S2:E1 "Numb Hands & Our Top Finger-Tips: Nerve Blocks for Upper Limbs"

We are super excited to bring this episode to you. Was it selfish for us to wait this long, or are we just in time? I'm Amit Pawa. Yeah. I'll take an order of pec minors, extra crispy. 

Hold the gumph. I'm Jeff Gadsden, and this is Block it like it's hot. Hey, Jeff. It's a new year and a new season of Block It Like It's Hot. We're now in 2024. 

How have you been, buddy? Hey, Amit. Yeah. I can't believe a year has passed already. Happy New Year. 

A belated happy New Year to you. New New Year, new me, new you. I've I've Yeah. Yeah. Absolutely. 

I'm good man. Thanks. Let's see. After we recorded our Christmas episode, which was which was so much fun, by the way, we had a we had a peaceful family Christmas at a few days off, but I had to work New Year's Eve. What? 

You were working on New Year's Eve? That means that means that you really had a dry January. I mean, you know what I mean by when I say dry January. Right? You mean, like, no rain at all? 

Just a No. Yeah. Of course, I know. Yeah. I know what you mean. 

Yeah. No. I I'm not really down with the whole dry January thing. I I'm more of a more of a moist January kinda guy. Oh my goodness. 

I heard somebody describe it as damp January recently. Yeah. That doesn't sound so nice. I regret that. I wanna take that back somewhere. 

Okay. Okay. How how have you been? What what have you been up to? Well, you know what? 

I've be I I've been pretty lucky actually. I had a decent stretch off over Christmas, and my main priority was not to be buying my wife Kate's Christmas present on Christmas Eve. So I totally nailed that. Oh, good. Good. 

So you got it on the twenty third? Well, nearly. I actually got it on the twenty second. Oh, nice. But but despite doing that, we spent the days over Christmas between our families. 

And then for New Year's Eve, rather than stay at home or or head to a friend's house, we did something a little bit exciting. We headed to a hotel on the Cornwall Coast and had a really fun time with with just the family, which is really cool. So I'm kind of feeling refreshed, and energized and ready for a new year, new podcast season, and hopefully lots of positive and exciting projects. Yeah. Season two, it's, I'm I'm really we got a lot of things lined up too. 

Thanks to all the listeners for for sending things in, suggestions. We have a long list. Right? A big, big list of things to do and kind of I think we've definitely got enough content to record for our season two. Yeah. 

I I I'm also feeling energized, motivated. It's like listening to a well-being podcast. Yeah. So maybe we should create a new podcast, block it like it's hot after hours. Oh, actually, that sounds like a slightly different kind of show. 

Yeah. I think we're trying to gain listeners, not get reported for inappropriate content. Any anyway, any anything else you wanna share before we, get started here? Well, you know what, Jeff? There is one thing. 

I have been a little bit obsessed by a certain song that has been released recently, and I've been listening to it on repeat. Uh-oh. I mean, do do you want me to give you a hint? Not really. Okay. 

If you insist, here we go. Every time the phone rings, I hope that it's you on the other side. Oh, do know what I'm talking about there? Yes. Yes. 

And I did I did see a tweet that you sent out. It's the, if I get jealous, I can't help it. That one? Smashed it. That's it. 

Justin Timberlake, selfish. I am loving that tune. Am I gonna convince you to to join me in being a JT fan on this? Oh, I'm already a JT fan, man, from way back. Yeah. 

Okay. Cool. Likewise. Likewise. Anyway, that that's kind of what I've been I've been into recently. 

Sadly, I've been listening to on repeat. I'm just trying to on my Spotify download, thing, when I get at the end of the year, my unwrapped, I get all of my kids tracks that normally come up top. So I wanna make sure I push JT up at the top there. We so listen. What have we got to what have we got to listen to look forward to today? 

What are our listeners got to look forward to? The Spotify thing, by the way. So we have one account. I is it same for your family? Like, you have one account that you share right now? 

Exactly. We've got the one account. So the the wrap the unwrapped thing, whatever, at the end of the year is Yeah. Is illustrative for for Cory and I because because I think we apparently, like, we are just, you know, average listeners, but our kids somehow some I I don't know when they're doing this. But two years ago, our son, Duke, pushed us into the top 99% of all Drake listeners. 

Wow. And then this past year, same thing. GG pushed us into the, super users for Taylor Swift. I I'm sharing the Taylor Swift love. Definitely. 

I was we were top Taylor Swift listeners too. Nice. Nice. When I say Gigi, I really mean me. You're a Swiftie. 

Of course, you're a Swiftie. Of course, you are. So listen. What we're what we're gonna talk about today, man? So, you know, looking at the topics we've had so far, I realized that there is one area that's, like, been staring us in the face that we haven't talked about yet. 

Okay. Let me guess. Was the face a clue? Are we gonna be talking about the sphenopalatine ganglion block? No. 

That that's a whole different episode. But Okay. Dude, I was aiming for something more mainstream. No. I was thinking about upper limb blocks for hand, wrist, and elbow. 

I mean The brachial plexus blocks. What do what do think? That is a great idea. I in fact, I don't know how we've missed that. And as as we talked about, in our first episode, my first introduction to regional anesthesia was actually a brachial plexus block. 

And certainly, my thoughts about the brachial plexus have changed over time. So I'm definitely up there. So it tells me there's gonna be a bit bit of controversy here as well. So let's let's get going. Okay. 

Cool. So I'm guessing, Amit, you do a fair amount of brachial plexus blocks for awake upper limb surgery or even as, you know, analgesic blocks with a GA because as we all know, power no like Gawa. So what what is let's just start with this. What is your favorite brachial plexus block for distal upper limb surgery? Okay. 

How long we got? This could take the whole podcast, man. So, I mean, if you ask me when I first started, I would have said, without a shadow of a doubt, the supraclavicular brachial plexus block. Okay. And and then as I started my consulting career, I then moved on to the axillary brachial plexus block. 

Oh. And now I'm well and truly firmly landed on the infraclavicular block. That that That warms the cockles of my heart. Yeah. Yeah. 

Well, you keep your cockles to yourself. Thank you very much. And I've got I couldn't tell you why. I had one list, about, three years ago, and I had no trainees. It was just me. 

And they were all awake upper limb surgery. And on each of the patients, I rotated through supraclav, infraclav, and auxiliary. And at the end of this list of about four or five patients, a 100% my preference for the infraclav was cemented. It just was the one that get it gave me the most joy. It felt like the the easiest one to do, and it was the one that felt less controversial with regards to needle tip placement. 

What about you, Jeff? What's your favorite brachial plexus block? I think I know where you're gonna go here. Raptor, dude. I I have it. 

I've had a sort of similar journey. Just to set a stage, we're not talking about interscaling. Right? That's a separate we that's a No. Shoulder block. 

But I have to say, I too love me a raptor. Oh my god. So I was, at one of our ambulatory centers yesterday, and there happened to be no trainee, which was which is a bit odd, but they had some kind of tests that they had to be at the main hospital for. So it was me. And I had one one list that was all upper limb stuff. 

So I just I did nine RAPRs in a row, and it's just so fast and so pleasingly obvious with your needle, the way the trajectory just goes, ping, right towards that 06:00 position. There's no fighting with the lateral cord or the hitting the cephalic vein or the little other vessels in the in the interpectoral plane. And then no trying to, like, scrape the artery and get get around that corner. I mean, I love a regular infracal vacator, but the raptor, every single time it gets to the right place with minimal fuss. Right. 

Listen. We are gonna dissect this when we get to the raptor section because I've got some I've got some thoughts about this. I kinda wanna Cut some thoughts. I I wanna just wanna I wanna I wanna wrap your brains. Wrap your brains. 

See what I did there. Listen. There are lots of ways we can tackle this subject. So how about starting from the top and working our way down? What do you think about that? 

Maybe. We could just go crazy and do random order. Jeff, I don't wanna have our second argument online. K. Please, can we start at the top? 

Okay. Alright. Let's do it. Okay. So what so so let's start with the supraclavicular brachial plexus blood. 

Now you'll remember when it first was introduced, people used that term, spinal of the arm. Right? That was a thing that people used to use to describe it. And I I that was my entry level into brachial plexus block for upper limb surgery. What are your thoughts about it now with this amount of experience, this amount of time? 

What do you think when you think about the supraclavicular brachial plexus block? It's interesting. So when you ask me what I think when I think supraclav, I do a little internal cringe because to me, to get it right, I have to do at least two needle passes. And it's in an area with a lot of important real estate. There's pleura right there. 

There's a lot of vessels that go in and around the supraclavicular brachial plexus. And so when I'm trying to take a relatively novice trainee through that and say, Here, go to the corner pocket. Yeah. But don't hit that bundle of grapes there. I don't want you to hitting a nerve. 

And then so we, you know, we get the needle there, and then it had to come back. And then popping through the omohyoid muscle, but then not getting my needle blink into the plexus again for the second deposition of local anesthetic. And I think that's important because sometimes that brachial plexus drapes itself over the artery and that lateral bit won't be covered by just the corner pocket approach. To me, that just adds a a level of potential hazard and complexity if you're doing at least two passes around this very sensitive brachial plexus. So I do a little shiver when I when I think of supraclav. 

Okay. Stop. So I wanna rewind. Let's go back. So so, for those of our listeners who are maybe not familiar or don't remember, supraclavicular brachial plexus block is how you target the brachial plexus in the supraclavicular fossa. 

So literally behind the clavicle, you got the subclavian artery and you want to see the subclavian artery resting on the first rib. You wanna be able to identify the pleura in front and behind it, and then you see the brachial plexus lying posterior lateral to the artery. So the first thing I wanna say is when I first started doing supraclavicular brachial plexus blocks, we used to blow the plexus up. I we used to stick the needle into the plexus and inject because that's that's what we were taught to do. So I know You're hurting my heart. 

But I know what you mean now when you get that kind of cringe. What your listeners can't see is when I when I talked about supraclavicular brachial plexus blood, you should have seen Jeff's face. It kind of contorted into this slightly odd looking face. He felt pain. I'm sweating. 

But we used to do we used to blow up the plexus. And the very funny thing is I remember being on a course where I'm gonna give him a shout out again. Kijin Chin was teaching. And his introductory lecture in this course, he talked about how people used to start off by blowing up the He's like, no. And that's not the way to do it, what we should be doing. 

And he talked about intra plexus hydrodissection or dissecting below and above. Now the thing that made me feel nervous was the next morning at that same course, I was meant to be doing a live demo to the audience from theater. So I had to adapt to my technique. So actually, what I started doing for a while was do the eight ball corner pocket where you lift lift that the lower lower trunk part, those divisions up off the first rib, the eight ball corner pocket, and then is to come back and I used to pop the poster lateral corner of that triangle and try and hydrodissect my way through the plexus. Now it felt a bit uncomfortable doing it unless you could see those clear divisions moving out the way. 

The problem is if I try to do what I've seen you describe, if I remember a London Society of Regional Anesthesia and Elsora meeting where you showed this beautiful video Yeah. Of a need. Uh-huh. It was a needle going right in the corner pocket. Right? 

And you just eject it. You're like, hey, guys. That was a six minute setup time. Boom. Now tell me, single pass, six minute setup time, really? 

I don't know if it was a single pass. Was it? Anyway. You showed you showed a beautiful video Yeah. Of a needle going down. 

It was the most beautiful lifting up of the plexus up of the first rib. And what you stated in your lecture, was that it was a six minute setup time. But, I don't know. I know I questioned you about it. No. 

No. I I I do remember that block. What I remember about that video was we're kind of making the realization that the supraclavicular brachial plexus is like a bag of marbles. And that the sheath is the bag. Uh-huh. 

The marbles all sort of move within it. And That's a great analogy. I love that analogy. Thanks. And you could you kinda see the marbles move as as they were lifted up. 

They kinda rotated around. And I thought, okay. If I stay outside the bag, this still works. Okay. So you're talking about an extra plexus injection. 

So injecting outside that sheath, that bag of marbles. But but does the does the block work as well or as quickly if you do that? Is the setup time longer? You talked about one or two passes. So I know in some of our, some of our colleagues in the NICE or recommendation, they talk about, you know, one needle pass underneath the plexus, and one needle path, above the plexus. 

Injections either side of that bag of marbles. Yeah. Is that sufficient to make the block work? So this this is my problem with supraclavicular. So I think first you make the decision, are you going to go inside the bag of marbles or outside? 

And if you well, I think we'll talk about this, but I I firmly believe we should stay outside to reduce the risk of neural injury. So now if you've made the decision, I'm gonna go outside the sheath, the bag of marbles, then how do I put my local anesthetic to ensure efficacy? Because the and because this plexus is potentially spread out in a in a way that that makes that lateral most part pretty far from that corner pocket, I think at least two injections is required. But to your point, it won't be as fast as a stick the needle in the in the bundle of grapes and blow it up. But that's that's not what we should be doing. 

So We we so I definitely we both agree you should not be taking a needle, sticking in the middle of the bag of model marbles, and injecting boot. I I think we we both agree on that. Yeah. So so I've got well, now we got a block where if you wanna do the right thing from a safety point of view, you've got two separate passes in a pretty high risk area and somewhat slower onset compared to an InfraClav Yeah. Be be because you're going outside. 

So I I I think the other thing to mention so so when I do this block, because we don't necessarily have the benefit of a block room and we do have to think a little bit about block dynamics, When I where I settled on doing the blocker, which is why I don't perform it anymore, is I do that eight ball corner pocket, the inferior injection. I do the superior injection. Yeah. And I do just tease a little bit of local anesthetic at that posterolateral corner, potentially where the suprascapular nerve is leaving the upper trunk or has left the upper trunk, but that's where I aim to pop some local anesthetic. So I do still feel in my hands to make it work to get the speed and reliable reliability. 

I've got to do a bit of an intra plexus injection. And for that reason, it has now fallen to the bottom of the pile for me because we've seen there's some work that, again, came out of Dalhousie looking at, intra cluster injections or extra cluster injections and how it we know it's dangerous, right, to do those injections. Yes. So friends of ours in Halifax at Dalhousie have published two studies now, one with interscaling, which which changed my practice. Right? 

So it was I used to be an intra plexus guy, and and and now I'm firmly extra plexus for that. But they they followed it up with a cadaver study for supraclavicular showing that if you're very, very careful deliberately trying to avoid hitting anything, but put a fraction of a mil of India ink in a cadaveric supraclavicular brachial plexus, 22% of the time, you will get intrafascicular spread of dye. Yeah. And that that's compelling to me. I do I do not want to get intrafascicular spread of local anesthetic because, you know, local anesthetic inside fascicles kills axons. 

So I I I you know, I'm I'm kind of convinced by that. And the other thing is if you do try to do that intrasheeth injection, the one thing you I I see it quite often is you see that artery that traverses through the plexus and separates the upper trunk from the middle trunk. Now whether we call it the suprascapular artery or the dorsal scapular artery, what's the what's the real answer? I mean, there's an artery that travels there. Which artery is it? 

It looks like it's a suprascapular branch, but tell me what what what nomenclature or nomenclature do you use? Yeah. I call it the artery of power. Oh, yeah. But, again, I'm hoping my trainees say that on some exam sometime. 

But there is there's there's an artery that travels Right? There's an artery. Yeah. Exact exactly. One more reason that I kinda roll my eyes when I put the probe on the supraclavicular fossa and go, ugh. 

God. I gotta do this again. This doesn't seem like a fun exercise. So so that's something to be be aware of. But but would you put a catheter where the supraclavicular brachial plexus is? 

I have done. In my mind, we end up with kind of the same problem, which is, okay. I'm probably gonna put the catheter underneath the like, deep to the plexus in the corner pocket area. But then if I expect that local to get up and around to the, you know, posterior lateral side, that's a big ask. And I will say, I've heard of people having failed blocks. 

I I no. Kidding. No. When when when I have had a failed brachial plexus block, nine times out of ten, it's supraclavicular. Yeah. 

I think because of the regional variation. I mean, because traditionally, it used to be the block that people would say you'd get ulnar territory sparing, right, because of the the the the lower trunk divisions getting spared if you don't get that corner pocket. But, you know, let's finish up supraclavicular by saying, if you were gonna perform it, we've already talked about how you gotta be careful of the artery and the branches of the artery. You gotta be careful of the pleura. You gotta make sure you're not doing the block while the subclavian artery is resting on the pleura so that the the the the plexus is lateral to it. 

But what do you think the tips are? What volumes and what how many needle passes? And then we can move on. Yeah. I like I like 30 mils, which Uh-huh. 

Seems like kind of a lot for brachial plexus block above the clavicle because we use we use a lot less for for inner scaling. You know, a lot of the data a lot of the, e d 95 studies that have been done show that, yeah, it ends up being 30 to 32 mils or so. Okay. So I'll do sort of maybe 20 below 10 on top. So I used to draw up thirty mils of local anesthetic, but actually, I used to finish most of my supraclavicular brachial plexus blocks with 20. 

But when I transferred that same experience down to infraclavicular, I came a bit unstuck. So we'll talk about that in a second. Okay. Cool. So that's the I I feel that we kind of I feel that we've we've understood each other in the supraclavicular brachial plexus block. 

We both could do it, would do it, but maybe not in our top two. So let's go on to your favorite, man. Let's talk about the retroclavicular approach to the infraclavicular re region, the the so called raptor block. Why is it your favorite block? Okay. 

So I let's start the story by saying that you heard my reasons for moving away from supraclav, and then I had some reasons to move towards infraclav, which was every time I did an infraclav, I'd be pulling the needle out and the patient would be sort of flexing and extending their fingers and saying, my hand feels numb. And so that's that's one of the 15 so called Gadsden signs that I Okay. That I'm I'm mess with our trainees with. It says, you know, play when you pull the needle out and the patient's already saying, yeah, my hands getting numb, that's the Gadsden sign. So I I began to realize, wow. 

This is a block that sets up very quickly. And it was one pass. Just put your local at 06:00 to the artery, and you will get an excellent effect. But the problem was there were times when there were vessels in the way. So there's the cephalic vein and the a branch of the thoracoacromial artery in that intrapectoral plane. 

It's steep. So unless you have an echogenic needle and a good ultrasound machine, there are times when you're not seeing your needle all that well. Uh-huh. And the lateral cord ends up in the way a lot of times. So you you get to that, let's say, two or 03:00 position to the artery and you're like, ugh. 

Now do I go above the lateral cord and then underneath the artery or do I go around and try to like bring the needle back up in a in a curve? And so that was always, well, not always, but it was frequently a problem. And then Kaman Vlasikov actually from from Brigham Yeah. Was the one that turned me on to this technique a long time ago. He said, have you ever thought about coming under the clavicle and just driving needle straight across? 

And my first reaction was, oh my god. Why would you do that? That sounds really dangerous. Like, what's what's back there? And then the more I thought, you know, he sort of he he reassured me and then sort of thought about it and did some thinking and looking at anatomy textbooks. 

And then eventually, I was at a cadaver lab and sort of really got to dissect back there and realized that, okay. There's a there's some muscle. There's some clavius muscle and subscapular muscle and some fat, but really not a whole lot else that's exactly deep to that clavicle. Yeah. But then when I started to play with this block, what I realized was it avoids all that dangerous stuff. 

It avoids the vessels. It avoids the lateral cord. And when you come through that clavicle shadow so so for those of you who have aren't familiar with this, what you're doing is the probe is in the same position in a sagittal orientation just medial to the coracoid process on the chest. And rather than bring your needle in very, close to the probe between the probe and the clavicle, you move it cephalad into the supraclavicular fossa and then drive it parallel to the floor so you're going deep to the clavicle. What that does though is means you're driving your needle through the shadow of the clavicle so you don't see your needle for a heart stopping couple of seconds. 

And then all of a sudden, the tip emerges from the shadow and you see it on the screen. And 99 times out of a 100, that tip is pointing right towards that 06:00 position. So all you have to do is, like, move it two centimeters and you're right where you need to be. No trying to negotiate around the lateral cord. No getting into vessels. 

So it it has it has become my favorite brachial plexus approach for those reasons. Easy, safe. We're about to present some data at the Azra Spring meeting, one of our fellows, looking at a case series of 450 raptors Okay. Wow. And looking at safety. 

And I don't wanna spoil Akshay's presentation. Uh-huh. But let's just say that, you'll be suitably impressed with the safety of this block. Okay. Well, listen. 

Here's my problem. So I hear all of that. And if you were a pro con speaker, you know, you would have swayed me with the passion that you described for this technique. But this is the problem I have. Okay. 

So you're you're placing you're placing the probe inferior to the clavicle. You get your classic view. That's great. I get that. But then you're asking somebody to take a needle and place it in the supraclavicular fossa where we've classically told people, be careful. 

There's a dome of the pleura. There's a subclavian artery. There are nerves there. And you're telling them to blindly stick the needle in the supraclavicular fossa. And when people have not done this before, they've got to get their head around how deep to insert it behind the clavicle, what angle to to direct in, and there's at least two centimeters where you have no idea what is happening with that needle. 

We've seen papers showing that their suprascapular nerve and or artery puncture that can be involved in that needle path. But actually, I'm more worried about somebody trying to do a classical needle insertion point and aim for the retroclavicular approach. And if you think about that classical, needle angle retroclavicular approach, that spells c r a p. That's a different acronym. But if you do if you do the classical needle angle behind the clavicle, then you're even more, you're in a worse position because then the needle's coming not nine not perpendicular to the artery. 

It's coming at an angle. So how do you work out how deep behind that supraclavicular fossa, deep behind the clavicle to insert your needle whilst aiming to get it to come in at 90 degrees of the artery? That's the bit I've the every time I've done this, that's the bit that's required a little bit of practice because if you get that needle insertion angle wrong, then you're in a whole host of danger. Well, that that is the intuitive belief. Right? 

Like, oh, I I can do a lot of damage back here. But to the pneumothorax risk, what's reassuring is if you look at the way the chest wall curves medially as it gets up towards the clavicle, when we do an infraclavicular block, we're actually outside the chest. Right? Because you got a sagittal orientation just medial to the corica process, can take a nail gun and put a nail right there and you won't cause a pneumothorax. You'll cause a lot of other problems. 

Yeah. But you won't get into the lung. And so as long as you maintain that same sagittal plane with the retroclavicular, you'll be okay from a from a lung chest wall point of view. Now I'm not saying there aren't things in the supraclavicular fossa, but they're they're typically much more medial than we're putting our needle. And I understand. 

I get it. Like, I mean, I had the same, like, man, that is a there's a lot of important stuff up there, and you're telling me to just poke a needle in this supraclavicular fossa and and and advance it blindly. But where we're doing this, it actually is a very safe trajectory. And so but my biggest tip for people that want to start doing the Raptor is make sure you get your needle far enough back from the clavicle. So it's gonna be two to three centimeters kefel add to the clavicle so that you don't have to take a deep approach to get under the clavicle. 

So imagine like doing a subclavian landmark based central line. Right? Like, you know, I was taught to sort of hit the clavicle and then kind of pull back and then scoop underneath the clavicle. It's kind of the same idea. But if you start too close to the clavicle, you have to go deep to get underneath it, and then it takes you and then you can't come back up again. 

So Right. Come back a few centimeters, and then you have that perfectly parallel to the floor Yeah. Trajectory that keeps you from But you do have to push you have you kinda gotta push down in the supraclavicular fossa. Because if you just enter the skill at that point, then you're you've gotta be deep down in a what I'm trying to get my what I'm trying to articulate, but I'm not doing a very great job is, if you just start your needle insertion point a distance away from the clavicle, but you don't penetrate deep enough into that tissue, the supraspinous fossa or supraclavicular fossa, you're still gonna have that odd angle that you need to direct your needle behind the clavicle. That's the bit I struggle with. 

So I've seen some people use their finger, rest it in the supraclicular fossa, and then push down a bit, and then they start to and then you could appreciate now if I was to advance in this direction, I would clear the inferior or the deep border of the clavicle and get to where I need to go. That's the bit I sometimes struggle with. Exactly. Yeah. You need to be you need parallel to the floor, which means to not hit the clavicle, you have to be far enough back. 

Well, listen. Yeah. Maybe I'm gonna try that next time. But the one thing I wanna just settle is when I'm performing a classical infraclavicular brachial plexus block, we already talked about how you sometimes need to navigate around the lateral cord, either go between the lateral cord and the artery or go careful out or cephalad to the lateral cord to get to that 06:00 position on the auxiliary artery. But we've also talked about the fact that there's a fascial plane or a little sheath that can sometimes separate the lateral cord from the posterior medial cord, medial cords in that lower compartment. 

So if you only ever direct your needle at 06:00 and you don't ever inject your needle on the way down past the lateral cord because you're bypassing that, how reliable is the spread in that u shaped position with just one needle path? You know, what happens if you're doing it at the point when the medial cord has rotated around medially between the axillary artery and the vein and the lateral cord is separate it's separate fascial sheath. Does the local anesthetic spread equally in a nice u shaped fashion? Or this is this a product of volume? I think partially it's a product of volume, but the way we teach this is is this is essentially a perivascular technique. 

So you have to be intimately close to the artery for this to work properly. So sometimes we'll see people get the needle to the 06:00 position and they'll begin to inject and I'll say, woah. Woah. Woah. Stop. 

You see there's a bit of schmutz between the That's a great word. Schmutz. That's exactly it. Schmutz. Yeah. 

Do know what I call that? I call that gum. But I kinda like Schmutz. Okay. Yeah. 

Okay. I like gum facts. We've talked about this. So yeah. So there's there's a little bit of hyperechoic something between your needle tip and the arteries. 

Oh, stop. Stop. We need to back up, scrape the paint off the artery Yeah. And make sure that that schmutz gumpf gets pushed down. You wanna see clearance. 

Right? You wanna see definite black fluid between the artery and the gump schmutz below. Then I wanna see artery wall and then local. I don't wanna see any gumpf between my local. And if you do that, I think what happens is, you know, if you look at the anatomy, those three chords are kinda rotating around in a longitudinal direction around the arteries. 

As long as you're right next to the artery and with 20 to 30 mils, it will spread a, you know, a bit cephalad and caudate, and you will get every cord. Okay. Okay. And then if you're gonna put a catheter, you put it at 06:00, just past 06:00, you're gonna do a raptor catheter? Yeah. 

Same Yeah. Same thing. Yep. 06:00. Okay. 

You know, maybe maybe you've reenlighted my passion. I don't know. I don't it it it it's something to think think about. Well, I I'm a fan. And and and lots of other people are too. 

I I wanna shout out here to to our friend Jerry Jones who calls this the spinal of the arm. Okay, Jerry Jones. Yeah. Yeah. Yeah. 

Lovely to meet him, last year as well. A great guy. Okay. Still working now on variants of the infraclavicular brachial plexus plot. I wanna talk about the most recent variant I was introduced to, which I just need to I need to pick your brains on this. 

So this is the costoclavicular approach to the, break to the infraclavicular brachial plexus, which I think looks like a mirror image of the supraclavicular brachial plexus. Tell me what your thoughts are. How do we do it? And then tell me what your thoughts are about this. That's exactly what I think too. 

When I when I do this, and I don't do it very often, but when I when we get the image, I I'll say to the trainee, what does this look like to you? What does this remind you of? And they'll be like, it looks like a supraclavicular brachial plexus. Yeah. Exactly. 

There's an artery. There's the plexus all on kind of one side. You've got pleura. It's it's exact you're right. It's exactly a mirror image of that. 

So as I recall, this was proposed as a way to get the infraclavicular, but at a spot where the cords were all together in a cluster on one side. Tightly tightly packed. And if you get a good image, you actually see them as Yeah. Three separate clumps in this little pocket. So I've done it. 

It it it it works it works well. My hesitancy with this block relates to the way that it's been described by some groups, which is get inside the sheath and blow it up. So I I say, well, I get it. I like the idea of where you're doing this, but I would also stay outside the sheath. And I have done an extra sheath costoclavicular, and it works just like supraclavicular. 

So that's my only my only cautionary notice. Please don't read the papers that say, yeah, jam the needle right into the center of these three chords and then and then go. Oh. So that so this is this is interesting because I don't necessarily agree. And so what I'll say is I I don't like I don't like the idea of directing your needle towards the pleura again because you're by definition, you're you're doing this block, and you direct your needle medially, and it's often the cephalic vein that peels off. 

Now some of our Indian colleagues, Indian regional anesthesia colleagues, I saw they they came up with a a clever way of of how to find this. And actually, I've used this when I've taught my trainees. So I I can't remember what they call it, but essentially, it's a one, two, three type thing. So they talk about laying the probe along the clavicle. So along the long axis of the of the clavicle, that's position one. 

Yep. And then you drop down below the clavicle. That's position number two. And then number three, you tilt up and under. So you're aiming to look behind the clavicle. 

So I've that's been quite a nice way to get people to generate the image because sometimes people just drop below the clavicle and they forget to look up and behind it. So generating the image is quite nice. You see the auxiliary artery, the cords of the brachial plexus in this tight pocket, and sometimes you see the cephalic vein moving out, you know, moving across and out of the way. Yep. But when I've done it, I just literally just popped into that pocket. 

And because you tend to see three separate cords, I don't think it takes a large volume to do the injection. And I feel better that there are three separate distinct or discrete structures that I I can avoid, but get inside that pocket. But and that feels different to me from doing a supraclavicular brachial plexus block where you got these divisions kind of intermingling. Here, you seem to have three separate chords. But I I see I see what you're saying there about the it's less, an indistinct bag of marbles and more like more it it is more like an infraclavicular appearance. 

Yeah. Yeah. But the other thing I've used it for is if we're if we've done the injection, we're like, have we got all of the cords? You know, sometimes when you inject with a classic infraclavicular at the six squat position and what you interpret to be the posterior cord is actually the medial cord that hasn't quite wrapped around. So sometimes you have a look and think, gosh, have I got both of those? 

What I'll get the trainees to do is go back to the costoclavicular approach and have a look. And that way, if you got within the right space, you can often see those three separate chords really nicely delineated. So often use it as a cross reference point. So we do the classic blocking thing. Have we got enough? 

We go back and look at the costoclavicular view, and then you'll see that sheath expanded because low clavicle has filled the area. So I think it has value, but it's not my go to. I do love that actually with with InfraClav or Costoclav. Yeah. Being able to scanning up and down and and and saying, okay. 

Let's check this out. We'll go above the clavicle now. And look. There's some local in our supraglavicular brachial plexus view as well. Alright. 

Cool. So now, Jeff, I think I wanna, you know, talk about something that's a little bit more maybe controversial. Oh. And I wanna talk about the intercostal brachial nerve and the medial cutaneous nerve of the arm and the forearm. So, you know where I'm going here. 

When we do our, our brachial plexus blocks, the nerves that we don't cover necessarily, certainly the intercostal brachial nerves, that innovation to the medial part of the arm. Now is this an issue practically? So if we were to do a raptor block, you know, one and done, boom, scrape the pain, all of the the the the phrases that used to describe that, yeah, fast onset block, but you won't get the intercostal brachial nerve. Is this an issue practically? Well, it it can be if you're if you're doing this for things around the elbow. 

So that intercostal brachial nerve and the medial cutaneous nerve of the arm sort of mingle together. So it's hard to sort pick out their territories individually on the medial arm. But suffice it to say that they can get down to that medial epicondyle. So if you're doing, let's say, AV fistula around the, you know, medial distal arm Uh-huh. That's territory that you probably wanna cover with some sort of technique to get that. 

What what I don't think is an issue is if you're doing a wrist or hand case and you have a an arm tourniquet and people will fuss about, like, I want you to get the coverage for the skin. I don't think skin hurts with a tourniquet. Okay. Hold on. Hold on. 

Hold on. Hold on. Again, rewind. So are you telling me that never never in your career have you done one of these isolated brachial plexus techniques and, you know, the surgeon pads the tourniquet and they put the tourniquet on? Never have they complained of discomfort at initial inflation of the tourniquet. 

I know what people are saying. Tourniquet shouldn't hurt, but practically, real world experience. Are you telling me that net patients have never complained of tourniquet discomfort? I'm not saying that. No. 

But I challenge the idea that sorry. You inflate inflate something on the arm that squeezes, like a blood pressure cuff, and people will go, oh, that hurts. So what you're saying is the only reason it would hurt would be if it was applied incorrectly or if something was being pinched. Or Well, I I I I think I I think lots of patients might interpret pressure and squeezing as discomfort for sure. And and if you feel that in the nociceptors in the skin, I I buy that. 

But I think that's easily solved with a little bit of appropriate sedation. What I'm talking about more as opposed to cuff inflation, ow, that hurts, is more like ninety minutes later Yeah. Deep pain that people feel that is manifested by an increase in their heart rate and blood pressure. That tourniquet pain is, I think, a different phenomenon. It has nothing to do with the skin. 

No. I agree. I but, you know, I I I will say there have been sometimes we've done what I would describe as a a really beautiful brachial plexus block, and the tourniquet goes up, and the patient's not happy. Some something's so they don't feel comfortable with something. And that's despite giving them good information, pre op counseling, telling them what it's gonna be like. 

In those situations, you know, I've I've got one magic trick actually, I'd like to share with you. One to two cc's or one to two mils of propofol. That's it. As a flush, you see, give them the propofol, then flush it through. It immediately takes that all away. 

So I don't know what it does. I don't know how that works, but that seems to be enough. So general anesthesia. Yeah. General anesthesia works. 

So not no. We don't do general anesthesia. I've said one to two cc's, one to two mils. You know I don't like Gower, but literally one to two mils of this stuff seems to work. But, you know, that's one thing. 

And then, of course Yeah. No. I agree. So you you understand what I'm saying that sometimes you need something. Yeah. 

Yeah. No. I I have some appropriate sedation, I think I think, solves this problem most of the time. But there are certain situations that you've alluded to right at the top of the answer to the question, which is, yeah, the surgeon's gonna be sticking a knife in here, but that's very different. Right. 

Yeah. And there's different ways to do this. You know, you can just take five or seven mils of local and do a subcutaneous wheel up by the axillary crease. Are you talking about with or without ultrasound? Well, I I used to do it without, but I've switched to doing it with now because a, it's fun, b, it's a teaching opportunity, c, you can reduce the volume you need because you don't always see the nerves, but you know where they should live. 

And so you can guide the needle just just above the fascia where the conjoint tendon is just posterior to the artery, axillary artery, and put, you know, two, three, four mils there and feel confident that you're gonna get it. And it's super easy and and fun to do. And I'll add a d to that because actually if you watch people under ultrasound guidance stick their needle in, it's actually quite easy to get very close to the structures that you might have beautifully blocked under ultrasound guidance. And without realizing, if you blindly stick a needle and think you're in the sub q tissue, it's possible that you actually end up skewing some of these structures. And I've watched trainees nearly go into the wrong plane when they've been trying to do this under ultrasound guidance. 

So Right. So, actually, I think you're right. So the way that I've seen it described is you get your classic, auxiliary brachial plexus block view, where you got the conjoint tendon, and then you scan you direct the probe towards the bed. So so inferior posterior just aiming to look over that belly of muscle of the conjoint tendon, and you look at just above the fascia. And sometimes you see these little expansions, the intercostal brachial, nerve and the medial cutaneous nerve of the forearm can little arm can live there. 

And sometimes I do see them, I think, wow. That's definitely a stretch, and I pop some local anesthetic about it, and I can I can trace it up and down? Other times, as you described, I don't see it. I just I drop local anesthetic in that plane, and it can be quite satisfying to do it that way. Right? 

Yeah. Yeah. I agree. Yeah. If you go two centimeters max past the artery, that's where you should find those those nerves. 

Definitely. Okay. Well, that's that's great too. So I feel that we kind of, we've covered a fair amount of stuff there. Do you think it's time for a break here? 

Yes. I do. Would you like me to tell you a joke, Jeff? Okay. I think it's about that time. 

Do you have any jokes for us? Yes. Well, I do. Thank you so much for asking. It wasn't like this is a predictable component of the episode or anything. 

I've got some, some episode theme jokes for you. Okay. Jeff, what did one hand say to the other hand? Don't know. I glove you. 

No. Okay. That's not bad. You don't sound that impressed. I'm hoping some of our listeners laughed at that. 

Have you got have you got I chuckle. Okay. Have you got one for us, for me? Okay. I do have one for you. 

Okay. So Okay. So you know the Looney Tunes characters. Right? Yes. 

Yes. Yes. I do. So okay. So Daffy Duck and Elmer Fudd are in Scotland, and they break into a distillery. 

Okay. And Daffy Duck pulls up a bottle, and he says, is this whiskey? And Elmer Fudd says, yes, but not as whiskey as wobbing a bank. Oh my god. No. 

Okay. That's good. But you know what? I think you you had you had to do the axelot. I I laughed a lot about it. 

That was good. But, know, that's that took me back to my childhood. I used to remember watching Looney Tunes, and I remember Elmer Fudd. But yeah. I okay. 

I like that. That that that sort of re took me back to my childhood. So thank you for that. I think that was joke was definitely better than mine. But before we before we get back into the episode, did you see that comment on x about our nomenclature episode? 

That that was the one from Alex Cumberworth. Oh, yeah. I did. The one about putting on on hold the write up of the oops block, the out of plane sciatic. We'd love to hear some yeah. 

Love it. We'd to hear some more ideas for block names you guys have made up for for fun. And if anyone can come up with the Ganston block, that would be cool. Come on. Right? 

Yeah. That we we we need a Gadsden block. And do you know what? I'm I'm just gonna touch on something. Before we get back into it, I'm gonna touch on something that is definitely controversial. 

Do do do. Do do do. And I just wanna take, yeah, I just wanna get your your take on it. So I was recently speaking to a colleague who's wished to remain nameless, and and he was talking to me about his recent change in tech for how he delivers anesthesia. So he's been doing some cases, some big cases, and sometimes some small cases, and giving them a general anesthetic as as they were expecting, and using very little, if not sometimes no opioid, And giving them, you know, multimodal analgesia, they get paracetamol or acetaminophen, they'll get a non steroidal anti inflammatory drug. 

They may or may not get clonidine. They have their surgery, and he showed me, like, the anesthetic charts on Epic of these patients. And they were tram lines, beautifully straight flat observations. Yep. And the patients wake up afterwards, and they're not in pain. 

And he's done this for a whole host of cases, and it's kind of it's sort of blown my mind. And he he's even done this. Check this out. He's even done this for a total knee replacement. So what's the deal here? 

You know? Is that is this gonna put us out of a job? I mean, literally, I heard this, and I thought this is quackery. So I remember, I gotta say, about ten years ago, there was a flurry of enthusiasm for getting away from opioids and replacing it because of the whole idea of the hyperalgesia that you get with any dose of opioids, but particularly with some like remifentanil Yeah. And instead using esmolol. 

And so I I remember doing some lap choles that were totally opioid free. Yeah. I do remember this. Yeah. And they they would get out and I I wouldn't say pain free, but comfortable. 

And it made me it made me realize that, okay. You don't have to use opioids. Now I'm not a opioid zealot in the in the sense that I like, I'm striving to be opioid free with all my cases. I think there's a place for them. And I think that if used appropriately in a hospital at the time of surgery, there's a a good use case for them. 

So But you'll use them associated with regional anesthesia as well. Right? Yeah. Yeah. Yeah. 

So so this particular individual doesn't, and the patients are okay. It it just you know what? It it blew my mind. I don't understand it, and I'm not sure if I could ever change my practice to accommodate this, but I just wanted to float it there. And, you know, it is a bit controversial. 

Be interesting to see if anyone picks up on that. But, you know, I just wanted to if it's something that you'd ever done, and it sounds like you have done it a bit, but it's not necessarily something you do again. Not routinely, but what every once in a while, we'll have a patient who has had a personal experience with opioids. You know, we have this this opioid crisis and have had for several years here in The US, and they say, look. My son overdosed on heroin. 

I do not want any opioids. And they're like, no problem. So so that becomes an opportunity to think carefully about how to Yeah. Provide the best possible experience without relying on that crutch. Okay. 

Cool. Well, let's let's let's get back into it. So we've kind of talked a lot about the infraclavicular the classic infraclavicular, block or the lateral approach to the infraclavicular block. But I just wanted to touch on a few things. So, again, the classic infraclavicular brachial plexus block involves, placing a probe in a paramedian sagittal orientation inferior to the clavicle, just needle to the coracoid process. 

You get a view through pec major, through pec minor. You see the axillary artery and vein, and you're aiming to identify in an ideal world, three chords positioned around the artery. Right? Often, you clearly see the lateral chord. Yep. 

But what you see deep to the artery can vary. So what I tend to get my my trainees to do is to to place their probe. Actually, I get them to place their probe medially on the chest, inferior to the clavicle, and scan from medial to lateral so they actually watch the axillary artery and the axillary vein emerge from under the clavicle. And I do that because I want them to be absolutely clear that they're looking at this the main branches of the axillary artery. Because once, I did do a beautiful perivascular injection of a branch of the axillary artery that had no cause around it Oh, really? 

And had a completely failed block. So, yeah, it's really important you identify those vessels correctly. Yeah. I think the other tip that and I agree with you. You can you can put the probe on the chest and be quite medial or quite lateral and Yeah. 

Maybe not get the best the optimal view or optimal location. And and my tip for trainees is make sure you have a good chunky PEC major and a good chunky PEC minor. Yeah. Because PEC minor is quite narrow. Uh-huh. 

A fun fact, the PEC minor is the chicken tender. So when you order chicken tenders at a at a restaurant, that's the pec minor of the chicken. I did not know that. Every day is a school day. This is amazing. 

I know. You'll never look at chicken tenders the same way. You might never order them again. Exactly right. And, anyway, so you can very easily slide to medial, and then you only have pec major. 

And then similarly, slide to lateral and only have pec major. So but if you go to where you see both pec muscles, that is a good spot to do your do your block. Exactly that. So I I get them to start medial and then slide laterally, see the vein and see the artery emerge from, from underneath the shadow of the clavicle. And at the point when they think they've got the best view, I always tell them to scan a little bit more lateral. 

I say, so so don't just assume that's your best view. Get a little bit more lateral to see if it gets any better because actually sometimes you get a great view, but actually you still got rib and pleura deep to you. So I encourage them to scan even more lateral to make sure they're clear of the chest. And then often, you'll you'll get a little sweet spot where everything highlights a little bit better. The other tip I get them to do is the one that you taught us many years ago, an Elsora course, which is then when you're applying pressure to the to the chest wall, just apply differential pressure so you kind of release up slightly on the keflat aspect to the probe to clear a space between where, you'd insert your needle between the inferior aspects of the clavicle and the probe. 

And actually, sometimes that tilts and change differential change in pressure allows the cause to highlight a bit better. So Yeah. I agree that. And we call it heel toeing. So you you heel in Heel toe. 

There you go. Heel in the the caudad portion of your probe. So the cephalad portion lifts up a little bit, and it changes the angle. It gives you a better needle visualization too. Absolutely. 

So I was I said to you I was gonna say this. So when I first translated my supraclavicular brachial plexus block practice with 20 mils of cc to infraclavicular, I often got unstuck. And often I'd have a block that was partial or incomplete. And in fact, it was Ed Mariano who pointed out to me some of the original papers and the dose finding studies that were talking about how 30 cc's was kind of the sweet spot. So as soon as I increased my volume to 30 cc's, all became good again. 

So actually Yeah. That that was but the the one issue I have every time I do it with the training, this shows that different practitioners have different approaches, is where to direct the needle past the lateral cord. So someone one of my colleague will get the trainees to pass the needle between the lateral cord and the auxiliary artery on their way down to the 06:00 position, and not deposit any local anesthetic up by the lateral cord, was I'd like to as I'm passing the lateral cord, either, you know, ahead of it, there's a kefel out of it, or between it and the to put a little bit of local athletic buy it on the way down. And then I go down to the to the 06:00 position around the posterior chord. But I know there are there are pros and cons to doing that, but that's kind of been my practice. 

It feels crazy to me to bypass the structure that you're interested in and not to pop a bit of local buy on the way down. What what are your thoughts? Honestly, I just put it all at 06:00. I I, I used to do the same thing. I used to Wow. 

On the way on the way in or the way out, put some puts about a lateral cord, but it it doesn't seem to make a difference. So are you saying that I'm behind you on my, my regional anesthesia journey, that you're a Jedi and I'm still a Padawan? No. May maybe it's the other way around. Maybe you've maybe you're thinking of new things. 

Well, I know you are thinking of new things that I haven't thought of. So Okay. Well, that idea is but but you don't tend to practice this much, and we've covered why you like the wrap tip block. But let's say you were, you're also using a similar volume of about 30 cc's? Yep. 

Same. And you put the catheter about 06:00 or just past it? Just just about 06:00. So I still when I when I inject, I always inject through my catheter with fluid. So it's either saline or local to check the final position because it's, inevitably have to pull my catheter back a little bit because we overthread when we're doing catheter through needle. 

And so it's, you know, squirt, pull back, squirt, pull back, squirt, pull back. And then finally, okay, there. Perfect. It's exactly where I would put it. I would have done a single injection technique at 06:00. 

Alright. Cool. So the last brachial plexus block I wanted to talk about is the auxiliary brachial plexus block. So do you know why I love this? It's great for teaching because Yeah. 

Me too. There's lots of anatomy. There's lots of structures you can you can point out, and they can use this trace down and trace back method to to to follow the nerves along their path, from the axilla down towards the antecubital fossa and beyond. So I think it's a really great way, to do that Do you agree? I love that too. 

Right? Like, I I I often waste time. Like, you know, oh, surgeons sitting there, come on, guys. Get back to the oh, sorry. We were we were tracing the the median nerve and then the the radial nerve and the ulnar nerve and and and that sort of thing. 

But it's, when you say trace back, for for listeners, sometimes when you put the probe in the axilla, you'll see the artery. That's the main landmark, and you'll often see one or more veins. But then there's this, like, collection of neural tissue that to me looks like pieces of popcorn around around the artery. Yeah. Right. 

It's hard to tell initially there which what is what is what. So if you go down to, you know, mid arm or down to the elbow and start tracing back and you'll see, okay. There's my ulnar nerve. Ah, now I see in that collection of popcorn, which one is the ulnar nerve. And you can do that with each each nerve. 

So to slide down and then slide back up again and see see them come together. So I love that. And and the other thing I'll do is, you know, I'm a fan of nerve stimulation. I don't do it for every block, but this is one that I I'll I'll sometimes pull it out for, not because I believe it's it's necessary for efficacy or safety in this particular approach, but it's it's fun to show the trainees. This is what an ulnar nerve twitch looks like in the hand. 

Yeah. Media median nerve twitch, radial nerve twitch, etcetera. And they're like, oh, okay. So I think that that would be a a great learning point because, of course, the the real, regen anesthesia heroes in the past would be able to do differential blocks or be it to identify those different different nerve structures by the different twitches they got in in response to nerve stimulation. The one thing I did wanna talk about with this, with this approach is, there was a paper that was published a while ago, a long time ago, that kind of demystified all of this. 

Or not not demystified it. It kind of dumbed down what we do. So, you know, take great pride in identifying these nerves as separate entities and putting local anesthetic around them. But this paper said, do you know what? If you just put some local around the muscular cutaneous nerve and dump half of your local above the artery and half your local below the artery, you know what? 

Your block's gonna work. And the annoying thing is it kinda does work, though. Right? That's that's that's how I teach it too. Like No. 

Yeah. No. Honestly, I I mean, like, it's fun it's fun and rewarding to seek out and and stimulate and block each of the separate ulnar, median, radial, and then MC. But at the end of the day, it is a perivascular block. And then, of course, musculocutaneous is a a little bit separate. 

But did you ever do the transarterial approach? Maybe inadvertently, once, but but but, no, it it wasn't something I I did paresthesia, but it wasn't my trans the transarterial approach to the axillary brachial plexus block was not something I did routinely. Although when I was training, one of the consultants did still used to do that. No. I mean, the transarterial approach to the inner scaling. 

No. I'm joking. I'm joking. I stopped breathing there for a second as would our patients. Transcarotid. 

Yeah. No. So, yeah, I, this is again, I mean, I'm an old I'm an old dude, but this is an approach I was taught as a resident, and it just proves to you that it that the perivascular deposition of local works. So Yeah. If anyone out there has not ever heard of this, you would take a sharp needle and it's in tubing and a syringe of local, and you would palpate the artery in the axilla. 

And your attending would say, okay. Put the needle in and go for the artery. And you're like, what? Yeah. Go for the get the needle into the artery. 

And as as you get in, they're aspirating, and you start seeing this bright red blood come back. And my first time I did this, I'm like, that's not right. I shouldn't be seeing that. They're like, no worries. Keep keep going. 

Keep going. And then you pass through the back wall and the blood would stop. And they're like, alright. I'm gonna inject half my dose there, and then you do the reverse. You come back through the artery and primary blood again, and then you come to the outside the artery on the superficial side and put half your dose there. 

And it and it did work. And you never got hematomas? No. We got brutal hematomas. So the patient the we call the patients up, like, the next day, they're like, oh, my hand feels great after that Dupuytren's contracture release. 

And we're like, oh, excellent. So highly satisfied? No. My armpit aches because of this huge collection of blood in my armpit. So Okay. 

We stopped doing it. Okay. Cool. Well, that's good to hear. The other thing I wanted to point out about the, axillary brachial plexus block is we always tend to talk about how the musculocutaneous nerve is sandwiched between, biceps brachii and coracobrachialis. 

But every now and then, when you look in that space, there's no little snake eyes nerve there, and it tends to lie right up there with the median nerve. Did you see that? You you must have seen that quite a lot. Right? Yeah. 

Yeah. Sometimes it's late to take off. And so if you don't see that little snake eyes traveling in that fascial plane, I will scan I'll just do a higher scan, a lower scan, scan back and forth. And sometimes it's just it's stuck to the median. And you see it drop off late. 

Right? Late. Yeah. Yeah. Yeah. 

And then in which case, you're good. You just do the perivascular and you'll get you'll get all four. Exactly. And the only other thing I was gonna say is, I do try to teach my trainees to identify the medial cutaneous nerve of the arm, which often will lie in that same plane as the median nerve. And when you're doing, I guess, your case, when you're doing your perivascular injection, but in my case, when we're injecting over the median nerve, you'll often see that separate nerve highlight out. 

And I think it's quite cool to be able to see that and pick that out. Yeah. Yeah. Between the ulnar and the median. Exactly. 

Yeah. Okay. So is this a good place to put catheters? I'm always confused. If you're gonna put a catheter, where on earth would you put the catheter in this area? 

It's awkward. Like, the the idea of a catheter sticking out of somebody's armpit just doesn't seem right. Forget the infection and, like, how do you tape that down issues. It just doesn't feel right. No. 

I'm with you. Right. So just to finish up the the chat about the brachial plexus, if you had to place a brachial plexus block in a fully anticoagulated patient, which I've had to do once with your actually quite a number of times, which technique would you use? So this patient is on DOACs or warfarin or coumarin or whatever you guys call it, needs to have surgery, the surgeon's happy to operate on an anticoagulated patient, which brachial plexus block technique would you use? I think I'd be very I mean, it's a little bit depends on where they're operating. 

But for the sake of this discussion, let's say it's forearm, wrist, hand. Yes. Very tempting to do an auxiliary because you can hold pressure. Now the caveat there is that there are a lot of vessels and oftentimes a lot of veins that with a slight amount of pressure from the probe, you can obliterate. And so you have to take care to not get into vessel, but you can at least see the vessels easily. 

And should you get into a vessel, it's easy to hold pressure there. That said, I have done lots of infraclabs in that situation too because, you know, you can kinda you see where you are, and you can see where the vessels are too. You know, it's I I wish I'd I'd had you to speak to at the time when that my first case as a consultant, I I had a patient who the surgeon said to me, I'm not gonna stop the anticoagulation. I wanna go ahead. They were high risk from a cardiovascular point of view and from a respiratory point of view. 

So they really needed to have a block. And it's the first time I had a patient who's gonna be anticoagulated and have a brachial plexus technique. So I did a straw poll of consultant colleagues that were far more experienced than me. I asked Rafa Blanco. I asked a chap Swiss guy who I'm sure you'll know called Roman Zurcher, and I asked professor William Harrot Griffiths. 

And I also asked John McDonald. So I asked four of these people who are all Wow. Experienced regional anesthetists. Four different answers. Well yeah. 

Really? So John McDonald said John McDonald said, do an auxiliary. Of course, you can do an auxiliary. I'm not gonna do the accent. I'm very proud of myself for not doing the accent. 

He said, do an auxiliary brachial block. It's fine. I've done it all the time. Don't don't, you know, don't be a he didn't say don't be a baby, but he sort of said, just crack on and do it. Rapha Blanca and Roma Zurica both said, you should do an infraclavicular brachial plexus block because, actually, there are only really two big vessels that you need to avoid, and it's easy. 

You and I both know now that's that's not quite true. There are many vessels in the way. But globally speaking, they will say they're two big chunky vessels. Sure. I get that. 

And then William Harris Griffith said to me, do the technique that you're most comfortable performing. Do the technique with which you have the most practice. See, that's wisdom right there. Isn't it wisdom? Yeah. 

He said now is not the time to do something that you're not experienced with just because people have told you that's the safest technique. So you know what I did? I did an auxiliary brachial plexus block, and it was fine. Yeah. Yeah. 

And it was of course, it was because it was because I was able to avoid all the nerves because I was comfortable needling the area. But subsequent to that, as I started on my infraclavicular journey, I've I've used infraclavicular brachial plexus plots for all of them. So it's really interesting. I think professor Eric Griffith's comments were were just really were were really spot on for me. And, again, when I spoke to Rafa and Roma Zuka afterwards, they told me that I should have, yeah, I should've been more gutsy. 

But I think I did the right thing. Yeah. No. I think yeah. It's it's a really it's a really good good advice. 

Do what you know you can do. Exactly. As opposed to trying to do the technique just because somebody else says it's better. Yeah. Exactly. 

Okay, Jeff. Well, listen. We you know, we've covered. We've done a whole tour of the upper limb there from all of the approaches to brachial plexus, a little bit of controversy, hopefully, something to get our our listeners get their teeth into and, and and ask them some questions. What do you reckon we close-up now? 

I think so. And just just so you know, I think we're gonna try to well, we will do we will do the more distal nerve blocks, like, in the in the elbow, forearm, wrist, etcetera, at a different episode. So stay tuned for that. Absolutely. So get I guess it's time for us to wrap up. 

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I like that abbreviation. Thank you, Tanya. Yeah. Absolutely. We're gonna go with that. 

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