the vascular area.

Yeah.

Amazing.

Favorite part about your job, favorite part about surgery?

Favorite part about it is always the aftermath.

So I think a lot of people who do surgeries, because because we do like sort of immediate gratification.

And it's very gratifying when you see your patients and they'll come back literally within a week and be like, I feel amazing.

Right.

And then you're like, okay, great.

Like I did something good and I helped somebody and now they're going to do great.

And if you can help somebody, that's always great.

The mood in the OR, because you're doing such delicate work, is it like classical music and hushed or do you need the energy?

Depends on the case.

But for the most part, I don't have music anymore.

i used to have music in the or but then i found that my voice isn't loud enough for anybody to hear me when i need something so i stopped with the music and we only get music if i have everything that we need and then they can we can have music because the team around me who's not focused they like the music and so i try to sort of meet them halfway because i want them to be happy so they can help me and then depending if it's an emergency no music yeah yeah focus time focus everyone because everyone's running around and trying to get stuff and we have to just stay focused.

So emergency is absolutely not.

Regular cases, if everything's good.

So they can, whatever they pick.

I actually don't pick the music.

I say whatever they want.

Yeah.

It's fine with me.

Aretha Franklin?

Maybe you don't just belt out Aretha Franklin.

Well, I can't start singing because then I've lost focus because I'm trying to hit my notes.

It was news to me that they even played music because obviously anytime I've been in an OR, I'm not super present.

Right, right.

It's like, what, really?

We actually take requests from patients sometimes because they want to set the mood for themselves when they come.

And yeah, they should offer you

your choice.

Yeah.

Spotify playlist.

Thank you so much for doing this.

This has been such a joy.

Again, you've been on my list for so long because there's not a lot of vascular surgeons and you're just the top of the game.

So this was so great to be here.

Thank you so much.

It was fun.

So ask cool surgeons weird questions because now you know about fake blood, karaoke, and how to die less.

Thank you so, so much to Dr.

Sheila Blumberg for letting me meet up with her and thank you to the NYU team for connecting us.

Links to Breaking Ground are in the show notes as well as a link to our website where we have so much info, links to the studies we mentioned, etc., all for you.

We are at Olagies on Blue Sky and Instagram.

I'm at Allie Ward on both.

We also have an Ologist starter pack on Blue Sky, so find us there for sure.

Smologies are shorter, kid-friendly episodes you can find anywhere.

You get podcasts, and those are linked in the show notes notes along with merch and a link to support ologies on patreon and submit your questions that i may read on the show thank you to aaron talbert who admins the ologies podcast facebook group aveline malak makes the professional transcripts kelly r dreyer makes the website noelle dilworth is our scheduling producer managing director is susan hail who makes sure everything flows on time and the heartbeats putting it all together are editors jake chafey and lead editor mercedes maitland of maitland audio Nick Thorburn wrote the theme music.

And if you stick around, I tell you a secret.

And this week, it's that we have oak trues in the yard, and I harvested a bunch of acorns a few weeks ago.

And I've had them in this cloudy jar in the fridge, trying to cold bleach the bitter tannins out of them.

And then I got impatient, so I tried to do one batch with boiling water and then dry them in the oven, but they looked burnt to shit.

And my almost former spouse, Your Mother Jarrett, said that they were not palatable.

And this broke my heart.

And I happened to meet up with my lovely friend and foraging ecology guest everyone loves, Alexis Nelson, aka Black Forager on TikTok and Instagram and she was in town last week and she agreed to sample my acorns and I was nervous here's what happened I have one here you can be completely honest

okay well it hasn't hit me yet oh no Ellie you should try this

it's more nutty like it's the bitterness of the end is reminiscent of like a fresh walnut this is edible you could you could dry that and make them and put it in a baked good

verdict edible jarret then tried another he said oh it was good and that maybe he just got a weird one so he remains my spouse now i'm going to attempt to grind these into flour and make acorn cookies and i'm going to report back but having a beloved and professional forager say hey you're not going to die from ingesting this and i found it pleasant is really enough of the goal for me i'll let you know how it goes all right be safe out there get those socks bye-bye

The pipes,

the pipes are gone.