You know, when we're talking about all this, we're thinking about PERT, but all these PERT models look so different, you know. We're also doing all this without a ton of Class 1 indications. What should everyone be doing as we're getting started and trying to expand these technologies? Yeah, it's a great question. I think, you know, that saying that all politics are local really do fit in there. I think you need to have one or more, but preferably one or two people that really want to champion this program and really drive it forward because they can organize the makeup of that PERT. And like you mentioned, it may look different depending on local expertise, local interest, the quote-unquote turf wars that you discussed. And so that makeup may be different, but you really do need to have somebody that's going to drive things. So things that are important when you actually establish a PERT is how are you iterating? Are you discussing cases? Are you discussing your data? Are you collecting your data? Are you having a monthly meeting? So there needs to be somebody that sits there and sort of organizes that. And I think getting everybody on the phone call at three in the morning is one way to cause a lot of burnout and maybe what's necessary at your institution. But that may not be the model that works for everybody. And I mean, I was obviously being glib, but that might be what works. But I think it doesn't have to be that. It has to be that the organization has to be deeper than that. I completely agree. You know, in Austin, when we first talked about building a PERT and doing a meeting, I asked, you know, do I get paid for it? No. Can I get sued for it? Probably. And then I was like, OK, let's do something else. You know, for the folks on the panel, what have your experiences been? Yeah. So, I mean, I'm at a community hospital, 500 beds or so. We take care of about 2 million people and we're the only PERT that would be there. You know, when I came out of fellowship, this was just the thought. And then five years goes by and now everybody's in the room just raising their hands. You know, I had a radiologist come up to me straight up to my face and say, just because you slap an acronym on it doesn't mean it's yours. And you know, it was a big it was a big deal when we brought this to the to the administration. But these possibilities, these likelihoods, these probabilities usually evolve to true benefit and p-values that come out as data accumulates. And we wanted to be on the forefront of that. And that's sort of how we started changing the conversation. We do involve the radiologists. We do call them. They don't really want to be called, but we keep calling them just so that they know they're a part of it. And then the devices, obviously, everybody in the room knows the large bore access and management has been become the forefront of interventional cardiology. And our abilities to do that is just, I think, superior and basically equal to none. And the radiologists want to learn that. But they do have their own ideas about what a PERT should be, given the fact that they were doing this before this acronym came about in 2012 and vascular surgeons were doing this with all the other devices and I would say low yielding devices and small bore thrombectomies that they were and they were providing a service and people were living. So to change that, that discussion has been a big deal. And I think we fight that mostly, that their ideas are that it's not that we were seeing everybody die. So why do you guys think you're better? We'll dive into that in my conversation, but. No, I mean, I think what we've found is that having too many people involved can be problemsome. I think we need to have a couple of people in CT surgery who are willing to support you and a couple of interventionists to share call. Then I think the other kind of crux of our team is vascular medicine. So they do a lot of the post care, also the outpatient care, and a lot of like the teamwork in terms of making sure the patient outcomes are better. So there are a lot of things, have the whole outpatient system set up as well. So I think you have to have a team from both aspects to really make it successful. Yeah, Allison DuPont, I'm from Northside Hospital in Atlanta, so we're a community hospital as well. We're not academic and we have the same challenges with interventional radiology. What happens for us is that we get all the sickest patients, right, the ones that are near death because we can put them on ECMO or, you know, do right sided support and we're not getting called so much about the ones that are straightforward. So those are kind of going to IR. And they're kind of getting the right of first refusal, you know, with these patients. And sometimes we don't, unfortunately, because we don't really have a true PERT team per se at this point, some of those patients never even make it onto our radar. So I guess the question for you is how do you navigate, you know, five years into this? How do you navigate that? What kind of conversations do you have to have with interventional radiology? And I love interventional radiology. My dad's an interventional radiologist, nothing against them. But I think, you know, some of these patients are very sick and they don't really want to take care of them. They want to kind of want to have their cake and eat it too in our institution. So I kind of wonder how you guys have navigated those conversations. So it's a great question. So the way our system works is there's kind of a central Austin hospital, it's a little more academic, and then there's outlying hospitals which are actually busier in a lot of instances. And there's two answers. So there's a bunch of trainees version was we spoke to the trainees, you know, we started doing all the outreach to the people that were taking the call at three o'clock in the morning and about what we do and how we do it. The private practice consultant version is we just tried to be better consultants than everyone else that was around. Now, that point about just because you call it PERT doesn't mean you get all the phone calls, that is a thousand percent true. And so, you know, when we first started, it was very much open conversation with interventional radiology, listen, we need people to cover this, we want to make sure every phone call is there, we're going to do this. When I first started in Central Texas, I was the only person there that kind of cared about any of this stuff, but I had 40 cardiologists running around. So we sat down with the hospital, we set a pathway and the pathway was, you know, ERs, hospitalists, just call cardiology and they'll take care of it. And I spoke to the cardiologist and I said, listen, when you get a call, just call me and we'll take care of it. And so instead of it being them trying to track me down when I was sitting in Phoenix at Sky, they would call the local cardiologist and then those cardiologists were interacting either with me or with IR and we were kind of breaking it up and teasing it out. In our situation, it might be different than yours, it's so great, by the way, talking to a room full of cardiologists because you can be bluntly honest. Interventional radiology, and I love them, they're my best friends, they didn't want to do the management piece. You know, they wanted to get called and say, hey, can you do this for this patient? And they would say, yeah, sure. ER doctors, they didn't want to necessarily make the decision about if someone needed the management piece and our goal is to fill that gap. And so we basically just said, call us with a PE and we'll figure it out. And they weren't getting that service from the other side. Yeah, I would add that, go upstream, right? So what was successful for us was that there is a consult to pulmonary embolism response team. They don't even know what services it is. They don't know that we're cardiologists. So they'll call us and they'll call cardiology because they don't even know because it's consult to PERT, right? So it goes to, and that can be IR, that can be shared by whoever, right? And it was so successful that now the people, they want to do the same thing for DVT, right? It sort of takes the burden off of the ER or the frontline, the hospitalist, the ICU, whoever it is, from having to think about who do I call? Who is on call? Oh, there's a PEI call, PERT. So you will get some of that non-high risk stuff. But I would argue that that, so people will say, well, we don't want to hear that. Actually do, because those patients need to get plugged into outpatient care and then you need to manage them so they don't come back with a massive PE or sub massive PE. So I think those patients are equally, it was just, you know, hey, we don't really need to see that patient, but here's my, here's the office number. They can set up appointment in one week and we'll manage their anticoagulation.

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