Maxx Enzmann and Zack Nelson, infectious diseases pharmacists and members of the Antimicrobial Stewardship Program (ASP) at HealthPartners, tell us the top three things everyone should know about antibiotics, what’s misunderstood about them and share how the ASP uses equity as its guiding principle.
Maxx Enzmann and Zack Nelson, infectious diseases pharmacists and members of the Antimicrobial Stewardship Program (ASP) at HealthPartners, tell us the top three things everyone should know about antibiotics, what’s misunderstood about them and share how the ASP uses equity as its guiding principle.
HealthPartners Antimicrobial Stewardship Program page (only accessible to HealthPartners colleagues)
Hosts: Kari Haley, MD, and Jimmy Bellamy
Guests: Maxx Enzmann, PharmD, BCPS, BCIDP; and Zack Nelson, PharmD, MPH, BCIDP
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together, we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is "Off the Charts."
Kari Haley:
Welcome back to another episode of "Off the Charts," the podcast covering topics around diversity, equity, inclusion, and anti-racism. Dr. Jackson is unfortunately out ill. Joining me today is our, normally our producer, Jimmy Bellamy.
Jimmy Bellamy:
Hi, Dr. Haley. Thanks for having me.
Kari Haley:
I'm glad you're here with me today because we have a great pair of guests. They are infectious disease pharmacists and members of the Antimicrobial Stewardship Program here at HealthPartners, Maxx Enzmann and Zack Nelson, welcome to the show. It's great to have you here with us.
Zack Nelson:
Thanks for having us.
Jimmy Bellamy:
Yeah, thank you guys for being here. And little behind-the-scenes, Zack reached out to me more than a year ago, and I know it's hard to tell when we are recording this because this is evergreen. People will listen anytime in the future, but Zack was incredibly patient with me as I worked to find a spot for him to be on the show and really appreciate your patience, and thanks for bringing Maxx as well.
Zack Nelson:
Yeah. Maxx seemed like a logical person to bring along, and I'm sure the wait will be worth it. Hopefully.
Jimmy Bellamy:
Well, I'm excited to talk about this topic because I am not a patient-facing colleague, so I know very little about antimicrobial stewardship, and I'm excited to just hear what it's about and hear your take and Dr. Haley's as well.
Zack Nelson:
Absolutely.
Kari Haley:
I think maybe just to first kind of start off thinking about both our lens in the health care field and then the layperson lens of what are antibiotics, why do we use them, and what are we going to be talking about in terms of the stewardship of antibiotics?
Zack Nelson:
Sure. Yeah. I mean, in the grand scheme of things, they haven't been around all that long. Alexander Fleming accidentally discovered penicillin back in the 1930s, and so it's only been, it's less than 100 years in the grand scheme of things, so not very long. But once he discovered that and more antibiotics became available, and these are drugs of course that treat a variety of infections. So, there are antimicrobials, as you alluded to in the name, antimicrobial stewardship, there are also drugs that will treat other types of infection causing bugs like fungus or viruses. But antibiotics are generally referred to as the drugs that treat bacteria. So, these are one of the most profound medications in human history in terms of increasing life expectancy outside of maybe vaccines or the infrastructure of sanitation and those types of things. So, these are very precious resources that we have.
And so, we often use an example of aspirin for heart attacks. Everybody knows generally about that, and for those, we can expect a modest reduction in death of about 3% in the month after that. But these antibiotics reduced mortality by up to 80% in some of these infections that were overwhelmingly fatal prior to having these available. So, these are very important drugs. They're a unique public good in the sense that they become less effective over time when they're used appropriately and when they're misused. So, very unique as opposed to other drugs that becomes less effective over time.
Jimmy Bellamy:
One thing I'm curious about, just because we live in the age of social media and information being non-stop, what are some of the things you face when it comes to either things that are misunderstood or not known about antibiotics?
Maxx Enzmann:
Yeah. So, I think probably the biggest mistake people make is thinking that antibiotics are benign. In many people's minds, if you're on the fence about, "Oh, maybe I should just take an antibiotic just in case. We get the sniffles, it's cold and flu season, maybe I'll just take an antibiotic because that's the easier approach rather than not taking antibiotics." And that mindset really needs to change. There's a lot of consequences of unnecessary antibiotic use. Everyone thinks about antibiotic resistance, which does remain a concern, especially in its pace, which is outpacing new antibiotic development, and that's infrastructure there, but that's not a very tangible thing you can say. No one's going to be like, "Oh, I can feel the antibiotic becoming less effective right now. I can feel my bacteria getting more resistant." I think an issue that needs to be stressed more is the antibiotic's direct adverse effects on patients.
C. diff, of course, is a big one, high morbidity, and usually tied with staph aureus for the highest incident in the hospital acquired infections. They're usually one and two back and forth, and that's obviously not ideal. No one wants to have diarrhea 10 to 11 times a day and be hospitalized for it.
Jimmy Bellamy:
Speak for yourself, Maxx.
Maxx Enzmann:
Suboptimal sometimes. Outside of C. diff though, there's some other things that I think are getting more and more, or should be stressed more and more, which is just altering your microbiome. And what I mean by microbiome is all of the good bacteria in your GI system, there's a lot of bacteria in our bodies that do a lot of good things for us, and without them, we're actually prone to certain diseases, maybe more infections. And so, when you take an antibiotic, not only are you killing off the bacteria that you're trying to treat that's causing your infection, but you're also killing off some of the good bacteria, which definitely is not good.
For example, if you give yourself oral Vancomycin for C. diff, you're essentially lighting a grenade in your GI system and wiping out not only the C. diff, but pretty much everything else that's good in your microbiome. So, that's why there's been a lot of good research done in the C. diff world about these fecal microbiota transplant products like Rebyota and Vowst, trying to figure out what to do after you've treated the C. diff because you've, like I said, laid a barren wasteland in your stomach. If you don't replenish that microbiome, those patients of course are going to be at higher risk of developing C. diff.
There's also more data coming out that are showing some warning signals about correlations with chronic diseases as patients, so like exposure in childhood to certain antibiotics are being correlated with chronic diseases like diabetes and things like that. I still think more data needs to come out about this, but there are definitely some warning signals out there. So, they're not benign at all.
Jimmy Bellamy:
So, I got my start working in health care communications in 2014. One of the first groups of people I worked with were some of our quality and infection prevention professionals. Explain to our audience who may not be familiar with it, what is C. diff?
Maxx Enzmann:
C. diff, clostridioides difficile, it's a bacteria that can overtake your microbiome in your stomach. It can overpower the other bacteria in your stomach and cause just very, very, very bad diarrhea to the point where there's even a part of C. diff that's the worst case scenario, it's called toxic mega colon, where essentially your colon can become so inflamed that it's just this massive thing in your stomach and people often die from that.
Jimmy Bellamy:
It sounds like a Marvel supervillain name.
Maxx Enzmann:
"Toxic Mega Colon!"
Kari Haley:
It is, it is. And I think, too, the piece for C. diff is, it can happen, for people who are 100%, they don't have any underlying medical problems, they're previously healthy, normal young person who eats well and takes care of themselves, and then get one course of a pretty strong antibiotic maybe to treat a sore throat or some bronchitis that they got. They get this antibiotic, and then within the next month or so, they start developing this diarrhea that's very profound. It doesn't go away, lots of stomach pain with it. And then, they end up seeing me in the emergency department and they get diagnosed with the C. diff, which is a longer course of antibiotics. And then, it just also, I've seen people too, afterwards, your gut biome as we kind of talked about, is just completely wiped out. So, their digestive system and complications of eating in general, they can have things that happen far beyond the infection that altered how they eat, what they can eat. It's crazy.
Jimmy Bellamy:
It sounds like a balancing act.
Zack Nelson:
It definitely is, and I think we see that with a lot of different types of infections. So, C. diff is a great example. Women who have had yeast infections, it's another great example of that good bacteria being wiped out by the antibiotics and allowing that yeast to overgrow. So, definitely a balancing act that we struggle with on a routine basis.
Kari Haley:
We talked a little bit about some of the pieces of giving the public some information about antibiotics, in particular some of the risks associated with that. What are some of the inequities that we have about infectious disease in general, and then also correlating with that, the antibiotics or the use of antibiotics in the general population?
Zack Nelson:
Well, we were hoping that the COVID-19 pandemic would stimulate overwhelming interest in infectious diseases. However, for whatever reason, that hasn't seemed to happen as we would've liked it to. But three's a great study done by the CDC in 2020 that demonstrated about 90% of U.S. counties have below average or no ID physician access. And this is largely rural parts of the country, which is not uncommon for some of these subspecialties to have a lesser influence in those areas. However, in 2024, only about half of the ID fellowship spots for ID physicians were filled. And so, this is concerning because we obviously just went through a pandemic.
Some might say it didn't go as well as it could have, and there's going to be another one. We just don't know when. And so, the fact that only half of these fellowship spots have been filled, it's a little bit concerning because we need those specially trained people who understand how the bugs are transmitted, how to treat them, why they become unable to be treated with antibiotics, those types of things. We need those people with that expertise to help us through those.
Kari Haley:
And I think there could be an argument made, too, for saying people who, especially people who maybe have some social determinants of health who are at more high risk of getting these infections or getting seriously ill with these infections because they don't have great access to care, they're going to end up at a hospital that may not have an infectious disease physician available to help guide their care. And so, they can... Sepsis causes, so sepsis, sidebar, is really bad infection where people can die from it. And it is something that we treat incredibly seriously and a lot of the times we hit it with antibiotics.
But people are not able to have access to people who are the experts in that care in terms of the infection because sometimes you need to change the antibiotic, you need to think about what specific bug is causing the problem, and if you don't have the right one or you don't have the right combination of medications and treatment for it, people can get really sick and die.
Zack Nelson:
Yeah, and I think especially with what Maxx talked about in terms of the risks associated with antibiotics, I think that, the fact that they might be able to actually cause harm to people if they're being taken when they're not needed means that if these experts aren't available, those people might actually be taking on more of the risk burden than folks in perhaps the urban areas who have more readily access to these ID physicians and other experts as well. So, I think, there are even some studies that demonstrate ID experts actually reduce the risk of death in certain infection types.
So, like you wouldn't treat cancer without an oncologist, serious infections need to be treated with people who have the requisite expertise to manage those. But I think the people in the rural locations, and especially within our system, right, we're not a two-hospital system comprised of regions in Methodist, the two largest centers. We're an eight-hospital system, and we have hundreds of clinics that are spread out throughout Minnesota and western Wisconsin. And it was very important to us understanding the harms that could happen associated with antibiotic use, that these people be afforded a better chance to get a good outcome too.
Jimmy Bellamy:
With the rise in telemedicine, both pre and post-pandemic and the demand and need for these experts, are you finding yourselves or your group consulting with other locations even outside of our system? Is that happening in recent years?
Zack Nelson:
Not too much. I would say, one of the benefits of adding more pharmacists to the, and establishing more of this formal system-wide program has been that one of our pharmacists in the ASP, the Stewardship program, is actually dedicated to the, outside of the metro sites. So, there's a lot more one-to-one or individualized consultative type services that are available to them that just weren't available to them before. So, it's a lot more accessible to the clinicians that are out there. And as Maxx will talk about later as well, here on the east side, we've implemented a new transitions of care type of service for patients who are leaving the hospital on IV antibiotics that just, there was a big gap before.
Kari Haley:
And I think that you're kind of alluding to your programs that maybe we can talk about a little bit more here now too, is the Antimicrobial Stewardship Program, or ASP it sounds like that you call?
Zack Nelson:
Yes.
Kari Haley:
When did this form, who comprises it and what are you guys doing?
Zack Nelson:
Yeah.
Maxx Enzmann:
Great questions.
Zack Nelson:
Yeah, those are all great questions. So, our two largest sites, Methodist and Regions (hospitals), have had an infectious disease pharmacist for quite some time, for more than a decade. And so, they've been practicing stewardship or the responsible use of antibiotics for an extended period of time, but it wasn't really until 2022 when a more formal system-wide stewardship program was established. And there were basically three main reasons why we did that.
One, the public good, we talked about how the health of the public depends on the responsible use of antibiotics and making sure that they continue to work in the future. It assures best practices are being followed, and then the sustainability of our organization. So, the ID experts in our program save our organization and our patients lots of money and lots of time based on the interventions that we implement. And then lastly, regulatory requirements. So, there are more and more regulatory requirements from certain agencies like the Centers for Medicare and Medicaid Services, the Joint Commission, that are requiring stewardship as part of routine hospital activities.
Jimmy Bellamy:
So, as of this recording, evergreen content again, but in recent months, we've seen a conservation of IV fluid due to the devastation of the hurricanes on the east coast, especially in the southern part of the east coast. What has your work done around that?
Maxx Enzmann:
So, there's been a lot of things that we can do from an antibiotic stewardship standpoint. Some IV antibiotics require a lot of IV fluid for compounding and administration. I think of high-dose bactrim, you almost go through a liter of D5 a day for those patients. Other IV antibiotics administered here, or I'd say most IV antibiotics administered within the HealthPartners system are IV piggybacks, which means they're generally 50- to 100-mil bags, which adds up. You think about all the patients that are admitted in the health systems. And then, compounding that, some IV antibiotics are administered over three to four hours, which means you need a minimum amount of fluid in that bag so that your pump can administer that fluid, otherwise you're using a syringe pump, which I believe are a hot commodity and only for our neonatal population. So, there's a lot of strategies that we did from our standpoint. Our most common IV piggyback antibiotics, we switched to the IV push formulation, so just 5 to 10 mils that you're just administering instead of 50 to 100 mils. That adds up.
There are some antibiotics that cannot be given IV push, and we promoted alternatives to those antibiotics, Vancomycin, Piperacillin, Tazobactam, and then even IV penicillin itself, switching over to other antibiotics that don't require as much fluid really added up. And then, this is something we do outside of a shortage, but as a wise man once said, you never waste a good shortage, is promoting the use of oral antibiotics in general instead of IV antibiotics. There's been a lot of myths out there that IV antibiotics are better, and this is a lot of work that Zack and I have been doing over the course of our careers is telling people that's not really the truth. So, seeing patients on IV antibiotics and really advertising that they don't need to be, if they don't need to be, to definitely pursue switching to PEO (polyethylene oxide) antibiotics.
Kari Haley:
Yeah. Maybe we can talk a little bit about this because I think one part of what people think about in terms of stewardship too is that oral to IV kind of medication route and that we have a lot of really good oral antibiotics out there that have good, what we call bioavailability, meaning it can get into your bloodstream, it can fight the infection at a quick pace, rather than people think it's going to take too long for it to really build up in my system and work hard and do what it needs to do. Can you talk a little bit more about how we can be, as both clinicians on the clinical side and maybe even just the general population, how we can understand that a little bit better and being OK with, "Hey, I'm good with some oral antibiotics if I really do need the antibiotic."
Zack Nelson:
Yeah. To state it simply, the bacteria are not smart. They're very smart, but they're not smart enough to know how the antibiotic gets to the site of infection. So, I think that's the first thing to remember is that what really matters is if the concentration or the amount of drug that's in the patient's bloodstream or wherever the infection is, as long as that is higher than the amount that is needed to stop the bacteria from growing or kill the bacteria, that's what matters, regardless of how it gets there. But we have a lot of evidence to say that we can treat very serious infections such as endocarditis or heart valve infections or osteomyelitis, bone or joint infections with oral antibiotics, and patients do just as good if not better than the IV drugs. So, we are treating a lot of these severe or complex infections with oral antibiotics. So, it would make sense that if you're coming into the doctor's office or to the emergency department with a urinary tract infection or pneumonia, that those would also be suitable in those cases, too.
Kari Haley:
I think that that's one myth out there for sure, and that people first, even clinicians, they think, "Oh yeah, this IV antibiotic is definitely going to make you feel better sooner," when it's really probably not truly the case, in most cases at least.
Zack Nelson:
Absolutely. And one of our big ASP initiatives over the last year or so has been transitioning patients who are in the hospital from IV to the oral antibiotic sooner, and it actually led to them going home about a day and a half sooner than if we didn't actually provide those formal recommendations to do so.
Jimmy Bellamy:
That's a great tee-up to my next question, too, because as a, again, non-patient-facing colleague, sometimes I paint things with a broad brush here that I think, "Oh, everyone who sees a patient has the same level or area of expertise." How are you supporting clinicians in your work where they definitely don't have the same perspective as you, so I want to know what that partnership looks like.
Maxx Enzmann:
Yeah. So, we have an amazing stewardship website that I have to give big kudos to Zack for, for maintaining this website. This website has amazing resources that any clinician can access. We have inpatient and outpatient guidelines for our most common infectious disease states, dosing and kinetics resources for how to dose the antibiotics, even ASP news. So, initiatives that we did during Antibiotic Awareness Week before Thanksgiving, even literature press releases about new articles that come out. IV fluid conservation strategies, as we mentioned earlier, we had a nice little document outlining all those things I talked about earlier. How to evaluate penicillin allergies, we could have a whole podcast about that, as well as links to many other websites and so many more things that any clinician can access. Outside the website, we also do a lot of work with order set, order panel development. So, within Epic, our electronic medical record, there's different order sets, order panels for common things that providers use, and one way to guide behavior and education is to simply have the things we want them to use pop up for them to click on.
So, that provides real-time decision support and education, working on those. Of course, each clinician has a way to get a hold of one of us if there's any more patient specific questions for those odd questions that aren't really answered by a website. And then, we also share a bunch of data at our various meetings across the enterprise, better goals, cost savings and things like that. And we also incorporate feedback. Zack recently made a survey that asks clinicians how they view the ASP and if there's anything they want more from us, and we've incorporated a lot of good feedback that we got.
Kari Haley:
That's awesome. I think that's also really a great way to incorporate an element of equity into antibiotic use is by making it easy for clinicians who may not have infectious disease specialty and/or easy access to a real-time pharmacist with expertise at their clinic location, to be able to just log onto the computer and when they have a patient there with a urinary tract infection, they can look and see what does the order set tell me that I should be ordering because somebody already has done the work to find the best ones for the population that we're treating. And that, I think, is huge. Instead of the doctor just kind of making it up in their head, or, "I think this will work, we'll see."
Jimmy Bellamy:
That never happens, though, right?
Kari Haley:
That never happens. Thinking about, "Oh, this is one I always use for UTIs," when it maybe is not the best choice for the current microbial workup of what's out there right now. And I think that's super helpful, and especially with the equity lens, thinking about that, because otherwise, people are just getting very different care depending on who they're seeing and where they're being seen.
Zack Nelson:
Exactly, and that's something that we've just reiterated thousands of times is that we shouldn't be treating your run-of-the-mill urinary tract infections, your run-of-the-mill pneumonias in eight different ways. We should be treating them in the evidence-based way, and if we can make that visible and accessible to all the clinicians that are treating those patients, that's going to make their care more equitable.
Kari Haley:
Yeah.
Maxx Enzmann:
Work smarter, not harder.
Kari Haley:
Yes. And as a clinician who uses the order set quite often in the emergency department that we have, it's just so nice to take that thought process because I know and I trust the people who've made these order sets that they have done the research, they are picking right drugs, and that I can just offload that mental task from my own brain of looking it up and finding the right information for that particular patient that I am seeing, and still trusting that they're going to get good care.
Jimmy Bellamy:
A lot of what we've covered is patients in the hospital. What are we doing for outpatient care?
Zack Nelson:
Yeah. So, 80% of antibiotic use happens outside of the hospital. And so arguably, equity is even more important on the outpatient side. But with that comes a lot more challenges on how to address it. There's a lot of different types of clinics. There's a lot of different types of settings that patients can present in. There's urgent cares, there's emergency departments, there's specialty clinics, there's primary care. So, accessing each and every one of those 100-plus clinics that we have is very challenging. But I think what we've done is use a lot of those same strategies that we've used in the hospital, such as creating outpatient guidelines. So, what are some disease states that our outpatient colleagues see more frequently than us here in the hospital? Some of them are the same, but some of them are different, like they might see more strep throat in the community, for example, and that's not something that we routinely treat people for in the hospital.
So, again, it's much more challenging to address that due to all the different settings. But actually, the survey that Maxx mentioned, a lot of our responders to that were actually either outpatients' internal medicine or family medicine, so your primary care doctors, or that sort of a hybrid between the hospital and outpatient. And they were seemingly very aware of the resources that were available. And so, that accessibility, that visibility was super important to us because if people don't know where to find it or if it's not accessible or even visually appealing or something they want to look at or feel good looking at, it's going to make it very challenging for us to convey that information to them.
So, I think we're using a lot of those same strategies and then really working with our other colleagues in the outpatient setting. Maxx alluded to the penicillin allergies. We're working with our allergist to try and reduce some of the impact of the social determinants on people's access to some of those specialists. So, how can we get rid of some of those unnecessary penicillin allergies in people who don't have transportation to the allergy clinic? Those types of problems.
Kari Haley:
Those are all amazing things, and I think just furthering as we are having a population with more of these resistant bacteria, but also I think people who want to know a little bit more about their health and are invested in their health, to know that we have people in our hospital system who are truly looking into at least the use of antibiotics, antimicrobials, other medications that treat infections, and that we're doing everything that we can to make sure that we are being helpful. That in the future, people will continue to be able to use these medications and reap the benefits of them.
Jimmy Bellamy:
We're doing this podcast right now. This is offering us an opportunity to look back. I know that in your jobs, a lot of it's probably "keep your head down and move on to the next thing," and it's rapid, it's fast-paced. What are you thinking about when you think about what you've accomplished, the improvements, the innovation? Is there anything that comes to mind immediately?
Maxx Enzmann:
Well, I think positive recognition is essential in ASP. Inherently, we have a long road ahead of all the things that we're trying to fix, and it's very easy to get bogged down by all those things. Something that I think that is very fulfilling is, during Antibiotic Awareness Week, we had developed some awards, ASP awards, called myPartner Awards, and we just recognized some colleagues that were going out of their way to do everything they can to give the right antibiotics to the right patient and promote education. So, it was fulfilling to recognize those clinicians and seeing their reactions. It was very fulfilling. And so, things like that helped me get through those days where I'm like, "Oh man, 10 more things to go." So, I think that's very, very important in ASP.
Kari Haley:
I want to maybe hotspot you for the last minute here. I want you to maybe give us the top three things that the general population should know about antibiotics. Go.
Maxx Enzmann:
If you have the sniffles, don't take an antibiotic.
Zack Nelson:
Yes. I think that underscores the issue that viruses cause a lot of the common things that we see. It causes a lot of pneumonia, it causes a lot of upper respiratory infections, and antibiotics generally don't work for those. Another perhaps misconception is that, historically, people have been told, "Take your antibiotics until they're gone," type of thing, and that's probably true if we're doing well at prescribing the right duration to begin with. But what we're finding in a lot of our studies is that shorter is actually better. And by better, I mean, you get the same outcome in terms of you get better in the same way that you would've if you took it for much longer, but you have a lot of the less risks and a lot of less side effects.
So, I think historically, there were a lot of not scientific ways that we decided to treat antibiotics for, for example, the number of fingers I have on my hand or the number of days that the Romans decided were in a week. But I think that's largely a myth, that people don't need to take it till gone. But if they do, if it was prescribed for the appropriate duration, but if it was prescribed for too long, and that's hard for patients, right, because how do they know when to stop? But I think that underscores the need for us to be better at the point of prescribing and the point of dispensing medications to make sure that they know that this shorter duration is just fine for them.
Maxx Enzmann:
I would say the third thing, to wrap it all up, is penicillin allergy. Zack and I have both touched on this. But just because you have a penicillin allergy, whatever the source was, whether you were told as a child you did, you experienced it yourself, it somehow just got added, you don't really know, the odds are you can likely still tolerate one of the antibiotics in the penicillin family with minimal to no adverse effects. So, I think that's a huge misconception that we're trying to de-label.
Zack Nelson:
Yeah. And I think, historically, the perception has been, well, we have other options. Let's just use them. But it's been tied to actual harms. So, it influences how the antibiotics are prescribed, and so that means that people might get more drug-resistant infections. They may be more likely to get that C. diff infection that we talked about earlier, surgical site infections, higher cost of care, all things that are bad for the patients and for the system. So, the more we address these, the better everybody does.
Kari Haley:
Well, I just want to thank you first for coming on the podcast and having this great conversation, but two, for all the work that you're doing, because this is hard work. You are swimming upstream for sure, in the world of antimicrobial stewardship. But keep on keeping on because I think the message is getting out there. I do think that clinicians are taking more notice of this, and I think that the public is starting to as well. So, I think you're on the right track, and I think you guys are just doing a great job. So, thank you for being here.
Jimmy Bellamy:
Yeah. Dr. Haley has heard this before. Our co-producer, Doug Peterson, who's also a paramedic, has heard me say this, Dr. Jackson has heard me say this. I feel so fortunate to walk these halls and work in this organization, at this hospital where we're recording, Regions Hospital, because I work with some brilliant minds who literally save lives. So, my hat is off to you two and your team for the work you do because it is incredible, and don't ever take for granted the amazing stuff you do.
Zack Nelson:
Thank you, guys.
Maxx Enzmann:
Thank you, guys, very much for having us.
Zack Nelson:
Thanks for having us.
Kari Haley:
Thanks for being on.
Steven Jackson:
"Off the Charts" is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.