When Failure is Not an Option

Host, Ken Harbaugh, interviews political leaders, influencers, and other history makers about the choices we confront when failure is not an option. Choices like Alexander the Great made when he landed his troops on the shores of Persia and ordered his men to burn their boats.

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Jon Heavey: On the Front Lines

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Jon Heavey: On the Front Lines

Content Warning: this episode includes some graphic descriptions of wounds and combat.

Dr. Jon Heavey talks about serving on the front lines - both as a battalion surgeon in Iraq and as an emergency room physician during the COVID-19 pandemic. He began his medical career as a battalion surgeon with the 101st Airborne Division in Iraq.

Jon is also the Director of Business Development at Cleveland Clinic Innovations and the co-founder of Minuteman Capital.

Find Jon on Twitter at @JonHeavey and read his 2012 article “An Unbearable Price” in the Dartmouth Alumni Magazine for more about his service as battalion surgeon.

Ken Harbaugh: Burn the Boats is proud to support VoteVets, the nation’s largest and most impactful progressive veterans organization. To learn more, or to join their mission, go to VoteVets.org.

Jon Heavey: It's not just throw in a couple chest tubes and intubate the patient and move on. That's a person you know in front of you looking up at you with their life on the line. That definitely ups the stakes in a big way. At the same time, it was also probably the most fulfilling medicine I ever had the chance to be a part of.

KH: I’m Ken Harbaugh, and this is Burn the Boats, a podcast about big decisions. On Burn the Boats, I interview political leaders and other history makers about choices they confront when failure is not an option.

Today’s interview requires a content warning - Jon Heavey was a battalion surgeon in Iraq and is now an emergency room physician during the COVID-19 pandemic. He has seen things that most people cannot imagine. He shares some of that today. There are some graphic descriptions of wounds, and of combat, so if that’s not something you want to hear, you might want to skip this episode.

My guest today, Dr. Jon Heavey, is an emergency room physician serving on the front lines of the battle against COVID-19, but he began his medical career serving on a very different kind of frontline as a battalion surgeon with 101st Airborne Division in Iraq. I asked Jon to join me today because I wanted to understand what it takes to serve in environments like that and how he thinks today about the battle against COVID-19. Also, because he's just got such an incredibly diverse range of interests from that day job as a physician, to being a tech entrepreneur and a patent holder, to being a former candidate for governor in Ohio. Jon, I hope we can get to some or all of that, welcome to Burn the Boats.

JH: Thanks, Ken. Really appreciate it.

KH: I've got a guest host for the first part of this. My oldest daughter, Katie is on the fast track to med school and wanted to talk directly to an actual surgeon and not just an amateur medic like me, who makes most of my stuff up. Katie, you want to take it away?

Katie Harbaugh: All right. Thank you. My first question is about the Hippocratic Oath, specifically, the part that says do no harm, and have you ever felt compelled to violate this oath in some way or another, whether that was for certain moral reasons or by saving a patient who wanted the opposite, etc?

JH: Wow. I'm very impressed by your question.

KaH: Thank you.

JH: I would say the vast majority of the time, you're not really challenged along those lines in terms of thinking through what's the right thing to do in any given circumstance. That being said, you will on occasion encounter challenging situations where you have to think through, “okay, what's what's the right thing to do here?” For instance, I recall seeing an enemy combatant in Iraq and he had been shot in battle and was brought to our base as a casualty of the battle, and he had a very serious gunshot wound in the chest. Had we not intervened, he almost certainly would've died. So the medical hat in me, at that point was - it was pretty clear, “We got to take care of the guy and do everything we can to try to resuscitate him.” That being said, it's not always an easy thing to sort of separate yourself from the emotion of that moment, knowing that this individual very well may have just taken the life of one of my dear friends. That's probably pretty deep to start off. But I will say, in the civilian setting, it's extremely rare to encounter a situation where first do no harm isn't more obvious, and doing the right thing by the patient is clearly encouraged.

KaH: Wow, that's fascinating. So obviously that situation with that particular patient was significantly memorable, so I want to ask, have there been any instances where you've maybe run into a former patient in an entirely different context from when you first treated them?

JH: I have, but it's relatively unusual when it comes to emergency medicine. Typically, there isn't a whole lot of continuity outside of the hospital setting. I will say, occasionally, that does present some challenges within the civilian environment as well, because we do take care of everybody 24/7. On occasion, that involves medical clearance for prisoners that are heading to jail and things of that nature. You do have to think through those things sometimes. For instance, what identification you're wearing in the room, and if you encounter sort of a challenging dynamic, you want to be sure that your family is safe and that you're simultaneously doing right by the patient. But you can't always have carte blanche in terms of what you can offer.

KaH: Wow, I've actually never thought about that part before, like patient to patient situations. So, as a trauma surgeon, how do you deal with witnessing things that most people probably couldn't imagine? Is there maybe an instant like detaching you do, or have you built up a resistance or a desensitization to some things over time? Or is it something that is pretty case to case?

JH: Yeah. By and large you have seen so much through your medical school and your residency training that by the time you get out in the practice, you're essentially just detached from the situation. I would say, while they refer to me as a battalion surgeon in the army, in the civilian sector I'm board-certified in emergency medicine, which is slightly different than trauma surgery. Typically, we do the initial assessments and interventions on the trauma patients coming in, and then they go to the trauma service. But that being said, I think, within the civilian sector as you're training, you'll get a broad exposure to all sorts of trauma, but you never know the patient in front of you. That changed in a big way for me when I was down range. It is a different series of consequences for you when you're treating your friends. For instance, in residency, it's more of a job, frankly, you're working long hours and you're getting terrific training. But then, when you know the person in front of you, it changes your perspective on the situation, because you aren't detached like you normally would. It's not just throw in a couple chest tubes and intubate the patient and move on. That's a person you know in front of you looking up at you with their life on the line. That definitely ups the stakes in a big way. At the same time, it was also probably the most fulfilling medicine I ever had the chance to be a part of.

KaH: Just to end on that, one last question, you mentioned that being incredibly fulfilling, and for somebody who really wants to make a change in the world, would you, despite the extreme difficulty and strain, would you recommend pursuing that type of dual perspective that you have in medicine?

JH: I'm very grateful for my experience. I hesitate a little bit because I'm a father too. So, if my daughter was considering a career in medicine, there are multiple paths that you can go down. The military treated me well from an experience standpoint, but you can certainly get excellent training within the civilian sector, and a very fulfilling career path that way as well, and perhaps have a few less IEDs and mortars in your life.

KaH: Yeah. Well, thank you so much for answering my questions today, and those answers will definitely stick with me.

KH: Thank you, Katie. I should have mentioned at the top that Katie is a kid who at the top of her Christmas wishlist had a practice suture kit, so she's taking it seriously, and I appreciate your time with her. We'll keep you posted on where she winds up.

JH: That's awesome. Awesome. Great talking with you, Katie.

KH: She is headed back to remote school.


KH: I wanted to press you on one of those answers, because I've been reading your book, The Guardian Class. There's one story in particular that just put a lump in my throat about encountering one of your battlefield patients at Walter Reed years later. Can you set the stage for that, and what that day in Iraq was like initially, and what you had to do to save his life?

JH: Yeah, absolutely. We were in Iraq with the first 502nd Infantry, 101st Airborne, and we were operating in some fairly dicey areas, Kadhimiya, Shula up by Sadr City area. Yeah, that day the convoy actually got hit right as they were coming back into our base with an IED that obliterated at least one Humvee, if not two. Thankfully I wasn't in that convoy, but I heard the blast. You pretty much know when it's going to be go time and “oh, shit, what's happening?” So based on the proximity of the blast and the concussive wave and what was happening, we got prepped and we knew that that badness was on its way in. The NCOs and the medics and the team that I was working with, those guys are ... They're the miracle-workers. They're the A-team. I'll never forget Tyrone Logan was running with Kap over his shoulder through gravel that had to be foot, foot and a half deep, just like a fricking superhero. When I saw him with the body draped over his shoulder, I thought, “oh, shit. Here we go. Let's figure out what we can do here.” He was in rough shape and the guys did what we do for trauma patients, and it was obvious that he was probably in the toughest shape of anyone who was surviving. He was bleeding out from the popliteal artery and was altered mentally. He didn't know where he was. I wasn't sure if he was going to be able to protect his airway. I was concerned he was probably going to develop blast lung in short order. All those things are just clinical medicine. I think the part that, like I said earlier, that really gets you is you were just at the dining hall with this guy, bullshiting with him and watching AFN on TV. Now here he is with his life on the line, and thank God for the NCOs and for everybody, the PAs and folks who were mobilizing the helicopters, come in to get him out to the operating room. We tourniqueted him as rapidly as possible, which is a big change from the standard civilian resuscitative acronym - used to be ABC, airway breathing circulation, and Iraq really changed that, it went to CABC, meaning circulation and hemostasis first so people don't bleed out and then airway breathing.

Anyway, I'll never forget, we got the tourniquet on him and he's screaming in agony because the tourniquet, it hurts like hell. You're threatening his limb by cutting off the blood supply. Then we packed the wound with HemCon and some other hemostatic agents. You don't have a chance to numb anything up. So, here he is getting these hemostatic agents shoved straight into his body and he's still conscious. We were wrestling with, how do we protect his airway now and put him down into a medically induced coma? Or is that something where we wait for the medevac? Anyway, this is all more clinical details than anybody would really be concerned about. I just remember the way he looked and I was scared to death he was going to die. That's what it amounted to.

KH: When you say hemostatic agents, you're talking about taking your fist and jamming a pack of something as deep into a wound, as close to the ruptured artery as you can, right? I mean, you're making it sound a little more sanitized and sterile than it is in real life.

JH: Right. Yeah, no, it's ugly. Those agents oftentimes have a heat component to them for the coagulation. After you stuff it in as hard as you can and you're holding pressure on it, you can often smell the blood as it's cooking and the tissue that's cooking around it. But that's what has to happen so that he ended up surviving and actually kept the leg, which was amazing.

KH: And you saw the results of that lifesaving quick thinking intervention years later, right?

JH: Yeah. That was surreal. I was working back stateside at Walter Reed and was just in the ER one night and the guy came in and he said, he was having pain in his leg and he was having some other issues, and I didn't actually even recognize him at first. He had probably put on 25 more pounds of muscle. He looked fantastic. Last time I had seen him, his head was shaved and he was ghost white. He was on the verge of dying and he was screaming and it was utter chaos. Then, as I'm looking at him and I'm looking at his wounds, I thought, “well, that's weird. This injury looks exactly like the one that we packed at Justice.” Then I took a look at his name tag, and I said, “oh, wait, I think this is Kap.” I started asking, I said, "Wait a minute, were you at FOB Justice?" He's like, "Yeah, yeah." I was like, "Did you get blown up right outside the fucking gate?" And he's like, "Yeah, yeah, that was me." I said, "Oh my God, dude, here we are on the other side of the world. I was your battalion surgeon that day." I mean, he was obviously in extremis and completely concussed. He had no idea who I was. Yeah, I'll never forget it. It was the most amazing moment I've ever had.

KH: You arrived in Iraq with a desire to not just be a battalion surgeon for the 101st Airborne, but to do some real good for the people you felt you were being sent there to help. At what point did disillusionment set in, and what were the things that you tried valiantly to do along the way to stave it off, to help those Iraqi civilians who were just caught in the middle?

JH: Yeah. I really think that there was a sense of idealism for what people were trying to do, and they were generally trying to do the right thing. You start to realize the scope of what's going on over there and you recognize, wow, even though I'm in the middle of this, I have such limited capability to actually influence a positive outcome here. That being said, I know my guys in the platoon were very dedicated to bettering the lives of the people around them. One of the things that we tried to do is we took on this notion of the MedROE, or the medical rules of engagement, which were quite restrictive. You basically couldn't intervene in certain situations unless there was acute loss of a life, limb, or eyesight involved.

KH: You're talking about with the Iraqi civilians caught in the middle that we're talking about, right?

JH: Right, exactly. Yeah. Unfortunately, that translates at the ground level to “oh, wait, we got a kid who was in proximity to a blast who has severe burns and disfiguring burns all over their body.” First, do no harm is, well, yeah, you got to get the kid help. I mean, that's a point of the mission here, right? Hearts and minds extensively, that's what we're here for. What could be more critical than taking care of a wounded child? The combat support hospital did in many cases work around that to make these sorts of things happen. But the fact of the matter is, is that there were just such massive issues that you had to take it one step at a time for what you could do within your sector to try to impart a positive impact and that's why we created the foundation that we did and why we started just evacuating some of these kids when we could.

KH: I think this gets to Katie's first question about the conflict that the Hippocratic oath sometimes presents. I mean, day-to-day as a physician in a large city emergency room, but especially in a combat zone. You said first do no harm, but the reason the American military exists is to break stuff and kill people and you’re there supporting it.

JH: Yeah, absolutely. Frankly, I almost named the book “Hearts and Minds My Ass”. It probably would have been more aptly titled based off of what you end up seeing, which is, to your point, the military is a massive machine that is designed for destruction. The State Department, on the other hand, has resources for reconstruction. You fall in the mix between those two within medicine where you come in with this idealism that you think you're going to be able to help a whole lot of people and then you realize, holy cow, this is such a blunt instrument from a policy perspective that the Iraqis who get caught in between in their day to day existence have some really terrifying outcomes that happen. That creates a real conundrum from an ethical perspective and from a medical perspective.

KH: So, you go from that experience as battalion surgeon with 101st Airborne dealing with just the most horrific trauma, as you can imagine, saving the lives of your friends, relying on those same friends to keep you alive, and then you come home and you're placed in a utterly different context in a civilian hospital. Is it the same kind of adjustment that other soldiers go through, or is it different as a doc, as someone with a scientific background? Do you self-analyze a lot more, do you know to get help sooner? How is that return like for someone like you?

JH: I mean, I have such blessings in my life that I think I would have an easier go of it than a lot of the guys, the 11 Bravos that I was rolling with. These guys are - they have hearts of gold and they come from really tough backgrounds. Oftentimes, they're 18 years old and they're rolling outside the wire on a daily basis and they're doing 24/7 shifts in the towers to protect the base, and then they come back. If they get out of the military, the transition in terms of opportunities that they would have would just be completely asynchronous. I think that ... Shit, asynchronous, they'd have shitty opportunities. That's what an 11 Bravo would say.

KH: For those who've never worn BDUs, that's an infantryman. That's someone who's at the tippy tip of that spear and the first to get hit.

JH: Yeah. They used to call them one-one bullet stoppers in Vietnam, the 11 Bravos. But at any rate, yeah, the transition back is a challenge for everybody. I think as a doc, I had resources and blessings in my life that were a lot more supportive than a lot of the guys that I was over there with. But it's definitely a difference. Within medicine, a simple example, you go from taking care of your young buddies with blast trauma, who you're working to resuscitate and get back into a living that they can exist with, to civilian emergency medicine, which is often an 80 year old coming in from a nursing home who thinks that Nixon's the president, and you got to sort of adjust your mindset for what you can do, and you get nostalgic for the time that you had with your friends.

KH: It's a funny thing, isn't it? Being nostalgic for the good part of those horrible days. I'm going to read back to you a LinkedIn endorsement from your LinkedIn page because I think it gets to this. One of your colleagues wrote about you, “Undoubtedly, the most intelligent, humorous and humble man I've had the pleasure of knowing. He is an incredible physician mentor, as well as a tried and true trusted friend. Jon is my brother in arms. I'd take a bullet for this man. We certainly dodged our fair share together in Kadhimiya.” I mean, that's not the kind of endorsement you rack up in normal life. Does it make a return to the real world tougher?

JH: Well, first off, God bless John Knight. I know that that's exactly my battle buddy's words coming across the page there. John's a remarkable human being. The things that you've been through over there together, as battle buddies and brothers in arms, you've literally risked your lives together, and that sort of camaraderie, I think, is once in a lifetime type experience. I mean, that's why my dad was ... He was a swift boat guy in Vietnam. I'll never forget. We visited his battle buddy for 40 plus years. That sort of closeness, there are some areas of civilian life where you go through things together and you do feel a bond, but there is something about literal life and death situations where you know that you have to rely on that person with your life, there's just no way to recreate that.

KH: You go from that to being a doc in a major metro US hospital, and then COVID hits. What was your first moment of awareness that this was something big, that this was every bit as dangerous - maybe not as gory right up front - but every bit as life-threatening as what you had endured overseas?

JH: Yeah. I feel like I should probably confess, initially, we didn't see a whole lot of the virulent strain here in Ohio because of some of the measures that were taken to mitigate exposure. We were seeing a lot of the non-virulent strains. That was rough for COPD type patients - that's emphysema patients, used tobacco most of their lives. I think the first time that I realized, “holy shit, this is something big” was when I saw a silent hypoxia patient. It still amazes me that you haven't heard the term silent hypoxia in many of the headlines because it's fundamentally different physiology than anything that we've seen in medicine. The first time I saw a silent hypoxia patient, I was baffled as to how they weren't dead already. What I didn't realize was that they would soon be dead. By soon, I mean within about 24 hours or so, and that's when the alarm bells went off in my head of holy cow, this is fundamentally different than anything we've seen before in medicine. Silent hypoxia is when a patient shows up with a pulse-ox, which is a percentage reading of their oxygen level in their blood, and the pulse-ox reading is alarmingly low, but at the same time, they're not in respiratory distress yet. That was a real conundrum. It didn't fit. Typically, if we see a patient whose blood oxygenation level starts to drift down to 90%, they will be short of breath, visibly short of breath, and start to be speaking in two or three sentences. If you or I, if we had a blood oxygen level in the high 80 percentage, we would look like we're in rough shape. We would not be comfortable in the slightest. These folks were coming in with initial blood saturations in the mid-60 sometimes, sometimes in the 50s, but they weren't in respiratory distress initially, and that made no sense to anyone, because it just doesn't happen that way. If I have a blood oxygenation level in the 60s, it's a comatose patient post-drowning who we have to intubate, put in a breathing tube and get on life support as fast as humanly possible. So, it was this paradox of “wait a minute, your numbers are really, really concerning, but you're not in extremis. You're not looking like you're short of breath yet,” which is why they called it the silent hypoxia. Well, lo and behold, if you give silent hypoxia patients 12 to 24 hours, they will be on life support and ventilators, and they will develop respiratory distress and they'll go into ARDS and have a whiteout on their chest x-ray and develop sepsis and DIC and all these things that you hear about in intensive care units. So that was when I first realized, “holy shit, we got something different going on here.” That fundamentally should have immediately raised red flags with public health officials. I sometimes said to friends early on, it felt simultaneously for the mild-strains like an overreaction, when there was considerable economic changes, but then, once I saw a silent hypoxia patient, it was evident that it was an underreaction for these virulent strains.

KH: So this is a function of a different strain. This isn't just a peculiar, physiological reaction to the same strain. This is something else entirely.

JH: Yeah. I think we're probably still epidemiologically trying to get our brains around the serotyping and some of these scientific details to really answer that question - is this the exact same strain that just has widely variable clinical presentation based off of the particular genomics of some given patient, or are we dealing with different substrains that present differently? I haven't heard a really good answer for that yet. I think there was the suspicion that we're dealing with different strains. At the very least, we are dealing with profoundly different clinical presentations. You could have an asymptomatic carrier who swabs positive, even though they're maybe having sniffles or no symptoms at all. It's hard to figure out, how could that possibly be the same pathogen that literally killed a perfectly healthy guy in his late 20s who came into my ER?

KH: What does that portend for the strategy going forward with dealing with COVID? Is it so mutable that we'll never completely beat it?

JH: Yeah, gosh, I wish I had some of my sharp epidemiology friends to consult with on that. I will say, in the recent weeks here, the drop-off in cases has been extremely encouraging. It wasn't even three and a half, four months ago around Christmas time when things were spiking and we were seeing more and more of the virulent strain here in Ohio. I don't know if it's progress that's happened with the vaccination efforts, if it's a social distancing sort of being more effective, but there has been a notable drop-off in the last two to three weeks. Around Christmas time, I was seeing probably four or five COVID patients per shift. Now it's, every four to five shifts, I'll see one. That much is very encouraging. I'm sure that they're going to have all kinds of challenges from a public health perspective to contain a pathogen like this. It's going to be something we're going to be wrestling with for a while.

KH: Do you think the new normal will include things like social distancing periodically and mask wearing? Will we ever, in other words, return to a pre-COVID state of affairs?

JH: I do think we will. I think that, knock on wood, of course, I think that the combination of the preventative efforts with the vaccines and some really encouraging data on repurposed drugs for active treatment interventions when prophylaxis and prevention fail, I think we're going to get back to a society where we're able to be interacting normally again, much like, once the 1918 flu started to die down after its third wave, I think, was when essentially it petered out. So yeah, I'm hopeful. I think we'll get back to that. It's just, I don't think we're anywhere near that yet.

KH: Have you given much thought to the mental health ramifications of this disaster for those in your line of work? I think this is an especially relevant question for someone with your background having served in a combat zone and having some awareness about PTSD and triggers and all of that. We have an entire profession that has spent the better part of a year now in a, for lack of a better phrase, a COVID combat zone.

JH: Yea, it’s a battle.

KH: Is it something we need to worry about, the death and suffering that they have endured for many, many months?

JH: Yeah. I like to think most of the folks that are involved in these areas that they've seen some pretty difficult stuff over the course of their careers and they're very resilient people. But yeah, I think there's probably going to be some analogy to - with PTSD, you sort of think of this like Rambo montage of just black and white flashbacks, and you think it's immediately after you come home and things of that nature. Really, I think it's more of a marathon than a sprint. I think it's people having changed their outlook on what they find compelling in their civilian work, how they manage their family dynamics, how their households run. I think there's probably going to be some long-term effects here that people underestimate. It is every bit as daunting to put a piece of plastic tube down the throat of somebody who's hypoxic and be literally looking into their throat, realizing if you try to insufflate their lungs with a bag valve mask or give them a breath that they very well may be exhaling COVID pathogen onto you that could be lethal. That for me, in some ways, it was more immediate than driving down Airport Road in the middle of the night like-

KH: In Baghdad.

JH: In Baghdad, right. Yeah, the risk of an IED going off was real, but it was not three feet in front of you, hoping that somebody doesn't exhale. I think that there's going to be a lot of folks who for years are going to remember, “wow, yeah, I had to do a 12 hour shift with PPE, gowned up with these masks and everything, and I had to do that for a year.” They'll probably celebrate when they don't have to have the PPE, but they're going to remember what it looked like when COVID patients invariably wound up dying on their watch. They're not going to forget that.

KH: Thanks, Jon, for serving on the front lines in more ways than one. We end every episode of Burn the Boats with the same question, what's the bravest decision you've ever made?

JH: That's a really good question. I think - not to wax philosophical here, but for me, bravery is less about the immediate circumstances and more about the person involved stepping forward and taking ownership of something they're uncomfortable with. The bravest thing I've ever seen is my PA, John Knight and our NCOIC Tyrone Logan. Not only did they not hesitate to be leading the charge to help guys who were blown up in blasts, bullets are flying around and they didn't give a shit. They just ran out to help their buddies. Those guys set the bar for me in terms of what I would say is the bravest people that I've seen. Bravery comes in a lot of different forms and in a lot of different ways. I think, at the end of the day, the fact that they had a reflex to run toward the noise, in my mind, is the most heroic thing that's possible. Because that's a brainstem reflex at that point. Either you're running away from the noise or you're running toward the noise, and those two motherfuckers ran toward the noise.

KH: Well, thanks, Jon. Been an honor having you.

JH: Thank you, sir. Ken, I really appreciate it.

KH: Thanks again to Jon Heavey for joining me. Jon also joined me for an episode of our other podcast, Warriors In Their Own Words.

Warriors In Their Own Words is an oral history series, where we hear veterans tell their own stories of war. It offers the raw truth of what we have asked from those who wear our country’s uniform. Jon’s episode of Warriors In Their Own Words includes some of the same stories you heard today, plus a few others - more raw and unfiltered. To hear that episode, subscribe to Warriors In Their Own Words, wherever you listen to podcasts.

Next time on Burn the Boats, I’m talking to Jon Soltz, the founder of VoteVets who served two tours in Iraq.

If you enjoyed today’s episode of Burn the Boats, please rate and review us on iTunes - it really helps other listeners find the show.

Thanks to our partner, VoteVets. Their mission is to give a voice to veterans on matters of national security, veterans’ care, and issues that affect the lives of those who have served. VoteVets is backed by more than 700,000 veterans, family members, and their supporters. To learn more, go to VoteVets.org.

Burn the Boats is a production of Evergreen Podcasts. Our producer is Isabel Robertson. Audio engineer is Sean Rule-Hoffman. Special thanks to Evergreen executive producers Joan Andrews, Michael DeAloia, and David Moss.

I’m Ken Harbaugh and this is Burn the Boats, a podcast about big decisions.

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