October 24, 2022 • 29 mins
Stellate Ganglion Block (SGB)—a medical procedure that effectively treats symptoms associated with posttraumatic stress disorder (PTSD)—is an injection of local anesthetic in the neck to temporarily block the cervical sympathetic chain which controls the body’s fight-or-flight response. 💉🚫🏃♀️🏃♂️
SGB has been safely used for over 80 years for many other reasons but was discovered ten years ago to provide relief of PTSD symptoms as well. 🕰️⚕️ Since that time, along with a handful of other physicians, I have pioneered the use of SGB for treating posttraumatic stress within the US Army. 🎖️🇺🇸 Due to its safety, success rate, and rapid onset of relief, SGB has gained wide acceptance in several locations at US military hospitals where it has been available. 🏥🌍
Check out more information about SGB and its applications here: https://www.drjameslynch.com/ 💻🔬
#trauma #ganglion #PTSD #treatment #therapy #cptsd #psychotherapy #neurology #Vasovagal #anxiety #nervoussystem #neuroscience Find more at: Taproot Therapy Collective
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
laying down on the couch
hi it's Joel with the chapter therapy
Collective podcast and today I sat down
with Dr James Lynch and talked to him
about the surgical intervention for
trauma uh you heard me right at surgery
not uh therapy
(00:24):
where the subcortical brain is regulated
through injecting an aesthetic into the
ganglia he's the doctor not me so I'll
let him take that away but this is if
you want to look it up a process called
the stellate ganglion block that we're
(00:44):
talking about which can help patients of
PTSD and Trauma disorders
learn to
regulate emotion and control the
symptoms of that disorder
here with Dr Lynch and he's going to
tell us about the stellate ganglion
process which is like a surgical
intervention for trauma and some other
(01:07):
things too but we're kind of interested
in its application for trauma here
um and it probably would be funniest if
I just explain how I think that it works
as a non-uh neurosurgeon and then you
can tell me you can correct where I'm
wrong but you're welcome to do that sure
go ahead Joel thanks for having me yeah
so the Gang like even the base of the
(01:28):
brain you start to have the brain
churning into the brain stem and
connecting to the body and a lot of that
is where trauma responses are stored so
if you drill in between like the C6 and
C7 vertebrae and inject anesthesia into
those roots of how the body is learned
to physically hold emotion and Trauma
then it
relaxes them and makes them be
(01:50):
reprogrammed is that is that right
yeah I love that you gave me that to uh
to start off with so
um this may be helpful and then stop me
if I ramble because I think in my
experience I've been doing Steely
ganglion block now for over 10 years
um as an adjunct to trauma focused
(02:11):
therapy it's been very helpful in
patients with severe anxiety as well
pardon me but it's one of my favorite
things to talk about because when you
hear about what it is that we're doing
and why it just makes total sense and
the fact that we hadn't figured this out
much longer goes is a little bit
puzzling so the first thing is the
(02:31):
stelic ganglion block it's a very very
simple procedure
um it's an ultrasound guided procedure
that's done without a whole lot of
fanfare frankly it's been around for 100
years
so when people hear that they're usually
fascinated at the hang on a second this
is not something new no not at all it's
been around since the 1920s what's new
(02:52):
is the application of using this
procedure that's been around for quite
some time as a as a procedure used in
pain medicine primarily the the new part
when I say new I mean really in the past
10 to 12 years it's been applied to
treating essentially in over stimulated
sympathetic nervous system and that's
exactly what it is so the stellate
(03:13):
ganglion block is really refers to a
nerve block using simple local
anesthetics so and I'm only laughing
because you did use the word drill so I
just want to remember honestly there's
no drilling involved in a procedure
takes literally a few minutes
um with a needle about the size of like
a coveted shot or a flu shot and most
(03:34):
people don't describe it as painful at
all they say it feels a little bit weird
and when it's over most people just say
that's it that's all there is to it
again so and I think we're doing this on
video but the procedure was performed
100 Years Ago by just touching next to
the neck there's a bone here at the C6
vertebrae and then injecting along your
finger a local anesthetic and that been
(03:55):
done like that for for many many years
way before the Advent of ultrasound
technology or fluoroscopy on thousands
of people for pain conditions very
successfully with very few risks so
about 12 years ago or so a few of us
myself and my partner Dr Sean Mulvaney
who are the two Founders here at the
Stellian Institute in Annapolis Maryland
(04:16):
really started uh
adopting this and researching it
um in the military and that's that's
really where both of our roots go
although both of us are now since
retired from the US Army
um but we take care of the trauma
survivors from all backgrounds initially
what what we ran into was primarily
combat related trauma
(04:37):
um based on the population of people we
served with but we have since learned
over time that that in no way is the
only type of trauma background that the
study ganglion block can be helpful for
but just to give you that again over the
over 10 years ago when we discovered
this there was a report kind of a random
report in the literature of someone that
(04:58):
was shot
um at a close range and had severe pain
from gunshot wounds to the shoulder was
treated with this procedure
um for pain the Stella ganglion block at
that time this was a young woman who had
severe PTSD developed from this assault
as Could Be Imagined but was
(05:18):
completely unable to participate in
therapy because of the amount of pain or
distress psychological pain that she was
having that she couldn't even couldn't
even go in the door of the
psychotherapist meanwhile she was
debilitated with her with her trauma her
traumatic injury after the study
ganglion blocks series she received her
(05:39):
uh mood changed dramatically and she
became much more willing to engage in
Psychotherapy as her anxiety symptoms
were dialed down so that's really what
started but but what the heck is the
Stella gaming Block doing that if we're
not drilling drilling holes in anything
we're literally placing a numbing
medicine called ropivicane alongside a
(05:59):
nerve in the neck
but for it to make sense it has to you
have to understand what the nerve is so
a lot of people who are in in this area
understand polyvagal Theory and
understand the vagus nerve which
controls the parasympathetic nervous
system and it lies also in the neck both
sides of the neck within the Carotid
sheath just outside of the Carotid
sheath in the neck is a nerve called the
(06:19):
cervical sympathetic chain or cervical
sympathetic trunk and this is the
easiest way to describe it to my
patients or other people when I'm first
describing it so I hope this will make
sense but there are areas within the
brain where the body stores threat
responses many of your listeners know
this and understand whether it's the the
amygdala the prefrontal cortex there are
several connections within the brain
(06:41):
where
um fear and threat centers and memories
are stored there's also several areas in
the body that regulate or
um that feel the effects of the
sympathetic nervous system so for the
the obvious ones like the heart the
lungs the muscles the sweat glands all
these things are connected through a
(07:01):
series of Connections in the body a
series in the brain and all of them come
together in a simple single nerve in the
neck called the cervical sympathetic
trunk that's the only thing that nerve
does is it carries signals in two
directions body to brain brain to body
and that's it and that nerve essentially
can become dysfunctional in some people
(07:21):
and by that I mean is that from an
environmental thing like a trauma
happens and then that stores some
information about how to communicate
with the body in a way that isn't
helpful yeah I think so I think we're
supposed to get stuck it it's what's
interesting is what um what it takes to
to get that nerve to stop working
properly could be anything so for some
(07:43):
people it's a single traumatic event
that has that traumatic experience can
be enough to take what's essentially a
circuit right because it's going through
so we're talking brain to body body to
brain if there's something that
conditions then a fear or a threat
response in the brain it then
automatically triggers the body to
respond a certain way so you can imagine
(08:04):
that if there is some insult I'll just
say or some experience that causes that
cycle to become dysfunctional where it's
all of a sudden now feeding back on each
other you can end up with a sympathetic
nervous system that's inappropriately
elevated or inappropriately stimulated
that comes the issue that we're
targeting with this particular procedure
(08:24):
it's the thing that
I think that's where the cognitive
therapy breaks down is where that
response that's causing panic is coming
from the body and we're trying to
control it totally mind of the matter
but there's a negative feedback loop
where my body is agitated so my brain is
stressed now my brain is stressed it's
making my body more agitated and leaving
(08:45):
the body out of it doesn't treat the
trauma a lot of the time no I think
that's the point too and something
that's probably worth noting right now
is I I never um have and never do
consider the study ganglion blocks some
Standalone therapy and you may run
across from providers it'll say you know
I do this procedure and this will ensure
your anxiety or cure your PTSD or
(09:06):
something like that that's not that's
not really the case and some people
might say that
um what I what I believe is what can
happen is this dysfunctional connection
between the brain the body becomes a
barrier it's allowing you it just won't
let you past it and and what you know
hundreds of my patients over the past 10
years have described as going to therapy
(09:27):
um and just not being able to break
through or more importantly I think are
the therapists I've worked with over the
years who say I just can't make the
progress in there because the person is
just my client is just not calm enough
in their body to make the things that I
need to do or what would normally take
three years in therapy following the
Stella ganglion block can now take you
(09:49):
know three to six months or something
because we have now taken essentially
these two areas of the sympathetic
nervous system and uncoupled them
learning how to talk
yeah and then so that's an interesting
point because for many people the the
effects of the study getting their block
are uh immediate meaning within minutes
(10:11):
um just in the exam room
um the way the procedure is done is in
an outpatient clinic you don't have to
go to a hospital or be in a fancy
surgical Suite done under fluoroscopy in
fact it's done quite safe
more safely under bedside ultrasound and
that's something that we do here at the
Stelling Institute you know every day
just
someone lying on the on a patient exam
(10:34):
table under ultrasound guidance locating
all the critical anatomy in the neck and
then really a simple ultrasound guided
injection
um with a tiny little needle that most
people feel very little at all they say
it feels a little bit weird and then
within recovery within a few minutes in
the recovery stage people will notice
(10:54):
things and many will actually report
a physiologic release of something and
it's interesting because a lot of times
it's hard to verbalize but it's not
uncommon at all for people to get quite
emotional
um even people who haven't cried in many
many years May sometimes feel emotions
well up or feel a release of some type
of attention
um that's what I was going to ask is
(11:15):
because with we use uh I I'm not a
practitioner of the physical therapy but
we work with ones that have an Roi sign
so we can talk and they kind of feed
back into each other but Rolf massage or
myofascial release where it's not a fun
massage that's rubbing the sore place
but you're kind of trying to rip the
fish and make the body unlearn how to
hold an emotion those after there's
(11:37):
significant progress people just have
emotional flooding of older stuff that's
now leaving brain spawning same thing I
mean my experience was I'd been in five
different kinds of therapy you know they
did different things but then 30 minutes
of looking at a pointer with brain
spotting I felt this thing under my life
and my body that I had been trying to
turn off my whole life that I had not
(11:57):
ever looked at that closely consciously
and then I could not turn it off and
there was two or three days of real raw
emotional stuff and then it was out you
know so I was wondering when you hit
that does that start to what's the next
couple days look like does creativity
come back online or is there more of an
intuitive I mean do you notice patterns
in what people report
yeah that's a great question
(12:18):
um so there's two things I guess as we
in terms of the the science behind the
symptoms that people have reported these
are things we've published in in
peer-reviewed literature that can be
found on the website
um the actual symptoms you know using
DSM-5 criteria for things those things
are on there the thing that's not I
think is when you sit in the room for
some with somebody after the procedure
and we just have some quiet music
(12:40):
playing and I sit in there and I just
allow people to relax and I tell you
know sometimes I I'm not a therapist so
I don't I don't pretend to be a
therapist but I'll just encourage people
to let their their brains go if they've
been trained in relaxation techniques I
I help you know
um reinforce that that's a good time to
do that whether it's belly breathing or
other things
(13:00):
um and then the the themes that people
will will report are actually quite
interesting just that day and
um the words that people will use to
describe the feeling after a Stella
ganglion block are things like light or
calm or more clear many people describe
their they feel instant and immediate
calm and their muscles relax and some
(13:22):
type of a a calm come over their entire
body so a physiologic thing as well as
that mental thing people also know a
Clarity of thinking that one is still
intrigues me but people will use the
different words to describe it as if
the swirling thoughts in their heads
have now calmed down or they can now
just concentrate and think on one topic
(13:43):
without
balls bouncing around inside their head
and these are kind of immediate
um immediate things that people describe
what I think over the course of the next
few days that many many have reported
back to me is the things that would
normally upset you might still be there
and I think this is important because it
reinforces the point that this procedure
(14:03):
is not a magical wand and it could be
anything right it could be the slow
driver in the left lane it could be you
know your kid drop or a plate and a loud
noise or something those things will
probably still bother you but what the
block may do is uncouple that immediate
and autonomic or automatic response that
you couldn't control before so that you
(14:24):
would always just go zero to 60 if
something happened and you had no
control over that it was completely
reflexive for you what most emotional
responses happening before is thought
even it's happening before conscious
language-based prefrontal cortex
thoughts so it's not something that you
could sit and have insight into to make
it go away no and I think that's you
(14:44):
know to your question I think that's the
thing that's interesting is people will
then feel farmed and able to actually
deflect that which is interesting and
that people use different words to
describe that like I got a little bit of
headspace I got a little bit of leg room
back I got just enough time where I
don't have to fly off the handle and and
so I'll realize this is something that
(15:04):
would really upset previously but it
seemed to be fine right now and those
could be other things like just being in
a public place or you know the example
comes up all the time I'm you know going
to a restaurant and maybe not having to
have your back to the wall now or a loud
noise you may maybe don't respond the
same way
um so it's I look at it as something
(15:26):
that allows the um the automatic
uncoupling of the body and the Brain
through the sympathetic nervous system I
I do think that people that have had
deep-seated issues for long periods of
time there's also a learning effect that
happens and I think you said something
earlier that made me made me think of
that
um some people do very very well
automatically feeling much better and to
(15:49):
give that a number what we typically see
is a 50 decrease in symptoms using
whether it's a Gad 7 or pcl5 type score
50 drop in symptoms
um some people feel so good that they
feel uncomfortable and I think that
that's worth noting there some people
are saying oh my God I haven't felt this
good in so long it feels weird and then
that's where they work with their
therapist to kind of get get used to
(16:10):
this new
period or new phase of kind of
unlearning some of those safety
responsive if I'm feeling good then
that's bad because it's going to be
taken away as soon as I'm feeling good
I'm going to be punished you know that
you get and some trauma in the body
symptoms calm down there's probably a
more conscious Panic response of oh no
this is bad I'm not allowed to feel like
(16:31):
that yeah there's I and I think that's a
good point and I think that's really one
of the key things is for me not a
therapist she does the procedure It's
always important to me that I that I
reinforce hey we we should try to tee
this up so that you have an appointment
with your therapist within the week or
so afterwards and I think that's
critical it allows people to just you
know do this as a as a team not just
(16:51):
you know some doctor somewhere off in
Maryland is doing his own thing so I
really welcome them and I find
um that a critical component is if I'm
working with new therapists that are not
familiar with the block I I'm happy to
take a phone call or an email or
something just to work through like okay
what's a what's a good way to um to do
this as a team yeah they're integrative
(17:13):
uh approach is so important I mean
that's one of the things that we work
with I mean 90 of the calls that we get
we're never going to see those people's
patients but we make sure that they're
going to get where they need we don't
provide ketamine we don't provide
medication we don't provide neurosity
and we don't provide Stella gang on
blocking we don't provide different
kinds of massage and one day maybe I'd
like to but you know with the massage
(17:33):
and some other things but we're able to
figure out what you need do you need one
or two you know if you're going to do
brain spotting let's get you with a Rolf
massage person if ketamine or neurostom
or Stella ganglion is better I mean one
the podcast is helpful because we can
just send the interview with the
provider to the person in there hearing
it I'm not just giving my impression
badly of what I remember
(17:54):
but the issue we've run in was still
like England is just that their people
do it here but they won't do it for
trauma they want to do it for
fibromyalgia and pain uh Phantom Pain
disorders but they won't screen the
patient and see them for trauma they
don't have a protocol for that or use it
yeah yeah it's too bad it's so that's
(18:15):
probably one of the most important
things to say about the whole
um the whole topic for anyone who's
listening to this that's saying hey this
sounds like a pretty good deal why
haven't I heard of this before there's a
there's a complicated answer to that
question but certainly one of the
barriers is the fact that insurance does
not pay for this procedure for
um behavioral health issues and
(18:35):
it's a significant barrier yeah
depending on where you look around the
country a lot of people charge somewhere
around three thousand dollars for the
procedure at our at our Clinic here in
Annapolis Maryland which is right
outside Baltimore and DC we charge
twelve hundred dollars and we both
myself and my partner Dr Mulvaney were
the probably fair to say the
(18:58):
um
if not the two most experienced two of
the most experienced in the procedure in
the world um were the ones that have
written published most of the original
research on this over the past 10 years
and when I retired from the Army I came
here specifically to join up with him so
that we could form a center of
excellence having said all that you know
we we try to make the procedure Within
(19:19):
Reach and I think that 1200 procedure is
not within reach for many many people it
isn't that's fair and
um
anywhere though I mean I was seeing
three and four thousand when I was
looking at different places yeah you'll
see that amount of money and I think
other providers will do it under
fluoroscopy in an or Suite some will use
sedation which we do not do here nor do
(19:41):
we believe that that's necessary in fact
believe that that has harm associated
with it so so we don't and and like I
said we've done more than anybody else
and we
um we spent a lot of time with our
patients is the other thing I think most
places you go and you get a procedure
you talk talks for a couple of minutes
and
um I like to spend you know close to an
(20:02):
hour with my my patients when they come
because I think if you're going to come
and have uh some Precision some provider
do a procedure like this like you you
want to you want to get their experience
you want to hear from them you want an
opportunity to ask questions you want to
uh you know I don't think at least
that's what I think spending an hour
with a doctor is not common I mean your
(20:22):
psychiatrist it's easy for three minutes
and writes a script when they hear
anxiety three times you know and it yeah
so it's not their fault all the time I
mean the industry realities in the
industry that are not good forced
changes and doctors and providers that
weren't you know it's not always their
fault yeah no I think you're right Joel
and when you're limited to insurance and
the all the the wickets that happen like
(20:44):
that you're kind of shoved into a hole
so in until insurance covers this
um we'll continue to do what we're doing
and then I guess the silver lining of
that is we can take as much time as we'd
like and provide the type of
personalized care as we can without
someone you know whipping us like like
the rest of the medical community for
right now so I guess can people push the
(21:07):
AMA and the APA to to try and enforce
provider insurance providers to cover it
to say that this is what's needed I mean
there's this view that you know you have
cognitive therapy and CBT just take over
in the 80s and the 90s and a lot of it's
your reaction to you know psych analysis
takes 20 years we don't want to pay for
that we want something faster but I mean
you do have this attitude that will the
(21:29):
body is a go-kart that carries the brain
around if your body's sick go to the
doctor if your brain is sick or the
therapist or the psychiatrist and that
just isn't how it works I mean the
Neuroscience we have now is like it's in
the interplay between those things and
the emotion and the cognitive so I mean
how fast do you see that changing and
what's the best way to kind of Lobby the
this unhealthy system to to be different
yeah I love I love it I spent so in the
(21:52):
in the 10 years or so that I've been
doing the procedure so I'm a full-time
clinician you know I'm I'm seeing
patients all day every day
um we are still conducting research
because we believe Dr Mulvaney and I
both believe that you're going to be
relevant you got to keep doing keep
studying what you don't keep making it
better so we're currently doing a
randomized control trial with Ohio State
University right now that we're paired
(22:13):
with for a study that we're currently
doing we got more you know in the in the
shoot and then really the advocacy piece
has been a major piece for me
um went earlier on when I was in the
military the advocacy was was designed
for military active duty military and
the veteran population
um and it's been you know pushing Iraq
uphill for 10 years frankly it's just
(22:35):
trying to change large organizations
what's available what's covered but I
think we made some gains within that
community so there are VA hospitals who
will offer the Stella gangling block at
no cost to Veterans it's just not that
many of them they're kind of sprinkled
around the country they have kind of
mixed
(22:55):
um
mixed experience levels and it comes up
a lot so we do take care of veterans and
Military who who don't have access to
those will come to see us as well but
but to me the the now that I've been you
know focused a lot on on the other eight
million trauma survivors in the U.S is
(23:15):
how do we how do we get that offered
um you know across the board and I just
think
to answer your question how do we best
do it I think what you're doing right
now you know spreading the word raising
awareness with uh you know a podcast is
helpful I think that patients that are
that may have influence talking to the
right people might help I just am a
(23:36):
little jaded at this point that it's
just a glacial process yeah and although
it doesn't make any sense to me that
that a procedure that's been safely
performed for 100 years that costs very
little money and it's very safe when
performed by the right people and has an
immediate impact why that wouldn't be
covered compared to all the other things
that insurance pays for that doesn't
(23:57):
make any sense
um it's just I'll just keep pushing the
advocacy and awareness piece and
hopefully the right people will catch
attention to get the the reimbursement
piece caught out to us well and I think
it is more of a philosophical fear maybe
than even a practical one that there's
these that if you start to rethink about
medicine in this way that the
(24:17):
environment is a bigger variable than
how does one how do you research it
because there's too many variables and
it's too big and we want something where
we can get it small and research it easy
um but then also you're you're saying
that medicine needs to be more
integrative than it is and that I think
that's a threat to a lot of um different
parts of the occurrences
yeah it is it is it's also just not what
(24:38):
people are accustomed to I'm learning in
my practice in North Carolina I had
um I had an office I had right outside
my office two psychologists and a social
worker and and we talked regularly and
and um that's not the case where I am
now in Maryland so I've made efforts to
try to build those type of relationships
and bridges with Community providers
(24:58):
around the state
um but it's definitely not what people
are accustomed to or or what we're used
to doing so uh but I don't care we'll
keep trying to do that and I think um I
think people like it I think that
clinicians who want to take care of
people
um I think more and more are starting to
see that hey this is okay teamwork's
(25:18):
okay I don't have to have all the
answers myself it's okay to reach across
the aisle and ask someone from a
different discipline to weigh in on
stuff and and that's my hope at least is
that that will
um hit a Tipping Point at some point and
and people will become much more
comfortable with reaching outside their
discipline to do something that maybe
they weren't trained of in their in
(25:39):
their training but it's the kind of
thing that they realize now there's
plenty of evidence to support
well I want to be respectful of your
time I know you need to hop off I just I
mean I guess to close we'll link to the
website and everything so people can can
find you on your research but I mean if
somebody's sitting there with trauma and
they're trying to decide between
ketamine which is IV ketamine is
expensive and not covered by Insurance
(26:01):
Stella ganglion you know neurosem is
expensive and not covered by Insurance
brain spawning if the provider knows a
lot and has a bunch of the somatic
training then they're probably expensive
maybe I mean that's the cheapest option
but it's still an investment I mean
where do I start what do I do if I yeah
looking at these new exciting things
that's a good question I think so to
(26:21):
answer this part if you're interested in
Stella ganglion block and you just have
a lot more questions for sure look at
our website which I think you'll
probably post up on a graphic I guess
but it's it's thus Stella institute.com
all one word.com
um on it are there's a whole slew of
testimonials that I think are helpful
for the personal story but there's also
full text Journal articles of all the
(26:42):
all the research that we published on
the evidence Tab and then on the FAQ
page we try to answer literally all the
frequently asked questions we get and
then there's videos in there too and
there's they're all on YouTube as well
but the videos are to answer your
questions are a little bit more you know
sophisticated that you can't answer in a
little three-line sentence so I would
(27:02):
encourage people to do their homework
because I I think it matters and I think
if it's the right it sounds like the
right thing for you if you're a
therapist looking at your client saying
hey I think this person could really
benefit from this and then coming back
to see me in therapy
um hopefully a lot of the answers to
your questions are on that website as
far as how to get scheduled
um at our place we take either two
(27:24):
things some people will refer themselves
which is fine
um in terms of Acts success preferably
if there's a therapist who is a client
to refer I would love to do that receive
that from you we have a simple referral
form that's on our website as well if
you scroll through the instructions
there's a hyperlink to a simple form
when in doubt old school is fine with me
(27:46):
and I'm happy to take a take an email
um or a phone call with hey how do I
make this work but to try to answer all
those questions we loaded it all up in
kind of a contact us piece on our
website to answer those things as far as
trying to decide which other modality to
do that's the million dollar question I
have people that come that have tried
(28:07):
everything or they're in the process of
trying any everything the only advice
I'd have is
um is if you're methodical about that
what what can I try now to see if it
makes a difference and then give it a
little bit of time so you're not
stacking things up together and I I have
some people that will come and they say
well I'm in the middle of a ketamine
treatment I'm doing this I'm adding this
(28:28):
and I think that's okay like I'm happy
to help you but I think when it's when
you get better you're going to want to
know which one it was that really helped
um although having said that sometimes
it just turns out to be a whole slew of
things or a combination of things so
um I wish I could give a better answer
that because I think that's a good
question and part of the the
(28:49):
um the research that we're doing right
now is to try to answer that question
which is we feel fairly comfortable
still getting in Black works okay got it
now what does it work best with how do
we combine it with certain things so I
think that's the next phase of what
we're doing in research-wise
well it's fascinating and I don't want
to make you run late but I really
appreciate your time and um hopefully
(29:11):
um and maybe if there's questions or
something we can do a part two I don't
know um how much uh
but we'll we'll see where it goes but I
really appreciate it thank you so much
Joel appreciate your interest and thanks
for what you do yeah thank you all right
so that was our interview with Dr James
Lynch if you want to uh check out more
information on him you can go to his
website which is Dr James Lynch
(29:34):
l-y-n-c-h.com again that's Dr James
lynch.com and thank you for listening
laying down on the couch
hi it's Joel with the chapter therapy
Collective podcast and today I sat down
with Dr James Lynch and talked to him
about the surgical intervention for
trauma uh you heard me right at surgery
not uh therapy
(00:24):
where the subcortical brain is regulated
through injecting an aesthetic into the
ganglia he's the doctor not me so I'll
let him take that away but this is if
you want to look it up a process called
the stellate ganglion block that we're
(00:44):
talking about which can help patients of
PTSD and Trauma disorders
learn to
regulate emotion and control the
symptoms of that disorder
here with Dr Lynch and he's going to
tell us about the stellate ganglion
process which is like a surgical
intervention for trauma and some other
(01:07):
things too but we're kind of interested
in its application for trauma here
um and it probably would be funniest if
I just explain how I think that it works
as a non-uh neurosurgeon and then you
can tell me you can correct where I'm
wrong but you're welcome to do that sure
go ahead Joel thanks for having me yeah
so the Gang like even the base of the
(01:28):
brain you start to have the brain
churning into the brain stem and
connecting to the body and a lot of that
is where trauma responses are stored so
if you drill in between like the C6 and
C7 vertebrae and inject anesthesia into
those roots of how the body is learned
to physically hold emotion and Trauma
then it
relaxes them and makes them be
(01:50):
reprogrammed is that is that right
yeah I love that you gave me that to uh
to start off with so
um this may be helpful and then stop me
if I ramble because I think in my
experience I've been doing Steely
ganglion block now for over 10 years
um as an adjunct to trauma focused
(02:11):
therapy it's been very helpful in
patients with severe anxiety as well
pardon me but it's one of my favorite
things to talk about because when you
hear about what it is that we're doing
and why it just makes total sense and
the fact that we hadn't figured this out
much longer goes is a little bit
puzzling so the first thing is the
(02:31):
stelic ganglion block it's a very very
simple procedure
um it's an ultrasound guided procedure
that's done without a whole lot of
fanfare frankly it's been around for 100
years
so when people hear that they're usually
fascinated at the hang on a second this
is not something new no not at all it's
been around since the 1920s what's new
(02:52):
is the application of using this
procedure that's been around for quite
some time as a as a procedure used in
pain medicine primarily the the new part
when I say new I mean really in the past
10 to 12 years it's been applied to
treating essentially in over stimulated
sympathetic nervous system and that's
exactly what it is so the stellate
(03:13):
ganglion block is really refers to a
nerve block using simple local
anesthetics so and I'm only laughing
because you did use the word drill so I
just want to remember honestly there's
no drilling involved in a procedure
takes literally a few minutes
um with a needle about the size of like
a coveted shot or a flu shot and most
(03:34):
people don't describe it as painful at
all they say it feels a little bit weird
and when it's over most people just say
that's it that's all there is to it
again so and I think we're doing this on
video but the procedure was performed
100 Years Ago by just touching next to
the neck there's a bone here at the C6
vertebrae and then injecting along your
finger a local anesthetic and that been
(03:55):
done like that for for many many years
way before the Advent of ultrasound
technology or fluoroscopy on thousands
of people for pain conditions very
successfully with very few risks so
about 12 years ago or so a few of us
myself and my partner Dr Sean Mulvaney
who are the two Founders here at the
Stellian Institute in Annapolis Maryland
(04:16):
really started uh
adopting this and researching it
um in the military and that's that's
really where both of our roots go
although both of us are now since
retired from the US Army
um but we take care of the trauma
survivors from all backgrounds initially
what what we ran into was primarily
combat related trauma
(04:37):
um based on the population of people we
served with but we have since learned
over time that that in no way is the
only type of trauma background that the
study ganglion block can be helpful for
but just to give you that again over the
over 10 years ago when we discovered
this there was a report kind of a random
report in the literature of someone that
(04:58):
was shot
um at a close range and had severe pain
from gunshot wounds to the shoulder was
treated with this procedure
um for pain the Stella ganglion block at
that time this was a young woman who had
severe PTSD developed from this assault
as Could Be Imagined but was
(05:18):
completely unable to participate in
therapy because of the amount of pain or
distress psychological pain that she was
having that she couldn't even couldn't
even go in the door of the
psychotherapist meanwhile she was
debilitated with her with her trauma her
traumatic injury after the study
ganglion blocks series she received her
(05:39):
uh mood changed dramatically and she
became much more willing to engage in
Psychotherapy as her anxiety symptoms
were dialed down so that's really what
started but but what the heck is the
Stella gaming Block doing that if we're
not drilling drilling holes in anything
we're literally placing a numbing
medicine called ropivicane alongside a
(05:59):
nerve in the neck
but for it to make sense it has to you
have to understand what the nerve is so
a lot of people who are in in this area
understand polyvagal Theory and
understand the vagus nerve which
controls the parasympathetic nervous
system and it lies also in the neck both
sides of the neck within the Carotid
sheath just outside of the Carotid
sheath in the neck is a nerve called the
(06:19):
cervical sympathetic chain or cervical
sympathetic trunk and this is the
easiest way to describe it to my
patients or other people when I'm first
describing it so I hope this will make
sense but there are areas within the
brain where the body stores threat
responses many of your listeners know
this and understand whether it's the the
amygdala the prefrontal cortex there are
several connections within the brain
(06:41):
where
um fear and threat centers and memories
are stored there's also several areas in
the body that regulate or
um that feel the effects of the
sympathetic nervous system so for the
the obvious ones like the heart the
lungs the muscles the sweat glands all
these things are connected through a
(07:01):
series of Connections in the body a
series in the brain and all of them come
together in a simple single nerve in the
neck called the cervical sympathetic
trunk that's the only thing that nerve
does is it carries signals in two
directions body to brain brain to body
and that's it and that nerve essentially
can become dysfunctional in some people
(07:21):
and by that I mean is that from an
environmental thing like a trauma
happens and then that stores some
information about how to communicate
with the body in a way that isn't
helpful yeah I think so I think we're
supposed to get stuck it it's what's
interesting is what um what it takes to
to get that nerve to stop working
properly could be anything so for some
(07:43):
people it's a single traumatic event
that has that traumatic experience can
be enough to take what's essentially a
circuit right because it's going through
so we're talking brain to body body to
brain if there's something that
conditions then a fear or a threat
response in the brain it then
automatically triggers the body to
respond a certain way so you can imagine
(08:04):
that if there is some insult I'll just
say or some experience that causes that
cycle to become dysfunctional where it's
all of a sudden now feeding back on each
other you can end up with a sympathetic
nervous system that's inappropriately
elevated or inappropriately stimulated
that comes the issue that we're
targeting with this particular procedure
(08:24):
it's the thing that
I think that's where the cognitive
therapy breaks down is where that
response that's causing panic is coming
from the body and we're trying to
control it totally mind of the matter
but there's a negative feedback loop
where my body is agitated so my brain is
stressed now my brain is stressed it's
making my body more agitated and leaving
(08:45):
the body out of it doesn't treat the
trauma a lot of the time no I think
that's the point too and something
that's probably worth noting right now
is I I never um have and never do
consider the study ganglion blocks some
Standalone therapy and you may run
across from providers it'll say you know
I do this procedure and this will ensure
your anxiety or cure your PTSD or
(09:06):
something like that that's not that's
not really the case and some people
might say that
um what I what I believe is what can
happen is this dysfunctional connection
between the brain the body becomes a
barrier it's allowing you it just won't
let you past it and and what you know
hundreds of my patients over the past 10
years have described as going to therapy
(09:27):
um and just not being able to break
through or more importantly I think are
the therapists I've worked with over the
years who say I just can't make the
progress in there because the person is
just my client is just not calm enough
in their body to make the things that I
need to do or what would normally take
three years in therapy following the
Stella ganglion block can now take you
(09:49):
know three to six months or something
because we have now taken essentially
these two areas of the sympathetic
nervous system and uncoupled them
learning how to talk
yeah and then so that's an interesting
point because for many people the the
effects of the study getting their block
are uh immediate meaning within minutes
(10:11):
um just in the exam room
um the way the procedure is done is in
an outpatient clinic you don't have to
go to a hospital or be in a fancy
surgical Suite done under fluoroscopy in
fact it's done quite safe
more safely under bedside ultrasound and
that's something that we do here at the
Stelling Institute you know every day
just
someone lying on the on a patient exam
(10:34):
table under ultrasound guidance locating
all the critical anatomy in the neck and
then really a simple ultrasound guided
injection
um with a tiny little needle that most
people feel very little at all they say
it feels a little bit weird and then
within recovery within a few minutes in
the recovery stage people will notice
(10:54):
things and many will actually report
a physiologic release of something and
it's interesting because a lot of times
it's hard to verbalize but it's not
uncommon at all for people to get quite
emotional
um even people who haven't cried in many
many years May sometimes feel emotions
well up or feel a release of some type
of attention
um that's what I was going to ask is
(11:15):
because with we use uh I I'm not a
practitioner of the physical therapy but
we work with ones that have an Roi sign
so we can talk and they kind of feed
back into each other but Rolf massage or
myofascial release where it's not a fun
massage that's rubbing the sore place
but you're kind of trying to rip the
fish and make the body unlearn how to
hold an emotion those after there's
(11:37):
significant progress people just have
emotional flooding of older stuff that's
now leaving brain spawning same thing I
mean my experience was I'd been in five
different kinds of therapy you know they
did different things but then 30 minutes
of looking at a pointer with brain
spotting I felt this thing under my life
and my body that I had been trying to
turn off my whole life that I had not
(11:57):
ever looked at that closely consciously
and then I could not turn it off and
there was two or three days of real raw
emotional stuff and then it was out you
know so I was wondering when you hit
that does that start to what's the next
couple days look like does creativity
come back online or is there more of an
intuitive I mean do you notice patterns
in what people report
yeah that's a great question
(12:18):
um so there's two things I guess as we
in terms of the the science behind the
symptoms that people have reported these
are things we've published in in
peer-reviewed literature that can be
found on the website
um the actual symptoms you know using
DSM-5 criteria for things those things
are on there the thing that's not I
think is when you sit in the room for
some with somebody after the procedure
and we just have some quiet music
(12:40):
playing and I sit in there and I just
allow people to relax and I tell you
know sometimes I I'm not a therapist so
I don't I don't pretend to be a
therapist but I'll just encourage people
to let their their brains go if they've
been trained in relaxation techniques I
I help you know
um reinforce that that's a good time to
do that whether it's belly breathing or
other things
(13:00):
um and then the the themes that people
will will report are actually quite
interesting just that day and
um the words that people will use to
describe the feeling after a Stella
ganglion block are things like light or
calm or more clear many people describe
their they feel instant and immediate
calm and their muscles relax and some
(13:22):
type of a a calm come over their entire
body so a physiologic thing as well as
that mental thing people also know a
Clarity of thinking that one is still
intrigues me but people will use the
different words to describe it as if
the swirling thoughts in their heads
have now calmed down or they can now
just concentrate and think on one topic
(13:43):
without
balls bouncing around inside their head
and these are kind of immediate
um immediate things that people describe
what I think over the course of the next
few days that many many have reported
back to me is the things that would
normally upset you might still be there
and I think this is important because it
reinforces the point that this procedure
(14:03):
is not a magical wand and it could be
anything right it could be the slow
driver in the left lane it could be you
know your kid drop or a plate and a loud
noise or something those things will
probably still bother you but what the
block may do is uncouple that immediate
and autonomic or automatic response that
you couldn't control before so that you
(14:24):
would always just go zero to 60 if
something happened and you had no
control over that it was completely
reflexive for you what most emotional
responses happening before is thought
even it's happening before conscious
language-based prefrontal cortex
thoughts so it's not something that you
could sit and have insight into to make
it go away no and I think that's you
(14:44):
know to your question I think that's the
thing that's interesting is people will
then feel farmed and able to actually
deflect that which is interesting and
that people use different words to
describe that like I got a little bit of
headspace I got a little bit of leg room
back I got just enough time where I
don't have to fly off the handle and and
so I'll realize this is something that
(15:04):
would really upset previously but it
seemed to be fine right now and those
could be other things like just being in
a public place or you know the example
comes up all the time I'm you know going
to a restaurant and maybe not having to
have your back to the wall now or a loud
noise you may maybe don't respond the
same way
um so it's I look at it as something
(15:26):
that allows the um the automatic
uncoupling of the body and the Brain
through the sympathetic nervous system I
I do think that people that have had
deep-seated issues for long periods of
time there's also a learning effect that
happens and I think you said something
earlier that made me made me think of
that
um some people do very very well
automatically feeling much better and to
(15:49):
give that a number what we typically see
is a 50 decrease in symptoms using
whether it's a Gad 7 or pcl5 type score
50 drop in symptoms
um some people feel so good that they
feel uncomfortable and I think that
that's worth noting there some people
are saying oh my God I haven't felt this
good in so long it feels weird and then
that's where they work with their
therapist to kind of get get used to
(16:10):
this new
period or new phase of kind of
unlearning some of those safety
responsive if I'm feeling good then
that's bad because it's going to be
taken away as soon as I'm feeling good
I'm going to be punished you know that
you get and some trauma in the body
symptoms calm down there's probably a
more conscious Panic response of oh no
this is bad I'm not allowed to feel like
(16:31):
that yeah there's I and I think that's a
good point and I think that's really one
of the key things is for me not a
therapist she does the procedure It's
always important to me that I that I
reinforce hey we we should try to tee
this up so that you have an appointment
with your therapist within the week or
so afterwards and I think that's
critical it allows people to just you
know do this as a as a team not just
(16:51):
you know some doctor somewhere off in
Maryland is doing his own thing so I
really welcome them and I find
um that a critical component is if I'm
working with new therapists that are not
familiar with the block I I'm happy to
take a phone call or an email or
something just to work through like okay
what's a what's a good way to um to do
this as a team yeah they're integrative
(17:13):
uh approach is so important I mean
that's one of the things that we work
with I mean 90 of the calls that we get
we're never going to see those people's
patients but we make sure that they're
going to get where they need we don't
provide ketamine we don't provide
medication we don't provide neurosity
and we don't provide Stella gang on
blocking we don't provide different
kinds of massage and one day maybe I'd
like to but you know with the massage
(17:33):
and some other things but we're able to
figure out what you need do you need one
or two you know if you're going to do
brain spotting let's get you with a Rolf
massage person if ketamine or neurostom
or Stella ganglion is better I mean one
the podcast is helpful because we can
just send the interview with the
provider to the person in there hearing
it I'm not just giving my impression
badly of what I remember
(17:54):
but the issue we've run in was still
like England is just that their people
do it here but they won't do it for
trauma they want to do it for
fibromyalgia and pain uh Phantom Pain
disorders but they won't screen the
patient and see them for trauma they
don't have a protocol for that or use it
yeah yeah it's too bad it's so that's
(18:15):
probably one of the most important
things to say about the whole
um the whole topic for anyone who's
listening to this that's saying hey this
sounds like a pretty good deal why
haven't I heard of this before there's a
there's a complicated answer to that
question but certainly one of the
barriers is the fact that insurance does
not pay for this procedure for
um behavioral health issues and
(18:35):
it's a significant barrier yeah
depending on where you look around the
country a lot of people charge somewhere
around three thousand dollars for the
procedure at our at our Clinic here in
Annapolis Maryland which is right
outside Baltimore and DC we charge
twelve hundred dollars and we both
myself and my partner Dr Mulvaney were
the probably fair to say the
(18:58):
um
if not the two most experienced two of
the most experienced in the procedure in
the world um were the ones that have
written published most of the original
research on this over the past 10 years
and when I retired from the Army I came
here specifically to join up with him so
that we could form a center of
excellence having said all that you know
we we try to make the procedure Within
(19:19):
Reach and I think that 1200 procedure is
not within reach for many many people it
isn't that's fair and
um
anywhere though I mean I was seeing
three and four thousand when I was
looking at different places yeah you'll
see that amount of money and I think
other providers will do it under
fluoroscopy in an or Suite some will use
sedation which we do not do here nor do
(19:41):
we believe that that's necessary in fact
believe that that has harm associated
with it so so we don't and and like I
said we've done more than anybody else
and we
um we spent a lot of time with our
patients is the other thing I think most
places you go and you get a procedure
you talk talks for a couple of minutes
and
um I like to spend you know close to an
(20:02):
hour with my my patients when they come
because I think if you're going to come
and have uh some Precision some provider
do a procedure like this like you you
want to you want to get their experience
you want to hear from them you want an
opportunity to ask questions you want to
uh you know I don't think at least
that's what I think spending an hour
with a doctor is not common I mean your
(20:22):
psychiatrist it's easy for three minutes
and writes a script when they hear
anxiety three times you know and it yeah
so it's not their fault all the time I
mean the industry realities in the
industry that are not good forced
changes and doctors and providers that
weren't you know it's not always their
fault yeah no I think you're right Joel
and when you're limited to insurance and
the all the the wickets that happen like
(20:44):
that you're kind of shoved into a hole
so in until insurance covers this
um we'll continue to do what we're doing
and then I guess the silver lining of
that is we can take as much time as we'd
like and provide the type of
personalized care as we can without
someone you know whipping us like like
the rest of the medical community for
right now so I guess can people push the
(21:07):
AMA and the APA to to try and enforce
provider insurance providers to cover it
to say that this is what's needed I mean
there's this view that you know you have
cognitive therapy and CBT just take over
in the 80s and the 90s and a lot of it's
your reaction to you know psych analysis
takes 20 years we don't want to pay for
that we want something faster but I mean
you do have this attitude that will the
(21:29):
body is a go-kart that carries the brain
around if your body's sick go to the
doctor if your brain is sick or the
therapist or the psychiatrist and that
just isn't how it works I mean the
Neuroscience we have now is like it's in
the interplay between those things and
the emotion and the cognitive so I mean
how fast do you see that changing and
what's the best way to kind of Lobby the
this unhealthy system to to be different
yeah I love I love it I spent so in the
(21:52):
in the 10 years or so that I've been
doing the procedure so I'm a full-time
clinician you know I'm I'm seeing
patients all day every day
um we are still conducting research
because we believe Dr Mulvaney and I
both believe that you're going to be
relevant you got to keep doing keep
studying what you don't keep making it
better so we're currently doing a
randomized control trial with Ohio State
University right now that we're paired
(22:13):
with for a study that we're currently
doing we got more you know in the in the
shoot and then really the advocacy piece
has been a major piece for me
um went earlier on when I was in the
military the advocacy was was designed
for military active duty military and
the veteran population
um and it's been you know pushing Iraq
uphill for 10 years frankly it's just
(22:35):
trying to change large organizations
what's available what's covered but I
think we made some gains within that
community so there are VA hospitals who
will offer the Stella gangling block at
no cost to Veterans it's just not that
many of them they're kind of sprinkled
around the country they have kind of
mixed
(22:55):
um
mixed experience levels and it comes up
a lot so we do take care of veterans and
Military who who don't have access to
those will come to see us as well but
but to me the the now that I've been you
know focused a lot on on the other eight
million trauma survivors in the U.S is
(23:15):
how do we how do we get that offered
um you know across the board and I just
think
to answer your question how do we best
do it I think what you're doing right
now you know spreading the word raising
awareness with uh you know a podcast is
helpful I think that patients that are
that may have influence talking to the
right people might help I just am a
(23:36):
little jaded at this point that it's
just a glacial process yeah and although
it doesn't make any sense to me that
that a procedure that's been safely
performed for 100 years that costs very
little money and it's very safe when
performed by the right people and has an
immediate impact why that wouldn't be
covered compared to all the other things
that insurance pays for that doesn't
(23:57):
make any sense
um it's just I'll just keep pushing the
advocacy and awareness piece and
hopefully the right people will catch
attention to get the the reimbursement
piece caught out to us well and I think
it is more of a philosophical fear maybe
than even a practical one that there's
these that if you start to rethink about
medicine in this way that the
(24:17):
environment is a bigger variable than
how does one how do you research it
because there's too many variables and
it's too big and we want something where
we can get it small and research it easy
um but then also you're you're saying
that medicine needs to be more
integrative than it is and that I think
that's a threat to a lot of um different
parts of the occurrences
yeah it is it is it's also just not what
(24:38):
people are accustomed to I'm learning in
my practice in North Carolina I had
um I had an office I had right outside
my office two psychologists and a social
worker and and we talked regularly and
and um that's not the case where I am
now in Maryland so I've made efforts to
try to build those type of relationships
and bridges with Community providers
(24:58):
around the state
um but it's definitely not what people
are accustomed to or or what we're used
to doing so uh but I don't care we'll
keep trying to do that and I think um I
think people like it I think that
clinicians who want to take care of
people
um I think more and more are starting to
see that hey this is okay teamwork's
(25:18):
okay I don't have to have all the
answers myself it's okay to reach across
the aisle and ask someone from a
different discipline to weigh in on
stuff and and that's my hope at least is
that that will
um hit a Tipping Point at some point and
and people will become much more
comfortable with reaching outside their
discipline to do something that maybe
they weren't trained of in their in
(25:39):
their training but it's the kind of
thing that they realize now there's
plenty of evidence to support
well I want to be respectful of your
time I know you need to hop off I just I
mean I guess to close we'll link to the
website and everything so people can can
find you on your research but I mean if
somebody's sitting there with trauma and
they're trying to decide between
ketamine which is IV ketamine is
expensive and not covered by Insurance
(26:01):
Stella ganglion you know neurosem is
expensive and not covered by Insurance
brain spawning if the provider knows a
lot and has a bunch of the somatic
training then they're probably expensive
maybe I mean that's the cheapest option
but it's still an investment I mean
where do I start what do I do if I yeah
looking at these new exciting things
that's a good question I think so to
(26:21):
answer this part if you're interested in
Stella ganglion block and you just have
a lot more questions for sure look at
our website which I think you'll
probably post up on a graphic I guess
but it's it's thus Stella institute.com
all one word.com
um on it are there's a whole slew of
testimonials that I think are helpful
for the personal story but there's also
full text Journal articles of all the
(26:42):
all the research that we published on
the evidence Tab and then on the FAQ
page we try to answer literally all the
frequently asked questions we get and
then there's videos in there too and
there's they're all on YouTube as well
but the videos are to answer your
questions are a little bit more you know
sophisticated that you can't answer in a
little three-line sentence so I would
(27:02):
encourage people to do their homework
because I I think it matters and I think
if it's the right it sounds like the
right thing for you if you're a
therapist looking at your client saying
hey I think this person could really
benefit from this and then coming back
to see me in therapy
um hopefully a lot of the answers to
your questions are on that website as
far as how to get scheduled
um at our place we take either two
(27:24):
things some people will refer themselves
which is fine
um in terms of Acts success preferably
if there's a therapist who is a client
to refer I would love to do that receive
that from you we have a simple referral
form that's on our website as well if
you scroll through the instructions
there's a hyperlink to a simple form
when in doubt old school is fine with me
(27:46):
and I'm happy to take a take an email
um or a phone call with hey how do I
make this work but to try to answer all
those questions we loaded it all up in
kind of a contact us piece on our
website to answer those things as far as
trying to decide which other modality to
do that's the million dollar question I
have people that come that have tried
(28:07):
everything or they're in the process of
trying any everything the only advice
I'd have is
um is if you're methodical about that
what what can I try now to see if it
makes a difference and then give it a
little bit of time so you're not
stacking things up together and I I have
some people that will come and they say
well I'm in the middle of a ketamine
treatment I'm doing this I'm adding this
(28:28):
and I think that's okay like I'm happy
to help you but I think when it's when
you get better you're going to want to
know which one it was that really helped
um although having said that sometimes
it just turns out to be a whole slew of
things or a combination of things so
um I wish I could give a better answer
that because I think that's a good
question and part of the the
(28:49):
um the research that we're doing right
now is to try to answer that question
which is we feel fairly comfortable
still getting in Black works okay got it
now what does it work best with how do
we combine it with certain things so I
think that's the next phase of what
we're doing in research-wise
well it's fascinating and I don't want
to make you run late but I really
appreciate your time and um hopefully
(29:11):
um and maybe if there's questions or
something we can do a part two I don't
know um how much uh
but we'll we'll see where it goes but I
really appreciate it thank you so much
Joel appreciate your interest and thanks
for what you do yeah thank you all right
so that was our interview with Dr James
Lynch if you want to uh check out more
information on him you can go to his
website which is Dr James Lynch
(29:34):
l-y-n-c-h.com again that's Dr James
lynch.com and thank you for listening
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