S1:E11 "Say My Name, Say My Name: Nomenclature in Regional Anesthesia"

Eminem, Destiny's Child, and Rihanna. What have they got to do with regional anesthesia? We think you're totally gonna love this episode. I'm Amit Pawa. Put on your boots and caps. 

We're gonna talk acronyms, and somebody might get spanked. I'm Jeff Gadsden, and this is Block it like it's hot. Hey, Amit. How you been, man? What have been up to since the last episode? 

Hey, Jeff. Good to speak to you. Do know what? I think you're probably gonna regret asking me that question. Why why is that? 

Not been up too much? Been thinking ah, you've been thinking about how you lost your debate against me at the RAUK twenty three last year. Is that it? Yeah. Very funny, Jeff. 

Well, listen. Listeners, if you wanna make your own decision about who won that debate, you know that you can watch that debate on either a block it like it's hot YouTube channel or on Jeff or my YouTube channel. But no, Jeff. The reason why you may regret asking me what I've been up to is that I might not stop talking about it. Oh, really? 

Oh, I'm intrigued. Tell me. What's what's going on? Okay. Well, listen. 

You know, one of my wife, Kate's, long term wishes has always been to visit Hawaii. So Ah. After a lot of planning, and maybe a lot of saving up, we managed to make it happen this year. We've just come back from this amazing trip. I love that place, man. 

Tell me about the highlights. It's it's a long way for you guys. Right? Holy moly. That was the yeah. 

One of the longest flights I've been to if I take, Australia out of the equation. It's a long flight, but, it kind of we had a little bit of everything, man. So we flew out to San Francisco, and guess what was happening whilst we were in San Francisco? Oh, that was the ASA. That's right. 

So the ASA was happening there, and we kinda had a bet as to whether we bump into anybody or not from that meeting. But, yeah, we so we went to San Francisco. We did Alcatraz, Fisherman's Wharf, Golden Gate Bridge, all of that stuff. Nice. You know, it's very different from the last time I was there. 

Well, the last time you were telling me the last time you were there was 09:11. Right? Yeah. Exactly. Yeah. 

So whilst the the landscape and the geography is all the same, the vibe was slightly different. But yeah. We sure We did that for a while, and then we flew to Oahu. I think that's how they say it. Your your Hawaiian accent is is incredible. 

It's it's almost as good as your as your Kiwi accent. But he was trying to give us something. One of the guys was trying to give us some advice on how to say things properly. I think oh, ah, oh. Anyway, we saved him Listeners, he's trying to say Oahu. 

But then we stayed in Waikiki. Okay. Oh, you nailed that one. Waikiki. That's good. 

I don't think I have, actually. I think I there's I'm probably not saying it correctly, but I got some tips from Ed Mariano and his wife, Carly, about places to go. So we checked out some restaurants, and we did a hike. That was amazing. You know what? 

There was one amazing highlight. So we managed to swim with turtles, dude. That was crazy. Yeah. Yeah. 

Yeah. Is incredible. We, so Corey and I got married in Hawaii back in 02/2002. Oh, wow. On on Oahu, on the North Shore, and, just just us. 

We had a photographer and a nondenominational celebrant, and it was on the beach. It was a it was incredible. So That sounds amazing. Yeah. It was. 

It was really awesome. It was, very, very special, obviously. And, so Oahu and Hawaii have a special place in our hearts, but we went back to 2021, the summertime, for the first time and and brought our kids for their first time and, saw a bunch of different places. But, but, yeah, we had a turtle we also had a turtle interaction. It was what was amazing was I I know you hear about people swimming with dolphins at these resorts, which is, you know, kinda planned and, like, here, we're gonna release a dolphin now, and you can pet the dolphin. 

But this was completely wild. Yeah. Exactly. Got to, yeah, got to the beach, and we're swimming around, and all of a sudden, one one of the kids are just going to the snorkel. They're like, oh my god. 

What's happening? You saw a shark or something? No, it's this gigantic turtle, green turtle. Yeah. Well, yeah, it's crazy because I I exactly the same thing. 

I was holding I was I went out with Sienna, and I was holding, and she's my youngest. We we were snorkeling, and then I suddenly grabbed her hand, and I was squeezing it so so tight because I was scared. But I'll tell you what, it was amazing. It was actually amazing. And I can't believe I had the same experience. 

There's obviously something Hawaii is known for that. I didn't realize you could just randomly meet them, but that was that was crazy. Same. Yeah. We thought, like, we just didn't expect. 

It was our fur first day. We just walked down to the beach. Hey. We'll go for a little swim before we go for lunch and end up with this magnificent turtle experience. Completely. 

So that will that will definitely be something that's etched in our memories. But what was amazing was when we went back to the beach to go and get my wife, Kate, and their eldest elder daughter, Sofia, they went out and they had the same experience. So we, you know, we kind of managed to to to repeat that throughout the whole day, which is nuts. But you know what? So after Hawaii so we did all of that crazy stuff. 

We did some walking. I was really put through my paces on the exercise front. We then flew back, via LA, and we did our favorite hobby, you know, Disney. Right? We went out to check out the OG Disneyland. 

Oh, yeah. Right. And now I'm back to work. So so that's that's what I did in a summary. Oh, man. 

That's, you're right. I do regret asking. Just kidding. Sounds like an amazing holiday. I was actually keeping an eye on your, your Insta, and I saw some of your pics and videos, which looked just incredible. 

So so I got, I I do have two questions for you. While you were in San Fran, did you actually bump into any anesthesiologist randomly? Well, it's really funny you should say that. So this was kind of a a constant source of, you know, amusement amongst the family. Are you gonna meet somebody? 

Are you gonna meet somebody? And, actually, we were in the lineup for Alcatraz, you know, as a family sitting there, just had a first coffee of the morning, chilling out, and a guy came up to me, big smile on his face with his wife, and he sort of said, hey. Doctor Power, just like to say hi to you. And my wife eye rolled, definitely eye rolled. And he was like, hey. 

He's like, hey, doctor Power. I know you from Twitter. And it turns out he was somebody who knew Nadia Hernandez very well, and he wanted to stop by and say hi. So that was so cool. And and it was weird. 

And then the funny thing is we were actually on an open top bus tour going around, San Francisco. And there was a dude who still had his lanyard on, saying ASA, and a name badge. He didn't catch his name. But I I was gonna go up and say hello, but, you know, my wife and kids said, just leave the guy to him because, like Yeah. Chill chilling out. 

So why? So we bumped into two people, which is which is cool. Yeah. Not surprising, I guess. Oh, so Disneyland, it was how did it compare to I can you've been in Disney World before in Florida. 

So how did it compare? I've never been to the California one. So, you know, it was it was amazing. It was great to see, you know, where it all started. And some of the rides that they duplicate, so like the Star Wars stuff, actually, it was a bit crazy because as you're walking around in it, you could quite easily have been in one in Florida. 

The layout, the the appearance was identical. But I you know, we kinda finished the park in a day and a half. You know, it's much smaller footprint. So the rides are good, you know, and the ones they've got in combat are the same. Right. 

But I kinda think Disney World's just a little bit bigger and better. Yeah. It's got a much larger kind of breadth of of things to do, and they've got more lands. But they're both great, but, you know, Florida's gonna have that special place in the heart for me. Well, that there you have it, folks, from a Disney expert. 

Yeah. Here's your here's your review. Well, listen. That's enough about me, man. So we've just done October. 

Right? So should I ask what you've been up to, or is that a silly question? By the way, Blocktober was amazeballs. Oh, thanks, man. That was that's kind of you. 

Yeah. I was was fairly fairly busy with that. A little bit different this year. Right? So, yeah, one one of the challenges that I knew I would face eventually was there are only so many blocks. 

That's right. How do you how do you fill That's right. Thirty one days full of content? So we kinda we kinda have I I realized I've have kinda reached that point. I mean, I could get into some really obscure blocks and that sort of thing. 

So, you know, I got into the making little shorts this year as as you probably Yeah. Saw. And and what was interesting is how you can get a message across in sixty seconds or less. I mean, that was incredible because you you're kind of forced to focus the point on on a particular part of the whole block, and it actually makes it really powerful. You say, look. 

Hey. I wanna talk about this bit. Check this out. And then if you wanna know more, check out the other side. I think it was very clever. 

Very clever. Oh, thank yeah. Thank it's it's interesting. And then the one that I I was quite happy with was the how to actually use intralipid. You know? 

Like, because because that's that's something we get across in lectures and workshops and that sort of thing. But to show someone, here, rip open the kit, take your syringe, pull the lipid, hand it off to your assistant, he or she gives it, and then, you know, that sort of thing. That was to do that in sixty seconds was I was I've got happy with that. But I mean, I think somebody somebody mentioned it on Twitter. They said, you know, you'll save lives with this shawl. 

And I I really think that's true. It's so powerful. It's such a simple mess, and it's not something that somebody would normally think about putting in that format. It's so clever. Yeah. 

Well done, man. Oh, thanks. Yeah. It's I I guess it's one of those thing it's like, doing a a surgical airway or a or a front and neck access. Like, until you've practiced doing it or watched somebody do it, when you're in a situation in when, you know, your heart rate's a 150, it's it's good to have thought about the steps. 

But, anyway, it was cool. It was a cool month. It's, it's over now, so focusing on the next stuff. Yeah. I mean, I guess for you, it it it's always ongoing. 

Right? There's always the next project, the next thing to do. But, yeah, I'm I'm I really loved Blocktober twenty three. I've literally got no idea what you're gonna do for Blocktober twenty four. Yeah. 

You you and me both, buddy. So may maybe we could get some people to to tweet us or to to send us some suggestions. Some ideas. What do they wanna what do they wanna know about? Well, speaking of suggestions and talking about stuff, what are we talking about today? 

Okay, Jeff. I've been doing some practicing. I got a bit of grief for my rapping last time. So, I'm gonna change up a bit here. K? 

That was great. So I'm gonna give you some hints. Thank you, by the way. So I'm gonna give you some hints as to what we're gonna be talking about. K. 

Here we go. Say my name. Say my name. Or nana. What's my name? 

Oh, nana. What's my name? You getting the vibe? Oh, I do. Yes. 

Yes. Okay. Let me see if I can follow it up. Let's see. My name is my name is my name is ticky ticky slim Jeffy. 

No. Wait. No. Was. I was wondering what you're gonna do with the Chikki chikki. 

Slim Jaffy. I wish. Dude, they have I have eaten so much Halloween candy. Oh, yeah. Do you guys do you I do you do Halloween candy trick or treating yourself? 

Oh my god. We def we definitely do. We definitely do. But, so it's not Slim Jeffrey anymore. Right? 

No. No. No. Listen, I'm so happy you went with that. I was wasn't sure where you're gonna go, but that that was that was better. 

So let's see what people have to say about that musical interlude. Well, yes. You're right, man. I thought we'd look at nomenclature and in regional anesthesia. So, like, what's in a name? 

Does it matter? What's the best way to describe a block? What do you think about that? Yep. I think it's it's great. 

It's another potentially controversial topic. Lots to unpack there, and I'm I'm guessing this might be a bit of a polarizing pod. Listen. I'm all about that. I want people to be talking about what we're talking about and getting into the vibe. 

So Yeah. Let let let's get into it. So I think, this has probably been an age old issue. This is not just something that's happened with ultrasound. So I'm thinking about to when I first started. 

And probably the again, we talked about some of the first blocks that we did, but I remember somebody saying, are you yeah. I'd like you to do a whiny approach to this interscalene brachial plexus block. I was like, what are you talking about? And then someone said, well, if you don't do a whinny, you can do a Maya. I don't know why I'm doing a posh English accent because the person's basically didn't sound like that. 

I mean Sounds sounds better. Do you know what I'm talking about? Yes. Of course. Yeah. 

So the all all the different variations depending on who described it and who modified it and and that sort of thing. But we named them after the people that came up with them, which, of course, doesn't help you with know how to do it. Right? Right. Yeah. 

I remember the Raj approach to the well, he had two, I think. I he had the Raj there's a Raj approach to the sciatic. That was my favorite. Because that was the one when you flex the hip, to and knee to 90 degrees right, draw a line between the ischial tuberosity and greater trochanter, draw them, and then kind of bang somewhere in the middle. That was a Raj. 

Right? Yeah. But you're missing, like, the memorable point for me, which was you you sit in a chair and have the patient's ankle on your shoulder. That's right. And you're coming at the buttock from the from the back Yeah. 

From the back. It was potentially potentially precarious situation there. That's right. And then there was a very but then what was the other Raj? I don't know the other Raj. 

Oh, infra infraclavicular. So it was like you started much more medial and then aimed out towards the axilla. So we got two Raj two Raj blocks. So you can't just say I did a Raj Block. You say which Raj Block did you do? 

Upper Raj, Lower Raj. Yeah. Exactly. Big Raj, Little Raj. What about the Labatt? 

You know? And there was a Labatt site. I mean, can I I can now I'm saying the name? I remember the name because I had to do with my Ezra diploma and remember the name. But I can't remember how to do it. 

He said Yeah. His names were so confusing. I mean, what else could they have done at the time? It's it's true. There was a lot of Euclidean geometry. 

So, know, palpate this bony landmark. Woah. Woah. Woah. Say that again. 

Say that again. The what geometry? Euclidean. You know? Okay. 

Help me. Draw a line between point a, point b, bisect it 90 degrees from this. You know? Oh my god. Euclidean. 

That is like I've I've never used that that word in my vocabulary ever. That's like now I'm feeling really stupid. No. No. No. 

I've got a I've got a I've got a handful of words that I just drop into, my teaching. Euclidean. Euclidean. That make me that make me sound really smart. But, I'm using that. 

I'm using that. Yeah. But look. I mean, we gave him a couple of examples there, but ultrasound has messed this up even more. Right? 

Yeah. It well, because it's been ex an explosion of techniques. And so, you know, you you move your probe a centimeter or tilt it a little bit this way and oh, I'm gonna that's a new technique. I'm gonna just I'm gonna call that the Yeah. The power block. 

Oh, yeah. And listen. I've got some ideas about that. We'll come back to the power block later. Don't you worry about that. 

But listen. And that's where it might get controversial towards the end of the episode. So we I will touch on that, but I wanna tell you a story. I mean, I remember so remember, I've mentioned before about how Ralph Blanco was one of one of the people I I worked with during my fellowship. Yeah. 

So I remember before he published the PEX block, we were having I'd started my job as a consultant. He started talking to me about the PEX block. And, of course, in theory, we'll come onto this. We don't call them, PEX blocks anymore. But I remember him saying to me, he said, oh, Amit, do you know just, know I talking about a lecture, and he said, oh, you could talk about the PEX and Boots block. 

I was like, what? It sounded like he was trying to PEX and Boots and Boots Boots PEX and Boots. I was I was like, what what's the PEX block? He said, oh, don't worry. You'll see. 

You'll see. It's coming out soon. I still don't know what the boots block was. I never I've never found out what the peck spot was. I don't know whether that hasn't been He's just messing with messing with you. 

Yeah. But it maybe he was. Wait for it. Still waiting. Yeah. 

What you know, Rafa wears a boots block. I've waiting to put it in my presentation. Oh, I like that. I like the name, though. Exactly. 

It's a great I I think it was something to do with foot and ankle, but I I don't know because I never I've never seen it. So but, you know, I so I heard about the PEX block before it first came out. And then, you know, the thing that really confused me about the PEX book, and this is the whole the whole thing that kinda gets my goat, is and especially happened with my American colleagues because I I don't know why. Maybe it was every time I came to Azra, people would say, did you do a PEX one or did you do a PEX two? And I was like, no. 

No. PEX two has got both endpoints. It's got the first endpoint and the second endpoint. And they like, no. No. 

But did you do a PEX one or a PEX two? So this thing kind of went on forever. And then Rafa created this serratus plane block. Thank god he didn't call it PEX three because that would have been disaster. Right? 

I know. Although so just so we're clear, the PEX one is depositing local between PEX major and PEX minor, so the interpectoral plane. That's the interpectoral. Exactly. And the PEX two, as Rafa originally described it, was that plus the sub PEX minor deposition of local. 

Or the pectoserratus injection. The pectoserratus injection as we call it now. But I know what you're saying about, like so, personally, I I'm guilty of that. Like, think pex one is between the two muscles. Which it is. 

Yeah. And pex two, it just ended up calling inaccurately. I I understand from Yeah. Because it didn't correspond with Rapha's original description, which included both. PEX two was just the between PEC minor and serratus. 

Yeah. And that that that became so much ease it's sort of a it's interesting how that happened. Right? Like, he described it in one way, but it very quickly took on. People said, yeah. 

We're gonna make our own little PEX one is this. PEX two is this. And but but that you ask a 100 regional anesthesiologists here in The US what PEX one and PEX two is. Yeah. That that's probably what they'll give you. 

Because it it probably makes sense to talk about it like that, and I do get it. But the problem is now when you start looking at the literature Right. When somebody says that you have to really dissect. When somebody said that did a PEX two block for procedure x or y, we gotta understand, actually, what did they do? And you have to really, you know, work look down into the details. 

And then when you collate these papers together and, system systematic reviews and meta analyses Yeah. Are all PEX twos the same or or not? And that's where it I think that's why we needed to have some clarity. Yeah. Yeah. 

I I agree. And then there's another one. So so I'm talking about the serratus plane. Right? So, of course, you know, we had a a superficial serratus plane block and a deep serratus plane block. 

And then there was this other block which you you know, the SIFB. Do know you what I'm talking about? The SIFB serrata intercostal fascia plane block? This yeah. Yeah. 

Right. So so is the SIFB the same as the serrata's plane? And this is where, you know, for me, I think what we call nerve blocks is really important, especially if you wanna bring more and more folks along on this journey with us of regional anesthesia where ultimately patients benefit. We all gotta be talking the same language, man. Yeah. 

Yep. That makes sense. And your point about being able to interpret the literature correctly is is a good one. Right? How do you trust a paper if or a meta analysis for that matter if if they're all being done different ways and we're not Well, I mean, a 100%. 

And then listen. How can we not talk about the QL blocks? Right? So this is where you know, we've kind of touched on it very briefly beforehand. But, you know, we've got this we started off with QL one, and then QL two and then QL three. 

And then there was somebody else who described the intramuscular QL block, sort of seems to have quietened down a bit. Yeah. But that was called QL four. I I remember that being called QL four as well. Did somebody call it QL four? 

I mean, it would make sense. Right? I like a QL eight. Well and you are you I think you might remember in our teaser about, about studying at the podcast, you made some gank about, about q you know, do you want me to teach you the q l I surgically remove the q l muscle, squirt local all over it, and replace it back in. And then it's yeah. 

So I think so, you know, that's what again, where it's got confusing because the one, three doesn't it's not an easy way of remembering where it is. So, thankfully, and we'll we'll talk about it later. There's there are there's a new way of thinking about the block. And, also, how can you expect injection at different locations around the muscle where there are different surrounding structures to behave in the same way? And are they all the same block? 

Well, that's that's a I've got opinions. Yeah. Yeah. Well, maybe maybe we'll get into that. And what about the painting? 

About the pain block? How many pain blocks are there, Jeff? Oh, wait. What? There's more than one? 

Yeah. See, I need it. What? So so there is we so the pain block that you you and I both know is the pain block associated with hip surgery. Right? 

Yeah. But there was also a shoulder pain block described. I can't believe you didn't know this because when I saw this, I was like, why do they call it the pain again? Oh. So there's a pericapsulate approach to the shoulder. 

So I I, you know, I saw that written, and I immediately thought I'm not gonna read this because I'm gonna get confused. Yeah. But wait. It's called the peri it's called the peng block of the shoulder still? Apparently. 

I I I read it, and as I as I started reading it, I thought I can't read anymore because I'm gonna get confused. So I, I'm not subscribing to the shoulder pain block, although I'm sure it's a technique, but I I am not gonna go there. I do have to say I admire Philip Peng for shoehorning four words into an awkward acronym that exactly matches his surname. What Yeah. So tell me. 

Is there a power block, that we're gonna read about in the next issue of RAPM? Well, if you're interested in posterior abdominal wall analgesia Oh, there it is. Or Lloyd Turbot came up with a periarticular wrist, analgesia block. So maybe there's what about the Gadsden? What would that be? 

Man, that's right. There is, it's too many letters, too many consonants. Okay. Greater auricular, and then I'm stuck. Yeah. 

But you guys, can you can you come up with a good acronym for an herb block with Gads Den's name in it? That would be great. Yeah. I really appreciate that. Thanks. 

You know, the funny the funny thing is I mess with our trainees, frequently. And one of I'll there's about 18 different Gadsden signs that I'll and I'll just I'll say it straight faced during during the procedure. So see you see how the, the artery is deforming there as a local is spreading around? That's called the Gadsden sign, and it's associated with a 100% success rate on this block. Or They please don't tell me they believe you. 

Do they believe you? You know, you get different reactions. Right? So but but different but totally different things. So the funny thing when you when the when the training comes back for their second rotation or or they're doing a different block and you're like, yeah. 

See how the, the nerve to vascular medialis is peeling off the muscle there? That's called the Gadsden sign. And they're like, wait. You told me the Gadsden sign. So what I want what I want is for someone to say that on the oral exam or the Viva and say, well, obviously, I would I would look for the Gadsden sign. 

Can you imagine? That's I'd yeah. That would warm warm my heart. Do you know what? I'm I'm gonna try that. 

I'm gonna because I've I've got a colleague called Dan Taylor. He's a colleague of mine from from Guy's and St. Thomas'. And he will quite often say, to to a trainee, oh, no. That's Taylor's first rule of anesthesia. 

And he always manages to to to to create these Yeah. Taylor's rules of anesthesia. So I think I'm oh, that's a great idea. I'm gonna I'm gonna have a look and see if I can create some of those guys. Oh, the power rule. 

Yeah. That's good. Maybe the patient's seizing as a needle's coming out of the tissue. Is that the is that the powers? Come on, listen. 

I don't wanna be associated with that. Certainly not with my hundred hundred mils of local and so that I normally need to get some of these blocks to work. And the other thing that's that's confusing, Ken, you know, and it's interesting. I just recently did a, a lecture or a webinar for the Royal College of and the BJA. They've got a hundredth year, anniversary coming up. 

So I did, a lecture on the, evolution of fascial playing box, and I was looking back to the first description. Right. I'll tell you what I use as what I use as a reference for that. I use an article. There's a a really great article called essentials of our current understanding of of abdominal wall blocks. 

Is that familiar to you, doctor Ganzler? It does sound familiar. Maybe Yeah. We were. We were we were both fortunate enough to be part of that publication, but Some shameless shameless self promotion going on in this episode. 

Listen. It's about time, man. It's about that time. So I kinda thought I would, I'd I'd use that as a reference. I went back to look at the first description of the of the of the tap block, which Kijin helped beautifully put together in that article. 

And do you do you remember when it was? Do you remember the year? I'm say 02/2001. Oh my goodness. That's some hardcore Gazan trivia. 

Absolutely. That was Rafi. Yeah. Rafi described it in 02/2001, but as a letter. Yeah. 

That was written as a letter. And it was landmark. That's right. It was a landmark approach. Now do you remember Triangle Of Petite. 

Yeah. Well, yes. But do you remember how long after that John Mcdonald, who I'd always associated with that block, how long after that he described the same technique but actually called it the tap block? Because Raffy in 2001 called it the abdominal wall field block, but it was called a transverse abdominis plane block. Do you remember when that was? 

I'm gonna say, like Do you know this? I'm gonna go on. Go on. This, by way, this is all unprompted. I didn't this is that's that was a didn't give you these questions ahead of time, folks. 

No. I didn't. I just wanna see. I'm gonna say 02/2007. Oh my god. 

That's unbelievable. You're absolutely right. But that was you have to remember, this is this is exactly when I was, like, learning all this stuff. Right? So it was, like, it was imprinted in my mind. 

So I'm gonna give you some time points. So 02/2001, I had just started as an emergency department, junior doctor. That was before I started in anesthetics. And in 02/2007, I was midway during my training. So 2007 was yeah. 

I I I was aware of the tap block then, but I missed the landmark description 2001 because I wouldn't even think about anesthetics. But interesting. But but since and again, the same year, 02/2007, after McDonald described it, and McDonald and O'Donnell, by way, Brian O'Donnell, who does listen to the podcast, I have on Good, Good Authority. Hey, Brian. So Brian and John did that 2007 paper. 

Then there was a dude in 02/2007, the same year who described the ultrasound approach. Do you remember who that was, Gadsden? Oh. If you get this, I'm gonna I'm literally I'm I'm out. That power's rule of anesthesia, know when you've lost. 

No. I don't remember that. That was 02/2007, same year actually as the as the book of Donald O'Donnell paper. Peter Hebbard, Peter Hebbard from Australia described the ultrasound guided approach to the tap block. But but it all got a bit crazy after that because, you know, was the ultrasound tap block the same as the landmark tap block? 

And what do you reckon about that? Oh, I think yeah. It got it got very confusing because then you got into, like, subcostal tap. And and at some point, someone was talking about I remember hearing somebody go, oh, I do a six point tap. And I'm like, woah. 

Woah. Woah. Hold on a minute. How many Woah. Where where are you putting the needle? 

Yeah. Yeah. And then lateral anterior posterior tap. So, like, it was tap tastic. Right? 

Too many taps. Taps. Too many taps. Sounds like a kid's story. Now there was a now there's something else that I'd seen recently, and this is when I know that it's getting too much for me. 

It's very, very wise and very productive Turkish colleague of ours, has been associated with another block called the tapa block. Mhmm. That's right. The TAPA. But I had to I couldn't remember, what the acronym stands for. 

I think it is thoracoabdominal perichondrial perichondrial analgesia. I don't know. Right. So what is it? So what does it sound for? 

Yeah. Yeah. I think that sounds right. Yeah. But And then there's a modified tapper. 

The mod as if the first tapper wasn't good enough, we've got a better tap for you. But it's but isn't but the tap is very similar to the external oblique intercostal plane block. See here is exactly my point. So now you're right. Now the EIOC, that kinda makes sense to me because it tells you two muscles, external oblique and intercostals, and it tells you you're gonna jet between. 

So I can understand that. Yeah. But these we've got a couple of techniques that are very set very closely related, but they've got completely different names. And I think this is kind of the whole point of talking about nomenclatures because, you know, there are lots of blocks. We could, you know, go on for a large part of this podcast naming some few names. 

I've got a few more that I do wanna cover. But we we've got to find a way of pooling it all together so people understand what we're talking about. I don't think my average or even a standard person who's being with me, as a senior and he's just doing regional anesthesia fellowship, I'm probably not gonna teach him a tap a block. But does that mean I'm failing? I might I'm definitely gonna teach him an external oblique intercostal because I can remember that. 

But if I can't remember the name of the block, I'm not gonna teach. And is that is that a bad thing? Am I a bad teacher? Well, no. I I think I think the way I'm looking at this is people will do external oblique intercostals, and people will do tapas. 

And at some point, as we accumulate experience, we'll realize, okay, that slight modification or maybe the original block or whatever, one of them is gonna be slightly better. Maybe. I don't know. And then we'll just say, okay. Well, let let's just all call it the one thing, and we'll all do it the same way. 

I I think there's I think there's a lot that we we kind of need to unpack. But listen, I've gotta I've ask you one thing. Having used the phrase fat pack, what does IPAC stand for? Now every time I say it, I say something slightly different. So when you say IPAC, what do you say? 

What does it stand for? Oh oh, is there is there controversy about this? I don't think there's controversy. It's just I I didn't get it right. I I'm sure you say something different every time. 

In interspace between the popliteal artery and capsule of the knee. No? Interspace between the popliteal artery, and the capsule of the knee. So I sometimes say infiltration in the posterior popliteal artery. Yeah. 

Posterior pop no. Into space with the popliteal artery capsule. And that that sounds so simple, but I definitely say something different each time. I'm not quite sure why. Well, so so shout out to Sanjay Sina who from Hartford who innovated this infiltration technique. 

Right? So he does a ton of knees and was looking for a way to do what the surgeons do with their posterior capsule infiltration, but do it better, more reliable, more precise, and use ultrasound guidance so they're not gonna hit the artery or hit the nerves. And then he came up with this putting local between the knee capsule and the popliteal artery and came up with a kind of a sexy name for it too. Right? I pack. 

But I think that yeah. You're right. So I think the reason I get it wrong is I say infiltration, but it's actually the space interspace between the poppity artery and the capsule. Okay. That is now ingrained in my head. 

I'm never gonna forget that. Listen. I I I just I think we think we said a few names for a while. Let's just have a slight diversion. I think it's time we go for a dad joke. 

Are you ready for Yes. It's always dad joke time. Okay. Well, listen. There this this dad joke has come from again, we've mentioned these guys a few times, the Salisbury. 

So Charlotte Salisbury, who with her dad, Ian, made a video about us, which I may decide to share on YouTube at some stage. But here's a joke that he came up with. Jeff, I was gonna tell you a periodic table joke about noble gases, but, unfortunately, all the best ones are gone. Argon. Argon. 

Okay. Argon. Yep. Good one. I'm still laughing. 

I thought it was really good. I wasn't expecting I wasn't expecting that. That's good. That's good. Have you got anything for me? 

Let's see. Okay. Here's mine. What do you call a beehive with no exit? What do you call beehive with no exit? 

I have no idea. Unbelievable. Oh my goodness. That is so up my street. I love that joke, Jeff. 

Thank you so much. That is brilliant. Listeners, we're gonna keep delivering these damn jokes until you tell us to stop. And then probably if you tell us to stop, we'll probably come up with a few more. So if you want to improve the quality of these jokes, please do do direct message us, and we can hopefully, entertain you. 

Oh, okay. So after that slight diversion, Jeff, I I kinda want to get back into this. So we were I was alluding to some of this controversy about different names, etcetera, but who's got the right to name a technique or to rename a technique? What do you think about this? So I'm glad you went there because I had a visceral reaction to the effort made to consolidate and rename some of these techniques. 

We're both involved with the paper that came out about nomenclature. Yeah. That was chest and abdominal wall. Right? The Ezra and Ezra. 

Yeah. The and, led by Karim Al Baghdadi in 2021. And so and and and the idea was it's it was rightly so an effort to pull together some of these disparate and confusing names like q o one two three four that we we can do a better job of of making it so that when you say to somebody, hey. I wanna do a Yeah. Fill in the blank, they know exactly what that means. 

And so a lot you know, trying to use anatomic names as opposed to one, two, three, four. So that's good. But but then, as I said, I had this visceral reaction, and that reaction was like, wow, man. I feel really bad for the people that did innovate these. Their imagination and efforts have not been not not wasted, but have been it's like, thank you very much. 

We're now this this other group is now gonna take that, and we're gonna rename your your baby kinda thing. Yeah. Well, I mean, it's important to mention, Jeff, isn't it, that when with this, Ezra Ezra, Delphi, consensus project we did involved a large number of regional anesthesia practitioners and experts, including people who had described these techniques. They were part of that whole panel. So they had a big group of people together. 

Yeah. So these exactly some of the people who might be hearing their block name being moved off the off the shortlist of what we're gonna call these blocks. Yeah. So it's an interesting question. Right? 

So does Rafa have more agency? Does he deserve more agency in the discussion of the QL or the PEX, or does Iwana Koustache who described the MTP block, the midpoint between the transverse process and the pleura, get to lead that discussion about if we want to rename that Yeah. How do we do that? Well, do you know what? So I obviously have a I have a personal connection to this. 

Iwana Kostash is an incredible regional nieces from Canada. And, you know, I met her in, I'm trying to think when it was. I think it was 2016. I'd gone out to the ISURA meeting in Canada, and I wanna pull me aside. She said, oh, can I can I have a word with you? 

She I was like, yes. She's like, listen. I've been watching your videos on YouTube that you'd made for Elsora, the London Society of Regenarses. And she said, I'd be watching your paravertebral video. And, did you notice that when your needle was behind the superior cross of transverse ligament and you injected the pleura dropped? 

I said, yeah. She's, you I I did notice that. I kind of but then I carried on advancing and and, you know, went into the space. She's like, well, because I've been finding the same thing in clinical practice, and I think there's a real thing here. I wanna investigate this. 

I think you don't need to have your needle deep to the super across the transverse ligament in order to get a block. And, you know, I think this is really great for increasing the utility of, you know, nearly paravertebral blocks. We haven't quite framed the the coined the phrase paravertebral by proxy then or paravertebral light blocks. So we had this discussion. We did some cadaveric work, and we came together. 

And so, actually, we we got some really great results. And Iwana said, what are we gonna call this? And she came up with a few variations in your midpoint between transverse process and plural. And there was, MTTP. I was like, Iwana, you know, I think that's gonna there's too many letters. 

I think we need to have a three letter acronym, so let's go with MTP. We called it MTP, but it was all Iwana's, observations, and she put all that hard work into it. And so then when Woah. Woah. So you you're a cofounder? 

Yeah. But yeah. But Iwana's the she's the she's the she's the big boss. You're a co namer. I was a co namer. 

Exactly. But we we we we had this discussion. So Yeah. But then, of course, people said, oh, MTP, does that mean it's somewhere in the foot? You know, of course, metatarsal. 

Yeah. So so I see so for that for that reason, I understand it. But, you know, now we've lumped that together with some of the other blocks that are near the paraspinal place. There was the, I can't remember now. Jens Borglum named the MICS. 

So multi something intercostal space. What does the MICS stand for again? Know. It's in that that's a problem. This is now we're now we've pulled them all together. 

Well, now we call them ITP. At least we know it's in that intertransverse process space. I kind of get the logic, but I do feel bad. And I interrupted your flow there, Jeff. Sorry. 

No. I just I I actually think that sometimes an eponym or a more memorable acronym is better than than one that is has a bunch of letters that truly describe the the anatomical relations, but are that has no meaning to it. Right? Like, ITP, I think, idiopathic thrombotic purpura, whatever. And I have to think to myself, oh, yeah. 

Right. No. No. No. That they're talking about inter spaced Oh, yeah. 

Yeah. Yeah. Yeah. Versus and I and I so I here's a case in point. The interpectoral plane block or the pectosoratus plane. 

Yeah. I get that those where those mean. But pecs is just so easy to remember. Yeah. Do do you agree, or I am I I do. 

Do you know well, what can I tell you? I can tell you that despite being an author on these ASRNomenclature guide project, this consent opinion thing, I still find myself saying we'll do a PEX for this. Yeah. I do. I do. 

I do. But And I think I think what I just I wanna say one thing here. We're both in favor of Yeah. Making things easier for learners and making things standardized for Complete. Description so that when you read paper a and paper b, we know what we're talking about. 

But I think perhaps maybe we go too far sometimes. And if there's a legacy name that that is easy to remember, that might serve the purpose. Except with the PEX one, PEX two, and and that's where I think it and I think that's where it may get confusing. But but, you know, it's all fair enough for us to come up with these opinions in these journals, but then we need people to start sticking to that and or or listen to all journals to say, do know what? When you've called it, the, the transversus thoracis plane block, do you actually mean to say deep parasternal intercostal plane? 

So so we need that translated to journals because, ultimately, we all want to to do evidence based medicine or practice evidence based medicine. And for that to be the case, we all have to be speaking the same language. Yeah. Speaking the same language is great, but also having a way to communicate it clearly is is also good. So for example, nobody's got time for retroclavicular inter infraclavicular. 

Just say rapper. Oh, but you've got a vested interest because you've invested in those raptor claws. Right? And then you give those to your fellows if they do a raptor block. Get a duke rap and raptor claw. 

I mean, that you've got you've got some skin in the game there. But So funny story. You know, the raptor acronym, we're sitting around the block area one day saying, this is a really cool block. We really enjoyed doing this. We think it's a lot of value and easy to do and you see your needle really well. 

Horrible name. We gotta come up with, like, just saying retroclavicular, infraclavicular approach is just it's awkward. So we actually started with the word raptor, and then we went back. Okay. How can we make the word raptor fit? 

Is that the is that how you came up with it? Yeah. Yeah. Yeah. So retroclavicular approach You heard it here first, guys. 

To the infraclavicular region. Yeah. It works. It works. And I there's a moment I had, about a year later. 

I was teaching a workshop in New York, and the workshop included infraclavicular. It was traditional infraclavicular block. And so we're sort of going through at the station with these people, and one of the guys is from Australia, and he goes, oh, yeah, mate. This is a great, great approach, but have you heard of the raptor block? Oh, no, mate. 

Were you serious? I was like, oh. Ugh. So how would how was this guy coming up with the, with the information about the raptor block? Had he had he read a I went Kiwi there. 

Damn it. Why can't I stick to one place? Sorry. But how did he find out about the raptor block? How did he find about it? 

So we oh, we we wrote a letter to a publication that was about the retroclavicular, and he said and we in the cheekily, in the letter, we said, just we we call this the whatever. And it just it sort of took off. I remember I I actually remember I actually remember the letter. And and the and you had you had a couple of diagrams with the color Doppler on the vessels or something. Yeah. 

I remember it. Exactly. Because there because there are I think there are advantages. I mean, we can go into one, you know, whether you like it or not. But but the name this is sort of part of my point is that the name is catchy enough. 

And I get it that's it's it's sort of a a goofy trick, but but the name is catchy enough that people remember that. And and when you say it, you know exactly what people mean. Well, I have a confession. I I think I might have shown you a screenshot. I I was asked to Ezra, to do a talk. 

It was an expert opinion on the raptor block, and I'd I put a graph in there about adoption of of the of people adopting doing the the raptor block, and I called it the Ganzden effect. There was a slight uptick when you called it the raptor block, you made it seem appealing, and you gave these prizes and all the rest of it. But you're right. Once you if somebody says, do you wanna do a retroclavicular approach or, you know, a retroclavicular inter infraclavicular, what does that even mean? Yeah. 

Or why would I do that? Because actually, still to me, it sounds a bit crazy, but we're not gonna get into that in this in this episode. It sounds a bit crazy to do it. But, yeah, I I think you're right. When you make the name seem, relatable or approachable or, dare I say, exciting, you might entice people to do it. 

But I still think, man, you have a nerve, you have a location, and you have a needle insertion. Does that make sense? So the lateral approach to the sciatic nerve block. That's the sciatic nerve block, and then it tells you where your needle's coming. That makes more sense to me. 

Right? Does that number you doesn't that make sense to you? I mean, because I can say retro clavicular approach to the infraclavicular region. Yeah. It kind of sadly now it's got it in my head. 

You've made me say raptor without realizing it. My evil plan is coming together. Yeah. But I, you know, I I I I'm I'm gonna just say also that I I fully recognize that I'm a bit of a romantic when it comes to eponyms and that sort of thing. Like, I I do I do like some of the old terms for things like like Quincy. 

Oh, yeah. Yeah. Yeah. Or or dropsy. Oh, yeah. 

Like, those the sorts of old fashioned yeah. I remember when, you know, doing the medical student, you know, learning how to use your ophthalmoscope, and somebody said, oh, you've gotta somebody said to me, oh, you gotta Argo Robertson people. Just just joking. I don't have syphilis. I I was gonna say, I remember what that was for. 

But listen. I've got another one for you. You're talking about you wanna have a an, you know, an acronym that's easy to remember. Have you heard of the spank block? Yeah. 

I have, actually. Yeah. We we giggled about that. I and I think that's I I suspect that that was a very similar story to the raptor. Like, people sitting around thinking, how can we make a a funny kind of a funny or memorable acronym? 

Jeff, I just wanna say something very quickly to our to our listeners. Please don't Google Spank Block. Please don't Google Spank Block because, unfortunately, I did, and you won't like what you see and certainly not a work. So don't Google it. An SFW situation. 

Exactly. But do you remember what Spanx stands for? It was it was the it was a variation on the iPaq. Right? Like, it was a It it was. 

It was a sensory posterior articular nerves of the knee, and this is a landmark. I'm laughing because on this webinar I did on, Friday, somebody actually put this question in the, in the chat. They're like, what do you think about a spank block? And I I I you know, when a question came out, I smiled. I don't know if that got caught up on the camera. 

But yeah. So, I mean so that's that's a perfect example. Somebody said, oh, would you wanna do a spank block? I, you know, I would just laugh, but I don't remember what it is. Whereas the iPAC is kind of been associated with it. 

I remember it. Then there's another one I want to talk to you about. So there's been a a an explosion of regional anesthesia experts, techniques, practice, and papers coming out of India. And there was a technique that was called the CAPS block. Do you know what I'm talking about? 

Yeah. I have. Yep. So this is an issue I have now. The guys are involved with it. 

I've I've met a couple of them. They're amazing physicians and clinicians and researchers. But the first part of that acronym, the c do you know what that stands for? Yeah. It was crosswise. 

Right? Yeah. I don't even know what that means. Yeah. It's so so stands for crosswise approach to popliteal sciatic. 

So, again, this is, I think, actually, it's a lateral approach to popliteal sciatic nerve block. So I don't know whether it needs an acronym. I think this is where, you know, I when I started off my career, I desperately wanted, to to make some impact, to get some papers, to get some publications. There is partly a desire for us to get publications. And, actually, we with research, we wanna share our ideas and our opinions, but I'm not sure all the time whether we get it right. 

I don't know. I I I know that I'm gonna be controversial here, but I'm just curious to know what your thoughts are about that. So I I think that so the sciatic nerve, you can block 12 different ways. Right? Like, the parasacral approach right down to the popliteal. 

But so I think it has value because it and I know we had this discussion during the Delphi nomenclature paper on upper limb and lower limb stuff. So infragal vicator is another another example. So you can approach it different ways, and this came up with with the raptor. Like, do we need to do we need to have that description? And there were some that argued, well, yeah, you do because even though your needle endpoint is the same, you're still at deep to the axillary artery. 

Where you're coming from differs, and that has implications for safety maybe or efficacy or patient positioning and and and so on and so forth. So Yeah. To me this adds clarity to say, I'm doing the CAPS block. Oh, and that means I'm not at the popliteal crease or a couple of centimeters. It's further as I recall, it's further up the thigh. 

So it's interesting. So so Vicente Roques said he wanted he wanted us to disagree with each other more. This, I think, is gonna be the first time we've had a a full disagreement on air. Because yeah. Is it because I because I I couldn't remember what crosswise means, and I still don't think I know what crosswise means. 

I don't I don't know what that means. Crosswise. What did I mean I mean, you told me told me Euclidean today. I'm gonna definitely Google that when I get off here. But, was if you said, oh, well, you're gonna do a proper sciatic nerve block. 

We're doing a a lateral approach. Yeah. I don't know. I don't know. I I think it's, I'm just conscious that every time a new block comes out, a new acronym maybe it's because I'm lazy. 

I guess I'm lazy now. I don't wanna learn anymore. We're always learning in regional, but I haven't got any space for any more names. So maybe I'll just have to I'll just consolidate what I know and then move forward. Maybe that's the answer. 

I think what I'm I think what I'm saying is a memorable acronym, and and CAPS is one of those. Right? Like, it Yeah. Where okay. If you say CAPS, I have an image in my mind of where my needles my needle ought to go. 

I agree. Crosswise, not a good word for not a precise anatomical word, but I I think caps works because I it makes me think of a head. It's on your cap. But I'm just I'm I'm I'm I I think it's good. And, actually, what I'm I'm really happy that I found something that we don't both agree on because that just shows Yeah. 

That, that's why we've got so many opinions. And and and it's okay. And it's you know, we can still be friends and not necessarily, have the same opinion, I hope. So here I got a question for you. So should the surgeons be encouraged to stop calling it McBurney's point and instead say, it's the point that's one third from the umbilicus to the As is, and that's where the appendix pain should be felt. 

Yeah. Yeah. Yeah. Yeah. Great. 

I know. I don't that's robot Jeff that came back. Robot Jeff coming back. Yeah. Yeah. 

Very good point. Or the glass the Glasgow Coma Scale. Is that should we just this is the trauma scale that includes eye, verbal, and motor stuff. But Or we just get rid of it and just have avpu. You know? 

I mean, that so that's to a certain extent, they've simplified that. Right? But you what? You have poo? You don't you don't? 

Are you you're messing with me now. Right? Is it I have poo. Alert verbal pain. So response is alert. 

Response to pain, I have poo. See Your AVPU acronym just failed. Responsive verbal responseive verbal or it's unresponsive. Say I have pooed. I have pooed, though. 

Yeah. AVPU is a thing that that you've never heard of AVPU? Guess no. Always learning. There we go. 

Searching up, Avpu. Okay. It's a yeah. Yeah. Yeah. 

Here's the thing. Listen, Jeff. I think we've I think we've talked a lot about, names. We've had our first online argument. Not argument, disagreement. 

This is a great time to wrap up the episode. What do you think? I think so. So what how would you summarize this? So I so so the way I'd summarize it, I'd say, look. 

I think be sensible, be logical. We're gonna expect maybe we should accept that some names ain't gonna change. Yep. And I think, you know, check out the Ezra Ezra and the make sure paper, the one that's out already on chest and abdominal wall blocks. Keep your eye out for the upper limb one, which is coming out soon. 

Have a look and see what we think. And if you are taking up some probe up and and having a look and looking at approach for a new block Before you think about naming a new block, have a think. Make sure there isn't something already out there that's doing the same thing because we wanna make sure that we're all doing the same things to benefit our patients. But be logical, be sensible, and make sure you document clearly what you're doing. If you're describing a technique to somebody, make sure you're very clear with the description of what you want them to do. 

I don't know. What do you think? I I agree. I think that's that's, that's good sound advice. Yeah. 

Okay. Cool. Well, listen. Let's wrap up this episode, guys. You know what to do. 

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