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Hi everyone and welcome back to Airway First, the podcast from the Children's Airway First

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Foundation. I'm your host Rebecca St. James. Today we're continuing with part two of our

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conversation with Dr. David McCarty. Dr. McCarty is a board certified specialist in sleep medicine

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and a pioneer in the practice of patient-centered care for those who suffer from sleep disorders.

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An award-winning educator, he is passionate about empowering individuals with knowledge that restores

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confidence and personal agency as each patient navigates the landscape of disease and wellness

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within an increasingly fragmented healthcare system. He is also the co-creator of Empowered

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Sleep apnea, an innovative cross-platform educational project combining storytelling,

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cartooning, scientific rigor, and quite a bit of fun, all in the name of helping individuals navigate

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the fascinating but complex disorder known as sleep apnea. Launched in 2023, the project

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comprises a website, a book, a blog, and a podcast. The Children's Airway First Foundation is proud

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to partner with Dr. McCarty and Empowered Sleep apnea in an effort to help create more information,

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education, and understanding around the subject of airway and sleep apnea. You can find out more

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about Dr. McCarty at EmpoweredSleepApnea.com. And now let's jump into part two of our discussion

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with Dr. David McCarty. And so when you're talking to a child, because I just don't see that you

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go into, like every parent, my children are exceptional, so you could have had the conversation.

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We're all of the children are above average. Right? Exactly. I just don't think any child,

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if you walked in and said, how are you sleeping, you can't have that conversation with them.

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It's very different worlds. So how do you approach this with children? I mean, it's a very different

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world. It's got to be done by surrogate. And you have to be, the caregiver has to be observant

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and has to be kind of the advocate for the child. And parents will be able to give you their sense

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of their child's sleep satisfaction by how lousy they feel. If the kid is not sleeping well,

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it's usually the parents who suffer. And I've heard that story many, many times. So parents

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can usually give you a pretty good appraisal of what's wrong with the sleeping experience and

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what's wrong with the waking experience. They can do some sleuth work to investigate the question

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of whether snoring is present and how bad it is. And there are now the wearable technologies and

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the bedside technologies that are available to consumers are, it's just over the top. So you

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can get data. And the question is how to unpack this data in a sensible way so that you can present

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it to your providers. So the structure that I just talked about, five reasons to treat,

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you can certainly apply that structure to unwinding a child's case of sleep apnea too.

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In many cases, the risk part of this discussion is more nebulous. Sleep apnea in kids, with

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exceptions, we still have heavy children that have rip-roaring, bad, bad obstructive sleep apnea.

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And I worry about heart failure. But for the most part, we're talking about the other four

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reasons to treat. And the risk to the child is much more nebulous. Is this going to make the

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child develop in a different way? Because they're breathing with their mouth open all night, is

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their jaw going to be underdeveloped? Are they going to be back in school and have limited

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potential because they're so tired all the time? Those are the risks that we're talking about for

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kids. So you can tailor the discussion differently, but you could say, for example, well, the first

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step of the five reasons monument is risk. I don't think this is the kind of sleep apnea that's

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going to give you a stroke. But let's talk about the other four reasons. And then we can kind of

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help people understand that there's still reasons to think about this very critically. And that

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means we're going to take it apart with the many moving parts and choose the right treatment

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for this individual. Not just say, well, here's what your insurance covers. Boom. Here's your

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seat belt machine. You know what I mean? Or, all right, let's pull teeth and slap on some

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retractive braces because that's what it covers. Let's not go there. So let's just get back at

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that discussion. That's the other thing that is hard for a lot of providers to kind of talk about

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these days is that many times these kids with crowded airways present with malocclusion, you

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know, which means that their teeth are wonky and kind of crooked and weird looking. And when that

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happens, if you go to an orthodontist that isn't thinking about the airway, the standard of care

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might be to pull out some teeth to make room and pull those teeth backwards. And that has the effect

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of making the oral vault smaller. There's no question about it. The big sort of consternation

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and debate is, you know, the orthodontists that practice that way are feeling kind of defensive.

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You know, they don't want to be accused of causing problems, but yet here we are. We're getting the

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message that this phenotype of a smaller mouth is not really that good. And this orthodontist is

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sort of moving people in that direction. So we got to think about these things critically with

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our children and think about the airway when we're thinking about this, you know, wonky teeth issue

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too. For sure. And this, and I swear I say this every episode. So this will be the point of this

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one that I said for parents and providers, both to please hear the guilt. We got to let it go

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because you don't know what you don't know. Y'all were taught what we thought was right.

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Parents were doing what we thought was right. Here's the new evidence. It's okay. You know,

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deep breath. This is an evolving discussion. I totally agree. This is nobody's fault.

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This is nobody's fault. This is the way science develops is we're getting, you know,

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a new signal that much of what we see as malocclusion is probably developmental rather than

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genetic. And that means it has to do with the way we eat and chew and swallow from birth.

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And it's just different than it was in pre-industrial society. We're eating a lot easier to chew foods.

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We're bottle fed. And so that just makes the face develop differently, you know. And that's

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a staggering reality to deal with that, you know, some of this that is affecting the label of sleep

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apnea is a skeletal developmental problem, which is probably going to require a different set of

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solutions for people. You know, this is the trajectory of what I call in my work, the sort

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of the outlaw. These are the folks who are outside sort of Western medical traditions

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who are pioneering this subject known as epigenetic orthodontia. And epigenetic refers to the elements

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that define and help with development that have nothing to do with your genome. It has to do with,

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you know, pressures from without. So the within, so the way the tongue is working, the way our

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teeth come together when we chew, the way we swallow, whether it's a pursed lip swallow or

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whether it's a normal swallow, all of these things can affect the shape of our face. And once that

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sort of concept hits home, it unlocks a completely different way of thinking about this. This is

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this is not a single issue problem anymore. No. So it turns out that many of the people who kind of

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fit into that narrower face, smaller jaw phenotype, they're usually thinner than the typical

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picwikian syndrome, heavy, snoring, sleepy person. And they usually present with these more autonomic

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um, um, um, imbalance towards sympathetic stimulation. So they're jumpy and they're, they're

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irritable, and they can't sleep. Completely different phenotype. That type of person self-selects

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against going to a Western medical provider, right? Because they have an intuition that they're going

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to be offered a CPAP machine, or they've heard from someone else, that that's what's going to happen.

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So they self-select and they don't go. And this way they start going towards these pioneers in

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another sort of silo of thought. And suddenly we've got two different realities that are defining

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their reality with the same term. How confusing is that for, for patients? They've got two different

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cultures. They've got two different ways of thinking about it and talking about it. And the

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people who get caught in the middle are, are feeling the tension there. Because the, the, the,

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the providers in Western medical don't understand what the outlaws are doing. And the outlaws are

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kind of unhappy with the fact that many of the folks in Western medical have been left behind.

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So now we've got two different professional organizations that can't talk to each other

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anymore. And that's a terrifying place for the patient. Yeah. You know. So again, if that's you

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out there, for the providers too. Yeah. Cause then, you know, it's sort of the human nature is to

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adopt a defensive stance on how you practice. And then you can't really hear anybody anymore.

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So, you know, to, to providers and patients who are kind of feeling like that, maybe where they

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are, this is the purpose of the blue book, is it really helps kind of unify the conversation in a

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way that deconstructs this for the patient. It's not really, railroading someone towards a specific

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treatment. It's sort of understanding how all fits together. You know, right, right. And I'm,

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I'm also going to put links to two previous podcasts with Dr. Becky Andrews and Stephen Hall.

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They are two of these pioneering outlaws. And I think it's important for parents, if they haven't

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heard it yet, to hear it, you know, in conjunction with this. And I mean, if you're up for it,

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it makes sense to me to kind of tackle the five finger approach at this point, because

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sure, sure. Yeah. You go through the risks and you talk about it. And, you know, now where do we go?

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Well, the five finger approach is another complexity deconstruction tool. This one,

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I actually came up with when I was still on faculty with the division of sleep medicine

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at LSU Health Sciences Center in Streetport. And I'll give you a brief backstory for why this

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tool was so necessary. It was early in my tenure as an attending there. And I had gone in to see

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a patient who had several, you know, notes, annual notes, kind of a soap note, that's how they did

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it back then, subjective, objective, you know, assessment and plan. And each one was the same,

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you know, subjective patient presents for follow up of obstructive sleep apnea, AHI6. Objective,

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patient appears no distress, doing well, no dermal irritation from, from mask. You know,

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the subjective probably should have included patient states using device, you know, assessment,

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obstructive sleep apnea on CPAP, doing well, plan, continue present therapy, follow up one year.

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Okay. So I'm like looking through this paper chart because it was back when we still wrote on,

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you know, cave walls with crayon, you know, I'm looking through this. Each note is the same,

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you know, I'm like, okay, so I don't know this person at all. So I'm thinking this is going to

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be a rapid visit, right? So I knock on the door, I walk in, I'm saying, how are you doing? And here's

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this woman who looks so disconnected from her activity there. She's not making eye contact.

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She's got this disheveled looking machine in her lap. I'm like, well, how are you doing with this

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machine? She's like, all right. And I said, well, you know, is it doing you any good? And then finally,

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she kind of looks me in the eye. She's like, I don't know. And she's, you know, a little bit

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defiant, but not mean, but interested. Now she's paying attention because like I asked her something

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important. And I said, well, it says here you snore. And she's like, I don't snore. And I was like,

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I was about to say yes, you do because it says so in the chart, you know, because that was what

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was listed on her sleep study report. But wisely, I think in the moment I said, I didn't say that.

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And I said, Oh, tell me more. And she said, Well, I used to, you know, I was 20 pounds heavier than

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you know, she presented with excessive daytime sleepiness, sleep disruption, and snoring. And

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then she had her sleep study and it showed an AHF six. So she got herself the label, right?

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Diagnosis of sleep. So I'm going to cut to the chase. Bottom line is this woman actually had

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narcolepsy. Okay, different problem altogether. That was responsible for the complaints that she

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had. When I got down into the weeds with her, I found out that she was using this only because

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they told her to because they told her that it gave her, it would give her a stroke if she didn't use

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it. And, and it didn't do anything for her that was perceptibly good. So, you know, she didn't

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snore without it because she'd lost some weight. It didn't improve her sleep experience. And it

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didn't improve her wake experience. And so when we sort of delved into those sleep wake complaints

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again, we realized that there was an alternate diagnosis that was present that hadn't been

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addressed. Because the thinking took a mental nap as soon as she got her label, and it became a

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label based sort of propagation. And I thought, Oh my God, this is embarrassing. I mean, I was

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terribly embarrassed. Because she's like, Well, why have I been using this all these years? And

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the answer was they told me it would give me a stroke if I didn't. And I felt that that was kind

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of mean. Because, you know, when we retested her, her AHI was too. And so it really wasn't that

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flavor of sleep apnea, you know, it didn't deserve that scare tactic to get around therapy. And

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yet there we were five years later. Okay, so the five finger approach was something that I worked

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on for about two years after that event. And I, and I published it as a special article in the

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Journal of Clinical Sleep Medicine. And it's it was designed as a memory tool and a teaching tool,

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a collaborative teaching tool, so that we can involve our patients and keep ourselves honest.

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And I broke it down into five different domains to think about. If someone comes to you with a set

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of sleep, weight complaints, like we established earlier in the conversation, we had no what their

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narrative is. Now we have to sort of sound off. Well, could there be many things going on? You

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know, could there be several contributors? And the original title of the paper was beyond

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Occam's razor, you know, because we're taught to find the one thing it's sort of conditioned into us

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that find the one thing that unifies it all. And I think that's a contributor that myth that

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there's going to be wondering. Yeah, and it's just not true sleep is complex. And usually people have

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several things going on. And so the five domains are circadian misalignment is the first one.

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And similar to the five reasons to treat, I put the most challenging one first, because it's also

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fundamental to the sleep wake experience. Understanding circadian misalignment is kind

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of easy. Okay, the idea is that there is a typically about an eight hour timeframe in our

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circadian cycle that's permissive for sleep to occur. The two hours, roughly two hours before

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that timeframe, we'll call that the circadian sleep phase. And for me, I'm a pretty regular guy.

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My circadian sleep phase is roughly 10 to 6 10pm to 6am. Okay, so for me, from roughly eight to 10,

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there is a timing of my circadian rhythm that actually amps up my internal alertness. Okay,

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that's designed to help get you through to your finish line, while all of this fume like sleep

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pressure is building up in your brain, you know, the desire to go to sleep can be kind of measurable

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by how much stuff builds up in the brain that is sleep inducing, we call them sleep regulating

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substances.

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You're listening to Airway First with today's guest, Dr. David McCarty. You can find out more

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about the Children's Airway First Foundation and our mission to fix before six on our website at

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childrensairwayfirst.org. The CAF website offers tons of great resources for parents and medical

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professionals. In our parents portal and clinicians corner, you can find educational and informational

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content, including videos, blogs, our recommended reading list, comprehensive medical research,

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podcasts, events, parent support, and educational opportunities. Parents are also encouraged to

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join the Airway Huddle, our Facebook support group, which was created for parents of children

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with airway and sleep related issues. You can access the Airway Huddle support group at

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facebook.com backslash groups backslash airway huddle. Are you a medical professional or a parent

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that is interested in being a guest on an upcoming show? Then shoot us a note via the

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contacts page on our website or send us an email directly at infoatchildrensairwayfirst.org.

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As a reminder, this podcast and the opinions expressed here are not a medical diagnosis.

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If you suspect your child might have an airway issue, contact your pediatric airway dentist

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or pediatrician. And now let's jump back into my interview with today's guest, Dr. Dave McCarty.

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Right now, what I'm getting into is a topic called the two process model of sleep wake

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regulation. There's the fumes that build up in the brain because you're awake and doing stuff.

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That's called process S. And then there's the signal towards alertness that's on a timer.

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That's on a 24 hour cycle. Okay, that's called process C process S and process C, the two process

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model. Okay, and got it. The issue is that process C, the circadian rhythm of your alertness

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can be damaged by environmental stimuli. It can be delayed most typically. So bright like

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yeah, lights and activity and socializing and all the things we do after dark, you know,

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fourth meal. Okay, all the stuff we do after dark pushes our circadian sleep phase later.

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And what that ends up doing is that burst of alertness activity, which the circadian rhythm

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researchers call the forbidden zone. Isn't that cool? The forbidden zone is a timeframe in your

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circadian cycle where sleep doesn't really tend to happen because it's when your brain is kind of

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on full steam helping you stay awake. Okay, but when that forbidden zone gets also delayed on the

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clock because you're shining lights in your eyes and you're suppressing your melatonin.

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What happens is people end up getting into bed and they're like, I can't fall asleep. Okay.

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Okay. The forbidden zone is to sleep. What a big giant unruly frat boy is to the keg of beer

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sitting on top of it. Okay. And so it's, it's hard to fall asleep on top of your forbidden zone.

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Okay. So all of this is to say that teaching this, these concepts to people is, is full of jargon.

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And so it's kind of scary. And many providers don't understand it well enough to discuss it

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with their patients. And so they don't do it and they don't consider it. And therefore it's not

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problem solved. So the good news is for circadian misalignment, which is the thumb of the five finger

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approach, the book gets into it and the podcast does too. It talks you, you threw it with imagery,

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you know, so we talk about the fumes and the attic for the process C and we talk about,

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or for process S, I mean, the homeostatic sleep pressure concept. And then the whole process C

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element, which is kind of scary because it has this circular time, I created something called

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the circadian rhythm wheel. And it's something that it's fun to look at. Cause again, it's like a

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crackerjack decoder ring, but you can turn it around and you actually see where these events are.

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And you can see how things can delay. So the dynamic aspect of the wheel allows providers to

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show, you know, where's the forbidden zone happening now? And where's your sleep phase? And

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what can we do about this? Well, it has to do with exposure to light. And, you know, you can also use

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melatonin strategically to try and manipulate where your circadian sleep phase is. But again,

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these concepts are complex, right? And, and getting them through in a way that's not terrifying is

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job one. And, you know, there's a whole section in the book that talks about how to deal with

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delayed circadian sleep phase. So just for transparency, the hand is on the other side

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of the island and I am not there yet. So you have more questions when I get there.

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You'll get there. You'll get there. But that'll take you through. The thumb, which is the thumb

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of the five finger approach is the hardest one to talk about because it contains all that jargon.

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And that's where the circadian rhythm wheel and the discussion of the two process model

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can be very helpful. Because it's really discussion of those things that allows people to get their

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hands around what we commonly call cognitive behavioral therapy for insomnia, changing how

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you behave and how you think about it is the natural outcropping of understanding that complexity.

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Okay. Normally speaking, CBTI, cognitive behavioral therapy for insomnia is given as a set of

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instructions, you know, restrict the amount of time you're in bed. If you're not sleeping,

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get out of bed. And it's these very, they're these hard instructions that feel hard. And they feel

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like eat your vegetables and people have a hard time with that. And in my experience, empowering

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them with the knowledge for why it all fits together puts them in a different decision-making

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place and then they choose the behavioral and cognitive things that they're supposed to do

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because I told them to. Gotcha. So anyway, that's the thumb. The second finger is a pharmacologic

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influences. I put this second basically as a trigger for my fellows to do due diligence and

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look at the med list. Many of you know, this came naturally to me, I'm a primary care physician

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by training. So I started my career as a primary care internist. And my favorite thing to do when

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a person would come to me as a new patient is to look at their med list. And let's talk about

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what's not needed. You know, this, I don't think you need this. Let's simplify this. Let's get you

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on something that's less expensive that'll do the same job that has fewer side effects.

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You know, really trimming that list to be the sleekest and most effective thing was kind of a

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point of pride. So alternatively, when your background is like, say, neurology or psychiatry,

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you might not feel comfortable even sort of glancing at the cardiac meds, because it's somebody

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else's specialty. I'm not supposed to talk about that. But there's a culture that you can't even

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go there. But the problem is that many, many substances that we can take either illicitly

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or recreationally or socially or by prescription can have adverse effects on sleep and or wake.

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And it's not something that a lot of people know about. I'll give you an example. Beta block. Okay.

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You familiar with the drug class beta blockers? Yeah. They block the beta receptors for adrenaline

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and they help control heart rate and blood pressure. People use them for lots of reasons, you know.

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Often it's for blood pressure, but in psychiatry, they're used to manage the side effects of

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anti-psychotic medications. They can be used to manage anxiety, you know. So there's lots of

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reasons why somebody might end up on a beta blocker. Sometimes they're prescribed for migraine

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prophylaxis, you know. But what a lot of people don't know, beta blockers can cause insomnia.

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Beta blockers can cause frightful nightmares and actually can bleed over into hallucinations

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that intrude upon wakefulness in some predisposed patients. And you know, it's not

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sort of on your cardiologist's mind that these sleep-weight complaints can occur. So the dots

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might not be connected. And it's like, I'm having these terrible nightmares. And then all of a

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sudden you've got nightmare disorder and somebody's trying to give you a different medication to

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treat the nightmares, you know. So I call this swallowing the spider to swallow the fly, you know.

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So a critical appraisal of the med list with respect to that person's sleep-weight complaints.

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And you know, could this be related to something we're giving you or something you're taking?

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That's what the index finger is about. And it would also be if you're talking to your

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provider, just a quick question that maybe your provider doesn't have the background that you had

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and this, you know, in your child or yourself has this list of things. Is this an okay time to say,

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hey, can we call and consult or can you reach out to whoever and consult and see, can we change this?

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Is this the right list? Is this? Arguably, that's where sleep medicine is supposed to pull their

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weight. Okay. You know, so this language that I'm sort of putting forward is the ideal. And, you

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know, I know that the reality is that there are many sleep clinics that are sort of Western medical

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stamped of approval. And the way they practically run things is sort of a pathway to get started on

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CPAP or a standard airway strategy. And these other issues may or may not be completely addressed.

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And it's variable. It's totally variable by provider. In many cases, providers feel hamstrung

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because, you know, CBTI, Cognitive Behavioral Therapy for Insomnia, isn't easy. You know,

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people train to get certified in this and many providers aren't comfortable with the concept.

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And so they will say, well, we can refer you out. But then that leads to a pathway that's usually

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not covered by insurance because it's usually a clinical psychologist that provides these services

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and that is often out of the scope of a health care plan. So there are often barriers to getting

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this type of care. So, you know, once again, this is part of the reason of the empowerment project

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is give people the language and the structure to understand where this fits together so they might

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self advocate for these things. Gotcha. Okay. Perfect. All right. Number three. Well, for anybody

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who's interested, there is an excerpt from the book that was included as part of the podcast

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series that in episode five, The Mountain, which is our season finale, I call it Five Finger Approach

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Mountain on the Island because it's the high vantage point to orient here from. But Five Finger

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Approach Mountain is addressed in that episode. And there is a link to a handout about substances

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that commonly affect sleep and wake. And that's, oh, okay, I'll make sure that we include that. Yeah.

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Yeah. Yeah. So that's available. That's available through that. The show notes of episode five,

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the mountain. Perfect. The third finger is the middle finger. That points us to the medical

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problems domain. So keep in mind sleep wake complaints when we're dealing with these sleep

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wake complaints, you know, feeling like your sleep is disrupted feeling like you're tired

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during the daytime. These are inherently not specific. And there may be other things that

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are disruptive to sleep that would fall under the medical domain. A common one is like chronic pain

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issues. There's so much chronic pain out there. Pain can be disruptive to sleep. And so whether

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pain is a major disruptor to sleep should be part of the calculus about how that pain is managed.

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You know, perhaps the strategy of strategic dosing at bedtime just to allow some relief from that

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pain so that the person can get some rest. You know, there's a big part of our narrative towards

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chronic pain that's scrutinizing the overuse of opiates for good reason. You know, these are

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dangerous drug class, but you know, we can't overshoot and stop caring about pain, especially

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when it comes to sleep. You know, if we can restore sleep functionally with a small dose of

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something that's not escalating that the patient can maintain dosing of, that may be the better

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part of that risk benefit narrative, you know, for that individual. So anyway, the middle finger is

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a free for all discussion about how are our medical problems being managed and could we get better

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control over these medical problems to perhaps have a better effect on sleep-wake experience.

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Okay, so that's what that has caused for. The ring finger is to call attention to the psychosocial

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and psychiatric components of the sleep-wake experience. I'll give you a startling example.

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A woman who comes in claiming to be anxious and can't sleep at night and feels tired in the daytime,

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what happens when you find out that where she lives, there are gunshots outside and people

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banging on the door and she has an abusive boyfriend that occasionally visits her at night.

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So now we have a completely different language to explore for what's happening with this individual

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with these sleep-wake complaints. Oftentimes, these mental health issues are scary to talk about

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and so creating a safe space to explore that with our patients, that's what the ring finger's about.

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Could we get this patient a better experience with referral to an appropriate mental health

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professional or is there something unsafe at home we need to be thinking about? It allows us to

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again move beyond the hard stop of a sleep-disorder breathing diagnosis and then moving along like

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we did with the patient who inspired this approach. Someone, there's actually a blog

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episode or blog entry for this backstory that talks about this on my website and perhaps if

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listeners want to we can put a link to that. Absolutely. Fifth finger, I did this on purpose.

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Again, this was a teaching tool for my fellows to make sure they made a methodical survey of

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this patient before landing on something easy like sleep apnea like we did for the patient

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who inspired this story. The fifth finger is going to be what I call primary sleep diagnoses.

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These are fluid categories. There are ways to organize this in your mind, but this would be

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something that you imagine would be labeled at a sleep clinic. Sleep apnea, restless leg syndrome,

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chronic insomnia, idiopathic hypersomnia, narcolepsy. These are the labels that you're

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going to get when you go to a sleep clinic. I put it last as a reminder to my fellows that yes,

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it's important to talk about the sleep apnea, but when somebody comes in with a non-specific

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set of sleep weight complaints, don't go there first. Let go there because let's say somebody's

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on a CPAP machine and they say, I'm using it, but I'm not feeling well and I'm not sleeping well.

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Let's go to the five finger approach mountain. Let's see if we can figure this out.

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And it allows us to go back and critically appraise, is CPAP resolving the sleep apnea?

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Are we doing a good enough job for that known diagnosis? Let's look at the data. Maybe your

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numbers are bad. It just so happens that people can do well for years on a CPAP machine and then

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like that, they flip into atrial fibrillation. It changes their circulation dynamics and now

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all of a sudden, they have central apnea events on treatment. Their numbers on their device

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out of nowhere go way up and to a provider that is unaware of the complexity of the moving parts.

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They may say, oh my gosh, well, we need to increase your pressure and do something to chase after the

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thing that they are holding onto that they still understand, that simple model. This is why simplicity

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is not- But the core has changed. You've got to go back there. Yeah. So we got to go back and revisit.

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So if we're saying, the fifth finger, well, you've got sleep weight complaints, could the sleep apnea

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again be part of the problem? Let's critically appraise that. Let's go back and look at your

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numbers. Let's talk about the comfort of your mask. Could we do a better job? Is this the best

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option for you? So that's the stopping point for that. And when I do this, I'm not doing it in

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secret in my mind. The point of the five finger approach is to teach it to our patients as we go.

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And that way, when they understand what we're working on and they see how we break it apart,

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I used to draw a hand on the paper on the exam table and the patient would crowd up next to me.

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We'd sort of sit there and look at it together and I'd write on it as we go. Anyway, if I felt that

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circadian misalignment wasn't part of the problem, I just cross out the thumb on my hand. I say,

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go, I don't think that's going on. Let's talk about your med list now. And let's go through this.

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And, you know, bit by bit, the patients engaged, they may start to think about their sleep in a

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different way. And usually they go home with a few things that they can think about. And often

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they come back and they say, you know, that bit about circadian misalignment, I started watching

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my phone use and I put it on the warm tones and I did my proactive wind down time before bed with

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the low lights and the chamomile tea and the soft music. And man, I fell asleep easier. That stuff

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really works. Wow. You know, so it really can make a difference. And the difference is agency

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and personal empowerment. You know, when I sign the books, I often write empowerment saves. I mean,

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big explanation for it. I'm not being silly. Empowerment saves people from falling out and

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from being left behind because they're a part of the solution and they're actively engaged.

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The disempowerment of the label based system is again, it's hard to talk about, but I think

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that's a major problem that we all need to get our hands around. And I think it's not just for

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very existential of me, but I don't think it's just patience back to something you said earlier.

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And I do think I'm labeling this podcast as empowerment saves because I think it's

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saved the provider because what you're doing is giving them license to follow through on the

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oath you took. The oath was to listen and to heal. It gives them the language to do that.

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Yeah. If you're 15 minutes in and out, you're not empowered. You're not doing what you spend

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all this time in school learning to do and care about doing. That 15 minutes can go so much more

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smoothly if the provider and the patient share the language. Patient comes in says, okay, like I'm

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ready for my coffee hut discussion. You know, I think I know what I want to talk about. And then

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you don't have to sort of have this hour long Bay of Narrative discussion anymore. Now we've got

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a common playing field and we can get into this together. And the provider who, no matter what

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silo they're in, if the patient is not doing well, they're going to be encouraged to think about

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the mechanics of this and break it apart into something more beautifully complex than their

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simple little one solution. And that's the turning point. When a patient gets that complexity,

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they become your medical assistant who works free of charge 24 seven. And they will help you do your

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job to find the way towards healing because they're motivated to do it. They just needed the structure.

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Right. Right. The tools, the tools. So at the end of every segment, I always

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say, and the four back over to our guests. I see this a lot of time. Y'all are the experts. This

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is this is your world. And there's been so much that we've covered. And I encourage parents,

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please check out the show notes and teaser coming soon to the parents portal. Check it out because

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we're working on some teaching stuff together. So what would you like? What message do you want

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to leave with our parent audience and our clinician audience? The message is complexity is hard. And

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talking about it is hard. And the discomforts that we feel with the system are no individual's fault

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that arriving at a new solution to this complex problem means arriving at a new language.

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And so the tools to unpack complexity that I want people to leave here with and

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understand are the five reasons to treat and the five finger approach. The five reasons to treat are

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discussed in, of course, our podcast and our book. And the five finger approach is actually a published

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paper. So if you Google five finger approach sleep, it'll give you a free PDF of the publication that

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I want to put it in here too. In 2010. And for providers, that's a good introduction to it. It's

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a little jargony for patients, but it gives you an idea where this approach comes from. And if you

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want it for patients and sort of non-sciencey people, just listen to the first season of our

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podcast all the way through episode five, and it'll give you exactly what you need to have a working

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knowledge of what to talk about. Yeah, I love it. And again, I cannot encourage parents enough.

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I will put a link to it in the show notes. It's already on our reading list. Get the book, listen

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to the podcast and empower yourself for your child's health span. Yes. Thank you so much for

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being on today. I cannot thank you enough. I'm delighted to be here. Thank you, Rebecca. And

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anytime you want me back, just let me know. I will. Thanks again to today's guest, Dr. Dave

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McCarty for sharing his medical insight into each of you for listening to today's episode.

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If you're new to our podcast, please don't forget to subscribe. And if you enjoyed today's episode,

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leave us a review or a comment telling us about what you enjoyed most. You can stay connected

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with the Children's Airway First Foundation by following us on Instagram, Facebook, X, LinkedIn,

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and YouTube. Parents can also join us via our Facebook parent support group,

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the airway huddle at facebook.com backslash groups backslash airway huddle. You can also find tons

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of great content for parents and medical professionals alike via the parents portal and

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clinicians corner on our website. If you'd like to be a guest or have an idea for an upcoming

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episode, shoot us a note via the contacts page on our website or send us an email directly at

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info at childrensairwayfirst.org. And finally, thanks to all the parents and medical professionals

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out there that are working to help make the lives of kids around the globe just a little bit better.

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Take care, stay safe, and happy breathing everyone.

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Bye.