S1:E8 "Social Media, Cadavers and Workshops: Where Do We Learn Regional Anesthesia Best?"

Cadavers in the brunch bar, TikTok, and cheesy dancing. What's your plan a to set up for success? I'm Amit Pawa. If you're not getting your education on YouTube or Insta, you could at least be creating some delicious edible ultrasound phantoms. I'm Jeff Gadsden, and this is Block it like it's hot. 

Hey. It's Jeff and Ahmad here. This is part two of a three part series on education and teaching in regional anesthesia. If you haven't listened to part one or episode seven, you may wanna start with that. Alright. 

Cool. On with the episode. Okay. Cool. Listen. 

I thought we'd change tack now. So let's talk about some of the the different ways we can deliver the teaching. Is there still a role for textbooks? Because my concern about some of these textbooks is whilst the anatomy is not gonna change, possibly by the time you've written a chapter and quoted some references there in there, by the time it comes out, is that a it's, you know, it's it's it's not current or it's not representing the current literature. Do we need to do you use textbooks anymore? 

I know. It's it's funny, but I I I don't I can't remember the last time I saw a trainee pull out a textbook and, like, blow the dust off of it. Yeah. You're right. As someone who who has written a textbook, I get the numbers from the publisher, and it's all elearning. 

Like, we're actually not selling any physical books anymore, but those same books are being consumed electronically, which is so there's I think there's some value still. Okay. Okay. As because I I've got a shelf full of regional anesthesia textbooks that I had from my fellowship when I was sitting the the EDRA exam, the EDRA regional anesthesia diploma. They haven't come off my bookshelf since the exam, if I'm being completely honest, which I'm embarrassed about. 

But I have used I'll tell you what I have used. I've used review articles. So ASR every now and then do these great big, big papers where they put all of the techniques together. So we you and I were both coauthors on the abdominal wall one, I think Yeah. And Kijin led and, with John McDonald. 

McDonald. To those, those review articles are brilliant. I know there was an upper extremity and a lower extremity one. So, you know, can review articles replace textbooks and keeping up to date? What do you think? 

Totally. I think so. That and that one you you just referenced has been cited so many times, I think, because it just was so comprehensive, and Kijin did such a great job with that. But Absolutely. Yeah. 

It's good it's good foundational knowledge, and we've got a little Dropbox folder of key articles that all our fellows should read, and those review articles are our main part of that. But I I tell you, man, it's YouTube. Is that what you think? That's the future? Totally. 

No. No question. Even our even in terms of our our teaching, like, I told you, we'll discuss the case the it before and say, okay. I used to say, I'm gonna email you a couple of articles to read for tomorrow. Now I'll just say, okay. 

You have the link? Yeah. Watch the YouTube video, and then we'll talk about it tomorrow. Well, I mean, it's it's difficult not to talk about, YouTube and then not talk about the duke rap, Blocktober videos. They are it's I I said it to you before when we did our initial interview for AZRA News. 

It's like a it's like a modern textbook. You've got everything in there, and, you know, I'm not gonna say how wonderful they are again because I've told you that many times, but they're brilliant. So actually Oh, go on. Go on. Okay. 

Well, they're amazing. I'm totally joking. So I will often say to my to my fellows, right. Tomorrow, we're gonna be doing this or maybe we've finished the list together. And I said, let's refresh that. 

Why don't you go on to the regional anesthesia and pain medicine YouTube channel, look at some of Jess videos and and search up the parasternal intercostal plane blocks or search up how his approach to knee surgery is. Or I'll say, you know what? You're with me tomorrow, and I'm gonna be doing my approach to thoracic periovertebral blocks. Why don't you watch my video? Because I've got a video that shows you exactly how I'm gonna do it. 

So actually being able to do that is amazing. So so we know some so we both talked about our own channel. So you've got the Duke Region Anesthesia and Pain Medicine channel. You got mine, and I've gotta mention Kijin Chin's because that is like a another real life living textbook of regional anesthesia. Any other ones that you wanna reference? 

Yeah. No. And I I just wanna make it clear to the listeners. I wasn't saying that it it's just about, like, our own videos, but because there are I love the, your your channel's amazing, and you have a way of delivering the information that is, you know, your style and just so easy to watch and and learn from. So that's that's incredible. 

What we probably should be doing is saying, here, watch these five different interscaling videos from Correct. These five different and then you'll get pearls from each one that not everyone, is covering. So they're complementary for sure. Because people are different type of learners. Right? 

So some people don't want so much of the anatomy. They wanna know just how to generate the image, and then they're okay. And other people are like, well, listen. I want the whole thing. I want as much as I can. 

But the key is people wanna ensure pieces of information. They don't people don't necessarily have the time to sit there and watch forty five minutes. So I know some of my initial lectures I put on are slightly longer. People aren't gonna watch them for the full forty five minutes. They want five minutes. 

Totally. Yeah. Vicente Roques from, from Spain has amazing videos too. I know Manoj Kamakar, from Hong Kong has has started a channel, I think, last year and has got some amazing stuff on there too. There's lots and lots of resources out there. 

But it's interesting your point about what is the sweet spot for duration. Like, I mean, my own attention span has has dropped Yes. In the twenty first century. Right? Like, five minutes seems good. 

Can you get the information across in one minute or less? That is really interesting because there are a couple of social media channels that are geared for short attention span people like myself. And we we both know. So Instagram's one, and I've kind of had a little bit of a of a dabble in Instagram. If you were to look at my channel, it's mainly selfies, or food pictures. 

But, there are a few people that have utilized this particular medium really well for education region anesthesia. And the one person that comes to mind straightaway is Blocker Girl. Right? So we both know, Sarah Amaral. Yeah. 

Sarah Sarah's amazing. That that channel I I I and I told her this recently. The ability to do what she does in such a small consumable space. I'm not a real Insta person, so I don't know what the format's called, but, you know, you can sort of swipe across and see her different slides slash videos. And Yes. 

Yeah. I'm like, that is exactly how I want to teach that block. And you've done it in I think I consumed that in thirty seconds. Yeah. Yeah. 

So with within each post, for example, you can flick through the different slides, different Yeah. Pictures that she's got there, and you got information. She also puts these little stories up with quizzes. The only thing from my point of view is that I'm not great at Portuguese because not all of it's in English, and some of this stuff is in Portuguese. Although you can you can work out what it's referring to, but that's a great resource. 

And what about TikTok, man? Have you verged or, you know, got yourself onto TikTok? Oh, yeah. Like a lot of people during COVID, I watched my fair share of, talking dog videos and learned some cheesy dances, but, no. Not not recently. 

I think the key with TikTok is you've gotta be quite focused, with what you use it for. But I've gotta say, Melody Herman, who is from your neck of the woods, I believe. She's from North Carolina. Yeah. Charlotte. 

She has absolutely nailed the regional anesthesia TikTok market. So she does she does some comical things, and we've done some transatlantic collaborations, which are more about fun. But she's also done some incredible educational pearls in, like, ninety seconds. Yeah. So within that ninety seconds, she'll have an image to have an anatomical slide, and she'll have a picture of probe placement or a video probe placement, and you could gain a lot of information in ninety seconds. 

Now if you ask her how long it takes to make those things, it know, it takes a while. Even though it's ninety seconds worth of video, it's probably taken a good few hours to put together, but there are some great resources there. So Totally. Yeah. Don't discard TikTok, and Instagram just for for for selfies. 

There is there's another rule here. Just moving on. So we talked a bit about social media. I wanna work out how useful are scanning workshops at conferences or courses. How can somebody attend a course or a conference like that and get the maximum involvement out of it? 

Because, you know, people will pay money when they attend a conference, go to a course. How can we use them to the best possible way? Again, I think it's a combination of getting the information across the didactic stuff. Here's the anatomy. Here's the image you're supposed to get when your probe's in the right place, and then the hands on coaching. 

So I've tutored lots and lots of workshops, and they've evolved over time. And they used to be like, you know, you'd spend half a day just in the classroom learning about the basics and, you know, half an hour lectures on interscaling and then half an hour lecture on supraclavicular and that sort of thing. It just it just gets tiring. Right? So I think the ones that I've been involved in curricular development with have tried to minimize that portion and and also offer some prework. 

So again, same thing. Watch the video and then come to the course and we'll spend your valuable time with our expert faculty who can then put their hand on the probe with you, show you that's the motion you're gonna make to get that view. You know, it's a bit like do you have driver's ed driver's education? Yeah. Yeah. 

Yeah. Yeah. In The UK? Yeah. So there's a point when you you learn about this what a stop sign looks like and what a yield sign looks like in the textbook, but you just had to get out there and and kinda do it. 

Even though you might you you certainly by no means an expert. There's a value to to just, like, jumping in there. I mean, my I I don't know what your experience is like, but driver's ed, we had this guy this guy with a practical portion. I grew up in this small town. So there's this one guy who taught the course, and he had this raw he was he was actually a drummer in a rock band, and he had a car to match. 

So you can just imagine what this car looked like. Yeah. He was a nut. He remember, like, you did your first little bit, and then, I think lesson two is like, alright, man. We're gonna go on the freeway. 

So we're kinda getting up to the on ramp to this freeway, and he's like, floor it. Floor it. Go. Go. Go. 

And I and I'm like, what? Are you are you serious? And and he leans over and gets art right in my face, I said floor the pedal. And so I think it it influenced my driving style enough that it probably explains why I've had to do community service for some speeding tickets. Oh, no. 

Anyway, I got off track there. Second, well well, I'll you I'll tell you the best scanning workshops I've been to were one of them was Nisora inspired, and that gave us some idea from for some of the early Elsora conferences we did, workshops we did. In fact, you flew over to The UK to do it that way. Because one of the dangers at scanning conferences or scanning workshops at conferences is faculty hold the probe for too long. Or they do a live demo at the station. 

They're eating into delegate time. Totally. So one of the best demonstrations I saw and was inspired by Neussora was prior to every workstation at the front of the hall of the room, the one faculty member will demonstrate what they need to do when they go to their respective stations and what what images to see. And then when they everyone broke off into their stations, the delegates held the probe straight away, and I think that made a big difference in terms of utilizing that time. Yeah. 

Totally. We tell we tell our instructors, don't hold the probe as much as you possibly can. Absolutely. Let them get their hands dirty, and then help them if you need to. But, again, getting back to that sort of you should be able to talk someone through something with minimal hands on as a teacher. 

So let me ask you a question. What do you what's your thought on the value of a cadaver workshop? So I think this is extremely important and extremely useful. And in fact, if I think back to my time as a regional fellow, when I was the first regional fellow at Guy's and St. Thomas's, the OG, one of the most useful things actually, I didn't even do a workshop at this stage. 

I did a I was given an afternoon in the Dissection Room at Guy's Hospital, which took me back many years to when I was a medical student. Right. And they got some they got some some specimens out for me, and I was able to sit and look at them. They gave me textbooks. I didn't have a demonstrator. 

They gave me some textbooks and some laminated anatomy kind of things. And they said, right. Just, you know, go for it. And so Right. I was able to go through and and appreciate. 

And that's the first time I really remembered or appreciated what the femoral nerve looked like at the groin. And I was expecting to see this kind of triangular shaped structure sitting next to the femoral artery, and I suddenly saw this this thing that was arborized. Right? It's kind of little things coming out. So actually, it suddenly made me appreciate Such a good word. 

Not as good as symmetrization symmetrization. Symmetrization is a great word. Yeah. But arborized. Yeah. 

I like that. But but it was the first time I actually appreciated, what it looked like. So so that was one that was one component. And then, of course, one of the best experiences I had in terms of teaching and education was when we were fortunate enough to have access to cadavers that were unfixed, and we were able to scan and see structures in real life and needle them in real life and know that you weren't gonna cause damage. And, actually, we intentionally tried we were allowed to intentionally try to perform intranural injections to understand what it would look like. 

So in short, I think cadherit workshops are absolutely key to part of developing that experience and and and knowledge and teaching in regional anesthesia. I'm guessing you feel similar. Well, I I think I have mixed I think I have mixed feelings on it. I think that your point about understanding anatomy is critical, and I I had the same experience. You know? 

I did anatomy as a student and then practiced regional anesthesia for several years. And then going back to see a cadaver again was completely eye opening. It's like, okay. Yeah. No. 

I'm paying attention to this part way more now, and I I get the relationship of the brachial plant or whatever. But I want it's such a resource intensive endeavor to bring a cadaver to a place and all of it all that goes into that. And and then there's a cost to that as well. Setting something up like that, if you're not dissecting, if you're just putting in probe on and sticking a needle in, I wonder how much more valuable that is compared to, say, a high fidelity gel trainer or something like that. I don't know. 

Right. So so I said, so now I understand. I I care. Now I understand what you're talking about because in theory, you can understand a lot of the three d physical relationships of structures without having a cadaver. Right? 

So without having a processed specimen, you could look at an app. And there are some medical schools in The UK that now do not have dissection as part of their medical curriculum. They do all virtually. So that I understand. And I guess what if you think about what I was talking about, I was talking about so one component was seeing me and asked me, but that very much is dependent upon the quality of the dissection. 

The other component is needling. Yeah. But as you say, if you can get a phantom that is as near as damage to the to the to the real thing or as close as you can get, then actually, you don't have to worry about all of the disclosures, disclaimers, and and consent forms that you need to sign and all of the special equipment, that you need to do if you were to to take these cadavers into a hotel where you're having a conference or something. And, actually, as a conference organizer, it's a whole different thing. Right? 

Forget about the fact if you're, like, just some other random guest at the hotel and you see this cadaver rolling by. That's just awkward. Do they do that at hotel? I'm trying to think. We've always we've only ever done these now. 

For sure, they've had they they occur at hotels. Yeah. Yeah. We've only ever done this in dissection rooms before. Don't mind me. 

I'm just pushing a cadaver through the the brunch bar. Oh my okay. So so listen. So I think it depends which side you're looking at it from. If you're looking at if if organizing it was no big deal and you didn't have the hassle or the stress, then I think there's something quite useful about doing something called real tissue. 

But, actually, if we're being pragmatic and looking at what we have in the future, then actually maybe high fidelity phantoms as near as damn it. That's probably sufficient. Right? And and actually, that's something you can have in a hospital in your regional anesthesia training room. I mean, how good is a meat or a tofu model compared to that? 

I mean, I I in terms of anatomical fidelity, not great, but I I think a meat model is a really, really good surrogate for sticking a needle in. So if let's say you had the cadaver as a dissection experience and saying, oh, that's the suprascapular nerve. Now I understand how that comes around and off the superior trunk, and then that that's extremely valuable. But in terms of needling, I'm a little less impressed with the value of cadavers. And I think I think a a good meat model like, we had a guy in New York, Da Kwon Zhu, who who would make these awesome meat he take a pork shoulder or a pork butt and, put a beef tendon inside, and it looked and felt like you were actually doing a nerve block. 

So I think that's good for generic stuff, but it would be cool if you could have something that was specific to the block you're looking at. I've gotta give one shout out. We had a fellow a long time ago called Kate Clocker, and Kate was you know, she was a great fellow. She had a quite an interesting imagination. So she decided to make some phantoms out of Jell O, or we would say jelly in The UK, and candy shoelaces, and bits of pasta. 

So she actually recreated an edible phantom, for supraclavicular, for femoral. So she spent a lot of time, you know, basically creating like a lab in her kitchen coming out with a perfect concentration of jelly. That sounds great. I just had an idea. The Great British Bake Off, regional anesthesia edition. 

Who can come up with the best edible dessert that is also scannable and Oh my god. We're doing this. That would be amazing. That would be amazing. Okay. 

I don't know if I've got the skills. I might have to recruit Kate who's now a consultant around the corner of us here. I can get her involved. So okay. So we both agree that the phantoms have a role here potentially. 

I'd I'd think so. Yeah. So we I've said this before, but there's a a company called Valkyrie that makes Mhmm. These high fidelity ones that look you know, all the structures are there. So you can you can practice. 

You can inject on them. I think there's a lot of value to using that as opposed to just a a block of gel. Block of gel is fine. It it helps you with that finding your needle skill, but then you quickly plateau. And I think you need something more realistic. 

Well, you know, I I'm still remembering the thing that blew my mind when you were telling us in the, the Gadsden's gadget and powers paraphernalia episode about this fake probe that you can just go into thin air or meat, and it generates the ultrasound image. And that, I think, has a role as do the Yeah. The virtual needle trainers where you can actually scan a real person and then stick a pretend needle into them. So yeah. I saw on Twitter recently, Garrett Barry and Mark Leonard on Twitter both showed some incredible three d printed brachial plexus, anatomical models. 

Now I think that is amazing to be able to have that at your disposal. So maybe you haven't got your iPad with you that day, and you just can have a look and see the the appreciations. That ties into that knowledge of anatomy. Yeah. So you're saying to somebody, you're gonna do a block here. 

These are the bits you need to think about. Have you got your your hands on any of those, those three d anatomical models? We so we haven't we have a skeleton, in our Yeah. Block area that we sometimes pull out and does a little dance, and they can point out x, y, and z. But, honestly, I have to get more up to speed on three d printing this this kind of stuff. 

Yeah. I need it'd be great to get ahold of it. And tell me, what about simulation? Is that something you've done? We haven't formally embraced simulation for regional anesthesia. 

Is this something that you guys do? We do, actually. So I have to give some a shout out here to Amanda Kumar, who's one of my colleagues and has a real interest in simulation. And she has developed a course both for our core trainees, but also our fellows where they go and spend an afternoon or a whole day in in the sim lab. So it looks like an operating room, and there's a a mannequin there that can do all the things, very high fidelity so that the monitors are on, the monitors can change, and there's a a, you know, voice telling you instructions. 

And she'll take them through scenarios like last or, you know, you've done a block and now there's a pneumothorax or counseling someone who's had a nerve injury over the phone. Like, what do you tell them? Yeah. It's really it's really, really valuable, I think. Because it those are things that you may not encounter in your training, but have to know how to deal with it. 

The stress of doing it in a evaluative scenario where someone's watching you through a one way glass, I think imprints on your mind and helps retention. Well, actually, no. That's very true. And having said that we don't use simulation formally, that's not entirely true because, actually, one of my previous fellows, Liana Zuko hey, Zuko. Zuko, who is actually originally Canadian. 

Right. So she was tasked with the role of introducing our new prep stop block strategy to minimize, wrong sided nerve blocks. So she was tasked with integrating that locally. And one of the way she did that was, you know, we had lectures at our clinical governance meetings, but then she went round. She had a mannequin, and she she got all the team there. 

And we actually went through the process of adopting this new prep stop block process to minimizing the side of wrong side of blocks. So she did use simulation in that format, and, actually, people found it a lot easier because rather than just seeing a a dry piece of paper printed out or a poster, you can't quite understand how a process will work in real time. So I can see, yeah, we we have used simulation not for the last pneumothorax, but we have used it for wrong sided blocks. So that's useful. Nice. 

Yeah. That's great. But listen, should we take a break here and talk about, and have our mug competition? What do you reckon? Because we're getting on for time here. 

Yeah. Yeah. Let's do this. Okay. So to win a mug, here's the question that you must answer. 

In episode three, Ahmet says he performed his first ever awake surgery using paresthesia. Mhmm. But what was the block he performed? So if you think back or go back and relisten to episode three, you'll have a chance at winning the mug. To be in with a chance of winning, you gotta post us your answer via direct message to our Twitter account at block it underscore hot underscore pod or the Instagram block it like it's hot, all underscores, or email us @blockitlikeit'shotpodcastatgmail.com. 

And we'll put all the correct answers in a hat, and we'll pick a winner. Absolutely. I can't even remember what it was, so good luck with that one. Now we talked before about artificial intelligence tools and some of the equipment that's out there. We've also talked about how important it is to know some of the anatomy beforehand and how important it is to get information across the courses. 

Where do you see artificial intelligence tools have a role? And and is there a danger if we become too reliant upon them and they're not, universally available? So if we're talking about the software that can overlay Yes. Anatomical structures onto the ultrasound image. Yeah. 

That's the I think that's a really good tool, for novices. So I think as you get more proficient at that pattern recognition, which is one of the core skills. Right? When you put the probe on the neck or the thigh, what is that structure? What is that structure? 

Until you have seen the 24 different possible variations that the human body can throw at you of that structure because they all look a little bit different. Yeah. Having that AI coaching or crutch is I I think I mean, I think there's a lot of work to be done there in terms of how does that accelerate your learning curve Yes. And and, you know, time to proficiency. I'm a fan. 

So am I. My only concern is at the moment, of course, you've got you gotta buy those tools separately. So I think, ultimately, once they become integrated into the machines that we use, it won't be that much of a big deal. I think there's a niche point in the market here now where, you know, there there are products out there that people can purchase, and that's gonna be the the biggest restriction to adoption is the fact that departments have to buy it. Once it's integral to the machines, which I I think will be the ultimate wish that would be then I then I think it's great because actually as long as you're you're using you're telling the machine what to look for, I. 

You've picked the right block, then I think it has a role. And, and I think, you know, I would I would definitely embrace that. The other thing I wanna focus on is so I'm lucky in that I'm in charge of, but not solely responsible for a group of of senior trainees who are regional fellows. And one of the things that I do in my own time is give them dedicated small session teaching where we will pick areas. You know, we'll do an hour, hour and a half, maybe two hours sometimes and say, right. 

In this hour and a half, we're gonna cover from, you know, the interscaling to infraclavicular. And that's all we do. We focus on that. We look at the anatomy, and then I scan, and I get them to scan. Is that the ideal model? 

Do you think that's the best way to get people through? Because I I can give them a lot of my time and attention. It's quite labor intensive, but that's a great way, I think, to impart those crucial bits of information. Do you think that's useful, or do you think we're better off teaching in practice in clinical scenarios whilst you're actually doing the blocks? No. 

I think I think there's a lot of value to what you do, and we do the same thing. We'll have a dedicated scanning session for, you know, above the clavicle, below the clavicle, thoracic, you know, different different things throughout the course of the fellowship. What I think it does is gives you a stress free time and place for the trainees to ask questions. I think it's intimidating sometimes when you're in front of a patient and you're, you know, you're probably trying to impress your boss and you're you're you got the view and you're just like, let's okay. I got it. 

Let's just do it and get it over with, and I've I've checked that one off. Having the time to say, but what about this? Or, you know, why do we do it this way? Or what is that structure Yeah. In a safe, easy environment is, I think, is hugely viable. 

You know, well, it's always a, you know, pull names out of the hat to see who is the one that takes their shirt off that day Yes. And be the be the model. Why does every name in the hat say Jeff? I don't know. So so you're very generous. 

I haven't dedicated my body yet because, you know, I've had to hold this probe. But as you've had a few of the fellows who have have volunteered themselves to be models, and then when it comes around to scanning, they've put the probe in their own groin and done the scanning. The groin always seems to be the area we struggle with with getting somebody for. The rest of the parts of body, we can we can manage. Same. 

We we've we've actually I've actually paid people. I've gotten put an ad on Craigslist, wanted someone to come to the hospital and take their pants off. I'll pay you $20. And you would be you'd be you might be shocked at the number of positive responses we get to that ad. I can imagine. 

I've I've got to tell you one story about this, which has just come to mind. So I remember we got one of our anesthetic assistants. We, you know, we we we'd said, oh, we we need some models for this particular part. I used to run a Sonic Club after hours for for all comers. We needed somebody for the groin station. 

One of the anesthetic assistants said, listen. I'm I'm happy to do it. So, It's a little bit of a warning sign when they're a little too enthusiastic about that. Right? Like, it's like Maybe. 

I need I need you to take your pants off and show us a I'm in there. I'm there for you, pal. But wait for this. So he gets he gets set up for scanning, and I said, look. How do you feel if we scan, you know, both sides at the same time to maximize? 

He's like, I came prepared for it. I was like, what are you talking about? So he had shaved half of his pubic hair on one side and the other side left as as as nature intended. And I said, why have you done this? He said, I thought I'd have a beginner's and an advanced size. 

Oh my god. So, yeah, that week and that that was yeah. That is That was amazing. I'm not sure if that's gonna be in the podcast. I think there needs to be a manual out there for, for how to properly prepare models. 

Yeah. There probably should be, actually. Coming on to to to different elements of teaching. So we've covered a lot of things, anatomy, image generation, AI. What we haven't talked about is should we be teaching all of our trainees residents to use ultrasound nerve stimulation and injection pressure monitoring? 

Because these are all tools that are out there. How essential is it that we teach them all of those things? It's a good question. I mean, we've sort of touched on this in another episode, and I think we're we're planning to do an episode on prevention of nerve injury at some point. Mhmm. 

So that I think we'll get more detail there. But I think I, again, see my role as an educator as I'm gonna expose you to as much as I possibly can so that you can then make a decision as to where this fits into your practice, especially for a fellow who's who I I know is gonna be dedicating their career to, in large part, to regional anesthesia. I I need them to understand the theoretical basis, but also how to use these technologies. And they may not agree with me as to the value of it in block a, b, or c, but at least they've got that exposure. I I I think I totally understand that because what you're saying is, as an educator, it's your responsibility to furnish them with as much information and knowledge as possible and say, look. 

These are the options available to you. You don't have to adopt them all. This is how I use it in my practice. But I think one of the beauties and I always say to the fellows that we have. So one of the beauties is of working with more than one individual is you get to see lots of different approaches to doing certain techniques. 

And as much as I wanna say my way is the best way, I also appreciate there are other people that do other things that they might find useful. So we have a responsibility to show them what's out there Yeah. Totally agree. And give them a whole host of things they can learn from, and then they decide what what what they wanna do afterwards. Exactly. 

And I'll say, like, here's what nerve stimulation offers you, and you can choose to use it. And if you don't, you're dead to me, but it's okay. I'm just I was kidding. Now listen. This is something that I feel quite strongly about, and that is self injection. 

I'm not talking about the type of self injection that you practice where you inject to yourself for all of the blocks. I'm talking about Which officially we are not recommending. Okay. Yeah. We are definitely not recommending that. 

I'm talking about, doing the injection of local anesthetic yourself. So effectively holding the knee the syringe and doing the injection. How important is that do you think? Because I understand, from speaking to a lot of my North American colleagues that they're so used to working with experienced block nurses that help them with with the delivery of regional anesthesia that nine times out of 10, they'll show up, they'll have everything ready, they'll do all the checks, and they'll do the block, and the the block nurses do the injection. Do you think we should be teaching people to ultimately achieve that self directed injection? 

That's an interesting question. So are you talking about the trainee holding the probe, holding the needle, and also managing the injection like a Jedi grip type thing. With Jedi being one of the one of the Yeah. The many grips. Yeah. 

I think it's a definitely a role for trainees to understand what the syringe and the compliance and all those things feel like. So Yes. It's practically, ergonomically sometimes a bit challenging. And we haven't we haven't done a whole lot. I'll I'll usually pull it up for the fellows or for for senior training and say, hey. 

You wanna see it? You wanna see a cool trick? You can do this whole block yourself. Hold the syringe this way. Hold the needle this way. 

And they're like, woah. That is that's kinda cool. But so I haven't done that too too much as a routine, but what I will do is if there's another trainee observing Henrietta doing the block, I'll pass the syringe over to them and say, here. You inject. You aspirate and inject. 

And so you get a feel for what this feels like. That's also a way of involving them, in the process as well. So they're getting an extra educational component. So so so I'm asking a very skewed question, and that is because, actually, I do probably, 98% of my regional anesthesia. I do the injection. 

And so the trainees don't get a chance at that stage to feel what it's like. They they're watching me doing it. When they're doing the block, I tend to do the injection for them. And the re there's one very simple reason. So I, I always used to get somebody else to do the aspiration injection as I'm sure the way that you do. 

But I found that depending upon which hospital I was working at, which department I was working at, and how experienced that anesthetic assistant was, I wasn't I didn't have consistent assistance. I think it that's one way of saying it. So I suddenly found myself in some situation where I say aspirate and inject someone with aspirate and then they inject lots of air, and there were certain things that weren't I couldn't control for. And then I watched, a very skilled anesthetist called Tony Allen. He did a live demo, of course, that I taught on as well, and he did the most elegant self directed ankle block injection. 

I was absolutely blown away by watching it. Well, number one, his skills, but also the way that he was able to do the injection himself. So I thought, do know what? I'm gonna learn this. And we made a Elsora YouTube video on the self injection technique. 

So I did the Allen technique. But when I started doing this, it changed the dynamic of my block. So I definitely reduced the volume of local anesthetic injected because I was looking on the screen. I wasn't specifically looking at the number of mils or or point points of a mil I was injecting. I was just looking for the spread. 

I like, okay. That's enough. No advance, and I could do real time. So I was injecting as I was moving the needle tip. So suddenly, my ability to do that dynamic injection without having to say to somebody else, stop, aspirate, inject, it changed. 

So from a personal point of view, I found I've I was able to be a bit more in control, but it's not a beginner technique. And I think, it would be wrong if we devoid dev dedicated lots of time and effort in getting people to achieve competence in that as opposed to image generation, needle insertion, recognizing the needle, all the rest of it. But I think it's a nice it's a nice thing to to achieve ultimately. And there are some people who will put the needle where they want, then let go of the needle Yeah. And inject themselves. 

I that gives me the heebie jeebies, but they they the people that do that are very happy doing it. But have you ever have you seen anyone do that? Do you do that? I've done it myself sometimes. It depends on the block and depends on the needle position relative to the target. 

And if if I feel like I'm gonna I can let go safely and it's gonna stay in the same place Yep. And I'm not and I'm watching it the whole time, I I have done it. But I think you're right. I think this is a these kind of techniques are the thing you teach your trainee when they're you're running out of things to teach them. Yeah. 

Absolutely. And they've they've pretty much shown competency at all things higher. Now what can I teach? Oh, here. Let me show you this cool trick. 

Absolutely. And then, of course, there are tools as well. We we discussed in the in the, in the gadgets episode. There are some some automated tools that can help you with that, and there may be a role for those in the future, definitely. Robots. 

Yeah. Quite. So now I wanted to ask you, what was what was your robot? You had a sarcastic robot. Don't remember. 

The trash talking robot. What? You want me to inject more, Jeff? Is that what I sound like? Yeah. 

No. No. I don't know what that was. I don't even that I didn't even know where that where that accent came from. It was just a nondescript accent. 

Now I wanted to ask you a question because not about your specific practice, but it's about what do you do if you're teaching on a patient or even at on an ultrasound course. And as you're scanning, you've come across something that looks unusual or abnormal. Oh. What are our obligations as practitioners in a situation like that? This happens not infrequently. 

We do a little ultrasound tutorial for medical students, once a month. And, so I'll I'll get them sitting around in a circle. It's circle time. And they you know, pass the probe around. Okay. 

Let's start with the neck and here, like, look at that. That's your sternocleidomastoid. And then we'll go around. Once a year or even more frequently, we'll get someone with some kind of thyroid nodule. That's the most common abnormality we'll find and I'll say, it's probably nothing, but that is not normal. 

So I would recommend you go see your doctor and figure out a way to investigate slash address that. I had one patient a patient. I had one student. It ended up resulting in her getting surgery for it. Wow. 

Really? Yeah. So have we not, like, you know, scanned her neck? Who knows might have happened, ultimately, but she was fine. But I think we gotta be sensitive with how we we we broach those subjects, especially if there are other people involved. 

So, you know, I haven't had anything quite like that, but I have had a few situations where where we come across abnormalities, and I've just spoken to the individual after and said, look. I don't I'm not qualified to make a call on this, to diagnose it. However, this is not something that I've seen before, and I definitely think you should get it checked out. It's just something I've I was it occurred to me because it's happened before. I was just wondering if you had any experience. 

It sounds like you do. Yeah. And your point about doing it discreetly is a good one. It's it's not like the kind of thing you wanna go, oh my god. Check this out. 

And now I have hitter students who are like, what is happening here? So yeah. Pull them aside afterwards and say, just just so you know. The thing that people you do see a lot are lymph nodes. Right? 

Especially when you're scanning the neck or the groin. So you can see lymph nodes quite a lot. And a lot of people don't know, number one, that they're normal or b, they don't recognize what they are. So that's something that it's, again, worthwhile, being aware of because lymph nodes are probably one of the commonest, anatomical structures I see that we're not necessarily looking for. Yeah. 

Yeah. For sure. You know, I'm I'm wondering, should all anesthetists be able to do regional anesthesia? Yes. Yeah. 

Firm yes. I mean, it's it's again, getting back to that. When I have trainees going out, then these aren't people that have done a fellowship, but going out to get jobs. Interviewing, they're coming back to me and saying, here's what this job looks like and what they require of me. More and more and more, it's you know, we started an ERAS program, and we need someone that can lead this and do all the blocks or most of the blocks and that sort of thing. 

But just, you know, it has been a core part of providing anesthetics since the eighteen eighties. Yeah. I mean, I I get it. It's it's so interesting because I I referred back to this in the maybe in our first episode. I definitely remember when I was a novice SHO before ultrasound, pretty much everybody in that department, all the consultants could do an interscaling brachial plexus block with nerve stimulation. 

Everybody could do it. Everyone could do a femoral, and everyone could do some kind of sciatic. But it seems that somewhere in this current era, we've lost our way, and that's not the standard. I don't know if everybody necessarily would have been happy to do a wake upper limb surgery, for example, but certainly everyone could do the blocks. And then it just took a bit of confidence to do more. 

Whereas now, we seem to have got ourselves certainly in The UK, we've got into a bit of a rut where that's not the standard, and now the new curriculum will mean that everybody should be able to achieve competency at a certain level of regional anesthesia if we can deliver it there. Well, it's interesting. Like, I work in a very specific place where we're quite siloed. And so if you're a cardiothoracic anesthesiologist at Duke Yes. You're doing hearts and lungs. 

Yes. Like, that's that's your Monday to Friday job. That's even your weekend job. Like, you're not doing gynecologic cases. Yes. 

And and same thing with, like, the OB anesthesiology team is mostly doing women's cases, etcetera, etcetera. So I feel a little bit fortunate in that when I'm doing general OR call, I will get trauma and I will get craniotomies and I will get the odd thoracic case and that sort of thing. But what we're seeing is we've actually had we have a very a very robust and excellent cardiothoracic anesthesiology fellowship at Duke. And some of those trainees with their elective time will come across and and do two weeks with us in a block area because they say, hey. I'm gonna have a a job where half my time is doing hearts, but I Yes. 

I'm gonna be expected to do some regional, not for the hearts, but for the legs and limbs and other stuff. So can you please refresh me as to how to do those blocks? So I I I think it's I think it's really important no matter what your what your job looks like. Well, I think you're right. I mean, similarly, guys in Saint Thomas', I'm very much siloed. 

So I tend to I have a a relatively fixed job plan where I know what I'm doing week to week, and most of the time it involves regional anesthesia. And I've got other colleagues who are doing heart or pediatric anesthesia. But what we're noticing is there are elements of regional anesthesia that are sneaking into job plans where they wouldn't have before. So sometimes in the cath lab, they'll have a procedure, where they're doing a mini thoracotomy. And, actually, they say, actually, it'd be really useful to have some regional anesthesia for these cases, and we've gone up and helped them do some some some regional anesthesia. 

So, actually, practitioners who may not have used regional anesthesia before are now coming across cases where there's a benefit. But, also, in some of the other hospitals I work at, so the Cleveland Clinic London, even the cardiac kinesis, on some days, maybe there's no cardiac cases happening. So they'll come out into the General Floor and be doing non cardiac cases, and suddenly they're doing a foot and ankle list. And these are experienced consultants who are naturally now, they're having to to do a bit of regional anesthesia or they're doing lists where anesthesia is required. So I think all anesthesists should be able to do a minimum set of regional anesthesia. 

The question is, what blocks are the minimum? And is that a dynamic thing, or is it a static thing? Does it change with time? I guess it it varies, you know, depending upon where you're working. Well, you know, I think what you're getting towards here is the the idea of the plan a blocks. 

Right? So the idea that, sure, they're the Ahmet powers of the world that can do every block, but what's the minimum Yes. That everyone should be able to do? I I think that plan a blocks framework is pretty good. I mean, you got you got an up a couple upper limb blocks, couple lower limb blocks, and then a truncal block that does a good job for midline abdominal stuff and a decent thoracic block. 

I don't know. We could talk about ESP again. But Yeah. So I I I do think that's that is a minimum. And I think we need to do a better job in of updating our minimum expectations Mhmm. 

Here in The US at least to reflect contemporary practice and what that looks like and what the job expectations are. And another interesting question is, who should be doing the plan b, c, and d blocks? Yeah. So if you're if I'm working in a small hospital, you know, not in a big academic center, do I need a department where everyone's just doing plan a, or do I need one person that's a champion that can do the plan d blocks as well? It's it's it's a very good question, and I don't know the answer. 

I think you probably need at least one person in the department that can do everything, but depends on how big the department is. And, certainly, one of the problems I'm finding is that the more niche your your skill set is, the more the more stress and more pressure you're putting upon yourself because then nobody else can do it. So, ultimately, I think everybody needs to do plan a, but you need to gradually start building up the competency in people that can do b c d. Because if you're the only guy that can do it, when you're on annual leave, then nobody else is gonna get an anterior QL block, for example. So I think we need to gradually increase that skill set of all of our practitioners. 

But to start off with, probably one or two, the best idea would be that some of your fellows stay at your own place. Right? Because then you've taught them the stuff that you like, and and they can come and deliver it. But quite often, they'll learn the skills and then go go forth and, out into the rest of the the country or maybe in the rest of the world and spread their knowledge there. Yeah. 

I I wanna say something a bit might be a bit controversial here, which is I like controversy. Let's go there. Yeah. Controversy. I think in 2023 with the resources available to us and the types of instruction you can get either at a live course or on a YouTube channel, I think you can very quickly turn someone who's a person into a plan d person. 

I don't know about you, but 98% of what I do all day with regional anesthesia, I learned after I graduated. Oh, a 100%. A 100%. So it's it's taking that baseline set of skills, how to do ultrasound, how to recognize patterns, and then applying them to each of these subsequent techniques that have been developed since I don't think that's quite as controversial as I thought it was gonna be, actually. But you know what? 

I I think the key is to get everybody up to plan a. I mean, we're using that that that descriptor, but to get everyone doing a minimum set first. Yeah. Once we've achieved that, then, of course, we could build on it. And I think there is you know, the problem is that so I'm still teaching some of my experience. 

Consultant colleagues will come and say, look. I haven't done this block for so long or or I did it before the time of ultrasound. Can you teach me that? So sometimes I'm finding I'm teaching a senior consultant to do a technique, that I haven't done for a while. So it would be great if we get everyone doing the type of blocks they need for their job plan. 

But you're right. Certainly, if you, you know, if you're qualified as a consultant, but maybe you weren't proficient in all of those blocks, I think we can get you there with the right time, with the right resources. We can get everybody to do, you know, BCD potentially. Yeah. I think so. 

I I think, once you've gotten that baseline competence, it's easy to translate to all the techniques. The last thing I wanted to ask was one of the things that triggered this episode was one of our previous fellows that Chris said to me, as he finished his fellowship, he said, Amit, I've been teaching other people now to do regional anesthesia. And he said, I don't understand how you remain so patient with me. How is it that you were able to sit back with your hands off and let me do what I was doing? You know, how do you deal with somebody who's doing a block and they're not quite getting it? 

How long do you leave them to to to attempt to do a block before you take over? And when must you take over and when can is it say take the hands off? And I, you know, I I thought this is not something I'd really could sum up in a minute, and a lot of what we're talking about will kind of deal with elements of that. But how how would you answer that? So I think that part of the way to mitigate that is to set the trainee up for success. 

So ergonomics, do the preeducation with whatever resources you want so they understand what the procedure looks like. Get them physically set up so that it's gonna be an easy procedure. And that way you don't have to do nearly as much talking through, oh, stop. You know, actually probes in the wrong orientation, etcetera, etcetera, etcetera. But I am also quite slow to take over some of the procedure. 

Yeah. You know, to me, I think my my priorities are number one, patient safety. Yes. Number two, patient comfort. Number three, trainee experience. 

And then somewhere way down the list is efficiency. Now I I do also care about efficiency, but Mhmm. Not at the expense of a trainee experience. I'll tell the surgeon, if you wanted to have a three minute turnaround on your case, then I invite you to go practice somewhere else because this is a training center. You Yeah. 

I think you come to this place knowing that there's a certain amount of teaching that has to go on. And and for that reason, I don't complain when your trainees take thirty five minutes to close a knee. Yeah. I think I agree with that. And, actually, I hope, the people I've spent time teaching and training will acknowledge that I take time, and I don't rush them. 

But I'll tell you what I have started doing just out of curiosity or just for interest is every now and then, I'll start a timer and have it on the background just so at the end of the procedure, they know That's cruel. No. But just just so they know how long it's taken. Clock's ticking, buddy. But but I won't necessarily give them a shout out of the time, but, you know, sometimes it's useful for someone to know. 

If it's taken them You have thirty seconds to complete this block. I haven't ever done that. Seconds to that'd be funny. It would be good. But but I've I've literally set the timer and said, right. 

Let's do the block. At the end of it, I say, right. That took you, let's say, argument's sake, fifteen minutes. I say, okay. So that's not bad. 

But actually, wouldn't it be cool if you could achieve the same block with, you know, maybe a couple of minutes faster? So I'm not saying I I don't care about time. I'm not saying I'm very conscious about time, but I think we need to be aware of it because ultimately, especially if you're working in a non block room environment, we need to be aware of that efficiency. And, yeah, I agree. I won't compromise experience, but I think we need to be aware of it. 

That's hard to assert. Totally. I I agree. I think that my goal is to get them competent so that they can go out and be a really safe, effective, and also efficient blocker. Efficiency does count. 

Absolutely. Dude, that's it. I think I think we've we've pretty much covered it. Right? Yeah. 

This I've I've learned some stuff here today. So that that's that's awesome. As always, please hit us up if there's things that you heard today or thought of that you want to to us discuss or respond to. Where can where can people find us? Well, they can find us at Twitter at at block it underscore hot underscore pod. 

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We'll see you then. So till the next time, we hope you all block it like it's hot.