S1:E7 "Gadsden & Pawa’s Top Teaching Tips for Nerve Blocks and Regional Anesthesia"

What do Ali G, video gaming, and Patrick Swayze from Ghost have to do with teaching regional anesthesia? I'm Amit Pawa. We feel required to admire those teachers who inspired us to inquire and set our academic interests afire. I'm Jeff Gadsden, and this is Block it like it's hot. Hey, Amit. 

I can't quite believe it. Time is flying and now we is at episode seven. Hey, Jeff. Hold hold on a minute. Was that your Ali G impression? 

I Well, you is right my regional brother from another mother. We is currently in Evan recording episode number seven and me and me Julie literally cannot believe it truly. Okay. That was that was amazing. I got no words for that. 

I could we consider that, like, the accent done for the episode now? Are we I think I think maybe we could. It may be safer for us to do that. But I gotta say, your Scottish accent got some pretty rave reviews in the hip episode. So tell tell me, Jeff, how are you doing? 

How's your time been since we last caught up? I'll see you. My last week, I had, some time at the I do some time at the aesthetic center every couple weeks, which is kinda cool. Uh-huh. It's interesting. 

Right? Like, you have a different set of priorities for your anesthetic than, if you're doing, say, an emergency laparotomy. But Mhmm. It interesting being at a place where the goal is to make people beautiful. But help me. 

So help me understand this. So this is you working in a hospital environment, but it's purely, I guess, the equivalent of what we would be doing in the private sector here in The UK. So just cosmetic type work or aesthetic type work? It's just cosmetic. Yeah. 

Wow. So it's, but the cool the cool thing is that you you can get paid in cosmetic procedures. So I I got my calf implants on there for free, you know, after doing, like, 40 shifts or something like that. So This is a joke. Right? 

That is a that is a joke. Yes. Okay. Okay. Because I was gonna say you do have some pretty good looking coughs. 

One can only one can only hope that that might be an option on the table at some point, but Okay. Anyways, that was kinda cool. It's it's, it's makes for a different day. It's good it's good to have variety. Right? 

Like, I we do enough super intense trauma call and that sort of thing that this a day like that sort of balances things out. We also had, every couple of months or so, we'll do a group journal club between us, our group at Duke, and the group at University of North Carolina, UNC, with some of our colleagues over there. So we had it at great friends, Stuart Grant Yes. Hosted at his house and, had some food and drink and, you know, good chance for some cross pollination between our two fellow groups and faculty and stuff. So that was that was a fun night. 

That sounds amazing. Yeah. Sounds great. Very good fun. Yeah. 

So how how about you? How how you been? Well, Jeff, do you remember that story by Roald Dahl James and the Giant Peach? Oh my god. Do okay. 

Fun fact about me. I'm a huge Roald Dahl fan. What? Who knew? Yeah. 

No. No. It's it's I I am I've read all the books and our kids have read all the in fact, we when each of our kids turned nine, I read to them Danny Champion of the World, which I think is one of my favorites. And it's because it's a really nice story about a father and the kid and the relationship and stuff. So it ended up being a a family tradition for us. 

Oh, wow. Anyway, so James and the Giant Peach, don't tell me you were kidnapped by giant insects. No. No. No. 

But but I have actually been in my own large fruit story. Okay. Okay. Yeah. I'll I'll bite. 

What was that? So I've been in Amet and the Big Apple. Or I guess, more truthfully, the powers in the Big Apple. Oh, yeah. Yeah. 

Yeah. I saw that your all your social media posts and everything. It looked amazing. Yeah. We just came back from New York City. 

I've gotta tell you, we absolutely love that place. I went with my wife, Kate, and the kids. We kind of did all of the stuff. The kids have been fascinated by New York for some reason since they were very young. And ever since the my eldest, Sophia, said she wanted to go and see the Statue Of Liberty Oh, nice. 

That's been that's been on her on checklist. So we did. We did Times Square. We did this Liberty Island. Went to the top of the Rockefeller. 

I think I probably broke the world record for the most number of photographs of that view and the sunset. Oh, it's amazing. We did Central Park and, you know, we had a very sobering, visit to the 911 Museum And Memorial. Right. I was actually in, in San Francisco on nine eleven back in 02/2001, and that was, yeah, to to to go there and visit with my wife and, and with the kids, that was quite something, something we'd normally quite, forget. 

But yeah. What and it was an incredible trip. That's amazing. Yeah. I mean, what a city. 

It sound like you had an amazing time, and I I saw some of those those photos. You know, I've never been to the Statue Of Liberty. I've I've lived there for twelve twelve years. Never been to Liberty Island. I mean, I've seen it a bunch of times, but seeing your pictures from inside the statue was really cool. 

Well, I tell you, I have to be honest. I, you know, I told you part of the other one of my, my New Year's resolutions was to get more fit. Holy moly. There were not that many steps, but there was the tightest spiral staircase that you had to go to get up to the crown. We went right up to the crown. 

And I tell you what, for the for two days afterwards, my I'd got Dom's delayed onset muscle soreness in both my thighs. That was that was it was quite some exercise. But to get right up to the crown, it was nuts. Absolutely amazing. No elevators, I guess. 

No elevators. That's exactly what my youngest asked for. Why is there no lift? Where's the lift? Wait. 

Dom's. Is that a thing? Yeah. You come on. You must have heard of Dom's. 

No. Well, I've Delayed the concept, muscle soreness. You've never heard of that acronym? I get the concept. Yeah. 

I've I've I've experienced Dom's before. Never never heard of phrase. Just stick with me. You know, not only do I make up words, like, symmetrization, I'm gonna give you, like, I'm gonna give you some new acronyms you've never heard of before. It's great. 

Hey. Can you believe the engagement that we've had online about the podcast? Over 6,000 downloads now. It's been amazing. Do you know I it's unbelievable. 

Right? Yeah. Tell us who who won the mug competition. Yes. Well, I believe this, this particular individual may be somebody that's known, known to you. 

So, it was a certain nieces from New Zealand called Matt Levine. Is it Levine or Levine? Levine. Yeah. Levine. 

Matt Levine, he was in fact, he was the second person to answer, but the first person to answer correctly. So I have dispatched his mug all the way over to New Zealand, bubble wrapped it. So fingers crossed it gets her in one in one piece. So Matt, let us know. Post us a selfie when you get that mug. 

Good on you, Matt. Well done. Fuck. Your answer was the beast. Okay. 

That was I guess I could tell that was New Zealand as opposed to Australia because you said your answer was the beast. Yeah. That's there. Yeah. Yeah. 

I'm gonna get in trouble with these accents at some point. I know. We're just about okay. We're just about we okay. Also have we had some great questions and interaction online. 

Shoot some shout outs. Yeah. Let's do that. Okay. First, Rahil Mandalia from Leicester in The UK says on Twitter that he is loving the podcast. 

Thanks, Rahil. But wished we covered hip fracture in our hip hop episode Mhmm. As he wanted to know what we were doing differently for sort of intracapsular hemiarthroplasty versus DHS long nail cases. So that's a great point. We I think we're planning to do a separate hip fracture episode because it's such a big public health problem. 

Right? Absolutely. I think, in fact, I'm talking about hip fractures at AZRA Spring, coming up very soon. But, yeah, I think we we'll we'll cover that specific topic later. I think if we get into it now, we'll detract very much for what we wanna talk about. 

But, Rahil, we hear you, and we will address that. Now we also have Marta Astravicava from The UK, and she messaged us via Instagram. And she said that she was listening to our episodes, while she was driving home, and she laughing all the way, which I could just imagine that sounds like fun as long as you're focusing on the road, Astra. She wants to know a specific question. She wants to know how we follow patients up who have been discharged home with active blocks. 

You do a block. They're still functioning. We send them home. Jeff, what do you guys do for that? Yeah. 

That's a great question. It it sort of depends if it's a catheter versus a single shot block, but it a lot of it is just the safety education and making sure that patient understands the trajectory of the block and when it's meant to wear off, when we think it'll wear off, what to do when it wears off. But also, I have this little spiel about, you know, don't rest your numb arm on the stove when it's, you know, it's hot and you're not gonna feel it, or anything sharp. Lots of pillows. Put your feet up. 

Watch your Netflix and, enjoy that block until it wears off. Yeah. And absolutely. So we, we actually do have some patient information leaflets, which we have an electronic version and a paper version. I'm not sure, truthfully, what percentage of people, get them. 

And then if they do get them, how many of them read them? We do do have the very similar, discussion with you. But, actually, in, on our day case units, our ambulatory units, actually, every patient who had a a general anesthetic or a block gets called the next day, by the nursing staff. They go through and call up everybody to make sure they're okay and address any concerns. Yep. 

We also have our friend, Amina Benussaf from Algeria. Hey, Amina. Hey, Amina. On Twitter, and she loved, the breast block episode. Thanks, Amina. 

But wanted to ask a question about blocks in thoracotomy and the optimal time period for intermittent boluses. So do you have any thoughts on that, buddy? Yeah. So it's interesting. So I was trying to work out so she showed a nice picture of a of a thoracotomy there, I was trying to work out what block she was referring to, whether she was talking about, a paravertebral block or whether she's talking about fascial plane blocks. 

Because the answer may be slightly different. And my answer is gonna be not necessarily reflective of what we do. So at our institution, we don't have the ability to do automated intermittent boluses, which I think would be the the perfect, recipe as she alludes to. So we're stuck with an intraoperative, catheter bolus or loading bolus and then a continuous infusion afterwards. But I think the optimal regime would be something like a four hourly or a six hourly intermittent bolus with maybe a low background rate to keep a catheter open. 

What what are your thoughts on that? It's it's a really good question and something that we have been, thinking about if not struggling with. Mhmm. Because, you know, we first switched over to an electronic pump that allows us to do an intermittent bolus. Our sort of default position at the time was, well, we've been giving, let's say, 8 mils an hour continuously. 

That was our previous regimen. So let's just give eight mils an hour, but as a onetime bolus, and then repeat that every hour. Oh, so you were doing every hour, you're giving eight mil bolus. Yeah. Because it it just it just seemed like, well, that's the an equivalent to what we were doing before. 

But what we've realized is that you obviously don't need that. Ropivacaine is what we're using, and it lasts longer than an hour. So you can stretch out that interval to two, three, four, six hours. Some are doing longer, but, there is not a lot of literature on this. So a lot of opportunity for people to do some studies and see what is the optimum interval. 

And the implication is that if we're sending somebody home with a 500 mil bag, you know, if you stretch your interval out from one to two hours, you've doubled the infusion duration. Right? So that there's a lot of good work to be done there to see what the what the best thing is. But, certainly, we know for, from fascial playing blocks, there's a lot of cadaveric studies now that have shown just looking at dynamic fluid flow and spread, the intermittent boluses seem to open up the space and and and spread a bit better. So Totally. 

We need to see more of that in clinical studies. Right? Yeah. And I know I think, you know, interscaling was an example of a block that we had been running at, you know, six or eight mils an hour as a continuous infusion. And when we did that with the intermittent bolus, it were super, super numb, like, uncomfortably numb, and they were to say, like, I I need this turned down. 

So we're Right. You can actually get away with a lot less as an intermittent bolus because to your point, it spreads in the correct way. Okay, Mina. So, you know, we we don't have the perfect answer, but it's maybe something that one of our listeners is gonna publish and work on, and maybe we'll get the answer soon. Hey. 

Alright. So what do our listeners have to look forward to today? Well, know what, Jeff? We've just received our new regional anesthesia fellows at Guy's and St. Thomas'. 

So this episode is especially relevant. We're gonna talk about how best to teach regional anesthesia and how education regional anesthesia is changing and, what resources are available. I I thought, you know, before we start, I'd love to give a shout out to some of my early teachers of anesthesia. Can I do that? Oh, for sure. 

Okay. You know, the first hospital I worked at was also called the Medway Maritime Hospital in Kent, and it was actually where I did my first consultant job. And there are two guys I wanna particularly single out. One of them doctor Graham Sanders, one of them is doctor Badri. They were they basically took me under their wings as a baby SHO, my first exposure to anesthesia, and kind of set me on the set me on the right path, I think. 

And then when I came to Guy's and Saint Thomas's, I came across doctor Imad Aziz. In fact, doctor Aziz's brother is Eza Aziz, is the president of the African Society of Regional Anesthesia. So Imad Aziz and doctor Sanjay Gulati were two two people who kind of really helped shape my regional fellowship and and guide me in the right direction. In fact, I learned with them as well as them teaching me. We call it went through that process together. 

And there's one person who who sadly is no no longer with us, that's doctor Geraldine O'Sullivan. Geraldine will have, is well known for her work in obstetric anesthesia. Right. And in fact, so she's the first person from whom I heard the pepper pot, phrase. And I'll I got I'm gonna just very quickly share a story. 

When I had done a year of anesthesia at Medway, I'd gone to do a list at Saint Thomas'. I moved to Saint Thomas'. I was doing a list with Geraldine O'Sullivan, and everyone had told me what an amazing, individual she was and how well known she was, and I was really scared. And I, you know, I put my spinal introducer in. I put the spinal needle through. 

Right. And I waited, and no fluid came out. And I was like, oh gosh. So I pulled the needle back and did it again, and no fluid came out. So I did this three times, and she looked to me, and I won't do the accent. 

And she said to me, what what what are you doing? And I said, I'm waiting for the CSF to come out. And she said, Amit, you're pepper potting the dura. You can't see CSF unless you take the introducer out. And I was like, oh my god. 

I forgot to take the introducer out. So so that's where I that's how I felt. I was so nervous. I forgot to do that. So that's why I heard pepper potting. 

Do you know I've I I had never heard that phrase before until you said that in the ESP episode, and I yeah. It's it's a an evocative phrase. Right? Pepper potting. Completely. 

But but it you know, it's stuck in my mind since then, and, of course, I've used it subsequently. And lastly, I've got two other people, Rafa Blanca, who I've mentioned before, and John McDonald, who were both very instrumental in my early teaching of regional anesthesia. So that's that's me. It's a long list, but I owe them a lot, and I wanted to say thanks. Anyone you wanna thank thank? 

Oh, yeah. Totally. I mean, you you you'd look back at your career and think of people that inspired you. And I think that that you know, we'll get to this later, but that's that should be the goal. Right? 

As an educator Yeah. You wanna inspire somebody. So, you know, early on as a medical student, I went to Queen's University in Canada for medical school. There's a guy there named Ted Ashbury. I've been doing surgical rotations and, like, just bored to tears. 

Right. You know, just not my thing. And then I did a day with Ted Ashbury. And I came away at the end of that day I wanna be like this guy. Wow. 

And that has been a consistent thing with some of my my mentors. And I think that's that's I think what a lot of us aspire to be, right, to for our mentees is inspire them to be like you. Anyway, he was Absolutely. He he pulled out a Swan Swan Ganz catheter, which should teach me about physiology and and just he made it really, really fun. So Vincent Chan for when I was in Toronto, obviously, really inspiring and he the, you know, early inspiration in regional anesthesia. 

I think my biggest influence was Admir Admir Hadzik for when when I was at in New York. And he taught taught me so much about how to approach patients and thinking about regional anesthesia and anesthetics in general and also just how to approach your career and and that sort of thing. Absolutely. He's a he's quite an individual. Right? 

Yeah. Amazing. I mean, I wouldn't be where I am without Admir. Another inspiration from from New York is a guy named Kevin Sanborn, who was an example of someone who was so tough and his expectations were so high of you that you just you wanted to impress this guy and you wanted to you actually, you didn't wanna you wanna just not fail in front of him. And but he he won teacher of the year, like, most years in in that institution. 

But an example of some like, you don't have to be a nice guy necessarily to be a teacher and to be well respected and loved as a teacher. He he was well respected and loved, but he was just very exacting in his expectations and made made you better, made me better. Amazing. I it's think nice when you get a chance to reflect and say thanks, so I'm happy we got a chance to do that. Yeah. 

Yeah. For sure. Alright. This is gonna be fun. Let's do this. 

Alright. Let's get into it. So I wanna start off with a quote from Alexandra k Trendfall that seems very, very relevant. She says the best teachers are those that tell you where to look but don't tell you what to see. That's kind of what I hope happens at the end of the fellowship to our trainees. 

Right? Yeah. Yeah. That's great. I was thinking of this this one as well. 

Education is not the filling of a pail but the lighting of a fire. Oh, I like that. Yeah. Well, listen. Why is teaching regional anesthesia well so tricky? 

What what why do you think I mean, there's lots of components to to teaching regional anesthesia, but why do think it's so tricky, Jeff? You know, I think it's there's a lot of elements that go into making a proficient practitioner of regional anesthesia. There's the anatomical basis. There's the pharmacologic basis. But it's a procedural skill too. 

Right? So you have to have a lot of things lined up to do it well. How about you? What do you think? What's interesting is if I reflect back on, the comments I've had from previous trainees that have spent some time with me, they feel that learning regional anesthesia in today's world is so time pressured. 

So the problem is in The UK, we'll have small limited exposures, maybe one to two month blocks where that's they're on their regional anesthesia block, and they'll come into theater. And if they don't have a structured program, they won't necessarily have been told to do the pre procedural reading. They won't necessarily been, known what's on the list. They won't know what what what blocks they're gonna get exposed to. They show show up to the list maybe not as exposed as they should be. 

And therefore and when they're doing the list, because we're in a clinical setting, everything's about time. So they get the patient to sleep or do the block first, everyone's sitting through the window and looking so they feel under pressure. So I think one of the issues is we don't get a chance to spend as much time with our trainees whilst they're doing the block. And if they take too long to do the block, we tend to be quick to take over. And so what I've tried to to impress on on the people I've had the pleasure of teaching is try and communicate with them beforehand and say, look. 

This is what we're gonna be doing. Check out some of the resources, some of which we may be talking about later on in the episode. Prepare yourself for what you're gonna be dealing with. So I've taken some of the onus on myself to do that. But I think it's difficult because otherwise, someone just shows up to a list and they haven't done the preparation beforehand. 

They don't have the time or the or the environment in which to practice and get proficient. And many of those people won't necessarily have had a chance to do the practicing needling beforehand. So everything they're doing is real time and based upon that cumulated experience. It's interesting you you say that because what comes to mind are a couple things. I have a friend, and I'm not gonna say who it is. 

But if if you show up to his block area and you haven't done the reading and you don't know exactly what you're doing, he's like, thank you very much. Go away. We'll see you tomorrow. Wow. Yeah. 

Like, just you you it's a it's a covenant. Right? Like, we do our part as teachers, but you gotta come prepared, and you gotta know your patience. Our trainees call us the night before, and we'll discuss the cases for the next day's case. And that but that always include like, just like you said, includes a little, alright. 

Great. So we we agree that inner scaling should be the block we're doing for this case. Watch the inner scaling video. That should give you a good basis from what should jump off, so we're not talking about fundamental concepts right in front of the patient. You know, I'm I'm wondering how much of your ease of, of those type of discussions is facilitated by having a nice integrated electronic patient record. 

Totally. No doubt. And it it I think back to the days when we had paper charts. And and, man, you know, I knew what cases I was doing the next day, but I didn't know anything about the patient because the chart wasn't available. So I had to do it in the preop area. 

I'm flipping through this paper chart, retrying to read people's handwriting. And then in many cases, struggling through a conversation with someone who doesn't speak English, And we didn't have great translation services at the time in that place, so I shudder to think of the informed consent that we were sometimes getting. But yeah. No. EMR is game changing. 

So now listen. So when, let's just imagine for us for a second, you've got somebody who's with you for a period of time. So let's pick a regional fellow, for example. So you know you're gonna have them for a while. Let's call him Henry. 

Henry. We got Henry again. This time, Henry is not the patient, but he's he's he's a regional fellow. Or Henry or Henrietta. So when Henry's coming, to to start off their regional fellowship with you, do you tell them where to start off when it comes to consenting patients? 

Do you give them any guidance as to what risks to discuss when they're doing the consent process, or is it kind of assumed they will have assimilated that information during the training? No. I think there's a unique set of risks, benefits, alternatives that need to be expressed to the patient. So I that that's part that's part of the teaching, but it's, sometimes, I think, overlooked. So I was gonna say, because do you do you think we should tell because I remember when we used to talk about, epidurals, we used to quote a risk of zero point five percent, a risk of postural puncture headache, and that was kind of a generic number that was thrown out there. 

And then you'd speak to one of the bosses and said, when was the last time you got one of these? And they said, well, I've done about, 800 spinals or or epidurals in the last, you know, three years, and I haven't had one. So should we be quoting standard risks, or should we be quoting, individual risks? And, of course, when you're a brand new novice, you can't you don't have a track record. So do you think we should be personalizing risk that we're discussing? 

And should we be discussing, you know, in The UK because because of a particular case that happened, we now have to discuss every risk that the patient may perceive to be significant irrespective of what the frequency is as opposed to just a frequent risk. So, what are your thoughts on that? Really? That's the expectation at every risk. That's a long discussion. 

Any risk that that the patient may perceive to be significant. And that's because of this case of Montgomery. This is, you know, due a lady who had, diabetes, and she didn't have all of the risks of, you know, shoulder dissociate, etcetera, discussed her. So she decided to go for a vaginal delivery as opposed to having a cesarean section. And as a result, because the small risk of x, y, and zed happening to her was not discussed beforehand, that changed the whole way that law was perceived in The UK. 

So, actually, because of this Montgomery principle now, we have to discuss anything that the patient may perceive to be significant. That's that's a tough one. So in theory in theory, yeah, death is is one of those risks. Sure. I perceive that as significant too. 

Yeah. But from a practical point of view, and I this is ignoring the legal viewpoint that you just outlined. I don't think patients want to hear all that stuff. Yeah. Here's what I say for nerve blocks. 

I'm advocating that you get a nerve block because here are the benefits that we've seen in the past and we think you could benefit from if you get this. There are there are risks. Those risks are if any percutaneous procedure, bleeding infection, and then with with a nerve block, there's a risk a small risk of nerve damage. And I'll stop there and say, do you wanna hear more about that? And most of the times, patients will be like, no. 

I'm good. I trust you. And I'm okay with that. And there's some people, yeah. You know what? 

Tell me more about the nerve damage bit. And then I'll go into much more detail about that. Do you think do you provide your patients with any written information beforehand, or will the risk they have be the the first time they hear the risk be that conversation? So most of our patients are seen in a pre op clinic days ahead of time, and they'll be provided with a written consent form for the anesthetic. Oh, how interesting. 

Which includes yeah. So it's I've worked in places where the anesthetic consent is implied in the surgical consent. But, at Duke, have a separate anesthesia consent. So and it has the boilerplate language about every possible risk, including, but not limited to, blah blah blah blah blah. So technically, yes, but I don't I don't consider that, you know, real information because nobody is reading, considering, having a conversation about that kind stuff. 

So it's it's really practically speaking, it's when I see the patient and have it have that little conversation with them. That's interest. So we, you know, focus a lot about teaching and discussing risks. And I think, actually, when my, when my trainees come and see speak to me before they speak to the patients, they say, what risk would you like me to discuss? And at that point, I usually, you know, highlight a very similar story to you. 

Now listen. What about anatomical knowledge? So before somebody comes to do a list, do you think we should get every pay every trainee say, should we get Henry to draw the anatomy of the block they're gonna be doing beforehand? I remember Michael Barrington, originally from Australia. He used he used to set up, a a regional anesthesia assault course. 

So he'd have all his residents come in, and they have to go from one station to another, like what we call an OSCE in The UK. And they'd have to do, you know, a needling test on one bit, and they'd to label anatomy on a diagram in another section. You know, should we do that? Because I don't do that yet. I I do get my fellows to draw the brachial plexus, as a as a little gimmick to see how many of them have actually revised it beforehand. 

But should we make this an integral part of what we do? That's interesting. So he you have to demonstrate proficiency at those things before you got to touch a patient. Interesting. Yeah. 

I think I think there's some wisdom there. Right? Like, I I want a trainee to come to the procedure having a a good baseline knowledge of the what's, the where's, the whys, and how's of of what Yeah. About to do. But, you know, I I've had people try to draw the brachial plexus before. 

It's it's a fun it's a fun exercise. You end up with some some interesting versions of it. But I I think there's probably a limit too as well about how much preparation. Yeah. Because it's a bit at some point, you just gotta get in there and do it. 

There's only so much preparation. And me having my hand there available to sort of gently adjust the probe position or guide them through an adjustment or saying, you know, stop needles too far, needles not far enough sort of thing. I think there's so much more value in that than hours and hours and hours of theoretical preparation. So so I think you're right. But the question is, I I guess what I'm alluding to is, should the first time that your trainee has seen that anatomical cross section that they've generated with ultrasound be on a patient? 

Because I don't think it's ideal to be telling them what the structures are for the first time on a patient. Have I done that? Of course, I have. Because sometimes, you know, you've never met the the individual before. You've not met Henry before or Henrietta before. 

And the first time you meet them, you're on you're on a list, you say, have you done these blocks before? And they said, well, I can't remember. So you end up doing it in real time, but I think it'd be great if they could have had some of that exposure beforehand. So the first time they're seeing it is not on a real patient. And and, you know, as you're talking about that probe handling, so, you know, how much should we have hands on? 

It's a good question. I think if you do a good job as a teacher initially, teaching someone how to hold the probe, how how much Mhmm. How much, you know, the PART sort of, maneuvers and and that sort of thing, that's a very good fundamental thing to go through before they actually touch a patient. I had another different faculty person I worked with when I was when I was a RAAT trainee who had a very personalized approach to this. And and, this person would sort of stand about right but directly behind you, like, I'm feeling you touching me with your torso and my torso and reach reach around and rest their hands on my hands and sort of guide the probe a little bit. 

Not at all awkward. It was like that scene from Ghost where they're doing As you were saying that, that's exactly what I was imagining. Yeah. Exactly. Oh, mom. 

Yeah. I I don't recommend that approach in 2023. No. But, actually, there's I know there's a big move along some some of the focus point of care folks to say that actually you should be able to direct your the person you're teaching to move the probe purely by using voice commands. Not not not like an automated system, but, you know, but but saying, you know, I there there's a whole so we used to say, you know, pressure alignment, rotation, and tilting, but there's a whole host of different phrases that they're trying to standardize. 

And I know the folks from Zedu ultrasound, are working on this, talking about tail up, tail down, talking about fanning the probe, but but it's all about the language that you use. So there's there is an argument. Every now and then I find that I'm not able to generate the response I want. So every now and then I do have to say, look. I'm gonna put my hands on the probe. 

The danger with that, of course, the moment you do that, the person then disengages. So it's important to say so always say, I'm gonna I'm gonna move your hand here. Okay. Now I'm letting go. You're fully in control so you know that they've yeah. 

I I 100% agree with you that philosophy. You should be if you're a good teacher, you should be able to to direct them verbally through the maneuvers. I might be one of the slowest people that I know to jump in there and and take over something. Because it's important. They've they've gotta go through that process themselves. 

Exactly. To understand the muscle memory and the movements required. Yeah. Yeah. Exactly. 

Not where I work currently, but some as other places, I've seen some poor examples of someone who's, okay. Do this. Do this. Put it here. I'm gonna put your needle here for you. 

There. Now inject. And, like, that's not a Yeah. Yeah. That's not teaching. 

So you gotta let them get into a little bit of trouble safely. Yeah. Right? And then get themselves out of it. The commonest problem I see so let's assume we've done the consent part. 

That's all okay. They've done the setup. They draw up the drugs. They know what drugs to use. They pick the right pharmacological pharmacological agents. 

They understand the anatomy. They generate image and maybe there's something slightly different from normal. And so understanding that there are some normal variants, so that's quite important. But also the commonest problem I find is the needle then goes through into the skin and then we can't find it. And then they're trying to think, okay. 

Well, now now what do I do? Do I move the I need to move the probe to the needle, and they try and move the probe to the needle, and they see the needle, and then the image doesn't look great. So that's quite that's quite a tricky area to to to navigate. So what are your tips for trying to improve that component of of practice? I think the question there is when you have that dichotomy between, okay. 

I can get the image or the needle, but not both in the same frame. When do you, as the practitioner, abandon that, take the needle out of the skin Yeah. Get the optimal image, and then try again to line things up? Teaching decision making is a little challenging sometimes, but there's just no to me, there's no point in trying to struggle with that. Fundamentally, you have to have a good image of your target. 

If you can see the needle but not the target, that's unsafe. And Yeah. It's gonna lead to a failed block. So I'm quick to say, look. You've taken the time to put the needle already in the skin, but it's not in a good spot. 

So let's just take it out, find your best image, lock your hand in place, and then retry to get that lined up. Because I find a lot one of the commonest problems I see is people generate so especially if you're doing an awake block. Right? So people generate an image. They go, great. 

That's great. And then they'll get the local anesthetic for skin, assuming that they're using local anesthetic for skin. And they'll start to put the local anesthetic into the skin. And as they're doing that, they're not looking at the screen, and the image is changing from where it was before. And then they go and pick up their block needle, and they go to put the needle in the skin. 

And what they're looking at on the screen is completely different from what they're looking at before. So I tried to get people to make local anesthetic infiltration an active process. So generate the image. K. Get everything set up, line up your trajectory, and then use your local anesthetic, needle insertion as a practice trajectory. 

So use that to kind of practice which angle you need your needle to go into. And in order to do that, of course, you have to have the right image on the screen as opposed to just something that's not ideal. Yeah. And then when you go to pick up your block needle, again, check the image before you stick your needle. Yeah. 

Because people that don't do that, I can't find them, and and it's it's frustrating because you know what's gonna happen. Yeah. Yeah. Totally agree. And and I think this brings up the idea of ergonomics. 

Right? So A 100%. If you're not comfortable and your arm is in an awkward position, that probe is gonna slide and and you'll you'll lose it. So I will pull the bed up from the wall. I'll change the angle of the bed in the room. 

So for supraclavicular or interscaling, I'll put the patient lateral. That's nice. So that you're not fighting with the pillow or the bed to get your needle in from the posterior aspect and that sort of thing. So and then the other thing is, you know, once you get the good image, making sure your elbow, forearm, wrist, ulnar part of your hand is resting on the patient or the bed so that it's not gonna slide. Same. 

Absolutely same. In fact, it's fascinating because despite saying all of this, I still occasionally find that I don't stick to that. And when we don't stick to that, that's when we get into trouble. So, actually, one of our new fellows started recently, and I allowed them. I said, you know, do you want me to change the height of the bed? 

Then they were like, no. No. It's fine. And I allowed that to go. Actually, what I should have said is no. 

We're gonna lift the height of the bed. You're gonna position yourself appropriately. I I and I didn't interject and actually because I knew what the answer was, but I gave them the choice. So, actually, it's difficult because you don't you'd you want somebody to go through that process and then appreciate why you were saying it. So actually now that particular individual, they've had the experience of like, okay. 

Right. Next time, I'm gonna make sure either I sit down or bring the table up or I'm gonna bring the patient closer to me. So a certain you you mentioned about you've gotta make some of those mistakes yourself Yep. In a safe manner to kind of find out, and I think that that definitely a truth to that. Yeah. 

Totally. So we've got the image. Any tips for how to have a trainee appreciate where the needle ought to end up? Yeah. So I think this is difficult. 

And, again, this would be the the type the type of situation where you need to have, a discussion before you've got the patient there because you need to say, right. We're gonna generate this image. What's the goal of the block? So I used to think back in the old days, and I used spend a lot of time doing what calls video gaming. I used to try to get circumferential spread around, a nerve endpoint. 

Or if I looked for the interskating groove, I'd go between c five and c six, and that would come back and go over c five and then come back and go between c five and c six. Yeah. So so that was me not understanding what I needed to do and what was acceptable or sufficient. So I think having that discussion beforehand and say and then saying to somebody, right, we're aiming to do an interscaling brachial plexus block. You just need to deposit your local anesthetic, a one side periplexus c five, c six, not doing what I used to do in the old days. 

Yeah. And also, some of the newer machines we referred to this before that give you the ability to scribble on the screen. So I have actually used that recently. I've said, right. Here's here's the here's the transverse process. 

Here's the pleura. That is where an x marks the spot. That's where your needle needs to get to. So giving them some guidance to, to work out where they need to get the needle Yeah. And also understanding what's acceptable. 

Because we used to aim for, or I certainly used to aim for circumferential spread at one given point. Yeah. So if you saw the median nerve, I had to make sure I surrounded the whole median nerve at that point with local. But actually, what I've learned is if at one side you just got spread, if you then do dynamic scanning after the block, you'll find probably you've actually, you've actually circled it, you know, higher up or lower down. So it's understanding those nuances of those particular blocks and those endpoints. 

So, yeah, so phrase I use a lot is to to explain this at the beginning of rotation is all blocks are fascia plane blocks. Right? So nerves don't go through muscles generally. They all nerves and plexi exist in a fascial plane. So you don't have to puncture the femoral nerve. 

You land several centimeters away, just click through fascia liaca, and then start to use saline to expand that space. And then eventually, your liquid will get to the nerve, and then you can switch to local anesthetic. And then that's been one of those sort of, oh, I didn't really understand that. I thought I had to get right. I thought my needle had to touch the nerve. 

Because you see a lot of those initial block videos, right, with with needles pushing the nerves around because they're literally poking them to get underneath and go around them. But, actually, if you approach the fascial plane just ahead of the nerve and open up that fascial plane, that's all you need to do to get into that space. But it's getting the understanding that that's acceptable, that's sufficient is is a bit that's a challenge. Our fellows from last year very generously got each of us a laser pointer, and that's been really, really useful to as you're standing across the bed. See this? 

See this? See this? And so, yeah, it's been that's been fun. Because just saying over here or over there, that's not particularly useful. Right? 

So they need to have some some focus information. Yeah. Okay. So listen. So we kinda talked a little bit about the various steps, but once the block's in, it's really important that we get our trainees or Henry or Henrietta's to follow the patients up afterwards. 

Right? It's the whole post block phase management. So because we you work, in a system where you've got a block room. So your trainees and residents won't necessarily be with that patient when they're having surgery. Right? 

Yes and no. So there are days when they're just in the block room and just cranking out blocks for other ORs in the hospital. But then there are days when they do their own blocks and then go and sit in the case and manage the yeah. Which is super, super important. Because I've heard I've heard that some blocks fail. 

So, you know, so what do you what do you do in that case? Or or, you know, find the arm is numb, but there's a whole lot more to that managing the anesthetic than just putting the local in the right spot. That is so true. I remember I did a a block for a patient many years ago, and I'd I'd I'd really, really oversold and really pushed regional anesthesia. This is for hand surgery. 

And, this particular, patient was nervous, and I kind of coaxed her through it. And the block went in, and it worked. And after about five minutes, she burst into tears. And I said, what? Oh my goodness. 

Are you okay? And are you in pain? Is something wrong? And she was like, no. I just didn't realize how numb it was gonna be, and it reminded her of somebody she knew that had an amputation. 

Oh. And she just went to a completely different and, you know, you wouldn't necessarily know to predict that or to expect that. So managing the patient through through that was was also it was learning for me. But we have to teach people to have you know, we gotta give people these skills. So you tend to notice that those anesthes who were obstetric anesthes, who have had a lot of experience or interest in obstetric anesthesia, they tend to do well at regional anesthesia because they are keen and interested to talk to patients. 

Mhmm. And they're sympathetic and reassuring. So I think these are really important skills Yeah. In addition to the hard skills. Yeah. 

For sure. So getting into this question of competency and proficiency, there are a lot of blocks out there now. Right? Yes. Yeah. 

How many blocks does one need to have done and of which type to be competent and proficient? And are there different thresholds for whether you're a regular anesthesiologist or anesthetist versus, you know, a consultant regionalist at Guy's and St. Thomas? So this is it's almost as if we knew this was gonna be a topical, subject here. This is really relevant. 

Alright. So when when I got my certificate of completion of training in anesthesia, I'd signed all of the modules required, and regional anesthesia wasn't a specific module I had to get a certain number of blocks at. And, I could have finished my training having done potentially a couple of interscalions, couple of femorals, a couple of popliteal sciatic, and that's it. But not necessarily having demonstrated it, you know, a particular competence at it, which was a problem. The new curriculum has got different stages of training, and they have embraced the concept, although not in the in terms of concept of plan a blocks where they basically said they're breaking down to into upper limb, lower limb, and chest and abdomen. 

And at various stages of training, they said, right. Number one, the the entry level, these guys gotta be competent in to do to do a spinal anesthetic independently, for what you know, whether it be for obstetrics or whether it be for a hip fracture, for example. And, also, at the early stage, they said our trainees all need to demonstrate competence in fascia, iliaca, or femoral nerve blocks. So they've kind of nailed that down. So how do you say what the minimum number is? 

That's a good question. I don't we haven't put any numbers in our curriculum. Oh, wait. So this is at a certain stage within training. Yeah. 

They are meant to be, quote, unquote, competent in spinal and fascia iliaca. Yeah. How interesting. For example, so the entry level yeah. So so actually, the the curriculum is beautiful in that they've broken it down into a lot of stages, but it puts the pressure on now because now we need to deliver the training to get people through those hurdles. 

So the next stage above that, it would be, you know, to be independent in upper limb blocks, or to have one lower limb block. I can't remember if the idea did a talk on this recently, but at every stage, it gives you a level of of requirements you have to achieve. And the final learning objective is that they have to have independence in upper limb, lower limb, and chest and abdominal wall regional anesthesia. So it doesn't say what type of block. It just says you need to be able to provide a block for that area. 

Interesting. So and that's to graduate as a A standard consultant. There is a separate, we used to call them, advanced training modules, and there's a new acronym, an SIA special interest in Sia. Love her. Sia. 

Yes. Sia is great, but I'm gonna be in so much trouble. I can't remember what this this acronym stands for. But, anyway, the equivalent of doing a a fellowship, that has a different set of requirements, including continuous catheters, etcetera. So, yes, there so the short answer to your question is, I think that every anesthetist, anesthesiologist completing their basic level training should be able to perform a technique reliably for something above the clavicle, something below the clavicle, something for chest and abdomens, and something to cover the lower limb. 

But I haven't given you numbers because I don't think I can give you numbers. Well, I don't and it's interesting, Greg, because you you touched on the idea of the competency based education, which I think is a is a great concept. So if I had a time machine to go back in time and I've got Amit Pawa as a trainee Yes. You might take three axillary blocks to to get to competency versus someone else who might take 40 tries to get to that speed. Everyone's got a different learning curve. 

Correct. Rather than just saying, okay. Thou shalt perform 40 blocks, and then good luck to you, sir. I think the competency based approach is much more natural and realistic, but you have to have, to your point, some way of assessing the competency. Well, some way of assessing it, but also making sure you can deliver those opportunities for learning. 

Right? Because if you're only doing two months of, let's say, a block in regional anesthesia, but you don't get exposed to any lower limb surgery, then you're not gonna receive achieve sign off of your lower limb blocks, and that becomes a problem. And then someone's gonna say, my goodness me. I'm not gonna get this signed off this year because I haven't done any lower limb list. But at least if they know what their targets are, they can make sure they get exposure to those lists in order to do it. 

So I think that's the difference with being a bit more prescriptive. So what does it say in The US? You have to do 40 blocks, for example. Right? So yeah. 

We're you're getting around to the idea of what should a beginning consultant anesthesiologist look like in 2023? What should they be able to do? Because I think the answer is different than it was twenty years ago. Yes. I look at our graduating trainees who are not doing a regional fellowship, but are going to a job where they're expected to do some regional anesthesia and what the expectation is. 

And it's it's way different now. They're getting jobs where the hospital and or the anesthetic department and or the surgeons are saying, I want QLs. I want ESPs. Wow. I want rectus sheath. 

I want Peng blocks for all the hips and etcetera, etcetera. So The expectation is higher. Very much so. Yeah. And so I think we're way behind. 

The ACGME requirement to be able to graduate from a residency is 40 spinals, 40 epidurals, and 40 nerve blocks. Now that can be Any. 40 ankle blocks. Ah. Right? 

So interestingly, there is also a requirement that you be proficient in transesophageal echocardiography. What? Yeah. Yeah. As a resident. 

So which strikes me as a bit odd. I mean, it's it's cool and everything that you that that's a a requirement. But, again, getting back to what what is your average consultant anesthesiologist? What are they doing with their day, five days a week? My guess is a lot more fascial plane blocks and or nerve blocks, far less TEE or toe as you would say. 

I mean, unless you have a very specific practice where you're doing a lot of cardiac anesthesiology or So that may that should be especially specific. I think if I was doing a a US residency or trying to gain those equivalent, exposures in The UK, I would definitely fall short on the TEE or TOE component because we only really get exposure to that if you're doing cardiac anesthesia now. Yeah. So I think that's made its way in and that wasn't the case when I was training, but it's it's made its way into the requirement, and yet the the regional stuff has not changed. Now a regional anesthesiology and acute pain medicine fellowship is new, relatively new. 

It's about five years old now in The US officially. Yeah. And so those programmatic requirements, they're a little bit different as you might expect. So 40 spinals, 20 epidurals. And these are minimums, by the way. 

So a 100 upper limbs, a 100 lower limbs, and then 70 truncles. And the truncal blocks, they say, yeah, 20 abdominal, 20 thoracic, and then 50 catheters. So if somebody's done that, they're they're gonna have a different level of experience now compared to the guys that have done the standard residency. So that seems appropriate. We're talking about two different areas. 

Right? Correct. Yes. That's that's a fellowship level graduation target. Now I would hope that most fellowships provide at least three to four times those numbers because think about get and getting back to the number of blocks. 

I mean, if you look at lower limb blocks, you got fascioliac, you have pang, you have femoral, you have parasacral sciatic, subgluteal sciatic, All the other ones going down the lower limb. Well, if there's only a 100 blocks expected, that means you're only doing, you know, 15 of each of them. I think for someone to emerge from our fellowship training program as an expert, and the expectation is you're an expert Yeah. You have to have done tons of those. Right? 

I think. Yeah. I mean, the thing that makes me nervous, if I'm looking at your numbers, in The UK, we you know, in in a given hospital site, you'll have general trainees. The trainees that are doing regional anesthesia, doing the minimum competency, and then you'll have the fellows. There'll be a limited number of fellows. 

If there's a limited number of blocks to go around, how is everyone gonna get exposure to them? And that's where I think I'm a little bit nervous about providing those teaching opportunities, and that's maybe where some of those other skills and technology or maybe some of those other technologies will come into play to make sure people get exposure to those block numbers or at least the process of doing them. Because what happens if you're working somewhere and on a given day, there's only, you know, three property or blocks to be And if there's a fellow there and the fellow sweeps all three of them up, then the the standard trainees don't get a chance to do it. So I'm nervous about that, essentially, you can't. Yeah. 

Yeah. No. It's it's true. It's a it's a conflict that comes up sometimes, and the the answer is here, you have to defend the core residency trainees first. So whenever when when we and our fellowship has expanded over the last, five, six years. 

We had three fellows, and then we're at four, and then now we're at five. And each time we expand it, we have to make a very, very good case for that expansion, which starts and ends with, is this gonna have an impact on the core residency trainees getting their numbers? And if the answer is possible, you know, maybe we'll be fighting for blocks, then that expansion is not gonna be approved. There has to be tons of blocks to go around. And the great thing is in 2023, I mean, we are doing a ton more blocks than we were Yeah. 

Yeah. Five or ten years ago. I mean, with the number of abdominal and thoracic fascia plane blocks that we're doing is bananas. So Yeah. Lots of blocks to go around. 

Cliffhanger alert. And that marks the end of the first of our three episode series on education and teaching. Stay tuned for part two where we'll pick up the discussion and share some more thoughts and tips. In the meantime, hit us up on social media if you have any thoughts or questions or concerns. Where can they find us? 

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