S1:E12 "Jingle Gels and Merry Blockmas! Season 1 Holiday Special"

We ho ho hope you're ready to join us for our merry Blockner special. I'm Amit Pawa. Naughty or nice, we'll be answering listener questions. But be careful, you might just get wham rolled. I'm Jeff Gadsden, and this is Block It Like It's Hot. 

Hey, Amit. Can you believe it's been a year since we started this podcast? We launched in 12/01/2022. All that talk about wham and mince pies. Wow. 

Are you it's literally been a year. I can't believe Yeah. That is nuts. I can't believe how fast time has has passed. And and now we're in episode 12, and it's December, so it kind of makes sense. 

I wanted to start off this episode with my ode to Christmas and regional anesthesia. So here we go. Oh, okay. No gel. No gel. 

No gel. Okay. Sorry. I had been planning that for, like, so so long. Oh, wow. 

Is that a just, you know, you're you're just abandoning in gel altogether? Yeah. Yeah. Yeah. No. 

It might be that we were about to do a block, but we can't because there's no gel. No gel. Oh, yeah. Okay. Got it. 

Yeah. Yeah. Listen. I'm just thinking, man. One of the biggest highlights for me over this, last year was was getting to know, you better. 

And I've gotta say, over the last 12 episodes, it's been phenomenal getting a little insight into into what makes your brain tick, and it's been absolutely so much fun. I hope you've enjoyed it too, man. That's a dark place, what makes my brain tick. But but no. Seriously, likewise, man. 

It's this has been a just a a wonderful, you know, piece to my year and getting to know you better. And I always look forward to our chats and having so much fun. Well, listen. It's it's a great way to exchange ideas, and I can't say how much I've learned. And we'll touch on some of that later, I'm sure. 

But I'm gonna do that slightly embarrassing thing, you know, when you come to an end of a show when people do that thing when they bring out flowers and stuff. I'm a do that little embarrassing thing now. I wanted to take the time to thank you, especially, Jeff, for spending all of the time to edit our audio and put the podcast together. So when people hear the finished product, they don't realize just how much work goes into that. And I know how time consuming it is, and I love the way that you make me sound. 

You know what? It's, it it's fun. It's it's a fun part of the job. It tends it does take a lot of special software to make your song sound good. Dude, I'm just kidding. 

I'm kidding. I actually love doing The the only disadvantage is having to you know, when you when you edit one of these things, you you you go over it again and again. So I have to listen to it, like, 20 times in a row. So hearing hearing some of the dad jokes for, like, eighteen, nineteen, 20 times in a row is is the only is the only potential disadvantage. Those jokes are golden. 

They're gonna go down in history. Oh. Just like Rudolph the red nosed reindeer. What have been your favorite episodes of the ones we've done this year? You know, that's really tough. 

That's like asking me to pick one of my favorite children. I I mean, I've only got two and they're both my favorite of obviously. But, if I was to think back, I think the introduction was fun because there was that uncertainty of how it was gonna turn out. And I actually remember the first time you sent me the edit and we're like, okay, I mean, I've done this. Check this out. 

And I actually got goosebumps as I listened to it because was like, oh, it's so cool. He's done such a great job. So I like the first one. Yeah. Yeah. 

Yeah. Just because it was, you know A surprise. And then, like yeah. Yeah. It was a surprise. 

Yeah. And I also it gave me an insight into just how great your editing was. So that was, you know, and how you can make it sound. So that was cool. I think the second that was that was my first favorite one. 

The second one would probably be the knee. And I think the reason I love the knee is we just we talk through everything and it a 100% changed my practice. You may or may not recall off the back of that episode, I went back and I added the QTs into my my general practice. And I'm actually Right. From that that kind of set me on my path and, you know, that was a game changer. 

We so much feedback from people Yeah. About the episode. Yeah. The knee the knee was a great one. I also I love the breast one too. 

Oh, yeah. Just be for this for the same reasons, like, hearing I mean, you you have done a lot of thinking and refining of your practice about how to provide optimal analgesia and anesthesia for for breast cases, and it was fun for me to hear how you went through that and where you are now. And I I took a lot away from that myself. Well, that's cool. That's really cool to hear. 

And and the other thing that was fun was actually the teaching episode. So we had we had so much content that we had to split that into two separate episodes. Right? So that was fun because it was like a reflection through our our own personal journeys and the experiences we've had. So that was cool. 

Yeah. That's amazing. Any other favorite ones of yours that jump out? I love the ESP one too just because of the controversy, about about about some of the you know, does it work? Does it not work? 

How does it work? And, you know, it's it's funny. Yeah. I've taught a bunch of trainees and and several weekend workshops since we've recorded that episode, and I I now use the word pepper potting as a as a no. As a because that that was sort of an moment for me when you described putting holes in the back of the ES muscle. 

And I was like Yeah. Oh, that makes a ton of sense. I mean, I've been trying to put local underneath it, but you know what? If you just put some holes there, that that would probably inch anyway, that was another one of those moments I was grateful for that you you gave me some tips. So Well, do you know what? 

It just occurred to me, we talked about our New Year's resolutions in our New Year's episode. I think that might have been the ESP. I might be wrong. I think that might be an ESP episode. But mine was something about getting healthy, which I think I've kind of done. 

I've been focusing on, you know, my diet and eating better food and doing a bit of fasting. The other one was to remember dad jokes. I have a 100% failed at that. I'm not very good at that. But yours, my friend, was to learn how to backflip. 

So how did that go? Well okay. So, the year's not over yet. Let's just say that. Okay. 

Okay? This is true. Okay. Ask ask me in twenty days. Okay. 

Yeah. It's going it's you know, there's a lot of preparation that goes into that just sort of, you know, planning. Listen. You've used this line before thinking about it. And I Yeah. 

I don't know. I I well, let's put let's table that one for now. Okay. Fair enough. Fair enough. 

Yeah. We're full we're falling into the Christmas baking here at the Casa Gadsden. The house smells amazing. It's always we've been doing lots of gingerbreads, and Corey does these Italian puffball cookies with a citrus glaze on them. They're they're incredible. 

I just Oh, really? It's about health healthy eating, it's not it's not gonna be good for me this this month. But Dude, that is worth a trip to come over and see you guys just to eat that. We're just fully into the holiday spirit here. That's cool. 

You you very nicely got out of of of admitting that you're not quite mastering the black flick, but I'll tell you that. Because I'm just picturing now the Gadsden House covered with Christmas decorations and the smell of Christmas. This is, yeah. It's gonna be good, man. I'm looking forward to it. 

Last Christmas is is on air on repeat. Oh, speaking of which, you're familiar with this, Wamageddon thing. Right? Are you familiar with this? Yeah. 

Introduced me to this. I think I think it was last year. Yeah. Did you know? So this year, I was determined that I was gonna get right the way through to Christmas Eve. 

And I won't name the individual that did this because I don't wanna give them too much prominence, but I got completely got by a cheeky video on Twitter slash x. Somebody put up a video and they were like, hey, check out this new way to mix Tiger plane in using a yanker sucker. I was, oh, that looks really interesting. Clicked on the video and after about five seconds, it came out with, last Christmas. Yeah. 

And and literally, it was a video to take people out. No. It's like it's like rick rolling. You got you got wham rolled. Exact I got totally wham rolled. 

And then and then It's so good. It was really naughty. And then I I sort of said I I quote tweeted that and said, thanks so much. I learned so much for this video. And boom boom boom, I started taking people out as well. 

Well, I'll go on the record to saying I I can't get enough of that song. So I get it. Have you have you seen the video? Have you ever watched the the the music video for last Christmas? Do you know I have? 

But it's been this it's been a long time since I've watched it from beginning to end, so I I can't remember much. It is hardcore cheese eighties. Yeah. It's just a bunch of shots of them in the ski cabin. George Michael has the full blow dried hair going on. 

It's A little bit like yours today, actually, if you don't mind me saying. I'm trying to channel some eighties wham. Anyway, so what do our listeners have to look forward to today? Well, you know what, Jeff? I kinda figured, because it's Christmas, I thought we'd go for a lighthearted mixed bag. 

Oh. A pick and mix or a potpourri, if you, if you will, of all of the questions we've had over the last year. We had so many questions. We haven't always had a chance to cover them. And people have sent questions in via YouTube, via Instagram, via email. 

So, what do you think about that? We, you know, we we go through those, and that would give us a nice way of rounding up the year. I think it's a good idea, you know, because with your attempts at wrapping and my mathematical issues with prime numbers, we don't always get a chance to cover all the stuff we'd like to. So I love it. Let's get into it. 

Okay. Cool. So I have the first question. This is one from Instagram from, Duane Moore from Durban, South Africa. Hey, Dwayne. 

Hey, Dane. Who asks if we have standard protocols for breast surgery and total knee replacement that are available for sharing. Absolutely. We should post these on our Twitter channel maybe. That sounds like a great idea, actually. 

We could do that. So have you got fixed protocols for both of those areas? We, the knee is much more fixed. The breast tends to be a little there are more options depending on the particular surgeon and Mhmm. And some of the circumstances if if there's gonna be pec work done that requires a pec an interpectoral plane. 

Oh, we got See what I did? I did the the new nomenclature there. Yeah. Yeah. Back one. 

Yeah. But we could easily make a sort of a flowchart for how to use how to use different blocks for breasts. Yeah. That be I mean, interestingly, The UK, British anesthetist don't necessarily like being told what to do for everything. And there are certain pathways. 

We've got enhanced recovery pathways where now we are starting to protocolize, and and they vary from one hospital to another. But my hospital, we are now looking at you know, we've got a protocol in place for day case hips and day case knees, which we're just trialing currently. So once that gets approved and that goes live, I'd be very happy to share that. For total knee replacement, you know, we haven't got a departmental, recipe, but I've certainly got my recipe, which I'm sure is very similar to yours. So, yeah, I I think we could definitely, share those. 

For breasts, it's so varied at my institution. And if we tried to protocolize it, I don't think anyone would stick to it because not that many anesthes are doing blocks for breasts. But, I'm I'm sure we could share our thoughts and our ideas, via Twitter for sure. Yeah. So thank, thank you, Dwayne, for that question. 

And now I've got another question now. This question is from, I'm gonna I hope I'm gonna do okay with the pronunciation. Help me. Joao Pinot from Lisbon, in Portugal, and that's by x. And that question is, what do you guys do for latissimus dorsi reconstructions? 

Jeff, do wanna take this one first? Yeah. So this is this is this question comes up once in a while. We don't do a lot of these. Okay. 

But if you think about the incision required to harvest that lat dorsi muscle and then the innervation of the lat dorsi itself with the thoracodorsal nerve, I always when I did do these, at a prior institution Uh-huh. We we did a serratus plane block. Mhmm. In an attempt to anesthetize the donor site and then the flap itself. I don't know. 

What do you think about that? So it's really interesting because I used to do a lot of these Ah. At at the first hospital that I worked at. And the very first time I I spoke to the surgeon, I said, look. I'd like to do a block for this. 

I'll see you at doing a serratus anterior plane block. She's like, okay. Where is your needle gonna go? I said, well, I'm gonna do a superficial serratus. It's gonna lie between, latissimus dorsi and serratus. 

She was like, so right near my pedicle. So you wanna stick a needle right near the thoraco dorsal artery. Right near the artery that's gonna be supplying this really important flap. And she's like, no. So, actually, what I ended because often these were done, in combination with mastectomies. 

So I basically did a bi level, a two level paravertebral rock. So I do a t three, t four paravertebral and a t seven, t eight paravertebral with about ten to fifteen cc's of local anesthetic at each level. And actually, that works really nicely. And then the last one of these I remember doing so we did, you know, a mass set to an LD reconstruction, and the anesthetic assistant I was working with said I've got a really clever way to fix the ET tube to the face, and she used all these sandwiched transparent Tegaderms together to, like, sandwich and make a a mesentery. And at the end of the case, we wake the patient up, and as I remove the Tegaderm from the face, large areas of skin, were removed. 

Oh. And actually, when you saw when you saw the patient on the ward the next day, she looked like she had major facial surgery because of all the gauze they put on to protect the face, but she she had no pain in the chest and no pain in the back. So, two lessons from that. Don't listen to somebody else suggesting to try a new way to fix an ET tube to the face, number one. And number two, actually, a dual level thoracic paravertebral block worked really nicely for mastectomy and LD reconstructions. 

Oh, that's cool. So the next question is from our friend, Robbie Erskine. I bet I know what this is. Go on. He writes on x. 

How important is the nerve to vastus lateralis as part of your total knee reconstruction package. Okay. Can I go first? Can I go first? So so first of all, I really, I enjoyed your live scanning session with Stuart Grant where you actually again, both he and I asked you to to demonstrate this, and you did. 

And it was lovely to see. I'm very aware of the fact that when we talk with passion about certain things, it almost gives the impression this is the only way to do it. We're never saying that. Right? We're never saying that this is the only way you can do Correct. 

This recipe for knee replacement. Absolutely. So these are just options that, you know, you've got had experience with and you're sharing with me, and then I get excited about it, and I'm sharing them with everyone else as well. We're using our Yeah. Our reach to do that. 

So to answer the first question is, how important is it as part of your TTR package? Well, the truth is it's not that important because I don't do it. That doesn't mean I don't think it may it doesn't have a role, but it's just not something I've added into my 27 slash block it like it's hot knee arthroplasty injection technique because that would make it 28 injections. So at the moment, I don't I don't do it. I know. 

How many how many pokes can you do on one knee? Well, do you know what? Very recent in fact, just on Friday, my knee surgeon came in to the anesthetic room to watch my fellow who'd just done the spinal do all of the blocks. And he sat there and watched every single block go in, which is a really I was like, oh my god. What's he doing? 

Have I done something wrong? Yeah. Is he timing you? But he just wanted to see. He was like, wow. 

That was impressive. And I thought, wow. That's so cool. Thanks, Rags. That was really nice. 

So he came to support. But I just wonder if I could away. I thought that story was gonna end a different way. I thought we were gonna say, oh, stop. Stop touching the bone next to the knee. 

Well, I was I wasn't sure, but, you know, she was wearing sterile gloves. She had nice, you know, probe covers on. She was doing a really meticulous injection around the knee. So, thankfully, there was no having to mop away like blood. It all it all looked really good. 

So I was very grateful for that. So I, you know, I currently don't add the nerve to vastus lateralis into my practice because I haven't needed to. But it may be more relevant at the point when I say to my surgeon, right, you can't do any infiltration whatsoever, and it's purely exposing what we're doing. So so it may be someone introduced in the future, but right now, I'm not doing it. How about you? 

So I it's hard to say what the value is. I will say that when we do a doctor canal, I pack, geniculars, and cuties And and so if you think about the innervation of the knee, only things that we're missing oh, and we get the nerve divasus intermedius as well. Right? Yeah. Yeah. 

Yeah. So the only thing that we're missed the major thing that we're missing is the nerve divasus lateralis. The pain scores are good. They're but they're not they're not zero. And so that has led me to to wonder about this. 

And we like you, I haven't fully incorporated this into my set of blocks, but I have played with it once in a while. And and it it's very hard to know, Robbie. I I don't I don't know. Some sometimes it's difficult to change something that's been a habit. You know, you've developed a habit and you you work at brain stem level. 

Right? You say, right, this is I'm doing a knee. Yeah. Boom. Boom. 

Boom. These are the blocks we're gonna do. And to remember to add in an extra step, sometimes it's hard to do. There was another question that came up sort of related to this, and somebody was saying that they do when they do their nerve to vasa intermedius, they use a larger volume injection, and they were wondering whether a larger volume injection at that endpoint of the nerve of aces intermedius would spread around to cover the whole of the femur and take out those geniculate. I don't know whether that's something that you've thought about or, or considered. 

So, yes, we have thought about that. Stuart Grant and I and and some trainees did a a day of cadaver work and where it was it was amazing. We had he got some cadavers at UNC, and we had a list of sort of questions we wanted to answer over the course of weekend. And Okay. And one of them was this question. 

And so we if you put dye at 12:00 in the femur and put, you know, reasonable volume, say 20 mils in there, would it come around and cover the parts of the femur that where the superior medial and superior lateral genicular nerves are? And the answer that we found was sometimes. So and the one that you would miss was the superior medial one Oh. If you're gonna miss one. So it wasn't it was a maybe answer. 

It was, you know, you could do it, but you may not get the same consistent effect if as if you take out each one individually. Right. Like, I mean, I I'm I'm surprised that I know you got you're a bit more generous, but, literally, I'm sometimes dropping one to two cc's of local assay around those nerves, and and often that's all you need. That's called power precision. Oh, yeah. 

If only, man. If only. But listen. I've got another question that's come from Shelley in New York. And Shelley has asked, will there be another procon debate between you two, and what will the topic be? 

That was one of the highlights of my year, I think, that procon debate at RA UK. Yeah. Likewise. Likewise. For sure. 

Because, yeah, we got to meet in person, and we got to have this debate. But but, I, yeah, I was nervous. I was really nervous. I was thinking we built up this rapport in the podcast, and I know, you know, you're the cool North American slash Canadian dude that's gonna come to The UK and tell everyone how cool they are. They gotta use nerve stimulators. 

How was I gonna take you out? So that was great fun. But are we gonna do another one? It I guess it kinda depends. Right? 

Yeah. I would love to do another pro kind. What what would we discuss? What would we do we disagree on anything else? Well, apparently not enough, but I don't know. 

We need to think about this. You know? I I think we'll we'll have to get back to you, Shelley. I haven't got a straight answer. If the opportunity arose for both of us to be at the same conference again and have a procon debate, a 100% I'll be down for it. 

In fact, I'd just be as long as you promise not to do any of that cheeky AI voice manipulation stuff that, that may have featured in your side of the argument? Sorry? Sorry. What AI? What? 

Yeah. Yeah. Whatever. Okay, Jeff. I need a few questions. 

Yeah. This is this is one that came through for and I don't know how they did this, but this is an anonymous admirer. What does Amit wear whilst in the hot tub? Does it it is not real. Wait. 

Wait. This is a three part question. What does Amit wear whilst in the hot tub? Does it depend on the season or the time of day slash night? So and and if one if one person is asking this, I guarantee you, there are others that wants to know the answer. 

Well, listen. Don't worry, guys. I'm not I'm not there's nothing gonna there's nothing this is a kid this is a family show. Okay? So don't have to think of that answer. 

Okay. And and our and our back garden, other people can look into it. Even though we have a privacy screen, I can rest all of your minds at ease and say that I I definitely wear swim shorts in there, and and nothing else. There's nothing know, so the only question we gotta decide is what we drink when we're in there, whether it's a cup of tea, whether it's a glass of wine, or a glass of champagne. That's it. 

So in Those are the options? Those are the options, basically. Or, actually, occasionally coffee. So tea, coffee Tea, coffee, wine, or champagne. I like the way you roll, man. 

Yeah. You know, that that that's probably the biggest, the biggest questions that we, you know, we need to answer. And then, you know, we go in there anytime, and it's it's 365. Right? So we go in there any any any time of year, any time of night. 

We've even had a welcoming the New Years in there with the family. So This curiosity about about your hot tub practices has given me an idea. Is there any chance we can get, like, a a power hot tub cam that people can just log log in log into and and watch you while watching you? There's already one there. We we have a security camera at the back of the garden, which happens to look over the my my outside office and the hot tub. 

So stay tuned for the link to that camera, folks at home. No way. Okay. Moving on swiftly. This next one is not a question, but it's a comment from Joe Stegman, an ED fellow from Boston Oh, hey, Joe. 

Via x. And it's really interesting. So so, so Joe is, you know, is exactly what we wanted. We wanted to inspire people from all backgrounds, not just from anesthesia. So this is great. 

We've got an ED fellow. And and he says after listening to the podcast, he started using geniculas for acute on chronic pain in the ED with patients getting amazing results walking out of the ED after coming in, on an ambulance to get them there for pain. What do you think about that, man? Oh, that's amazing. See, this is this is partly why I after 15 of doing this job, I still get excited to come to work because this kind of innovation and finding new ways to solve problems is with, you know, regional anesthesia techniques and that sort of thing is inspiring. 

Right? Like, I would never have thought to to use geniculate for an acute pain problem in the ED, but Completely. Good on you, Joe. That's amazing. Yeah. 

They're really, really exciting to hear. And, you know, if you if you guys are doing new novel and effective interventions like this, publish these. Get them out there. Share them with all of us because it's great to hear about the work, and you might inspire other people to do exactly the same. Yeah. 

For sure. That should be a case report at least. Yep. Yep. Okay. 

Another here's here's another one from, our emergency medicine friend, Kylie Baker from Queensland, Australia via x who asks Good day, Kylie. How are you going? Hey, Kylie. That was good. That was really good. 

I like that. So Kylie asks, two questions. What is the highest dose of local anesthetic you would use without comprehensive monitoring or a person present? And do we ever use sharp needles? I'm thinking these are, like, fodder for our pro con debate, perhaps. 

Yeah. It sound this sounds like a good setup here. Good good controversial questions here. So what do you think, man? What So I'm gonna I'm gonna do the second one first. 

I'm do the second one first. Okay. Because there is only one block that I use sharp needles for. And so we got these really long 27 gauge sharp needles. Like, these are like nerve danger territory. 

They should have they've got a red light on the box when you say, don't use these for regional anesthesia. So I use these for ankle blocks. Uh-huh. Yeah. And the reason I use this for ankle blocks is because they're so sharp that patients don't feel them going through the skin. 

And, actually, I can I can do my ankle block in, like, about, I don't know, five minutes or less than five minutes? I don't have to put low cancer in the skin. I don't even need to use sedation, to be honest with you. That's that's so well tolerated. Ah. 

Okay. One just obviously has to be careful that you don't skewer the nerve, because if you do, then, you know, that that's bad news. But that is the only block that I use sharp needles for. How about you? Yeah. 

I do agree, actually. So we'll we'll take, you know, because sometimes those blunt block needles getting through the skin is just I just cringe as the the trainee's like, okay. Little little sharp poke here, and then it's like But then about a minute later, they're still trying to push them through the skin. I see. So that ankle block, yep, same thing. 

We'll use a 25 gauge needle and a little bit of tubing and then a syringe. Yeah. Yeah. And the other one that we'll use a sharp needle for, Kylie, is sphenopalatine ganglion block. Oh. 

Yeah. This is kind of a cool one. It's the same thing. We use a 22 gauge spinal needle and then some tubing and for the part of the same reason. Just just allows you to get in easily and through some of those initial soft tissues. 

And I'm not so worried because the end point of my advancement is to get close to or contact the lateral pterygoid plate. Now, guys, for those of you who don't know, I'm watching Jeff on this phone call sticking his finger, like, in his face underneath his, like, zygoma towards, like, his eyeball. There is no way I'm gonna be sticking a 22 gauge needle just for just for the record. As he was telling this story and pointing his fingers, and I was like, oh my gosh. I won't be sticking any needle, let alone a sharp needle, but but credit to you, man. 

We should we no. We should do an episode on this because this is this is a in a really, really interesting block. And and, I will I will admit to you, it is it is not not for the faint of heart. Like, you're you're sticking of knee. Like, oh my god. 

That's going right into this patient's skull, it looks like. Again. I'm putting my finger right beside the but so it it takes a bit of, like, understanding of the anatomy. I'm like, am I really this is really safe. But yeah. 

Anyway, so that that's another example of a sharp needle. So those are your two sharp needles. One, like, far away from anything dangerous whatsoever, and one straight into your brain. Straight towards the brain. Yeah. 

Okay. Cool. What about what about Kylie's second question? This is, an interesting one. So the question is, what was the highest dose of local anesthetic you would use without comprehensive monitoring or a person present? 

Now my answer to this is whenever I'm doing a nerve block, it's usually for surgery or it's for postoptic pain or it's for treating analgesia. So if someone's coming with a rib fracture or a hip fracture. So I would always do that with monitoring present. That's that's the honest truth. In my institution, if I were to do something like that without any monitoring present and there were to be a problem, I think it would be difficult to defend. 

And the highest dose of local answer that I would use yeah. To be honest with you, I generally tend to stick within the the maximum dosing limits, maybe ten or twenty percent either side of it. But, I'm I don't really know how to answer that question because I'm kind of getting the impression that this may be related to some specific circumstances where someone's trying to do a block and maybe in remote circumstances. I mean, what what do you take on this question? Well, so imagine Kylie's doing a digital block, you know, for a finger laceration or something. 

And that's like That's often done without monitoring, right, if we're being honest. It's five I'm I'm just imagining five or six mils. Am I really putting the patient at risk for last with five or six mils? No. Unlikely. 

Right? So and but I have seen last with 20. I've seen last with two mils. Oh, right in the vertebral artery? We're literally doing a a carotid, actually. 

So there's a bit Yeah. Yeah. There was a bit a little bit of supplementation. Boom. That was it. 

Happened almost straight away. That's a bad day. Yeah. But, okay, that's an unusual circumstance. I don't know. 

I think it I think, Kylie, it it's very context dependent where it's gonna go, obviously, near the carotid versus in a finger, but it's gonna be single digits for me. Prime number? If you inject a prime Nine nine? No. God. 

Not. So if you inject a sorry. I think you have to turn the sound on. My laugh just then goes about to go nuts. So yeah. 

I was I was deliberate. I know nine is not a problem. Yeah. Okay. What's the first one? 

Okay. I'm not gonna put you under pressure. It's fine. It's fine. Yeah. 

But I but I think there are very few circumstances where I am injecting less than 10 cc's. But I guess single digits, I wouldn't think twice about it. Now I understand what you're saying. Now I understand the question a bit better. If I was doing, a serratus anterior plane block for rib fractures, if I'm doing a fascia iliac block, these are high volume blocks. 

And, also, these are in patients who may well have already received opioids. And then you give them a regional anesthetic technique, and then you take the pain away and then goes a respiratory drive. So that's an even more reason or even more of a reason to use comprehensive So, yeah, I I like your single digit answer. That that's one thing. But, you know, I think it I think it's it's difficult to answer. 

It's so context dependent. So I feel like copped out of that. But Well, it's it's a it's a tricky issue. Yeah. For sure. 

Good good question, Kylie. Thanks. Yeah. Great question. And and it is very rarely that we're stumped here, but thank you for that. 

Now, Jeff, there was a comment from our friend Tanya from Australia, Gong gas girl from ex. In in in her regular appraisals of our episode, she said, one of us is weird Barbie. Now what do you have to say about that? I never remember I remember her saying that. That was an amazing analysis of of that of that episode. 

Thank you. First of all, thank you, Tanya, for listening to to our, you know, ridiculous podcast, and thank you for taking the time to to do your your comments and analyses that we it's it's much appreciated. Weird Barbie. Does that imply that one of us I don't know who the other one is. The one of us is, like, non weird Barbie or one of us probably be Kanner. 

Right? I I don't know. So I guess we have to define what weird Barbie is all about. What's weird Barbie? What is she? 

She was like the original. She'd she know she'd been she'd been treated badly by the kids. She had, you know, her hair cut up and, you know, matching your hairstyle from today. Right? But she was but she was insightful. 

Right? She had the She was had the answers that for Yeah. For She was like the oracle, kind of. I can say it to you then. You've got the answers. 

Okay. Well, I'll take listen. I'll take it. I'll take it. But she also suggested you know, we we informally shortened our hashtag from hashtag block it like a sock to hashtag b l I b I l I h. 

Oh my god. I can't even deal with the shortened hashtag. It's a billy. So she she suggested we do that. And so, actually, maybe we'll slowly introduce that as we move on for, forward hashtag b I l I h. 

It's a lot to type out the whole hashtag. Block it like it's hot. It is. Yeah. And let's use the text replacement, hack on Twitter, which we can, I can show you how to do if you want? 

As a oracle or weird Barbie, I'll show you that that trick. Hashtag weird Barbie. Well, here okay. Here's another question from, Neha Padi from Burla India via x. Is there an ideal plan to spare the diaphragm when dealing with ORIF for proximal humerus fracture? 

That's a good question. What's your you've got a proximal humerus fracture, Amit, and and you're worried about the patient's respiratory status. What do you do, hotshot? What do you do? All I I guess it really depends upon how important it is for you to to to spare the diaphragm. 

I what would be the consequences of you getting phrenic no paresis? So we're talking about phrenic We just want an answer here, Amit. Yeah. Okay. Alright. 

I'm just thinking out loud. This is what politicians do when they're trying to think of the answer. I still still like a low volume superior trunk block, but, you know, we we've got the other options. We've got the the if you really wanted to be super super sparing, of course, we could do suprascapular. The only thing about taking, out the auxiliary is, it's likely the auxiliary nerve could be caught up in the fracture. 

Right? So trying to scan the posterior part of the, of the humerus where there may be a cast on, it would be a nightmare. So my answer, there we go. I've now managed as I was talking, I've managed to come up with my answer by killing some I would do a posterior cord injection and a posterior approach to the suprascapular nerve. That's what I would do. 

How about you, hotshot? Well, that that is my default, you know, diaphragm sparing technique. That's what I like the best. It's a it's a posterior suprascapular nerve block. But you do a you do a proper infraclavicular as opposed to just opposed to posterior to get all the other stuff. 

Yeah. Yeah. I do. So I gave the gold answer. He gave the platinum because he's Ken. 

Right? Or was I don't know. I think yours is a better answer. But, anyway, yeah, that's a that's a nice technique and allows you to get essentially reproduce an interscalene or, you know, the proximal humerus shoulder gold standard without risking the diaphragm. Because you're literally not injecting in the in the base of the neck. 

You're nowhere near those Yeah. Those those nerves that would be of concern. So I think that would yeah. I think, phew. We handled that one okay. 

Think after my little procrastination, we got there. Yeah. Now on the same kind of vibe, here is, another emergency medicine trainee question. This is from Gokul Saga from London who's in emergency medicine training via x. And he said, what are our thoughts on suprascapular nerve and axillary nerve for difficult shoulder dislocation reductions in non fasted patients in the ED? 

So rather than doing interscalene, do an axillary or and a suprascapular nerve block, for shoulder dislocations. What are your thoughts on that? Okay. Non fasted ED patient. The implication is you don't wanna use a lot of local to avoid a situation in which if you get last, then you've got a real problem Mhmm. 

With potential risk for aspiration, etcetera, etcetera. Don't wanna use sedation. My gut says I would still do a low volume inner scaling. Phew. Thank god. 

I was wondering where you'd go there. Okay. Good. Yeah. And and I I think this is one of those things. 

If you just use, like, five mils or, you know, single digit mils less than 10 at c five or c six or the superior trunk, somewhere in that region, you're gonna get enough muscle relaxation of the shoulder girdle that you can just pop that shoulder right back in. You will. Right? So so I guess my my question back to Gokul is why wouldn't you do an interscaling? I don't know whether the thought process is maybe this is safer or less invasive, but, know, sometimes a suprascapular nerve, depending on which approach you go for, isn't quite as easy as as, you know, as it said. 

And, certainly, axillary, trying to get the axillary in a patient with a dislocated, shoulder isn't gonna be easy. So my personal feeling is, whilst it's an option, why wouldn't you just stick with what we know works best? Yeah. And I think you can also more effectively limit the number of mils of local you're using there. So instead of having to put, like, five or seven at the suprascapular and another five or seven at the axillary, just use that single dose of five or seven at the interscaling brachial plexus. 

Yep. Yep. For sure. Okay. Cool. 

Alright. So, hey, we agreed on that one. Here's a comment from Miguel Solis from Madrid, Spain as to whether we could upload our podcast episodes to YouTube so that subtitles could help. What do you think, man? So I think this is because my accent is sometimes difficult to understand, so people need subtitles to help. 

So you know what? We did we did upload episode one to our YouTube channel, but in and that was after a request by people saying they wanted to see the episodes there. But really interestingly, we haven't had that many views of the episode. Now it may be just because people didn't realize it's there. In theory, we could do it. 

It just is an extra couple of clicks in order for us to set that process up. But I guess we wanna hear back from all of you guys. Those of you that are listening to the podcast on whatever format you're listening on, if you would like us to upload some of our episodes to our YouTube channel, we can do. But I just wasn't aware that there was that much of a of a demand for it. So, yeah, you know, if it's something that you guys are interested in, please do let us know, and we can we can certainly look at doing that. 

You know, maybe we could try another episode. What do you Jeff? Yeah. I think it's I think it's worthwhile. If if if that seems to be if if the subtitles are helpful, I'm just thinking back to my, like, my Scottish accent and my my attempt at a Kiwi accent and that sort of thing. 

I think maybe the rapping rapping needed some tough subtitles as well. Certainly up for it. Yeah. Alright. Cool. 

Well, listen. I've got another question here. Now this is from Patrick Schulte from Sweden, and this is we've almost touched on this already, actually. He said, how do your surgeons react to multiple blocks in the operative area? And I suspect he means where the knife is gonna go, and he he he gives the examples of geniculars or IPAC. 

So do you wanna take this one first? Yeah. Well, it's interesting to hear you say that your surgeon watched you do all those things and was was, just impressed? Well, we have one surgeon that that when I explained the idea of geniculateurs, he did not like it. He just thought it was just a bit too close to the knee with the hardware and infection risk and that sort of thing. 

Now we are actually currently doing a, an analysis of patients who have received geniculate blocks over the past four or five years. So stay tuned for those results. And my suspicion is that we will see that there is actually no difference in joint infection rates afterwards. So Oh, you're specifically looking at joint in joint infection between those who've had them and those who didn't? Yes. 

Because even though our surgeons, say for that one, are are mostly in favor of it, they this question does come up. You know, you're putting a needle so close to the joint. Is there not an infection risk, etcetera. So stay tuned for that. But to me, the the biggest thing is hemostasis. 

And so in addition to being the one that's pressing the syringe plunger for the trainee when they're doing all the blocks, I have gauze in my hand Mhmm. Ready to jump on those little pinholes and apply pressure so that we don't get this big hematoma. They're very quick to come back and say, you brought the patient back to the OR, and there was blood all over the stretcher. And Yeah. You know, I I'm very quick to hold pressure there for a minute or two. 

Yeah. No. I think you're right. And certainly after the the knee episode that that he we recorded and you mentioned that point, I've literally that's now become part of my practice. So the moment the needle comes out from from the first genicular, the gauze is down there putting pressure just to minimize the chance that there's any any blood and also allowing any blood to get down on the sheets or the drapes or what you know, you just don't want that to be there. 

It needs to look pristine. A lot of optics. Yeah. It is about it. Some so I think what we decided is, you know, we gotta be transparent and honest about it. 

So I always let my surgeons know what I'm doing. And, ultimately, if they say no, then fine. We don't push it. But, yeah, there is some anxiety about it. And what we need to do is to make sure we adopt, you know, good practice, make sure we use you know, make sure we do in a clean way with, you know, probe clovers, gauze, make it all look clean and presentable. 

So valid question, I think. Okay. Here's, here's Mitch, the gas man from Twitter. He wants to know what is our preferred technique for hip fracture. Is it PENG? 

Is it sup per inguinal fascia iliaca? Is it femoral and lateral cutaneous nerve? What do you do? So what is what do you think he's talking about? Do you think he's talking about hip fracture analgesia? 

So when they come, into ED, or is he talking about perioptive? So the hip fracture analgesia, I have always been I call them sci fi. I think you call them SIFI, or supra inguinal fascia I like it. I've always been a fascia I like it kinda guy. But our ED guys are trying to convince us more and more that they like pings because they, I don't know. 

They find them slightly easier to do, scanning up from the femoral head, boom, straight onto the iliopubic eminence and pubic ramus. So they quite like those, but I don't know. I I like the supranuval fascia iliaca. And, actually, I was again watching one of my my very skilled consultant colleagues, somebody who taught me who who I did my first ever auxiliary brachial plexus plot the other day. He was doing a hip fracture list, and he gave them all a light GA. 

And he was doing either supra inguinal fasciae iliaca blocks or lumbar plexus blocks. That old bad boy. How about you? Well, I I think I I like a I like a fascialiac as well. I think it's a it's a an excellent block that covers, you know, most of what you need. 

However, in a 90 year old with what I call, like, mushy planes and muscle and, you know, it's it's it's man, it's a hard plane to to land your needle in sometimes. Do you mean all of your blocks don't look like your Blocktober videos? Is that what you're saying? No. Every what are you talking about? 

Every every block looks perfect. No. No. Man, I it is it is hard and sometimes. And, and so I do love the simplicity of a pang where you see, you know, little trough of Schwartz and bring a needle down and boom, hit it and and inject. 

Hold on a what? A trough of Schwartz? Is that a new thing you've just introduced into my vocabulary? Oh, no. The trough yeah. 

The trough of Schwartz. That's the, you know, the little trough between the ileopubic eminence and the AIIS. OMG. How can I not know this? Is I don't know. 

It's a sub Did you make this up? No. No. This is a Who's Schwartz? Not Gary Schwartz. 

I don't know. I don't know who Schwartz is. I just this is a thing. Oh my god. Guys, Google this. 

I wanna know if he's yanking my chain. The trough of Schwartz I'm asking my hip surgeons about this. What on earth? Okay. So you like sticking a needle into Schwartz's trough. 

Yeah. You can say that, I guess. I think so I'm aware of one publication for this is not for hip fracture analgesia, but for hip replacement showing that the fasciaelyak and the pen give roughly equivalent analgesia. So so I think it's a coin flip. Yeah. 

I mean, I I I do quite like, if I'm doing a pain, I do quite like adding in the lapsed cutaneous nerve of the thigh, just because it's kind of in theory, I wanna make sure I don't take it out on the way in inadvertently, but also it's a nice block to do. If I've got, you know, patient which who doesn't have that much tissue, then, of course, you can do both with the linear probe, and I quite like to use the virtual convex footprint variation on the linear probe. But failing that, I might do, the the pain with a with a curved array probe and do a latch cutaneous nerve of the thigh with a linear probe. But, yeah, for me, at the moment, I'm still a sci fi super inguinal fashionica kind of guy. Okay. 

I've got the last question, Jeff, before we go and do the next bit of, a fun entertainment. Oh. This is for from Keng Tang from X. And Ken Tang asks us, do you guys use adductor canal casters for day case knees? We we have done. 

We have migrated more recently to a a single injection solution Mhmm. As as think we talked about it in the episode. But for for several years, we did do adductor canal catheters and then send them home with a pump. The challenge there is this is assuming you have the infrastructure to manage a catheter program and do the follow-up and, you know, what happens when the pump fails or the pump's leaking and how do you address and meet those needs. The other specific issue that you have to deal with sometimes is where the catheter tip is sitting and is the injectate from that going to get both the nerve to fascis medialis and the saphenous nerve. 

And Mhmm. It can be tricky, just laying the catheter in the right subtorial plane to get both of those. So certainly doable. So, you know, people may or may not realize that, many years ago, I was asked to do a, a procon debate at Isura about the benefits of of of pay sending patients home with catheters. And, actually, I'd just written an editorial in anesthesia about interscaling catheters, which is where I got the cold shoulder pun from. 

And so I had a hashtag hashtag no catheter, which I used to, you know, put out all the time on on Twitter. I I remember this debate. Did you remember? Yeah. Yeah. 

So so actually, I I we don't use we don't use catheters. It would be perfect in a way because our knee patients certainly prior to us changing our regional anesthesia protocol, many of our knee patients were in hospital for a few days. So we could have used a catheter, but it's just not something that's flown in our institution. I don't think our knee surgeons would be that happy with catheters, so it's not something that we've used. Now that we're looking at day case knees, we are looking at other potential strategies to deal with that. 

And, of course, the challenge is you can keep most of these patients comfortable for up to twenty four hours with regional anesthesia techniques alone, but it's what happens after that period that where it gets a bit tricky. So we are currently not using adduct canal catheters, and I suspect we probably won't. Okay, man. Listen. I've got some jokes for you. 

Okay? How does and and these are obviously going to be Christmas themed because of, you know, when we're doing this podcast. So how does a gingerbread man get around with a broken leg? Okay. Gingerbread man. 

No. Tell me. He uses a candy cane. Come on. Okay. 

Give me one. Give me one. Give Alright. Here's where do you buy a Christmas gift for your pig? I haven't got a pig. 

Okay. Assume I have a pig. I'm assuming you had a one of those little teacup potbelly pigs. Okay. Okay. 

Cool. I'm I'm getting the picture now. I don't know. Which I actually I actually want one of those. Have you seen them? 

I have seen them, but they're so cute. Okay. So where where are we gonna buy this Christmas present for your pig? Tell me. Amazon. 

Oh my god. And if that and if that pig if that pig needs to go to hospital, how do get him to the hospital? I don't know. Tell me. The ambulance. 

Oh god. Of course. Okay. This I've got I've got one for you. What did one snowman say to the other snowman? 

Don't know. What? Does it smell like carrots to you? Because of the nose. Yeah. 

Okay. Okay. Hello. If this if if that bad a joke, you have to explain it. Okay. 

Okay. Now I've done a bit of research, from chat GBT. I'm gonna be honest. Right? I'm gonna fess up. 

These are my sources. So I've got a couple of jokes. I I'm gonna share one with you to for for you to read out, and then I'm gonna read it out. So I'm gonna read my one first. Sorry. 

Hold on. These these are jokes that have been constructed by AI? Or Yeah. So I I I went to, to one of the AI tools. We're not sponsored by anybody at the moment. 

And I said, At the moment. At the moment. Dear AI person, please can you make me a joke relating to regional anesthesia, and Christmas? And this, is what we got we came up with. So I'm gonna read the first one. 

You're gonna read the second one. So my joke is, why did the anesthesiologist bring a Christmas tree to the regional anesthesia party? Okay. Because they wanted to numb the holiday pain with some festive needle. That I know. 

I don't know if I heard that. I don't know. What do you think? I don't know. First of all, numbing the holiday pain? 

That is Yeah. Yeah. Yeah. That's actually bad. This guy must have been having a dark day. 

You're right. I didn't But, anyway okay. Assuming that not everybody's holiday is full of merriment. Like, okay. But the the festive needles and the Christmas tree and regional that's pretty amazing, man. 

This AI this AI stuff really It's not bad. It's not bad. Blows my mind how it puts that conceptually those things together. Yeah. It's not bad. 

That's a very that's a very sophisticated concept, like Christmas tree needles needles for regional anesthesia. I I think I think it's clever. I mean, this was literally and it was done instantly on the end of the request. Oh, yeah. I yeah. 

I know. It's amazing. So I've just texted you one, so you read this out to us. My my by the way, my current use of AI, my most common use is now to tone down emails that I shouldn't hit send on that very clever. That are that oh, have you have you used this? 

No. I haven't for that. I have heard people doing that. Most of my days are pretty good. But suffice it to say a couple months ago, had this, like, issue that I had to resolve, and this I was it was getting heated, or I was feeling heated. 

And I had written out this email, and I said I had the foresight to say to my friend, Josh, just take a look at this. Is should I hit send or should I just wait on this? And he goes, no. No. What you should do is take this, put it into this AI engine, and say, make this sound more professional. 

And I did. And it was it was absolutely incredible. I sounded so smart and so, like, gracious. And, so now Wow. I'm gonna do that. 

That's great. That's a hot tip for you. That is great. Okay. Why did the regional anesthesiologist ask Santa for a new ultrasound machine for Christmas? 

I don't know. Tell me. Because they wanted to make sure they always had a clear view of their gifts. Oh, I like that one better. That's a good one. 

I like that. Okay. You got the good joke. You got the good joke. That is very good. 

Okay. No. No. I like I like the needles. That was good. 

Okay. Cool. So that feels to me like we got a nice a nice bit of festivities, dad jokes in there. Do know what? As we're wrapping up, Jeff, I thought it'd be really interesting for our listeners to to to kind of get a bit of a lowdown on the stats for our podcast. 

So, I remember a few episodes back, we talked about how we had nearly, like, 17,000 downloads. But, dude, do you know what the latest numbers are? What is it? 24 and a half thousand time all time downloads. That means That's great. 

Episodes of us have been downloaded, and that's excluding anybody listening on, on YouTube incidentally. But that's 20 that's amazing. So thank you guys so much. That's my it's mind boggling. Yeah. 

Thanks for listening to us just ramble on on this stuff. It's humbling. Yeah. Yeah. It's it's it's really cool to know that there are some people wanting to listen to that. 

Yeah. Yeah. Now if you were to think, about episodes as they came out, There's a top four, which have been downloaded the most within the first month. So can you think of which episodes you think had the highest, first month downloads? If you were to guess, what do you think they would be? 

Probably the more recent ones. Right? Because I think our hopefully, our audience has grown a bit since the initial yeah. So because because because the first month, people gotta know about it to kind of hit download. Right? 

So, yeah, this is just really a metric of whether or not people have, have been tuning in. So what do you think was number one? Well, our last episode prior to recording this was the shoulder one. So is that it? Yeah. 

Number one was the shoulders. Absolutely. Uh-huh. Okay. There we go. 

So it's interesting. So we had shoulders number one, then breasts, the breast episode Uh-huh. Then our teaching episode. And then interestingly, the RE UK roundup where we kind of, summarize what happened in RE UK. Oh, yeah. 

Oh, Okay. So this is a now a more interesting, a more relevant, metric. Of our of all of our, 10 episodes which have been released, the eleventh one needs to be edited and go out, and then we got this twelfth one. But of the 10 episodes that are out there so far, which do you think had the top all time downloads? I reckon you might have worked this one out, but let's see. 

Top all time downloads. I'm gonna say ESP because it was early on, so lots of time for people to listen to it. Mhmm. Yeah. Interestingly, that's not number one. 

It's in the top three. So number one, knees. Number two, breasts. Number three, ESP. So it's interesting. 

I probably would have thought they would be there. We haven't I guess we haven't had long enough for shoulders to get in there. So number one, the top all time downloads is knees, then breasts, then ESP, then the two teaching episodes. So, actually, we mentioned all of those as being our favorite episodes. So maybe that's why they were they were in there. 

How about the top 10 countries where our podcast is listened to? So this is really fascinating. So where do you think? You probably can guess one and two. Right? 

I know one and two because I watch this I watch this all the time and to see so UK is number one and Yeah. And US number two. Right? Yeah. Yeah. 

I I'm I'm I'm waiting for that to flip. It may happen. May happen. You never know. Well, you never know. 

I don't know. And then I think, I think Australia's in there. Yes. Number three is Australia. Okay. 

I think India is up there. Number five is India. So what's number four? UK number one. USA number two. 

Number three is Australia. What's number four? Oh, Canada. Oh, yeah. It is Canada. 

Great. So Canada's top four. So, in fact, the top four are all places that we've done the accents of. That's interesting, isn't it? Wait. 

Have I done a Canadian have I done a truly Canadian accent? Or is that something we can look forward to? And Of course you did, You did that quite you did wait. Wait. You did a little bit. 

Not not a full epic not a full intro in Canadian. Maybe that's to come. And then we got India, Portugal, Germany, Ireland, New Zealand, and Brazil. So that's fascinating. Oh, cool. 

Yeah. Nice. Well, listen. The way I thought we'd fill it finish this up is, you know you know that song, on the twelfth day of Christmas, isn't it? That that one. 

Yeah. Yeah. Yeah. Twelve days. I thought we'd think about our 12 blocks of Christmas. 

Okay. We gotta pick 12 blocks, and we'll take it in turns naming them. If you could pick your top 12 blocks, what would they be? So, Jeff, let's start off with your 12 blocks of Christmas choice number one. I'm gonna go wreck the cheese. 

I wouldn't have predicted that, but now you said it, I know why. Okay. Well, I'm gonna come in day two, paravertebral. The king of blocks. The king of blocks. 

We got Rett has got paravertebral. What are gonna go with for day three? My favorite lower limb block, popliteal sciatic. Oh, nice. Nice. 

Okay. Sticking with the lower limb, and we've talked about it already, I'm gonna slide in on day four with this supra inguinal fascia iliaca block. Mhmm. Mhmm. Good choice. 

Okay. K. Where are we gonna go with day five? Inter scalene. Oh, I like inter scalene. 

Okay. Cool. How who who doesn't like the inter interscaling block? Yeah. Yeah. 

So I'm gonna mix it up now for day six. This is a block that's been recently described, and you know I've got my thoughts about new blocks, etcetera. But the external bleak intercostal plane, I'm gonna pop that in there at day six. Yeah. A little a little bit a dark horse there. 

Like, it's a a new block, not a lot of papers out on it, but it's are are you using it a lot? We've done it for a few open coles, doing it for a little bit of some upper abdominal work. Yeah. Just having a play, having a feel. I I think I think it's got some some good vibes. 

I'm I'm feeling that. It has to be on the list somewhere. ESP, number seven. Yes. Number seven is ESP. 

Okay. I like that. I like that. And then for day eight, I'm gonna come up with another three letter acronym, maybe even the original, the o g, the t a p, the TAP block. Here we go. 

So I'm gonna go number eight. I'm gonna go with the TAP block. My gosh. So where are gonna go next? I just realized that, yeah, I'm missing a number here. 

But okay. So s a. Then where are you gonna go next? Nine, I'm gonna say you know what? Oldie but a goodie and very useful ankle block. 

Oh. Yeah. Why not? Why not? I do like the ankle block, and there was a period of time actually when the ankle block was my favorite. 

So okay. I like that. Okay. So number 10, just because it's featured so heavily in my life over the last year, I'm gonna go femoral triangle block. So the old school adductor canal, but actually the femoral triangle block, I'm gonna say number 10 for me. 

Okay. Yeah. Yeah. Yeah. Hard to hard to argue there. 

I'm well, I'm gonna kinda follow that right up with number 11 cuties. Oh. Anterior femoral cutaneous block. Yep. I totally gotta give you maximum respect for that, for introducing that to my practice. 

So I like that cuties. And you know what? Talking about small tiny nerves I never used to look for, but now I really like to look for, I'm gonna finish off my twelfth or our twelfth day of Christmas with the lateral femoral cutaneous nerve of the thigh or lateral lateral cutaneous nerve of the thigh. Hey, that's not bad, man. So we got 12 blocks of Christmas. 

Yeah. Rectus, paravertebral, pop material siddex, fascia iliac, interscaling, external beak, ESP tap, ankle, femoral triangle QTs, and lapsed cutaneous nerve. I feel that that has brought our gear to an end, Jeff. What a pleasure it has been working closely with you. Man, it's been it's been amazing. 

Thanks for everything. Well, thank you too. What we got to look to look forward to next year, man? Season two, we've got, hopefully, some meetings in person. Yeah. 

Absolutely. And in fact, next year, I'm excited. I've got the REK meeting in London. I'm, you know, I'm hoping and praying there'll be some way, shape, or form that you and I can meet next year. Hold on a second. 

Let me just can we just back it up for a second? You don't just have the REUK meeting in London next year. You are the Bruce Scott lecturer of that meeting. So Yeah. Yeah. 

Yeah. But, I mean, that's very exciting, and all and almost I don't believe it. But this will be this I feel like this might be my last my last ROUK. So we're gonna make sure we, we finish it properly and, a lot of a lot to live up to. So I'm nervous and excited, but I'm looking forward to it. 

And listen, dude, You're gonna be hitting us up with some backflips. Right? That's what we wanna know about. That's that's the plan. Yep. 

Well, listen, guys. We're we're we're coming to an end. Right? Yeah. What do you think? 

Do you think they wanna hear us do a season two? Because if they're if they're up for it, I'm definitely up for it. Let's do it. Okay. Well, listen. 

Why don't we wrap up our final episode of the year, Jeff? What do you reckon? As they say, it's a wrap. What? You you mean we're over? 

It was short and sweet, Alma. That's how I like it. Well, listen, guys. If you want us to do some more or maybe even have some special guests on our next season, please let us know. Please, can you feed back to us what you think about season one, whether there's appetite for us to record some more episodes. 

And I'll tell you what, we are totally up for it. So let us know what you think. Please like and subscribe and rate to the podcast from your usual podcast provider, and let us know if you want more. And if you do that, we will a 100% be up for that. And where can they follow us, Jeff? 

Well, I'm gonna just jump in here with Insta block underscore it underscore like underscore it's underscore hot because you always get stuck with that one. So I'll just take that one. Or you can do Twitter at block it hot pod with two underscores between it and hot. And there's YouTube. Right? 

Yeah. Which is at block it like it's hot. Now we have got the hashtag, which is hashtag block it like it's hot, but we're gonna try and encourage you to use our abbreviated hashtag now, hashtag b I l I h. We hope you all have a very happy and merry holiday season, and all the best in 2024. Absolutely wishing you all the best in season's greetings. 

So until season two, we hope you all Block it like it's hot.