S03_E11 - Keeping Up with Pacemakers

Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:19

Hey everybody. Dr. David Hilden here, and welcome to episode 11 of the podcast. Today we're gonna talk to Dr. Rahan Kareem. He is an electrophysiologist. What's that you say? Well, he's a cardiologist who specializes in the electrical systems of your heart. Dr. Kareem , thanks for being here.

Speaker 3: 0:34

Thank you for having me here. It's

Speaker 2: 0:35

Great to have you here. And I'd like to focus today on pacemakers. Uh, I know you do a lot in your job, and we'll maybe get you back on a future episode to talk about other things, but today I wanna talk about pacemakers and what do they do and why are they used, things like that. So, could you start us off and tell us what's the function of a pacemaker?

Speaker 3: 0:53

First of all, thank you again for having me here. In simplistic terms, the only job of a pacemaker is to prevent the heart from going too slow. For whatever reason, heart rate is going very slow. That is making someone symptomatic. Then the job of the pacemaker is to make sure that there is a minimum heart rate that it provides.

Speaker 2: 1:17

So it sets the pace. Yes. So what's the problem? If someone's heart's going too slow?

Speaker 3: 1:22

They could have a lot of problems. The main complaint , uh, people can present with is feeling dizzy or lightheaded. Or if heart decides not to beat for a few seconds, a person can actually pass out and injure themselves. They can feel fatigued. A normal person, if they start running or the physical activity goes up the heart, the human body , uh, has an amazing way that it can sense that body needs more blood supply, and it increases the heart rate. And there are some situations where someone's heart rate, if they're exerting, would not go up, and that would make them extremely fatigued. They're not able to do , uh, usual activities that they are able to do otherwise. So in those scenarios, also, it can provide a backup heart rate support.

Speaker 2: 2:12

So I'm gonna talk a , uh, a little bit later in the episode of some of the specific conditions that people have that lead to that , um, that condition that you're describing. Let's talk about the pacemakers that people get. So people have this idea of what it is, but I don't know if , if everybody knows exactly what it looks like and what it does, could you give us just a little walkthrough history, a little bit of the history of pacemakers? How, what did they look like? How big were they, and where are they now?

Speaker 3: 2:37

So there has been an evolution of , uh, over last several decades , uh, with regards to pacemakers. And , uh, believe it or not , uh, Minnesota has a great history , uh, is part of that history. In fact, the first , uh, battery operated pacemaker was , uh, invented , uh, here in , uh, Minnesota. So they used to be really big initially, you know, external devices. In fact, the original pacemaker was just , uh, transcutaneous , uh, pacing. And , uh, there was like straps onto the chest, which again, in emergencies are still used nowadays as pads. Looks

Speaker 2: 3:16

Like the electric chair, they had pads on your chest and

Speaker 3: 3:18

All that. That's right. And then they came up with these , uh, wires , uh, which they could put directly into the heart. The surgeon would just put it onto the heart muscle and connect it to a pulse generator on the outside of the body. And they used to be really big. And as the time has evolved, the newer ones are much smaller, much smaller than your, your hand. So they're much, much smaller. They're lasting much longer. Uh, the batteries on the pacemakers, they can last as much as , uh, 10 to 15 years, kind

Speaker 2: 3:51

Of a backwards way for me to get into medicine. I remember that back in the eighties. I went into , uh, engineering school because I wanted to work on those things like pacemakers and stuff. I was gonna be a biomedical engineer. Well , that didn't work out. And I , I settled for being a , a medical doctor instead. But the pacemaker was one of the reasons I sort of got into this field. So you put these things in all the time. It's not the only thing you do, but you do also put pacemakers in people. You're the guy that does it. Could you talk us through it? What do you, what do you do?

Speaker 3: 4:21

Yes. So traditionally , uh, the pacemaker, again, there are different types of pacemakers, which , uh, we may end up talking about later. But , uh, traditionally , uh, pacemaker procedure includes , uh, it's a small little battery operated device. And it has wires. Those wires go inside , uh, inside the heart. And essentially the procedure takes less than an hour or maybe about an hour or so. It's , uh, same day procedure. Usually patients are, they can be completely awake , uh, or sometimes we give them a small dose of medication to make them a little sleepy, just similar to what , uh, if you go to a dentist's office, they give you some , uh, light sedation, but the

Speaker 2: 5:04

Dentist isn't putting wires into your heart.

Speaker 3: 5:08

So , uh, it's, it's, it's amazing. Uh , and you

Speaker 2: 5:11

Do it while they're awake?

Speaker 3: 5:13

Yes, I have done it while , uh, they're , uh, they're awake also, you know, we are chit-chatting and talking to them. But again , uh, for comfort, we do give , uh, some mild to moderate degree of , uh, a sedative drugs to make sure they're not having too much pain. So essentially we give local anesthesia and the incision may be about two to three finger breaths. And , uh, all they feel is like pushing and tugging kind of sensation on the skin. And we make a little pocket under the skin. And, you know, they say all roads lead to Rome, you know, all the veins, they go to the heart. So basically you get access to a large vein , uh, under the collarbone usually. And , uh, thread a couple of wires , uh, into the heart. And those wires , uh, have a little screw at the tip most of the times, and we can just , uh, you

Speaker 2: 6:06

Screw it in,

Speaker 3: 6:07

Put it into the heart muscle.

Speaker 2: 6:08

It does , and it stays

Speaker 3: 6:10

And it usually stays, it usually

Speaker 2: 6:12

Stay . Do , do you literally, like, okay, so you're standing next to this person, you got this wire down into their heart, you know, it's in there. Yes. Um , 'cause you use a , an an X-ray thing to guide you. Yes. Do you literally turn it, like screw it in?

Speaker 3: 6:23

Yes, yes. Uh, there are different types of wires , uh, and some of them we actually have to, there's little torque tool. We kind of extend these screw out. Uh, there are some wires which actually have exposed screw, and we just turn the whole wire into the heart muscle. Wow.

Speaker 2: 6:39

It's like a cork screw right into your heart there. Exactly. Okay. So you're going in right under the collarbone usually. And you said you put, you just put the battery then under the skin?

Speaker 3: 6:47

Yeah. So just connect the other end of the wire to this , uh, what they call pulse generator, which has the , uh, electronic circuit in there and the battery , uh, together. And just connect the wire and put it on the skin . Sew it up.

Speaker 2: 7:02

I've seen you do it, actually. And it is , to me, it's fascinating. It is like an hour procedure, so, so, right . Do they ever need to be replaced?

Speaker 3: 7:10

Yes. So, you know, the batteries, as I mentioned earlier , uh, nowadays, depending on of course, how much somebody is using it up, if somebody is , uh, dependent on the pacemaker a hundred percent of the times versus somebody's only using it intermittently still, most of the times the batteries end up blasting more than 10 years. Believe it or not. The longest battery life that I've seen is 29 years. So yes, they need to be replaced. If the battery is going down, we then change it and take the old one out and connect the wires to the new one. And the longest one I have , uh, personally seen is, has lasted 29 years.

Speaker 2: 7:51

You know , uh, my cell phone doesn't make it 29 hours. <laugh>, why don't they put that battery in the cell phone ? Does that make sense? Am I right or am I right? I think they should put the pacemaker battery in the cell phones .

Speaker 3: 8:01

Yes . It's, it's very complicated because as time passes by, we get more and more demanding and there's more and more data, right? So the older versions of pacemakers, they just had a simple function to keep the heart at a minimum rate that we program. The newer ones, they have a lot of additional functions. They store a lot of data. We communicate , uh, with these pacemakers more often. So the battery usage is of course more, but still, I think 10 to 14 years is a pretty decent timeframe. Wow . It's

Speaker 2: 8:32

Basically a little computer in there. 'cause you know, so you said you communicate with them? Yes . What do you mean? Yes, is this telepathy? <laugh> telepathy.

Speaker 3: 8:40

So essentially , uh, there's a little computer programmer which communicates with the pacemaker to tell us how much battery is in there, how the wires are functioning, has the person had any other rhythm problems, it stores the data. Uh, so it has a lot of , uh, that information. Plus the newer ones can also have some sort of , uh, communication with , uh, via Bluetooth to , to an app.

Speaker 2: 9:08

Yeah . Bluetooth app. Can it play my favorite songs ? That's what I want to know.

Speaker 3: 9:11

I don't think so. <laugh>

Speaker 2: 9:13

<laugh> . Okay. Let, let's shift now. What conditions would , uh, cause the need for a pacemaker?

Speaker 3: 9:19

Uh , a common indication is called complete heart block. Now, in general, when people talk about blockages in the heart, they're usually talking about plumbing system of the heart. You know, the arteries, when they get blocked, people get stents and the bypasses and that kind of stuff. Uh, but here we are talking about the electrical block in the heart. So normally heart has four chambers to top and to bottom. And the electrical impulse activates the top chambers first. Then that message goes down to the bottom chambers. So there are times when there can be a delay or there can be , uh, a disconnect , uh, with that connection between the top and the bottom chamber. And the top chamber wants the heart to beat at a certain rate, but the message would not go through. So in those scenarios, patients do benefit from a pacemaker. So the ,

Speaker 2: 10:19

The electrical circuit is blocked.

Speaker 3: 10:22

Exactly. Do you put

Speaker 2: 10:23

The lead then in the ventricles, the lower chamber?

Speaker 3: 10:26

Yes. So the wires then are put in the top chamber as well as in the bottom chamber. And essentially it functions as a connection between the top and the bottom, that it communicates the message to the bottom that, hey, the top chamber has done its job, now it's your turn. And that's in simplistic , uh, ways , if you can put it. There are other reasons where , uh, someone may need a pacemaker. As I mentioned, their heart rate may not have enough adequate response to exertion, so they can feel fatigued, extremely tired. Now, there are many other reasons people can get tired, but one of those reasons is if the heart rate does not increase appropriately in those scenarios, it's just too slow. It's just too slow.

Speaker 2: 11:10

Are there other conditions we've talked about heart block, bradycardia, although we haven't used that term. That's the slow heart rate. Yes . Anything else that you put pacemakers in?

Speaker 3: 11:17

Yes. So you might have heard of a condition called atrial fibrillation. In those scenarios , uh, the heart rate tends to go fast at some times , but there are some scenarios where the heart rate can also get slow. So now you are in a bind that, well, if I treat the fast heart rate with a medication that's gonna slow it down, the heart may slow down really low. Uh, at other occasion in those scenarios, again, preemptively, sometimes we end up putting a pacemaker in.

Speaker 2: 11:47

I'm hoping you'll come back for a future episode. 'cause I would love to delve into atrial fibrillation.

Speaker 3: 11:52

Yeah, happy to. Yeah,

Speaker 2: 11:53

We'll have, we'll have Dr. Kareem back to talk about that topic, which is, I think, the most common arrhythmia , uh, like in the world. So to sum up the conditions, it's various arrhythmias of the heart and arrhythmia is just a , a inappropriate rhythm, like heart block, bradycardia, too slow of heart, things like that. Sometimes in atrial fibrillation.

Speaker 3: 12:11

Yes, yes.

Speaker 2: 12:12

Excellent. So I think we've earned a break. Uh, listeners, when we come back, I'm gonna ask Dr. Kareem to talk a little bit about the statistics and impact of pacemakers worldwide. And then we're gonna talk a little bit about future directions in the electricity of your heart. We'll be right back

Speaker 4: 12:31

When Hennepin Healthcare says, we are here for life. They mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital, HCMC, and a network of clinics both downtown and across the West Metro. They provide all the primary care and specialty care you would expect to find, but did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis? Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 13:09

And we're back. I'm talking with Dr. Rehan Kareem . He is an electrophysiologist, which is the, a cardiologist who is the electrician of your heart, not the plumber, the electrician. Did you ever think you'd be an electrician? Rehan ? That's what you are. I've heard you describe yourself as that.

Speaker 3: 13:22

Yeah, that's, that's a good question. I, I had always wanted to go into electrophysiology. It was my passion.

Speaker 2: 13:29

It's actually a fascinating , um, subspecialty of cardiology. We've been talking about pacemakers, some of the reasons people get them and , and kind of the basics of what they are and what they do. Let's talk a little bit about the global impact of pacemakers. Do you have a sense for how commonly people have to have them place? I don't expect you to know the exact number, but roughly ,

Speaker 3: 13:49

Uh , in general, it is felt that , uh, in general population around 260, out of 100,000 people have pacemakers. But again, the prevalence varies by age. So if you have younger folks, between 18 to 65, 40 out of 100,000 would have it. But if you look at the older population, more than 75 years of age, actually almost 2,500 plus out of a hundred thousand , uh, people may end up , uh, having pacemakers.

Speaker 2: 14:21

So it's clearly a a you're more commonly doing it in older adults.

Speaker 3: 14:26

Yes, that is correct. You know, you can think of it this way that as time passes by, the electrical wiring tends to get worn out and may need some extra support. Oh,

Speaker 2: 14:35

That's a great way to look at it. Kinda like my house, which will probably burn down one day from all the old electron , the , the faulty wiring, if you will. So men and women, both generally older people. Yes. Talk us through a little, if you could then about the pros and cons, how successful it is in putting in it , and, and even like, what are some of the risks when you do it?

Speaker 3: 14:54

So as far as the success of putting in a pacemaker is concerned, it is in general considered a relatively straightforward procedure, and it's done very commonly throughout the world. So from that perspective, the immediate success rates are fairly high. It's, it's very, very uncommon that anyone who's wanting to have a pacemaker put in and they are unsuccessful in putting in a pacemaker. It's , it's very, it's extremely rare, but certainly it is an invasive procedure. So as with any invasive procedure, there are risks involved, and that's why , uh, risks and benefit come into play. So anyone who comes in there , my heart rate is slow. I want a pacemaker, and we don't put it in like that, right? We have to make sure that it's actually going to make any difference in that person's life and in symptoms. So risks involve risk of infection , uh, again , uh, as the time has passed by sterile techniques and , uh, more focus on cleanliness , uh, of the procedure itself and the operating rooms, the risk of infections are fairly low, but they're not zero , uh, risk of any damage to the tissue where you're putting it in , uh, damage to the blood vessels or the nerves, any bleeding. Now we are putting these wires inside the heart, which have a little screw on them. So there's always a rare chance of poking a hole , uh, in the heart, causing a little bleeding around may require a little drainage. But fortunately, it is extremely rare. Now, when we put these wires in, there can be slight risk that it can get dislodged or moved from its place. And that's why after putting 'em in, we usually warn patients to just keep the arm the sling for a few days and not to move it aggressively , uh, for some days because until the wire settles in place, it can get moved , you know, dislodged from its place where we may have to go back and unscrew and ew a different ,

Speaker 2: 17:02

Different place . Can I, I dig into that a little bit more. So you, you have somebody to keep your arm by your side, put it in a sling, and , and I, is it true they're not supposed to raise their arms above their heads and do pull-ups or serve a tennis ball or something like that? Yeah,

Speaker 3: 17:14

For a short period of time until it heals in place. After that, usually they're able to resume most of their routine activities.

Speaker 2: 17:24

What about what it feels like? So obviously, you know, there's a , you had something cut and put into your skin, so you know, you have a little discomfort at the place of that, like you would whenever your skin gets cut. Beyond that though, after those, that first week or two, do people even know they have them ? Is it uncomfortable in any way, shape, or form?

Speaker 3: 17:41

So most people don't even feel afterwards , uh, other than little pump there and a scar,

Speaker 2: 17:48

You can often feel it. Yeah , I feel it all the time. On patients in your left upper chest, usually, yeah .

Speaker 3: 17:52

Yes. But you know, as with any wound healing, every person heals differently. And there are rare circumstances where someone may have severe incisional pain or they may have scar bigger than usual. Some people tend to form keloids, some people may have some burning sensation at the scar for a longer period of time, but that's very, very rare. And that, again, as I said, everyone heals , uh, in a different manner. But for the most part, most people don't feel this. One other question that comes up is , uh, you know, do I feel shocking sensation with this pacemaker? Again, most of the times people don't feel any such sensation. There's a nerve that goes next to the heart. It helps us breathe. It's called phrenic nerve. It goes to the diaphragm. And there can be a rare circumstance where the wire can be closed to that and it can stimulate that nerve resulting in hiccup type of sensation. Now, when we put it in, we specifically test for it to make sure that it is,

Speaker 2: 19:02

You put it in there, you tickle their heart and see if they hiccup. Uh ,

Speaker 3: 19:05

Yes, we do, we actually do stimulate at a high output to make sure it is not close to the, to the nerve. I did that before , before we fixated in , in , in place. So

Speaker 2: 19:16

After they've had it placed, are there any risks with things like being extra microwave or going through airport security or metal detectors? What about that?

Speaker 3: 19:25

Yeah, the newer devices are really smart. So microwaves are not an issue unless you don't microwave yourself. But , uh, right ,

Speaker 2: 19:33

Right , right . But you can, you can cook your oatmeal on your ,

Speaker 3: 19:36

You can cook your oatmeal. That is , uh, that is not a problem As far as , uh, going through metal detectors is concerned, the patients do get an identification card saying the model number that they have a pacemaker or a defibrillator, whatever, implantable device. So when they go through airport security, they have to show and tell them that they have an implantable device. In general, most of the times it is okay, but just for certain safety reasons, it is always better to mention it to them and they go through a manual search.

Speaker 2: 20:08

What about an MRI? Because an MRI uses a magnet. This thing's metal, it's got metal wires. What about using, historically we haven't allowed people with pacemakers to have an MRI .

Speaker 3: 20:18

Has that changed ? That is correct. The older devices, that was a concern. The newer devices , uh, have a , a specific FDA labeling called MRI conditional. These are MRI . Conditional means if they meet certain conditions, those patients can have MRI at a certain power level of the MRI . So they need to be reprogrammed , uh, and they can get the MRIs done. Let's talk

Speaker 2: 20:43

About the future. So where do you see future developments in pacemaker technology?

Speaker 3: 20:48

Well, a lot of things have changed actually over last , uh, several years. Most recently, the advent of leadless pacemakers. So, you know, we talked about these wires, they're relatively easy to put in, but taking them out again involves a different set of risks. Uh , if someone gets infected for whatever reason, it is a bigger deal to have them taken out. So over last several years, they have come up with leadless pacemakers. So it's just looks literally like a bullet and it gets directly implanted into the heart without a wire in place. So they don't have any incision on the chest. It just goes directly through a , a vein in the leg, and through that, it gets directly implanted into the right ventricle.

Speaker 2: 21:35

Okay. I gotta ask into the right , I was gonna ask where <laugh> , where do you bury this thing in the right ventricle? That's not a very thick part of the heart.

Speaker 3: 21:43

Yes, it is not a very thick part of the heart.

Speaker 2: 21:45

The left side's the thick, beefy

Speaker 3: 21:47

Part. That is correct. And that's why when we put it in, we have to make sure that it is onto the wall in between the right and the left side. It cannot be on the free area because that's pretty thin

Speaker 2: 21:58

Wall. It has to be the wall between the two ventricles. That is fascinating. Is that ready for primetime? Are people using that or is that a down the road kind of a thing?

Speaker 3: 22:05

That has been out , uh, out and about for several years now.

Speaker 2: 22:09

Wow. I don't even think I was terribly aware of that one. So you do this and probably could do it in your sleep, putting wires and pacemakers in. And so for you it's never a big deal, but it is for the patients. Everything's always a big deal for the patients. I tell patients that all the time. They , they say, is this a risky thing? And or , and I said , the cardiologist, it's routine, but I know it's not for you. But that being said, you are putting wires in people and this pulse generator, why wouldn't everybody want this leadless model?

Speaker 3: 22:37

That's, that's a good question. That certainly is a possibility that anyone can get a leadless pacemaker. However, right now the way it is being done is that, let's say when the battery goes down, then you have to put a new one in. So then heart gets filled,

Speaker 2: 22:53

Filling up the heart with little metal little

Speaker 3: 22:55

Metals. Yes. When you asked earlier about the future directions, one other development that has , uh, happened and is really picking up a lot of his steam is , uh, what they call conduction system pacing. So when we put these wires in the heart, we don't randomly put it anywhere in the heart muscle, but we actually put it just onto or next to the normal electrical wiring of the heart. So you can think of it that the heart has electrical wiring, and the way it is made is the whole heart can beat in an effective manner. Now, when we artificially stimulate the heart from just anywhere, it may not be as effective of a synchrony, if you were to say. So the newer ones, we put the wire specifically next to the normal wiring of the heart. So that is getting more and more popular, and we are doing more and more of those types of devices. So the pacemaker is the same, but the wire is slightly different, and the place where it goes requires a little more precision about where exactly you wanna put in . And that has been shown to be more beneficial.

Speaker 2: 24:09

That's super cool. That's super cool. Many people have heard of ICDs, implantable cardioverter defibrillators. We've been talking about pacemakers that deal with arrhythmias of the heart, slow heart rates, complete heart rock . We're not gonna get totally into all the reasons for an ICD , but it's also a device that's implanted with wires in your heart. Could you give us just a little bit of a comparison of what the difference between those devices is ?

Speaker 3: 24:32

Yes, absolutely. So as I mentioned earlier, the sole purpose of a pacemaker is to prevent a slow heart rate or to treat a slow heart rate. The purpose of a defibrillator is to treat a very rapid heart rate, which could result in a cardiac arrest. So you can think of it two extremes. Very slow heart rate is treated by a pacemaker, but the purpose of a defibrillator is purely to shock the heart, or in certain scenarios, treat that rapid heartbeat just by a pacemaker function. But essentially, the pure purpose of the defibrillator, or ICD , is to treat a very rapid heartbeat or a cardiac arrest.

Speaker 2: 25:12

It's like an insurance policy against sudden cardiac death. Really,

Speaker 3: 25:15

You can think of it that

Speaker 2: 25:16

Yeah, that's kind of the clumsy, you know, high level weight . And we're we'll , uh, perhaps get Dr uh , Kareem on the show in the future to talk about that too. There's a lot of conditions , uh, involving the electrical conducting system of your heart. The heart is fascinating. It just is fascinating. It's, first of all, a chemical reaction that then leads to an electrical current, which then leads to a mechanical pump. It's an engineer's dream, actually <laugh> . All the engineers , uh, out there listening their heart , it has, has a mechanical and electrical and a chemical all put together. Before I let you go, Dr. Kareem , if you could give three tips to our listeners when they're thinking about pacemakers in their heart, what would you like them to remember?

Speaker 3: 25:52

The first and the foremost thing is that the pacemakers are there to treat your symptoms. So just do not go after a number of the heart rate. My heart rate is this slow. Now I'm gonna feel bad if someone is having symptoms with that slow heart rate, that is what pacemaker is supposed to do. So that's first thing to keep in mind. The second thing is, if needed, they can really make a big difference to someone's life and people can lead as normal of a life as possible with these pacemakers. Uh, the third thing is there are a lot of resources , uh, which are available if there are any questions. And the one that I would , uh, recommend strongly is Heart Rhythm Society is a , a National Society for Heart Rhythm Disorders, and it has a lot of resources. And there is a website for patients , uh, specifically it's called upbeat.org, U-P-B-E-A-T uh , dot org. It has , uh, a lot of information about heart rhythm disorders in general. So

Speaker 2: 27:01

We can put a link in our show notes to the upbeat.org at the Heart Rhythm Society. If you wanna learn more about your heart, I've been talking to Dr. Rahan , Kareem Electrophysiologist here at Hennepin Healthcare and a colleague of mine. I am not exaggerating listeners. I am not exaggerating when I say that if I needed an electrical procedure done on my heart or one of my loved ones, it is Dr. Kareem that I would send them to. He is as good as they come. And I just want to thank you for being on the episode

Speaker 3: 27:27

Today. Well , thank you so much, David, for having me here, and you're too generous.

Speaker 2: 27:31

No, I'm not. Thank you . He is truly the best electrophysiologist I know. Thanks for listening to episode 11 of the podcast. We have another one coming up in two weeks, and I hope you'll join us. And in the meantime, be healthy and be well.

Speaker 1: 27:44

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive Producers are Jonathan, CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.