S1:E4 "Gadsden’s Gadgets & Pawa’s Paraphernalia: Our Fave Bits of Equipment"

Is that a cadaver walking around your living room? This is giving me the heebie jeebies. I'm Amit Pawa. Artificial intelligence is coming to regional anesthesia. Is it the rise of the robots, or is your machine just trash talking you? 

I'm Jeff Gadsden. And this is block it like it's hot. Hey, Jeff. How you been? We're back here for episode four, which we have called Ganson's gadgets and Powers paraphernalia, our fave bits of kit. 

How are you, man? Episode four. Who knew? One, two, three, and to the four. Ahmet and Jeff here to block your duct door. 

Oh, very I like it. I like it. I'll that I'll take that back. That's Yeah. Okay. 

No. It's all good. It's all good. Hey, man. How are you? 

How has how has your week been? My week has been has been pretty great, actually. It's been pretty fab week. Had a couple of weeks since we since we last did our recording. So the you know, in the last couple of weeks, I've got stuck into to covering everything. 

We've done lots of upper limb, lower limb, trunks, and I've even had some trainee free days. So it was really weird doing the blocks by myself and and saying to myself, okay, Amit, show me the tip. No. That's not the tip. Show me where you're going, not where you've been. 

So I was kind of doing the lines that I normally do for my trainees, but to myself. Just for yourself. That's Yeah. That's nice. I like it's it's heartwarming. 

I feel sorry for my trainees because they're brilliant, but they must get so bored of hearing me say the same stuff again. You must have some Jeffisms. There must be some things that you say all the time. Oh my god. I I shudder to think of the the small small booklet my trainees could write about my Jeffisms. 

A a lot of it's unconscious at this point, but, like, you know, scrape the paint off the artery. That's one. I love that one, though. I love that one. It's pretty it it tells you exactly what to do. 

Yeah. Yeah. Yeah. As long as they don't get into the bucket of paint in the artery. That's that's yeah. 

And I'm sure they get tired of hearing about unzippering. I never I never get tired of hearing you talking about unzippering. I don't. I mean, I don't get tired of talking about it. But, hey. 

Listen. If any current or former trainees of mine are listening, feel free to chime in and tell us what, what things we do say that Yeah. That are that maybe we should stop. Oh, I mean, I I definitely changed some of the things that I used to say. When I think back to to some of the things that you say in the past, I don't think they're necessarily appropriate in in the current in the current era. 

So I I've had to be a little bit conscious about what I've said, but I'm sure there'd be things that I don't remember that that we would hear about. Melissa, what have you been up to in the last couple of weeks, man? It's been good. Yeah. We actually had a retreat with our regional team, which was just fantastic. 

So we blocked off most of a Saturday at an off campus Oh, very good. I like that. Uh-huh. See, even when I'm not thinking about regional. So, yeah, got it got into a a conference room and and sort of locked ourselves in and and didn't emerge until we'd answered the question, you know, who do we wanna be as do crap in the next five years? 

It was great. It was amazing. And I'm so I really feel fortunate to be part of a extremely talented, creative, and hardworking team. And, yeah, we came away with a renewed sense of purpose and a vision for going forward. And and then, of course, there was a, you know, boozy dinner afterwards and stuff. 

So it was good. My god. That sounds amazing and, like and I and very cool. I can imagine that kind of getting together, deciding what you wanna do with the future of the department and what difference you wanna make. That's fabulous. 

Yeah. But listen. You know what? I've I've gotta tell you, after our last episode, which, of course, is on knees, I've gotta tell you I had the most amazing experience. I, work with the knee surgeon regularly, who actually tweeted about this experience. 

I'm gonna share some of it without giving away any patient information. So, you know, you kind of educate and reinforced the Gadsden twenty seven block technique, which we've got some we've got some some flack for into it, but that's all good. It's all good. But the one thing that I wasn't consistently doing out of that recipe was adding in the anterior femoral cutaneous nerves. So Right. 

Three or four days after the episode dropped, I I I had a list, and I did the full recipe for a patient who's having spinal anesthesia. And the surgeon for the I can't I can't remember this ever happening in my career. The surgeon, who's a good friend of mine, Rags, he called me up at the in the early afternoon and said, oh my goodness, Amit. This patient is insane. They're up and about, and they're walking, and they're pain free, and they're fully flexing and extending the knee. 

It was an absolute game changer. So That's so good to hear. It was great. It yeah. That was that was fabulous. 

And then you you I actually timed I saw I had two other two other fellows I worked with. We talked about the Chris regularly. To the fellow that was doing that was was Nulla. So Nulla was working with me for that case. And then a few days later, I had one of my other fellows. 

This is Maria. So Maria was working with me, and I timed her because, of course, we got some some some flack about how long it was gonna take to do all of these blocks. So I timed Maria, and she did all of the, the GA blocks, everything plus the lidocaine femoral in twelve minutes. That's not bad, man. That is pretty good. 

That is I mean, I told you our record was, like, nine minutes and something. So twelve is pretty darn close. And, actually, that was the first time that Maria had been doing out of plane genicular. So she really pushed herself and said Well done, Maria. I I was really chuffed with that. 

That's amazing. Something else happened that was really exciting. One of How was your chuff chart that day? My chuff chart well, I I don't know if my chuff chart was off the scale. Right. 

And I'm pretty sure I, you know, I called Newler up after to tell her how excited the surgeon was, so I'm pretty sure her chuff chart was high. And I think Maria couldn't quite believe that she managed to to knock out all of those injections having been prepped in that time. So I think we were all chuffing happy, so that was great. There was there was something else that I wanted to share. So there's an niece. 

It's called Mitch from Newcastle who reached out to us via our Twitter channel to tell us that he had adapted or adopted rather our technique for a patient having a revision knee, and he was really, really impressed with the analgesic benefit he had and how much opioid reduction it achieved. So, Mitch, thank you so much for listening. We're really happy that made a difference. Yeah. Thanks, Mitch. 

And I've got a couple more things to say. I last week, I also managed to get out there, I met Rosie Hogg, one of our good friends in the regional anesthesia and and poker's world. I managed to give her give her one of our block it like it hot mugs. Nice. Representing. 

Absolutely. So she was pretty chuffed with that. And then, unfortunately, I'm now in trouble with the theater manager at Cleveland Clinic London, Ian Coyne, because he saw that I'd given a mug away, and now he wants one. So at some stage, Jeff, before the end of this episode, we're gonna have to think up with competition question. Mug contest. 

Yeah. Mug contest. Yeah. Have we got any more shout outs, Jeff? We do. 

Yes. We've had some good traffic. Thanks so much for all of you that are giving some feedback on social media. Let's see. We have Sofia from Brazil who says, love your podcast. 

You guys sound like a married couple. Can you Fair. Fair. Yeah. Tough but tough but fair. 

Can you talk about, best tips for teaching students and trainees? Yeah. That's that's on our list. We're gonna do that. It's totally on the list. 

There was also a message, that we got our tweet. We got on Twitter from Taras Grosch from, from UPenn, and he he messaged us about a recent FDA approval for, an artificial intelligence system. So we're gonna be talking about that at some stage. So I'll I'll I'll won't give any spoilers. And then, of course, this is, this is episode four. 

And so Raj Gupta tweeted us and said, well, why didn't you call it A New Hope episode four going with the Star Wars vibe? So, yeah, thanks thanks guys for for jumping in. We should have timed this for for May 4. Yeah. We should have done. 

Right? What's gonna be happening on May 4 on this? Well, did you do that on purpose? May 4 be with you, and there there's something happening in May 4 and May 5 What could it be? 2023. 

Well, Jeff, it's r u k twenty three. What could be that rhymed? Oh my god. That was a wrap. That was the wrap there. 

That that is what we're done. Okay. Yeah. So, Jeff, RUK23 is gonna be in Newcastle in The UK, the May. I I know this guy called Jeff Gaz, and he's gonna be there. 

And, actually, we may have a date on stage. Right? We do. We do. We've got a pro con debate coming up. 

And Yeah. We'll we'll be taking bets, side bets. Absolutely. Please do check out the REUK website. Check out the hashtag RE UK twenty three and book your place. 

But, Jeff, before we get in, I've got one joke for you. Okay. I'm I'm scared to ask. Okay. Go go for it. 

Jeff, what is an elephant's favorite type of block? Go ahead. A trunk block. Oh my god. Okay. 

That was good. That that was Thank you. You got me LOL ing here. Okay. Excellent. 

That's good. Alright. Dad joke. Check. So, Amit, what are we gonna talk about today? 

Well, today's topic, Jeff, is gadgets. I love gadgets and cool pieces of text. I think you like gadgets too. Right? Yeah. 

Love them. So I figured, Leo, why don't we start by discussing various tools that we both use and the potential benefits from them? And I think it would be cool to start with something that I know you've been interested in before, and that is injection pressure monitoring with a view to minimizing nerve injury. First things first, Jeff, do we need to use injection pressure monitoring? Yeah. 

That's a that's a great question. There's good evidence both in cadavers and animals, and there's some human evidence too, live human evidence, that there's an association between a high opening injection pressure and nerve injury. The question becomes, you know, once you begin to inject local anesthetic at a nerve or near a nerve or into a nerve, the damage could be done. And so if ultrasound isn't perfect and if nerve stimulation, which of course we're both using. Right? 

Isn't isn't perfect. Revealed. Isn't perfect. Then is there something else that can fill in that gap? And and we do have, as I said, some evidence that injection pressure monitoring can alert you to a hazardous needle nerve relationship. 

It's not perfect. It's very nonspecific. You can have high injection pressure for a variety of reasons. Your needle could be lodged in a tendon. It could be clotted with blood. 

It could be, up against the bone or all other manner of of reasons for having high resistance to injection. But it's really, really sensitive in in compared to nerve stimulation or paresthesia, it is way more sensitive at telling you that your needle is touching a nerve when you go to inject on it. So 15 is a sort of cutoff that we believe based on the the animal and cadaver evidence is a good sort of cutoff. So you can if you can keep your injection pressure below that throughout the course of the injection, you're probably in a safe space. You're not gonna cause harm. 

Now do I use it every every case? No. For fascia plane blocks, I don't think there's a real use case there. Even for some of the peripheral nerve blocks, I I I won't use it. But for the the high risk ones, think interscalene is a great case, and I think popliteal sciatic is a great case to use injection pressure monitoring. 

Yeah. So it's interesting. So we we've had to play with some stuff. So I'm I mean, I'm I really like what you've done there. So you're kind of risk stratifying the indications when you might use it. 

And that kind of makes sense because I think the problem is whenever you introduce something or a technology into the mix that isn't commonplace, people kind of think it's gonna be an all or nothing phenomenon. They're like, either we're gonna use injection pressure monitoring for everything or we're not gonna use it. What we don't necessarily do is think, well, actually, hold on. Which situations am I really worried about it? So for example Yes. 

Supraclavicular brachial plexus block used to be my go to block for upper limb surgery. Oh my god. Is this the moment you tell me that you're now team infraclab? Well, I don't wanna give it away, but yeah. Yeah. 

Okay. But yeah. Yeah. Yeah. Yeah. 

Yeah. So so listen. I don't enjoy doing supraclavicular brachial plexus blocks anymore because even though I considered myself to be an expert at intra plexus hydrodissection techniques or as any experience of doing it Shutter. It gives me the heebie jeebies now. Have well, we used that term already, heebie jeebies? 

Yeah. That one that one I know. Peter Pointer didn't didn't know that one. Heebie jeebies. I'm all over that. 

So, actually, you know, I I we're going off off tangent now, but that's kind of the way we roll here. So I had one list where I where I was by myself, and I had a number of patients all having upper limb brachial plexus blocks or needing to have them. So I went from axillary, supraclavicular, and infraclavicular. I did them all. So ran ran through them all, and I have to be honest that the block that made me feel the most uncomfortable was the supraclavicular brachial plexus block because the way that I do it to get a degree of certainty, you know, decent time, bot block onset, etcetera, it was too aggressive. 

And, actually, I still find it too aggressive. So maybe maybe using an injection pressure device would be useful. So I've I kind of used some of the initial stuff that were, that produced the plastic ones that you put in line with your injection syringe, the b smart devices, I think they were cool. They were okay. An extra piece of kit you had to purchase. 

You know, I just I didn't I didn't vibe with them so much, but there is a new product on the market. I have no conflict of interest, but it's called the Saphira safe injection for regional anesthesia device, the Saphira device. Now that is cool. I have had a play with that. It's a an electronic or a battery operated syringe driver that comes with specially fitted syringes. 

And what that does, it has either a palm operator or a foot operator. So, essentially, you can hold the needle and you can control aspiration injection either by using a palm operator or your foot. And it has a fixed slow rate of injection, and if the injection pressure is high, it won't inject. So that is a cool device. Yeah. 

That is cool. Have you had it have you had a play with that? I've seen it at a meeting. I forget where it was, but I I sorta yeah. I played with the foot pedal a bit, and, I was impressed with the idea that it'll just it'll just stop if if it gets to I think we've I think it was 15 psi. 

Right? That's right. Exactly. But what what's interesting is in the same way that you're talking about, if you're in a fascial plane so I've used it for a whole host of different blocks. If you're in a fascial plane or you're up against a transverse process trying to do an erect spiney plane block, again, you'll have an issue because or it it will detect that high pressure, so it won't let you inject in those areas. 

So, I think depending upon where you're using it and how you know, I'm I'm still very early on with using it. I haven't used it. Probably used it about 30 or 40 times. One of the main advantages I think it has is if you're not somebody like me I I I like to do the injection myself, so I'm a self injector. But if you're not someone who does that, what this does will by virtue of the fact it's administering the local anesthetic in a slow and controlled manner, you end up using less local anesthetic than you would do if you'd said to somebody aspirate inject a mil or aspirate inject two ccs. 

Because, effectively, when you see what the spread you need to, you stop injecting. And and even for myself, managed to reduce the volume of some of the blocks I did. So I think it's interesting. I think it's one of those watch this space, areas, and it may well have some some some decent value. Well, I think you've touched on the one of the key points there, and that is you, Amit Pahwa, are not always the one with your finger on or thumb on the plunger. 

So Yes. We'll do blocks all over the hospital, and it sometimes we have to hand the syringe over to a emergency room nurse who is not used to doesn't have a hand feel for what what's a tight injection pressure feel like. And so that objective sort of stop or or at least a monitor is is very, very useful. God, you know, God forbid it's the the orthopedic registrar who's, you know, white white knuckling this this syringe out done. Wait. 

What? You're done already? That's 20 mils? Well, you know, it's funny to say that I've had one of my first femoral nerve blocks with ultrasound was with an anesthetic practitioner who was not, okay with ultrasound guided blocks. He was used to the you get a twitch, bam, drop down the current, smashing the local. 

So I remember I was I was trying to do this femoral nerve block. I was like, okay. Aspirate. And he said, yep. And I said, know, just inject a bit. 

And then I was looking at I didn't see anything on the screen. I went, aspirate again. He said, what are talking about? I've injected it all. So literally, when I said inject, he slammed in That was it. 

20 cc's. Yeah. Exactly. It's interesting that you what what you are saying is that not everybody's gonna be happy to do the injection themselves. So this may well have a role where it allows it puts the the the the person who's got the needle back into control, but without compromising their needling techniques. 

They can focus on getting great hand eye coordination, holding the needle, but they've got another way of doing it. So this they may well have a role. Yeah. It's pretty cool. And and I I should probably just mention for our listeners that there, you don't have to have extra kit to monitor injection pressure. 

There's, you know, Bansui, who's now at Stanford, came up with this really clever idea using Boyle's law. Now, Amit, when's the last time you thought about Boyle's law? Probably He's gonna he's gonna say, like, noon today or something. No. I wish it was. 

Oh, no. It was it was the last time I did my exam, but a long time ago. A long time Right. So yeah. Physics stuff. 

Anyway, so too long didn't read version of this is if you hold a syringe upright and have some fluid and some gas, if you let's say you have a 20 mil syringe, you have 10 of local and 10 of air. If you never let that 10 of air get to half its original volume, you'll never double the pressure in the system. And the pressure of atmosphere is, you know, 14.7 psi. Oh, how convenient. That's really close to 15 psi. 

So just never let that air bubble get to have its original volume, and you won't expose the nerve to injurious pressure. Do you remember what the acronym is for that technique? The Kate technique. Compressed air injection technique or something like that. Right? 

Yeah. Yeah. That's right. Exactly. I thought it was gonna catch you out there. 

That's so cool. Oh, mate. Mate, I'm all over the Kate. Yeah. Oh, god. 

Oh my god. We're coming out with so many rhymes. This is on fire. Hey, man. How cool would it be if you could put a probe on a patient and the image would tell you where the nerve or the vessel or the muscle would be. 

Like, I'm talking artificial intelligence. Wow, man. Artificial intelligence would be very cool. And I this is a this is, this is a subject that's very close to my heart because I'm aware of at least three devices that do this already. That would be very, very cool. 

And in fact, I remember many years ago talking to people, and and they were talking just like we were. So was saying, wouldn't it be really amazing? But actually, I never thought I'd see the day when it happened. And actually, I I'm aware of one product, product called ScanNow from Intelligent Ultrasound, which you hook up to your machine. It slaves the image, and they've put lots of work into, you know, teaching this machine how to interpret images from a certain number of blocks. 

And and this stuff is clever. You you feed your image in, and it will highlight muscles. It will highlight arteries. It will highlight nerves. So that is very cool. 

And there are a couple of other systems. There's a GE system and Mindray machines that have this inbuilt technology. Have you used any of these already? I've seen the ScanNav one. It's, it's really cool. 

The one I've had experience with personally is another product called nerve blocks with an x. And it's from a group from Turkey actually that developed this, but it it same idea. It paints over the tissues. So muscle, you know, middle scaling, anterior scaling, there's the artery and there your there's your brachial plexus kind of thing. And what's what's fascinating about this to me is is the number of scans that like, just normal scans that they had to feed into this computer and correct the computer as it was learning how to identify. 

Like, it's in the tens and tens and tens of thousands, but, it's pretty it's pretty darn accurate. Like, it's it's impressive. It is impressive. Now what I'm interested to know is how would you envisage this type of technology being used in clinical practice? Because, you know, we currently, you go to a course and you'll go to a workshop and some will teach you something or you watch a video. 

How are you gonna integrate stuff like this into into clinical practice? Where do you see it having a role? That's a great question. I I think it's the I think it's the beginner, the novice who is putting the probe on the neck or the groin or wherever for the first time and thinking, you know, there's so much to think about in terms of image acquisition before you even get to how do I put the needle there. But so if you can give them a crutch for those first ten, fifteen, 20 procedures so they can get, okay. 

Yeah. Right. That's the relationship I'm looking for. That's the pleura. That's the fascia iliaca. 

I think that's and then they just turn it off. So that that that's the bit that I think you've nailed, you see, because I've seen people using this technology and and have and not quite figure out what to do. So either, and and this is where having a a dual, display or having everything on one display may show differential learning pen. So I think if you've got an image overlay and that's the only image you've got to look at, you gotta know so I I my my understanding is you'd I think you'd have a look. You think, I've been to the course. 

Can I decide what their structures are? So what if I was to take a best guess, what would I say? So I think you gotta put some effort in yourself, then you turn on the artificial intelligence and say, ah, does that correlate? And if it does correlate, you turn off and you do your block. Where I think it can get dangerous is if you try to do the block with the image overlay on because then you don't see the structures, you don't see the borders. 

And, also, if you got a dual display, you gotta work out at what point you're gonna look to the other screen, at what point you're look to the main screen. So I think I think we'll have to train people how to train with the AI, but I think it's very cool. So we were actually doing a study. I won't give away any of the results because I well, because I don't know all of the results yet, but we we were effectively teaching a group of novices, and and they all got given, the basic, the same basic teaching at ultrasound stations about how to do certain blocks. And then we then took them off into an assessment area, and half of them were able to reproduce the the block view using the assistance of of artificial intelligence, and half of them weren't. 

And it was interesting to see there's many factors involved here, but certainly, those that decided to use the artificial intelligence to help them, it helped to corroborate what they're looking for. So it'd be interesting to see that that study when it comes out, and see exactly what the results show. But I think there's there's there's merit in it, definitely. Cool stuff. I mean, it gets to kind of the question of how do you and we're gonna have a whole episode on teaching and teaching tricks and that sort of thing. 

But, you know, I I struggle sometimes with the idea of, okay. I've got this brand new trainee. What do I take them through that's not actually sticking a needle in a live patient Mhmm. So I can get a sense of their competence before they, you know, jam a needle into somebody's neck. Yeah. 

Different solutions to that problem, but, this might be another way to sort of accelerate that learning curve. Yeah. Absolutely. And you know what? There's some there's some other cool stuff that I've seen on some of the machines. 

Some of the machines so I always find, you know, if someone's doing a block and I kinda say, well, you know, take your needle over there. And they go, where? And I say, right over there. And they think, what are you talking about? Well, actually, one of the machine one of the companies that, that I do some work for, g, they've got a scribble pad function. 

So you can actually draw on the screen. So you could let's say you're doing, you know, a block and you wanna highlight some a vessel in the way and they can't quite see it, you can actually activate a function and draw around the vessel or you can draw an arrow and, you know, with some basic trigonometry and say, this is the needle trajectory you're aiming for. You can highlight structures. Yeah. Yeah. 

So all these machines are definitely moving forward. It's great to see innovation coming with these machines, and that's something that I think, you know, will only get better. Yeah. Totally. Now also, how cool would it be if you could control the ultrasound machine with your voice? 

Machine, increase depth. Turn down the game. Do you know any machines that do any of this stuff? No. But I want one. 

It would be cool. Right? And I wanted to talk back to me. So if I say, like, machine, increase the depth. Of course, Jeff. 

And and then, you know, as as the day as the day gets on, the machine gets more and more sort of grumpy and sarcastic. You know? Is that not enough depth for you today, Jeff? You did this block last time with not as much depth. You're getting slow, old man. 

I could I could totally imagine that. I could totally imagine that. It would be interesting, though. They would have to teach these machines to be very sensitive to accents. Right? 

Because there are so many accents out there, and we all we've all got some friends and colleagues who've got different accents. Yeah. Yeah. I'm not gonna do any accent. I'm gonna try one episode with no accents. 

Okay. So so so there is actually machines. So Mindray have a a machine out in the market, where you could ask it to do stuff. So I don't know how effective it is. I've not used it, but I know the technology is there. 

So that's cool, man. Watch this space. Mindray, fantastic. But if it's not a sarcastic machine, I don't wanna hear about it. Okay. 

Now you talked a little bit about how you can train a brand new trainee before they've got to do stuff. So I wanna talk about anatomy apps. So these are cool gadgets. Do you use anatomy apps? I know the answer to this, of course. 

But what do you use, and how do you use them? Yeah. I I I I agree. So so useful for getting your head around. So the QL block is a is a good example. 

Right? Like, when people started talking about the chorditis lumborum block, I'm like, what? What? Is that a muscle? Did I miss this muscle in anatomy class? 

God. I'm so happy you said that. I thought the same thing. I'm like, q l. Pauses to look up q. 

Oh, yeah. Yeah. Right. Sure. Yeah. 

Q l. But but being able to to peel away the layers, skin, muscle, fascia, and then and then reverse, you know, overlay stuff on top of that as you wish. It has been a remarkable. So I just I use one that I got off the the Mac app store. It's called human anatomy atlas twenty nineteen. 

I think it's the last version they had, but but it's it's really good. And and you you I've seen you use some really, really wild augmented reality one. Right? Like Yeah. So I've, you know, I'm I'm very lucky that I've kind of I was introduced I I I there was a trainee of mine many years ago. 

So I was trying to draw something on a piece of paper. I it was supraclavicular, very complex plot. I was trying to draw the relationship of the first rib and stuff. I was doing this on the back of an operating theater list, and he's like, oh, doctor Power, just give me a second. And he opens up his iPad, and he and he shows me this app, and I was absolutely blown away. 

So I use an app by three d for medical. There are various iterations. I started off using visible body, then essential anatomy five, and now I'm using Complete Anatomy. These apps are crazy. So exactly as you say, you can manipulate a structure in three d. 

You can peel layers off. You can highlight. You can fade. You can isolate structures. But the bit I started playing with recently was this augmented reality where you can effectively get your three d model, move it around, peel back the layers you want to, and then superimpose it into space, whatever you're looking whatever your iPad or I I or iPhone is looking at. 

Please tell me you have, like, cadavers walking down the street in London. Yeah. Well well, not not in the bedroom and not in the kitchen, but, no, we have had them in the dining room. So I thought I could have a on the dining room. And, actually, you know, we'll do a block. 

Right? So we'll do a block, and I'll say to the trainee, wow. You know, how do you think that went? And then I get them to walk through the block using the phone to zoom in on the area where they would've inserted the needle and they'll get and I say, you you know you were hitting bone there when you did the paraversal. That's why. 

That was you hitting the Costotransverse Junction, and and it's amazing. You can actually peel layers away. And in fact, I I did one video on on Instagram when I actually walked inside the body. But, yeah, there's there are there crazy thing. Yeah. 

Oh, hey. What was just speaking of Mike, what was the name of that body again? It was You mean the really ripped muscular body that was using that yeah. It was Jeff. The the guy was called Jeff. 

That's right. Yeah. And also, these anatomy apps, you know, they're great because, as long as you give them credit, you can use them in, in lectures. And I know you use them in your videos, and I use them in my lectures. And it's it's incredible. 

It's it's it's it's a really great way to teach because talking about anatomy sometimes, in lectures can be difficult to engage attention. And and, actually, this is a great way to bring an anatomy to life. So that's a great bit of tech. I love that. Totally agree. 

So taking that one step further, like, about VR headsets? So now I know that a program exists for that, and I haven't used it. There's a colleague of mine in London called Boyn Beloo. He has started doing some work with virtual anatomy classes using VR headsets, and that would be great. You can have Yeah. 

Everyone looking at the same stuff you're doing. You're pulling layers away. That would be amazing. So I haven't had experience with that, but I want to. But we've used VR headsets for in lieu of sedation. 

So we've we've got three, VR headsets at at at Guy's and St. Thomas's, and we started using it for some patients in lieu of giving sedation for them having surgery under regional anesthesia. And it's really interesting because some patients, it literally you know, it occupies them. They're completely distracted. But, of course, you gotta pick the right scene because you don't want them going on a roller coaster or moving around whilst they're doing delicate hand surgery. 

Have you have you guys had any experience with BI head surgery? No. It's funny you say that, though, because that was one of the things that we came out of our, retreat was that that would be a cool area to explore and, know, see how that could help reduce anesthetic requirements, sedation requirements, and and satisfaction and all that kind of stuff. Now, okay. So VR headset's cool. 

There's potential there. We know some people are using them. There are two other things that are moving on that are slightly different but linked. Google Glass. Have you used a Google Glass type of device either to record a block so you get the Anesthes iView because that would be cool as a training thing or as some kind of eye tracking thing or a virtual ultrasound screen. 

Have you have you I mean, have you used any of those type of devices? Because that would be very cool. Yeah. So I haven't haven't personally, but I have I'm aware of at least one study done out of Stanford that, where they used that and had a sort of a heads up display of the ultrasound screen while they were looking down. Their gaze was directed at the patient's skin and the hands and the needle and stuff. 

So they could sort of tilt their head up and down. They it's all one So hold on. So you're looking down at the area, and you can see your hand going into the skin. And on top of that, you can see projected the ultrasound image. Yeah. 

That that's my understanding of of what they can see. But Well, I saw somebody I thought I I think I saw somebody from Turkey post a video of that. That sounds very, very cool. Yeah. Ken actually did that. 

He he was posting about that. Yeah. There you go. I thought so. Right? 

Okay. So so I need so I need to get get a hold of that. That'd be great. So anyone listening from these device companies that would like to loan Jeff and I some of this stuff for evaluation on the podcast, please reach out to us. We would love to do that. 

Now what about training gadgets? Because we talked a little bit about learning anatomy. We talked a little bit about ultrasound machines and where they're going in AI. But I the one of the problems that we have in The UK is now regional anesthesia the great thing is is regional anesthesia, has now become a core part of the curriculum for trainees coming out. So whilst it was in the curriculum before, now it's one of the core 14 modules that people have got to to to tick off to become a specialist in anesthesia, which means that we need to make sure we increase the level of exposure that trainees get to regional anesthesia. 

And often, there aren't as many opportunities for everybody, and it can vary across the region. So phantoms, I'm talking phantoms. And I'm not talking about phantom menace. We're going back to the Star Wars vibe. I'm talking about phantoms. 

Now I remember back in 2014, surprise surprise, you and I were together. I've got some photographs of this with a paravertebral block trainer. This was super cool. Right? I'm glad it's what you said. 

I I thought you're gonna go somewhere else. We But this no. That that's not that's Some stories are not told, Alas. Exactly. Exactly. 

Oh my gosh. Okay. Sorry. You've distracted me now, Jeff. Right. 

So we have a phantom, and and this phantom, you stick a needle in, and you get an an translated image on a computer of where your needle is in three d space or this virtual model. But the next level was you then suck a virtual probe on top of the phantom, and on another screen that shows you where your needle was in an ultrasound image, on a on a virtual ultrasound image. Now that blew my mind, and that was back in 2014. Well, to tell me about this you know these guys. Right? 

Yeah. That's that's Boris Inesenka from University of Florida and his team. They they want a grant for that, but the amazing machine. He still uses it. I've I've did a workshop at the ASA with him last fall, and it's an it's an incredible sort of innovation. 

But I do like I do like trainers or phantoms, and there's good evidence to show that if you do something as simple as, you know, a block of gel and you put an olive in the middle of this block of gel, you can accelerate their time to competency with ultrasound guided tasks. But I am a big fan of a high fidelity trainer. So it's one thing to use a block of gel, but then I think, honestly, between you and me, it gets kinda boring after about three or four times. There's the there's the olive. I'm hitting the olive again. 

You're all over the olive. Sorry. I just sorry. Never. Carry on. 

On. To have a model that, you know what? I wanna learn how to do PEX blocks. Hey. Here's a here's a trainer phantom that looks like someone's chest wall, and there's the PEC major, PEC minor, etcetera, etcetera. 

So the best ones I've ever seen are ones made by this really amazing engineer, Robert Nichols from Valkyrie. He supplies Nisora with with those models, and they they're they're pretty cool. They got them for every even even genicutors. So every single block Oh, they really? Oh, wow. 

Yeah. He he's got he's got one made up. He's like he's like the Steve Jobs of of regional anesthesia. Like, he's making these things. I don't I think it's actually in his garage, but I I picture him in his garage, like, pouring liquid latex into these molds and and and that sort of thing. 

And I know he's used his his wife. He takes, like, CT scans of his wife somehow or don't ask me how this is done, but and then he uses those to make like, they're actual he made some paravertebral models for us, and they were basically his wife's back. Wow. Yeah. See, now I've seen these. 

I haven't had a chance to get my hands on them, but I I'm guessing they're not cheap. But I'm gonna tell you something interesting. One of my regional anesthesia UK colleagues, Jono Womack at REUK and I saw at the joint meeting 2022, he brought along one of his colleagues, a medical student who three d printed a spine and embedded it in some gel. I'll tell you what. So it was for it was a para virtual trainer. 

It was really good. I agree. High fidelity trainers, I think, are the way because that's right. You can teach somebody to get all over the olive Sorry. You can teach someone to do that or or to chase a a shoelace or whatever it may be, you know, a chest drain within within phantas, but it's not real life. 

It or it's not close to real life. But if you can teach somebody and, you know, use artificial intelligence, get them to highlight the anatomy, and then say, right now, I'm gonna get you to needle the same thing on this thing. And, actually, if the phantom looks like the real thing, hey. That's almost as good as doing the block. Yeah. 

You know, there's there's some phantoms you can actually inject into, and, of course, they have meat models. In fact in fact, in North Carolina, mate, we what we do here is we'll take a big old piece of pork butt, and then we'll stick a stick a needle in it. And instead of saline or local anesthetic, we use barbecue sauce. And, when we're done when we're done with the pork butt at the end of the workshop, we'll just we'll just throw that sucker right on the grill. And, yeah. 

You're killing two birds with one stone, man. This is this is Are you serious? No. But I wish I wish. One of these days. 

One of these days. God. That would be brilliant. I would love to that would be brilliant. Okay. 

Oh my gosh. Okay. I've got one more cool thing that I've seen. To the same company that we talked about, Intelligent Ultrasound, they have a needle trainer. Now check this out. 

You, stick, an ultrasound probe on the neck and you generate an image, and then they've got this virtual needle. It's like one of those fake swords. So, you know, it contact with the skin and the sword retracts into the body. This is the same device. So you you've got the whole, like, this pen thing with a with a retractable or a compressible point. 

And then you place that probe, that fake needle on the skin, and you'll get an image on the screen that will show you exactly your needle going into the image. So as you push the needle on the skin, it retracts into the body. But on the ultrasound image, you see this virtual needle coming in. It's like doing a block on somebody without ever doing a block on somebody. I can see the prank potential here. 

I like that. Complete completely. Ah. I've failed myself, but no, I haven't. But do know what? 

So I had to play with this, a very quick play. And I think this could be one of the ways that you could address you know, you might work in the center where they don't necessarily do a lot of paravertebral blocks or paravertebral blocks, and you might wanna you you've got to know how to teach it, and you might want your trainees to have a play at doing it. This would be a great way to start someone along that path. So I think this is a perfect example of where technology is taking us that will ultimately benefit our trainees and our and our colleagues that are wanting to learn more regional. Regional. 

Yeah. I totally agree. And it reminds me of something else I've seen. I am there's a company called Ezano, and Oh, yeah. They they have they make an ultrasound machine that was one of the first to have this sort of needle trajectory prediction tool. 

So you could sort of they use a magnetized needle. And, as you get close to the probe, it would show you where your needle was gonna cross the beam and where it was gonna intersect with the tissues at different different depths and that sort of thing, which is which is really, really amazing at yeah. So what how does it so as as you make contact with the skin, it would show you if you were to carry on going in that trajectory where you'd end up. Yeah. And so you could you could actually touch the skin and then sort of wiggle the needle around and see the lightsaber for lack of a better term. 

There's a lot of Star Wars Star Wars Star Wars theme. Yeah. You can see the lightsaber sort of wiggle around in the tissues. And then and it was as it crossed the the intended target, you can say, okay. That's my trajectory. 

I'm gonna sort of drive it in now. But more than that, it gave you a a three-dimensional sense as well. So it it changed color as you're getting closer out of plane so that you could say, okay. I'm about to see my needle tip. About to see my needle tip. 

There it is. There's my needle tip. That's that's cool. So that's been around since at least 2013 that I can think of. But what which is really neat. 

And I think of of that type of technology has been adopted by or licensed to other other ultrasound manufacturers. Very cool. But what I what I saw and have played with in the last year that also came from Enzano was a fake ultrasound probe that connects looks and feels like ultrasound probe, connects up to a laptop with a USB port, and then you can use a a same magnetized needle and you can simulate any tissue using their app. So, you know, PEX, ESP, whatever. What? 

And then you can practice either in midair or you can get a piece of meat or just a a regular old gel block that doesn't have the high fidelity. And it looks like on the screen that you're actually, you know, driving the needle in. That is nuts. That is nuts. Totally. 

And to me, the the advantage there is that you've got a fake ultrasound probe that's cost, I think it's $500 versus having to buy a $20,000 ultrasound machine, and we can send these home with our trainees and say, take this home for a week. Do plug this into your laptop. And when you come back in a week, you're gonna be so good at driving needles and finding your needle that you I don't have to take you through 30 actual blocks on a real patient. Oh my goodness. That is incredible. 

I love that. I really love that. Very good. That's I so I I wanna get my hands on that. No. 

I'd I've I've seen them. I definitely wanna get my hands on that. That's put me off my boat where I was going. But now so I'll tell you what I have seen. So I've seen this needle visualization software on a lot of a lot of machines. 

And I have to be honest. So needle tracking or needle enhancing stuff, I don't always like it because often you'll turn it on and it may degrade the rest of the image just to, you know, just to sacrifice seeing the needle or to increase that field of view. But what I have seen is some of this, so I think Philips machines in in partnership with B Braun, there's something called OnVision. So they allow you with using their needles to to visualize a needle tip. Now, again, the in plane thing, there are pros and cons to whether or not that's valid. 

But outer plane, I think that's a game changer because a lot of the times we go through tips and tricks for how we should make sure we don't miss our needle tip, but this definitely gives you that degree of confidence. You like it. Okay. That's red. So I'm getting close, but that's not needle tip. 

Boom. That's green. I know that is a needle tip. And I did have one situation with an in plane technique. So I had a trainee who was very early on in his paravertebral training, and we didn't get a great view. 

But we were using the on vision stuff, and it was showing me that his his needle tip was near. So he knew exactly what he needed to do to what angle he needed to move the needle to bring it in because it went red, red, red, green, and we saw needle tip, and then he proceeded with the block. So I think there is a potential to use it. I don't like the idea of being reliant on technology to identify your needle. I think there's one potential disadvantage. 

If you work in an institution that uses this needle tip technology the whole time and then you go somewhere that doesn't have it, then, of course, you'll lose that crutch. But I think it has an advantage potentially. Have you what do you think about that? Totally. Yeah. 

I I, I have used the On Vision. I actually, I gave a talk at Azure last spring, about sort of new technology, and that was I showed a video of an an an in plane pang block that was Oh, I was there. I thought that was a great talk. Oh, thank you. So so steep so steep that you couldn't really see the needle that well, but the On Vision helped, you know, track that needle tip down to the bone and and it was all good. 

We your point about education is really really good. When we presented we did some work back in New York with my fellows, and we presented this as a as an abstract at ASR. So we took complete novices. They were actually internal medicine interns. So they weren't anesthesiology people. 

Internal medicine interns gave them an ultrasound guided task, and we trained half of them with the needle tracking and half of them without. And and then we sort of give them a week to sort of, you know, just go away and then came back and then we said, oh, here's a different ultrasound guided task. It's not the one you've been practicing, but let's see how well you can do it. And the people that had trained on the needle guidance system did significantly better. So there's something that it it helps you learn better even in the absence of using it for the actual procedure you wanna use it for. 

Well, there you go. Well, then that's that's fabulous because you obviously learn and appreciate the muscle memory and you could adapt. But even without the cue of telling you where the needle tip is, I mean, that's that's fascinating. Well, listen. I don't know about you, Jeff, but I'm kind of my mind is buzzing and with all of these different technologies that are out there. 

I'm just trying to imagine, what we've what was left to come. Looking forward, what would you like to get your hands on next? I'm talking about technology, nothing else. What would you like to get your hands on next? Obviously, I want a robot that does my job for me. 

So I can sit at home in my in my robe and slippers drinking a coffee and say, robot, do the block. Can somehow somebody work on this? Do know what? It's not gonna be long. I'm sure you've seen, but it but is is is there is there anything else? 

You know, I I think I would wanna get my hands on this this Google Glass thing that projects the ultrasound or whatever the projects the ultrasound image ahead of me. That would be what I wanna get my hands on. Anything you particularly wanna get get funky with as they say? I think I want well, lots lots I wanna get funky with. That's a different show. 

The VR stuff, think that's really cool. I wanna I wanna give that a go. Yeah. Yeah. Yeah. 

Well, it sounds that would that will fit nicely with your jute rap mission for the next the next five years. So that's cool. Right. Well, listen. We want you guys, to let us know what you think. 

If you've had a play with a, with a cool piece of kit and you wanna tell us about it and share it with us, please hit us up on our social media. So we've got a few ways they can get in contact with us. Right? So we I'm gonna go first this time because you always get the easy stuff. So you can contact us at or at Twitter with at block it underscore hot underscore pod. 

What else we got, Jeff? Oh, we got, we got the Insta. We got block underscore it underscore like underscore its underscore hot. Yes. Gave you that one. 

We've we've also got YouTube at block it like it's hot. So please send us videos, send us photos, give us questions, give us comments, use the hashtag hashtag block it like it's hot without the apostrophe and get involved with conversations online. So what do we gotta say? I think we we gotta tell there's only one thing we end the episode with. Right, Jeff? 

Every time. Till next time. We hope you all block it like it's hot.