The last couple years have been challenging for all health-care personnel.
Improving morale is something that I have worked on substantially in my practice.
Many of us could do more in appreciating our nurses.
Nurse retention is a problem everywhere.
I am married to an ICU nurse for some additional context.
A paper looking at this was published yesterday titled “10 areas for ICU clinicians to be aware of to help retain nurses in the ICU”.
The paper is free for you to download. I recommend you read the article for yourself. Hat tip to the authors.
Here are the 10 areas which are broken down in the paper.
1. Recognition, respect and value.
2. Role and responsibility
3. Intellectual stimulation and professional development
4. Teaching opportunities
5. Good leadership and management
6. Team work/collaborative practice
7. Clinical discussion and exchange.
8. Good work-life balance/wellness/rehumanizing the workplace
9. Psychological support
10. Humane care.
After reading the paper, let me know what you think!
Sending much love to all my nurse teammates.
CLICK HERE to learn why you should work in the ICU.
CLICK HERE to learn why you should NOT work in the ICU.
Learn how nurse familiarity helps save lives.

Citation for Appreciating Nurses

Vincent JL, Boulanger C, van Mol MMC, Hawryluck L, Azoulay E. Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU. Crit Care. 2022 Oct 13;26(1):310. doi: 10.1186/s13054-022-04182-y. PMID: 36229859.
Link to Article
Link to FULL FREE PDF

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Podcast Episode Script

Welcome to the Critical Care Summit.

Thank you so much for tuning in today. My name is Eddy Gutierrez but some of you may know me as Eddy Joe or eddyjoemd from my various social media accounts, website and the Saving Lives Podcast for which I am the creator and host. I am an intensivist with a passion for education and am proud to be giving the keynote presentation today. I welcome you to the Critical Care Summit by PESI. Aside from all the work I do to make critical care education free and accessible to our community, I actively work at the bedside as well. In fact, that’s what pays the bills. Everything else is just for fun. The institution where I work does not have medical students, residents, nor fellows. The nurse practitioners who work with me and I are directly in charge of the patients who we manage. In my practice I attempt to provide as much autonomy as possible to everyone who I work with. I’ve been out of training now for over 5 years and every day I strive to learn more. My goal is to bring as many of you along with me as we strive for excellence in caring for the critically ill patients who trust us with their lives. (1 minute).

The purpose of the summit is to learn from some of the country’s leading critical care experts. Experts who have worked hard to bring the best so you can provide the best care for your patients. Over the course of the next two days you’ll learn a wide range of concepts. Please forgive me if I mispronounce anyones name although with my last name being Gutierrez, I am used to it happening to me. I spent some time doing some homework on the speakers for this summit and it is easy for me to say that I am quite impressed. You all are in for a real treat.

Paul Langlois will be discussing emerging and current infectious diseases which seems very timely with flu season now approaching. I just got my flu shot last week.
Rebecca Bierle will be discussing Atrial Fibrillation and Cardiovascular Implantable Electronic Devices.
Robin Gilbert will be talking about stroke. Seems like she will leave no stone left unturned based on her program. Definitely exciting stuff.
Laura Gasparis Vonfrolio will be covering endocrine emergencies. She will be covering disorders of the pituitary, thyroid, and adrenal glands. In addition, pancreatic disorders will be discussed as well.
Heading back up to the brain, Filissa Caserta will be tinkering with intracranial pressures, going over tips and tricks of diagnosis and management.
Given my passion for hemodynamics, I am personally most excited for the presentation by Cyndi Zarbano who will be discussing cardiac output manipulations for hemodynamic stability.
Last but definitely not least, Pam Collins will be discussing Pitfalls in Nursing Documentation. For some context, my wife is a critical care nurse so she may sit down next to me while we watch her lecture. In this litigation-heavy society, we need to protect ourselves.

Today, I will be discussing a variety of topics within the current state of critical care medicine, and the future of our specialty that we love so much. I was asked to discuss critical care perspectives as the welcome session. This is an easy but yet challenging discussion considering what we have all been through together in the last couple years. I have been trying really hard to not discuss anything pertaining to the C word, but one cannot ignore the devastating ripple effect that it has left upon our community. There’s an elephant in the room and it needs to be discussed. We cannot look towards the future unless we address the pains and learn from the lessons of the past. There is no ICU throughout the country that has been spared. The first thing I would like to do is thank everyone who has stuck with us been in the trenches over the last 2+ years. I will not be getting into the weeds about covid as the topic will be discussed further later in the conference by Paul Langlois. (2 minutes)

That being said, I would like to start off with some good news. Better days are definitely ahead regarding COVID, at least in my opinion and this is supported by data. There is a significant amount of controversy regarding therapeutics in this pandemic. I will not be engaging in a discussion of these therapeutics. I will not state the name of the medication studied. But there is some good news hidden in the weeds of this recently published double blind, randomized, placebo-controlled trial. In fact, it was published on the 21st of October. I always try to bring the most current data to the table. The researchers looked at almost 1600 patients with mild to moderate COVID. Half got the study drug and the other half received a placebo. This study took place between the summer of 2021 up to February of 2022. This means that the waves taking place at the time were post-delta including Omicron. Amongst the baseline characteristics of the two groups one can see that more than half of the patients were unvaccinated. That’s a key point to bring up but not something I am going to dive into any further. (3 minutes)

The reason why I tell you about this study today is because out of almost 1600 patients who had documented COVID, only one passed away. This includes patients who received and didn’t receive the study drug. More than half were unvaccinated. Just 19 patients ended up in the hospital. This is great news for us because fewer patients will end up needing our assistance in the ICU’s. The percentages of death and hospitalization were much higher earlier in the pandemic with the first two waves. Hopefully, this trend will continue. I am a glass half full kind of guy so these data made me happy.

As the late queen Elizabeth stated “I hope in the years to come, everyone will be able to take pride in the way we responded to this challenge”.

there was a recent lecture given by Dr. Wes Ely from Vanderbilt at the CHEST 2022 conference where he described the last 50 years of critical care. He stated that from 1970 to 1995, we added machines such as ventilators to patients. then from 1995 to 2020, we learned how to get remove things as soon as possible without hurting patients. Since the pandemic, we went back to those first 25 years and it has damaged many of us. we started using versed gtts again. We saw the few patients who survived their prolonged ICU stays develop long-term cognitive impairments. (3 minutes)

I recently shared a paper written by the legendary Dr. Jean-Louis Vincent on my social media accounts. The paper was titled “Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU.” Retention has definitely been as issue, as well all know quite well. Who could blame those nurses who left to other facilities offering better pay and opportunities? There were nurses who came to speak to me prior to accepting travel assignments to explain why they were looking elsewhere for more financial resources. They were hoping I was not going to be mad at them. Although disappointed because I was going to miss their skills and talents, I supported their decision. The ability to rid themselves of debts and place themselves on a stronger financial footing is not an emotional decision, it’s an intelligent decision in my opinion. Institutions that retaliated against the nurses by telling them they wouldn’t be welcomed back was beyond disappointing. (4 minutes)

I have no trouble whatsoever admitting that, relatively speaking, the time I spent at the bedside during the last 2 1/2 years is microscopic compared to that spent by the nurses and respiratory therapists. Due to patient loads, I would have to see volumes of patients that will limit my ability to sit down with every patient for the amount of time that they normally would have received with me at the bedside. That time was instead spent by the nurse. Unfortunately, after several months and several waves we pretty accurately learned how to identify which patients were likely going to make it and which were not. It was hard to look these folks in the face while on maximum oxygen support, trying really hard to avoid intubation, and tell them that they need to keep fighting and they might be OK. The problem was that we knew well within our hearts, that they likely weren’t going to survive. (5 minutes)

Turns out that almost 67,000 people saw my post regarding the paper by Dr. Vincent and his colleagues. Many comments, as one could expect, came pouring in. Understandably, numerous individuals explained that the emotional trauma experienced caused them to leave the workforce. Some stated that they left their facilities thinking that the grass was greener on the other side but it really wasn’t. The main request made by those who saw the post was more money. That is honestly something entirely out of my control. I am not an administrator nor ever want to be an administrator. I love my patients too much. I love my staff too much, and I love the camaraderie of being the boots on the ground too much. The hospital is honestly the place where I go to socialize and see my friends. I’m going to use these 10 areas as pillars to this part of the talk, but ultimately I am going to describe my perspective on it. After all, these are real-world perspectives. (6 minutes).

The first of their 10 areas is in recognition, respect, value. Let me make this very clear. Physicians cannot do the jobs of nurses. My wife is a critical care nurse and, although the years kind of jade us, I am in awe by what she does regularly. This is not a dig or a slight at nurses and staff who do not work in the ICU, but I must admit I have my bias because of the environment in which I work. The ability to stay on top of the numerous components necessary to keep our critically ill patients alive is a skill that not everyone develops, nor has the ability to develop. The critical thinking skills associated with ICU nurses should be valued. Whenever a nurse tells me that they have a bad feeling about a patient, I immediately respond by going to the bedside. During rounds I frequently ask the nurses “what do you need from me to take better care of your patient?” I do not want to speak on behalf of the nurses but I have been told that, us as physicians, trusting their intuition and addressing their needs immediately makes them feel more integral to the team. The times where I disagree with their assessment is met with education and discussion. We are all wrong from time to time anyway. (7 minutes)

The second area described is role and responsibility. One of the components of my practice is allowing for as much autonomy as possible. This applies to the nurse practitioners, respiratory therapists and nurses who I have the opportunity to work with. The development of protocols that promote their autonomy have been met with open arms. No one wants to be micromanaged nor does anyone want to have to notify the person putting in orders numerous times an hour of interventions. I believe Cyndi Zarbano will be discussing hemodynamics later in the conference so I will defer to her expertise but protocols exist to allow the nurses autonomy when it comes to fluid responsiveness. Protocols would allow for fluid challenges to assess for changes in stroke volume followed by the initiation of vasopressors in patients who are hypotensive and no longer fluid responsive. Electrolyte protocols, sedation protocols, vasopressor titration are all within this autonomy that you all need. (8 minutes)

Continued education, such as what you are all here for today, brings a certain excitement when you’re able to implement the skills you have learned at the bedside. The third area in the paper is intellectual stimulation and professional development. Once again, I have to resort to my bias, but the staff caring for ICU patients are the ones most hungry for knowledge. It pleases me greatly when I have stragglers joining in during my multidisciplinary rounds to see if they learn something new. ICU nurses by default are a curious, ambitious bunch. Many are looking to go to CRNA school or become NP’s. So I frequently find them chit chatting about what they learned and how their patient is being managed. This natural curiosity allows growth. It always puts a smile on my face when I see a fantastic nurse have his or her first shift as a charge nurse. I often tell them they were chosen for that role because they can handle it after they confess their doubt and trepidation towards the assignment. (9 minutes)

Teaching opportunities should be plentiful for our nurses. As high as turnover unfortunately is, there is no shortage of new, hungry minds who want to be more educated. Actually, I take that back, there is a shortage, but not something that I will address here today. But I should also emphasize that, at times, physicians need to be educated by nurses as well. It is challenging to put into words an appropriate assessment of how many times my butt was saved during my formative years by nurses in the ICU. Fond memories of crunching my brain alongside the night shift nurses during residency flow into my mind. One could spot those nurses who have worked hard to grow their education skills. They become a resource for the ICU and everyone goes to them to have their questions answered. (14 minutes).

Good leadership and management is the 5th area described. In my opinion, one will get the best out of the staff if the leaders have a positive, approachable demeanor. As the saying goes, you’ll get more bees with honey than with vinegar. But the most respected leaders I noted during the last couple years were those who were in the trenches with the team rather than those hiding in their offices. Those who put on the PPE to help prone patients and were constantly lending a hand. In addition, leaders who fail to accept feedback are destined to fail. There’s a book by ex-Navy Seal Jocko Willink titled “Extreme Ownership” that I would recommend anyone who has leadership or management aspirations. It’s also a great book to listen to as the authors read it themselves.

Teamwork/collaborative practices is the next area. Daily, I encourage the nurses and team to come up with strategies to better care for the patient. But this also includes the ability to voice concerns. If something is felt to be unsafe, it needs to be said. Is there a bad feeling that the patient is too unstable for CT? It needs to be said. This leads us into the next area being clinical discussion and exchange. In fact, it is kind of the same and could all be lumped into one.

The next several areas can also be lumped together. Good work-life balance/wellness/re-humanizing. Over the last two years we have all lost something of ourselves. At NTI this year I was asked how I’ve personally been able to stay motivated throughout the pandemic. I answered by stating that we each have a calling in our lives and our calling is to take care of the critically ill. The pandemic has given each and every one of us involved in caring for patients the opportunity to step up. A challenge presented itself. We stepped up and did the best we can. Despite all the tragedy we have seen, it has given us the ability to shine and persevere. Many have been left feeling unrecognized and undervalued not to mention under compensated. Part of the reason for that is because unless you’re in the ICU’s, people don’t know what we have been through. We have to be very proud of ourselves for enduring what we have endured, and showing up every day to take care of our patients and our communities.

As crappy as many of us have felt, we need to remain proud of ourselves. This was a time in history where most people ran away from a situation but we ran into the fire to take care of our communities. At the end of the day, if we can’t take care of these patients, no one else can. No one else has the skill set that we have. Do we need psychological support, which coincidentally is the ninth area where physicians can help our nurses? Absolutely. A suggestion in the paper is for physicians to debrief after challenging cases that do not go well. This will be implemented in my ICU’s moving forward.

Humane care is the last area but definitely not the least important. There’s a significant amount of moral injury that takes place in the ICU’s. This moral injury happens to us. We all know about those patients who have no business being alive and they’re being kept alive by their families. The things we do to them only prolong suffering instead of letting them go to their next life. At the end of the day we are all humans who will one day reach the end of this one glorious life we live. We all wish for ourselves and loved ones that we will fade into the sunset in peaceful sleep but this is not necessarily the case. The rest of society does not deal with death the way we do. Thankfully, they don’t have to. We often complete dreaded prolonged family discussions where the only thing that is advanced is our ability to tolerate frustration. We feel like we are doing something inhumane.

Unfortunately, I have no solutions here. This is just the way it is. The best we can do is have the previously mentioned psychological support to help us overcome the emotional rollercoaster we live regularly. Adding to the lack of humane care in my opinion were families not being able to be with their loved ones as they passed to the next life. I watch so many nurses pulling up a chair and holding the hand of patients they just met as they took their last breath. That was absolutely demoralizing for all of us. (18 minutes)

Next Step: Fix What is currently broken.

It is my opinion that the next step in critical care is to replenish what we have unfortunately lost. What good is new technology if we do not have the personnel to operate, interpret, manage, and care for the patients? We need to reward, motivate and incentivize our teammates who have stuck with us. After all, they are the most influential recruiters towards our field. I know this is much easier said than done but it needs to be a priority. Meme accounts on instagram, for example, have hundreds of thousands of followers who are constantly exposed to solely the negative components of our field. Should students from all disciplines see this and not understand that it is a venting mechanism, they will likely change careers. I often see local nursing schools come by with groups of nursing students to knock out some clinical bedside hours. If the nurses training them are upset, angry, frustrated, burned out, it will not lead those young, bright-eyed nursing students to want to pursue critical care. The emotional toll and moral injury on some will never be recovered. We’ve noted that. But we need to continue to support our teammates. This includes all facets of the healthcare system. The foundation and structure of critical care is based upon the team. If the team is not fulfilled, there is no cathedral. (19 minutes)

Staying up to date

Let’s switch gears as it’s time to start talking about the importance of staying up to date with the evidence and practices. It’s a pillar of our growth and future. I know I am preaching to the choir here as you all are dedicating your time and financial resources to attend this summit. One of the reasons why I have been as successful as I am, not bragging or anything, on social media is because I have harnessed my academic curiosity in a way that helps many others do the same. You see, like most of you, I did not receive robust training on how to read medical journal articles. I honestly found it overwhelming and time consuming at first. I started reading daily because it is my duty and obligation to provide the best care possible for my patients. But after reading many articles, one can recognize that they have a certain ebb and flow about these publications. After reading papers that pertain to ones specialty or a topic of interest, one will start noting little tidbits of valuable information and how to extract that knowledge.

In the content I create, whether it be a quick post, an addendum to my blog, or a whole podcast or youtube episode, I work hard to bring an unbiased analysis of the relevant data in a concise, easy to understand manner. What you all don’t know is that I am basically trying to explain it to myself. You’re just being brought along in the journey.

The future of critical care medicine starts with education. Social media, webinars, youtube, and online conferences have been normalized. Those who are coming out of school and training have grown accustomed to finding reliable sources for education on these platforms. Yes, there are people who are up to no good, but we’re here to celebrate those have opened new ways of educating both locally, nationally, and internationally. No longer is the bulk of education taking place at the Universities. We’re out there seeking and creating it ourselves. Much of it is also either free or very accessible.

As an example of something that’s taking place that you likely have no idea about, recently, there have been numerous studies looking at the microbiome. You know, the billions or trillions of microorganisms that co-exist on us. The microbiome could help us guide therapies moving forward as we’re digging deep into the microbiome of the lung and gut. Animals studies have show that making modifications to the gut microbiome could improve the mortality from sepsis. It took rats eating the poop of other rats to find this out but it’s fascinating nonetheless. These cutting edge concepts will be at the bedside sooner rather than later. (21 minutes)

Upcoming Technology

There is a significant amount of technology being researched to assist us in caring for the critically ill patients. I will not highlight one specific technology over another as I am privy to knowledge that I am not allowed to discuss. My conflicts of interest will also not let me disclose additional information on the topic. That being said, as much as we despise our respective electronic medical records, they have the power to capture extensive amounts of data from our patients. All of a sudden, instead of data from just one hospital, they are able to capture data from numerous, if not hundreds of institutions in the form of registries. Skepticism aside, these data could be analyzed to tease out how to better care for patients. Many of us have heard the term “machine learning” over the course of the last couple years. Artificial intelligence, known as AI for short, honestly scares me but there are people working on ways to harness this to help us better care for patients.

Other technologies that we may see at the bedside include bioadhesives. Wearable ultrasound imaging devices are being looked into. I’m personally curious as to how this could work as they are particularly studying the lungs, carotid artery, and abdomen. Sensors, circuits, and radios for the skin are also being studied. These are implemented via patches or sub-dermal applications. Hopefully these technologies could assist us in those holy grail questions such as volume status that leave us so often perplexed. An example of that is when people say the patient is volume overloaded but intravascularly dry. I never quite know what that means. One of the best parts of these upcoming technologies is that they seem to have a goal of being non-invasive meaning they do not cause the patients any pain. (23 minutes)

Switching gears again

Next up, let’s discuss some concepts that we should have a deep understanding about for our every day practice. It’ll be easier to think about the future if we thoroughly understand what we are working with today. Let’s optimize current practice starting off with optimizing fluid boluses. The first thing I really like for the culture to change with, is to stop giving fluid boluses by hanging a liter of fluid on the IV pole, and hitting 999 on the pump. Moving forward, I would like everyone to understand that this is not a true fluid bolus if we were to give said liter by hitting 999 on the pump. If we are to provide fluid boluses, it should be done via appropriate tubing, pressure bags, or other devices that increase the rate of infusion. There are several reasons why I am asking you to do this. At the same time, I know that it is not possible to give fluids via a pressure bag in certain parts of the hospital per policy. I also know that physicians need to order the fluid boluses to be provided outside of the IV pump.

I obviously do not feel that changes like this could be done overnight, but it is something that I am already implementing at my hospital in certain units. The first reason for this is extravasation of IV fluids. We have to keep in mind that the IV fluids that we administer in the patient’s intravascular space does not necessarily stay there. For example, if I were to give you 1 L of IV fluids , how much do you think would stay in the intravascular space? Studies have been done on healthy volunteers where they have found that 68% of the fluids provided to them have extravasated within one hour. Now the numbers get worse in critically ill patients. Due to the patient is having leaky capillaries and vasodilation, they end up extravasating 80% of the fluids they receive. Also, of that fluid, they extravasated 50% of it in just 20 to 30 minutes! Keep this number in mind as it will be relevant shortly when I talk about fluid responsiveness. I am aware that we are not rats, but data has shown that less than 5% of the IV fluids infused into septic rates remained in the intravascular space after three hours. Due to similar responses to sepsis, we can expect the same with our patients. (25 minutes)

The second reason is because of fluid responsiveness. Have you ever given fluids and not seen it make a difference in the the hemodynamics of our patients? I know I have. But fluid responsiveness is not defined as an increase in MAP after the fluids are provided. After all, we need to ask ourselves what is the purpose of giving IV fluids? Well, the purpose of giving fluids is to increase cardiac preload and therefore cardiac output. We need to remember a very simple formula in hemodynamics that can help our minds realize what we are trying to do.

Slides here.

There are multiple definitions for fluid responsiveness. They include a change in stroke volume, cardiac index, cardiac output by 10% or more. In the correct situation we can use pulse pressure variation and stroke volume variation. We can also do it with a bedside echo. There are other more esoteric ways to determine fluid responsiveness that is outside of the scope of this keynote talk.

So if we were to give a patient a liter bolus by hitting 999 on the pump, this would mean that the patient would receive that whole liter (which I do not regularly recommend giving) over the course of an hour. Do you think the fluid given at this rate, given what you know about extravasation, will be given fast enough to change the stroke volume of the patient? I certainly do not think so.

There’s also technology that we use every day that I am not sure we understand how it works. I know that in the ICU we pay really close attention to blood pressure. We try to aim for certain goals when it comes to hypertension and hypotension. More often than not, our hearts race when it comes to hypotension. After all, patients who are in shock will not survive unless we address the underlying etiology and provide them with appropriate vasopressors. Guidelines such as the surviving sepsis guidelines tell us that we have a MAP target of 65 or greater for patients who are in septic shock. Nurses work their butts off to titrate vasopressors to this magical number. In all of our training we learned that the formula for MAP is MAP = DP + 1/3(SP – DP). Something I have seen over the years of my practice is that we do not know which number to trust on the monitor. This is why I feel we need to have a deeper understanding of how our oscillometric blood pressure cuffs work.

Delirium (3 minutes)

Switching gears yet again, let’s talk a bit about delirium. Here we are going to look into the future and a new study that came out just a few weeks ago. Wes Ely, the physician who I mentioned earlier in this talk is a champion on delirium and minimizing the harm we do to patients. He and his team published a paper recently, in July of this year to be exact, where they boldly state that delirium should not longer be an issue in the future. I must admit that I was quite excited but at the same time skeptical of this. We all know the validated tools and therapies that exist for delirium prevention. But can we take it a bit further?

The authors put together this schematic of how we should design our ICU’s moving forward. As beautiful as it may seem, I feel it is quite unrealistic. Patio’s and fresh air all sound great, but I feel we have bigger issues to tackle in our immediate future such as nursing ratios and compensation. Not to mention that the last two years have put quite the hit on the finances of the vast majority of hospitals in the country. We can’t reconstruct all our ICU’s to look like this.

Thinking on a smaller, more local scale, we all take care of patients with delirium on a regular basis. As much as we try to avoid delirium in our patients by giving them their eyeglasses, hearing aids, having family around, opening up the blinds, etc. it still happens. Just last month there was a study published in the NEJM looking at haloperidol, which we all call Haldol for delirium in ICU patients. The primary endpoint was days alive and out of the hospital at 90 days. The consensus when I discussed this study on social media was that the endpoint should have been nurses and staff who were not punched or kicked because of haldol. That’s not a typical endpoint, of course. These patients often received demedetomidine as an adjunct to either placebo or haldol. Around 30% of patients in both groups received benzodiazepines, but we all know that we should avoid benzodiazepines at all costs in delirium. I personally only use them when I really need to advocate for the safety of the staff.

I recall a mistake I made in residency where I gave a milligram of ativan to a very elderly patient in the ICU who was sundowning. He was ready to leave the ICU the following day. Well, my ignorant mistake prolonged his ICU stay by several days when he went into hypoactive delirium. Significant resources went into CT scans, EEG’s, and other testing to ensure that nothing structural was going on with the patient. After being appropriately reprimanded, I learned quick to avoid benzodiazepines in these patients, especially the elderly.

They enrolled almost a thousand patients into this study. When it was all said and done, there was no statistically significant difference in the primary endpoint. When taking apart the composite endpoint, there is a statistically significant difference in mortality alone in patients receiving haldol. This is interesting but the authors did not emphasize this very much. There were no other difference in all the secondary endpoints. That being said, I am not going to stop using haldol in my patients. These data make clear that it doesn’t help the primary outcome, but the reason why many of us use it is to calm our patients down who are a threat to themselves and our staff when they unfortunately develop delirium.

delirium 3 minutes

Acute pancreatitis

New data has come out about fluids in acute pancreatitis.

I want to take the last part of this talk to discuss lactate. I feel that there’s a large misconception about lactate that we need to clear up.