S2:E12 "Season 2 Holiday Special! 🎄 (Where we discuss compartment syndrome, nerve injury, rebound pain and more!)"

Have you put all your Bublés on the Christmas tree? Are you ready to wrap your presents? Join us for our season two finale and our special Christmas episode. I'm Amit Pawa. Yippee ki yay, mother Russia. 

Wait. That's the wrong accent. In any case, Feliz Nervy-dad. I'm Jeff Gadsden. And this is Block It Like It's Hot. 

Hey, Jeff. It's beginning to look a lot like Christmas everywhere you go. Oh, I take take a look at the five and ten. It's glistening once again with candy canes and silver lanes that glow. Woah. 

Hey, bud. Hey. It's almost as if we rehearsed that, bro. You surprised me with that, but, you know, we got I'm surprised I remember the lyrics to that. I like the old songs. 

I have to admit. I'm a I'm a I'm a I'm a Christmas classicist with things. Think you're I mean, I remember. Do know? For my music exams, I sang a Nat King Cole song, actually. 

Really? Yeah. Yeah. Jeez. I love the old music. 

Oh, you put a you put a Bing Crosby Christmas album on. I'm I'm done. Do that. I think maybe the next thing that we do should be maybe we should do a Christmas song. Anyway, listen. 

I'm I'm getting sidetracked. Can you believe it's Christmas again? And that means that we're at the end of another season of our podcast. I can't, but I was talking to someone in the block area the other day and telling them about the podcast, and they hadn't heard about it yet. It's I know. 

Shocking. Someone at my work hasn't, and I but they're like, wow. You've got two seasons already. I thought, wow. Yeah. 

That's that's right. So, yeah, time flies, man. Well, I mean, you you remember when we recorded the our very first episode that was about Christmas time. Right? I think was that November? 

It was late November. Yeah. Yeah. But you were wearing a Wham t shirt. Please tell me you got your Wham t shirt with you. 

Oh, why didn't I do that? No. I have my Wham t shirt is is in the wash because because I've been wear wearing it a lot. I should've I should've come prepared for that. Yeah. 

Well, listen. I have come prepared for you because check this out. Here is a mince pie, a mince pie for you. So there we go. So I'm saving this view. 

I'll leave mine later. Is there a way you can, like, transmogrify that mince pie through the Can you imagine if there if there was, like, a way I could, like, put this in the camera and then one appeared on the other side of the screen? That would be amazing. I'm just waiting for that. Yeah. 

I mean, if you told me as a kid we'd have FaceTime and describe that, I'd be like, that's the future. No no one would believe that. And actually now, let me ask you a question. When was the last time you used your phone to make a phone call? Like, it not that often. 

Right? When my phone rings, like, out of the blue, my first instinct is, how dare you? Yeah. You know? Like, text text me first. 

Or or or I'm thinking it's an emergency and someone really needs me. But Right? Yeah. Yeah. No. 

It's it's not I know we still call them phones. I know. It it's very bizarre. Yeah. And we and we do that thing when we hold that thing up. 

And and most young kids, when when you do that thing, when you hold, you know, one thumb up to your ear and the small finger up to your pinky up to your mouth, they're like, what what is that? What is that? There's that phone. No phones look like that before. I saw a great meme the other day. 

It was it was I grew up in a time where when you hung up on somebody, you could actually slam the phone down. It was spectacular. Yeah. Okay. And I might have done that a bit in my time. 

Let's be honest. Listen, dude, it must have been a really busy time for you because October's just done, and we know what October means for you. That means your whole life gets taken over by Blocktober, which I thoroughly enjoyed again. It was absolutely brilliant. But how are you? 

Oh, I'm I'm doing thanks, man. I appreciate that. It's was a hectic time of year, but I love doing Blocktober. And and most of all, I love I love the engagement. Like, it gives me this little ping of joy when I hear and I watch a a side conversation happen between someone in Europe and someone in South America about something that we're all discussing at the same time across the world. 

It's and I and I learn a lot too. I mean, there's some really insightful comments and people sharing their own stories and experiences. It's awesome. Listen. I got to tell you, I also love watching from the sidelines this year. 

On occasions, just sitting there and learning for what people had to say kinda reminds me of what Twitter used to be like in the old days. And do know what? There were loads of people that returned to Twitter or x just for Blocktober. And a perfect example of that is Amina Ben Yusuf. So she she came back to Twitter just for Blocktober. 

Yeah. I saw that. It was really, really touching. I I could I I wasn't quite sure if she was being serious when she said that, but I but I guess she was. I think it's really true. 

That was really, really touching and special that I mean, it was great to see you, Amina. I hope you're listening. Yeah. Hey, Amina. So, hey, what did you think of our our two part pot with pod with Tanya Selak? 

Wasn't that so much fun? Dude, that was amazing. I think it's incredible. And in fact, lots of lots of people new people that I've come across have been listening to the podcast. And, oh, I just heard your, your latest episode, the one with that really cool kiwi chick. 

I was like, what? I told I said, I really, really loved that. That should be her new Twitter hand I'm not sure that would go Cool cool kiwi chick. But I think it's true. She's very cool, but I'm not sure how we go down with it. 

But you know what? It was That's the only thing. Right? Like, having having a guest like Johnny Wilkinson or Tanya Selak makes us look far less cool. This is true. 

That's this is the downside. But you know what? In the you know, for the we're we're doing it for the good of spreading the word and for the good of the podcast. So I don't mind playing second fiddle to these amazing individuals. But but, you know, I got so much out of that discussion, and it was really amazing to hear her insights into training and social media. 

Although she was a little bit cheesed off with the quality and the number of our jokes. Right? Yeah. I I mean, maybe we had a slightly unfair advantage. Think I think she understood that we often come preloaded with two or three jokes in our pockets. 

So but anyway Yeah. Tanya, thanks for joining us. Yes. Us, regional anesthesia tragics, would love to have you back in the future sometime. Now Oh, for sure. 

Yeah. Now now, Amit, we really have to thank all of our listeners for helping us cross that important landmark of 50,000 downloads. Actually, now we're at 55,000. 55,000 downloads? That is amazing. 

I mean, guys, thank you so much for your support. It is quite unbelievable to think about the number of times that people have listened to us chatting all over the world. I I really can't believe it. Last I told someone that statistic the other day. They're like, what? 

55,000 times people have listened to you guys talk nonsense? That's amazing. My kids won't listen to me. My dogs won't listen to me, barely 50,000 other people. Exactly. 

But, you know, there there is there is one thing I wanna know, though. What's that? Well, I kinda wanna know what people thought of the rap and the rap video. Well, that was that was so much fun to write and record with you, buddy. I hope that, people enjoyed listening to it as much as as much as you and I. 

You and I had fun putting it together. If you haven't had a chance to check it out, folks, you can search Spotify for how you're gonna block it for the rap, and you can check out our personal YouTube channels or the b I l I h YouTube channel for the music video that was made in as a sort of a celebration thank you for getting us to 50,000 downloads. Absolutely. You know, Jeff, I really enjoyed recording the vocals. Those lyrics were dope, as some people might say. 

And I really enjoyed doing the filming whilst my kids, both Sofia and Sienna, were standing in the background cringing. They refused to have anything to do with that. But Come on. That was a that was a legit your performance, man. That was I think they saw the way I was dressed. 

They probably are. But, know, I tell you what you think I think I suspect they were publicly cringing in front of you, but then were running off to show their friends what a cool guy you are. I'm pretty sure a lot of their friends have seen it already, and that's probably what makes it more embarrassing for them. But you know what? You did such an amazing job on the music editing and the video production. 

It looks so professional. People kept saying to me, I mean, where did you get those dances from? And I was like, oh, they're just Jeff's buddies. And it's I said it before. If you if you ever looking for another career outside anesthesia, you definitely got one in video and audio production for sure. 

Thanks. Thanks, man. My those dance those dancing clips, my my kid Reef was like, bro, that's so random. Why are those in I thought I thought that's what made it, but everyone can say, who are these people? Who are these people? 

What what what didn't understand, I had to point this out to him, is, dude, they they didn't come set to the rhythm of our track. I had to, like, slow or speed up those dancers to match the actual our actual track. That was thirty minutes of my life that I had to do to make it look perfect. But I really yeah. It was it was a fun little project to do. 

And I and I loved, you know, I loved accessorizing as you may have noticed with the extra items I picked up just for the video. Dude, that necklace and the grill, oh my gosh. They were so great. I need to get me some of those. Well, listen. 

What dude, where where did you get those from? I got them both from Timu, from the the Chinese website. And you just designed them yourself? You can just punch in the b I l I h and that made that little that little diamondy necklace thing. The grill, I didn't realize you didn't need glue for that, and it just it came off about a week later. 

What? You had you you put it on. You and you glued it on. Patients loved it. I bet can you imagine? 

I can't even imagine people showing up to your block crew with you with that with that big sparkly grin in your face. Apart from the grill glue, what else have you been up to, man? Well, we've man, been really getting into the, the whole spirit of the season here. I don't know if I told you this, but we have been making gifts for each other for several years now. So, like, for the kids to Corey and the kids to me, they all make things. 

Uh-huh. And they've made some really amazing things. You know, beautiful pieces of art and Reef made me a a board game last year that we still play as a family. Really creative ideas. Really fun. 

And it it makes it makes this part of the season, like, the month leading up to Christmas really really special, and and it gives me something because I'm obviously helping them with you know, hold did some woodworking stuff a couple couple years ago. So I at Seriously? Fun really fun helping them out and and planning the special things. And that's and it's funny. Like, when I was a kid, my best Christmas ever, I got the Millennium Falcon Star Wars toy. 

Wow. In my memory, that was the day that was the best day of my life. But it's funny. Their best moments of Christmas morning are giving their handmade gifts to Corey or Gosh. Or to me, I guess. 

Yeah. So it's it's been, it's been a kind of a cool little tradition. Cool. Cool. So that's so that's been taking up a lot of your time. 

I mean, mean, you're you're doing well. You have, a a month out, so that's great to be prepping this far in advance. Yeah. Yeah. What about you, man? 

Anything else to share before we get into the meat of the pod? Yeah. So I was delighted that my regular knee surgeon, I've talked about him a few times before, Rags Kacker, he was recently talking at an orthopedic meeting on osteotomy, and he used that opportunity to promote our podcast as surgeons. So thank you, Rags. That was really great that he he was using that as an opportunity to promote us. 

Oh, thanks, Rags. And on one note, Jeff, I made a bit of a boo boo. In our block it like it's hot down under episode, I made a a big shout out to my Aussie Courtney anesthetic nurse who I who I referred to as Aussie. Yeah. Right. 

Of course, she's actually from she's actually from New Zealand. Oh, god. And somebody took great pride in saying, hey. Amit gave you a shout out on the podcast, and she listened to it, and she's like, but he knows I'm Kiwi. So, Courtney, I'm sorry. 

I got that wrong. She's not talking to me anymore, but I just wanted to correct that. Courtney, I I understand. I get that. You know, it's interesting. 

The Kiwi Aussie relationship is very similar to the Canadian American relationship. I can imagine. Like, the small the smaller country in population, largely overshadowed by the their neighbor, but a lot of a lot of pride in in in in being that little underdog kinda kinda country next door. I'm with you, Courtney. The thing is I I knew I knew that I knew Courtney was from New Zealand, and I was so focused on making sure that we didn't mess up Tanya's thing because Tanya's being a Kiwi in in Australia. 

I got it all messed up. Anyway, the other thing I wanted to talk about was that we recently celebrated Diwali because, know, it's Diwali, and we've got a restaurant in Black Keith called the Everest Inn. And I promised the owner you had to have that I would give the Everest Inn Black Keith a shout out because we had an amazing Diwali celebration there with our friends, the Bonners and the Soulsby's again. So I thought I'd give them a shout out. So that's kind of my bit done. 

That's great. And when you go to the Everest just mention the block it like it's hot podcast to get 20% off your meal. Oh, can you imagine if that happened? That would be I'm joked. You've got me in so much trouble. 

I'm joking. Please don't go to the Everest and ask for a discount. Wait. You know you know what? They maybe they'll hook us up. 

We don't know. But I saw I saw those pics. It looks like so much fun. And I believe you told me you also that outfit you were wearing was the same outfit you wore at your wedding reception. I can't believe you remember that yet. 

So The fact that you can fit into that outfit still is pretty impressive, man. That's that's good. Yeah. Look at that. Split it down the back, man. 

I split it down the back so just the front the front didn't look good. But it it was funny because my wife and Sarah and Marie Claire are are the the the wives of our friends that were coming. They all got beautifully dressed up in in Indian outfits. And so I was feeling a bit kind of left out. So I was like, what can I we what ethnic stuff have I got? 

And I had the wedding reception outfit I had that I got, you know, married in eighteen years ago. Thank god I got that right. Eighteen years ago. I think it's eighteen. I can edit this part out. 

Yeah. Yeah. I think it's eighteen years ago. Please do edit it out. My wife's gonna kill me. 

But, anyway, I I found the outfit, and I fitted into it. So it was great it was great to wear it. Well done. Thank you for remembering that. Well done. 

So what are we gonna talk about today, buddy? Well, you know, I think, you know, bearing in mind I spent forty five minutes talking about my life, I think we should probably get into the podcast. So I figured for our season finale, some of our listeners had, you posed us questions throughout the year. I thought, you know what? If we collate some of those questions together a little bit like our controversies episode, we try our best to cover some of those things. 

So are you ready for this? Yeah. Let's do it. Okay. Right. 

So our first question comes from doctor Andy Langdon from X. And his question was well, he's got two questions. We'll start off with the first one. Upper limb tourniquet pain for awake upper limb surgery. How do you deal with it, treat it, and prevent it? 

And I know what you're gonna say, so I'm gonna go straight over to you first. So upper limb tourniquet pain for awake upper limb surgery, how do you deal with it, treat it, and prevent it? Thanks. Good question, Andy. We get we actually get this one a lot too, at workshops and and other other places. 

Mhmm. My feeling on this is that tourniquet pain is largely an ischemic problem of the deep tissue, the fascia, periosteum, muscle, etcetera. Less so pinching of the skin. If your skin is pinched by the tourniquet, that's a misplaced tourniquet and or padding underneath underneath the tourniquet. So you need to sort of find a way to address that and replace the tourniquet on it in a way that it's not the skin. 

In other words, I don't think the skin is very important at all for for tourniquet pain. So I I when I was a trainee, we had people say, well, you gotta you gotta do it in a cost of brachial nerve block to get that little patch of skin for the tourniquet. And there was work done at the University of Florida, and I'll I'll leave a link to this paper in the in the show notes, showing that actually it doesn't really matter. Uh-huh. And so intercostal brachial versus no intercostal brachial, it doesn't seem to make a difference in turn of that in terms of that tourniquet pain. 

It's it's that it's that deep pain that comes from having a tourniquet on for forty five minutes, and those deep tissues are being squeezed. And the other thing is it depends what you mean by awake, I guess, is the other thing, Andy. So I think that's that's the bit I was waiting for you to say. Okay. So now you've fallen into my trap. 

Okay. Go. Go for it. Oh, god. Yeah. 

So, I mean, there's there's awake and there's awake. Right? So we make good use of some other sedation. I mean, to the point where, you know, you can you can have someone talking to you or you could have them completely snowed with propofol, but Uh-huh. A little bit of sedation goes a long way for that. 

But whatever component of discomfort is coming from skin pressure, That's my feeling. Okay. Before I give you my take, I'm gonna ask you a question not because I wanna put you on the spot, but just because I wanna understand this. Yeah. Yeah. 

Yeah. So are you telling me that in all of your time of practicing awake upper limb regional anesthesia, you have never had a patient complain of tourniquet pain within the first ten or fifteen minutes of the tourniquet being applied? Well, I think that discomfort and pain is a very subjective experience. Right? So Agree. 

When you squeeze someone's upper arm at, you know, how many millimeters of mercury pressure, I think there's a proportion of patients that will interpret that as an unpleasant experience and relay that to you. Uh-huh. I don't think that means skin is ischemic. Skin is hurting. Let's block the skin. 

I think I think that's fair. And, you know, that's whole that's the whole thing about going into about the fact that pain is a very subjective experience, and it's a patient's perspective. And some people will not be bothered by that, and some people will find that troublesome. So I can say that I've been doing awake upper limb surgery and much more of it truly awake. So either no sedation or lightly sedated. 

And we have encountered discomfort, let's call it, from the tourniquet being applied much more frequently than I think you have. So that either means one of two things. Either my patients are much more awake than yours are or you're better at regional anesthesia than me. And and both of those could be true. Yeah. 

No. I don't I don't definitely the first one. I mean And but you know what? So to tie back into what can you do to treat it, so how many times do I actively preemptively do an intercostal brachial nerve block with ultrasound either or either Landmark? Very rarely. 

The truth is very rarely. The only time I I will do is if I know that the tourniquet time is gonna be approaching two and a bit hours, I and then I want everything in my armamentarium to help, so then I will make an effort to block the intercostal brachial, but don't do it routinely. But what I do utilize is in a patient who was previously completely awake, very small incremental doses of propofol, ten to twenty milligrams, one to two meals can be amazing at dealing with that discomfort they get from the tourniquet. And this is a, you know, these are tourniquet placed by a very meticulous surgeon with plenty of padding, so I don't know what that's about. There are proportion of patients who feel some discomfort and that propofol works, or I just use some light sedation. 

Well, you I mean, you had this experience too where you the blood pressure cuff goes off and the patient's like, oh, that really hurts. And you're thinking to yourself, okay. Let's everybody just calm down a bit. It's a blood pressure cuff. I know it's tight. 

The first time is the tightest. It's gonna get better. But Yeah. Yeah. Yeah. 

That gets to that, like, subjective interpretation of a cuff squeezing at a 180 millimeters of of mercury. I think sedation is very is very key. I I have my own feeling on what I would want as a patient Yeah. And what I would want as if I was working by myself in an OR Yeah. With no helpers, trainees, CRNAs, or anything Yeah. 

Man, I don't want those patients awake. Like, I don't I don't get the benefit. The the main benefit for us is in some of the institutions, some of the units that we work in, we get the patients to walk off the table and go straight to the to the discharge area from the OR, from the theater. And if you've used depending if you've used a a bit of sedation, then that means they have to go to PACU or to OR. That's the main reason. 

I think it depends on your setup. Yeah. Yeah. Okay. I see that. 

Yeah. But still, if that were the case, one to two cc's of propofol is amazing, and it will not stop them from doing that. So I think we're yours your solution or your answer is that maybe it doesn't happen that often, but you tend to use some sedation, and that tends to mask it. And I guess I'm saying if I've got an awake patient who complain complains of 20 k pain, I tend to use a bit of sedation. So we're probably saying the same thing but slightly different angles. 

Yeah. I think so. But very rarely, I will use intercostal brachial nerve block. But I I get what you're saying. That's not gonna deal with the ischemic pain, the deep pain. 

That's just a cutaneous phenomenon. Well, so then I think a little bit of and I know that this is kind of probably gonna hurt your efforts to get the patient up and walking off the table, but if you can slip in a little bit of ketamine, if you can slip in a little bit of fentanyl, if you can slip in a little bit of something else, that goes a long way too. But I will use intercostal brachial when I have AV fistula, and and the surgeon's gonna start to cut the skin up near the axilla. Yes. Because that's a that's a sharp incisional source of pain that I need to cover. 

Yeah. Absolutely. That makes that makes perfect sense for me. So listen. There's so Andy had another question. 

These are not small topics he's come up with. So his next question is Get on you, Andy. Compartment syndrome. What's the evidence for or against blocks? In those cases, when the surgeon says, no. 

I'm worried about compartment syndrome. Don't do a block. So do you come across this a lot with with with some of your trauma surgeons? We have. Yes. 

In the past. Yeah. And what tends to happen is we'll achieve a consensus, and then a new surgeon will be hired, and he or she has trained somewhere else and with a different culture. And we have to we have to re sort of educate, about, like, how how we think about this. And so to answer what's what's your thought? 

So so the the problem is we we will often run into this issue, and exactly as you allude to, it depends upon who's doing the surgery. So if we have experienced low limb surgeons and low limbs, their specialty area, and they're aware of the evidence, they'll be like, okay. You know what? This case, the swelling is not too bad. I think it's gonna be okay. 

You can do a block. Or sometimes they've even said to us, I'm really not happy for a long lasting block, but I'm happy for you to put a spinal in. And if you want to use, again, know you're not a big opioid users intrathecally, but they said, but if you wanna put some opioid in your spinal, that's fine. But I don't want, you know, long lasting block. And one even said the other day, I don't mind if you use a dilute local anesthetic because they're appreciating that ischemic pain that you get from compartment syndrome will break through a sensory or a low level regional anesthetic technique. 

Having said that, we then also have other say so maybe we'll have an upper limb surgeon who's covering the trauma list, and they are sticking to that old view of tibial plateau fracture, you can't do a block, or this is a swollen ankle, or if I don't want you to do a block. And that's very difficult because what we don't wanna do is have a massive argument and be unprofessional, and that's really difficult. Now I know that one of the big trauma societies in The UK is working on a consensus guidance document where they're looking, and these are coming from the surgeons, and they're looking at the evidence against for and against blocks in the orthopedic community or trauma community. But until those guidelines come out and say it's okay to do blocks, many of the more established, possibly old fashioned surgeons are gonna stick to their rules. And then it's difficult because no one wants to have a bun fight. 

It's I love that phrase, bun fight. I did it in my head. I'm picturing, like, just a bunch of people with dinner rolls in a cafeteria, but, you've you've hit on all the same points that I've had when I had these conversations. And so part of the issue is what is the outcome of interest? And so what they're worried about and and this is you know, circling back to to Tanya's comment about, like, put yourself in the shoes of the surgeon and what their problems are. 

Acute compartment syndrome is a life or limb threatening problem. Right? And and can lead to lifelong disability if it's missed. And and their dogma is it's a clinical diagnosis. Yeah. 

You need pain to diagnose it. Yes. So if anesthetists take away pain, I can't diagnose it, and we're gonna miss it. And so that's what we run up against in the early stages of the discussion. Then to Andy's question about the evidence. 

Yeah. So there are, at my last reading of the literature, zero cases of a peripheral nerve block leading to a delay in diagnosis of an acute compartment syndrome because of what you just said. It is extraordinarily hard to mask ischemic pain Yeah. With a peripheral nerve block. Epidural is probably different. 

Yeah. But a peripheral nerve block, we know this. Right? Like, getting back to the tourniquet you can have a peripheral nerve block and a tourniquet pain will break through because those tissues are ischemic and and You know, that's a great that's a great example. That's a great example. 

Yeah. So zero now, you will find case reports in the literature that look like block delayed diagnosis, but then there's one there's one in particular, and I'll put this link in this in the show notes. There was a an orthopedic case report. Femoral nerve block delayed the diagnosis of a tibial fracture compartment syndrome. Right? 

And then I know where you're go. I know where you're gonna go. Like, no one stopped to think, wait a minute. Does the femoral nerve even innervate the calf? Yeah. 

On the other hand, there are plenty of cases of opioids Exactly. Delaying diagnosis because the opioids are fantastic pain medications, and they will they will treat ischemic pain. And if you give someone a button to press and they keep pressing, pressing, pressing, pressing, and and they're titrating themselves to their increasing pain needs, when someone rounds on them on the floor, they'll say, oh, this patient looks comfortable. Next patient. That's when ACS gets missed. 

There are lots of cases of those. Now, Andy, the evidence base is not great here in terms of, like, quality of evidence. It's all all case reports and case series. Right. And then finally, there are specific cases that people have published. 

Andre Bozart from South Africa has done good work in this area. Sort of showing us, hey. You can have patients that go home with a catheter, and then something's not right. Mhmm. The patient realizes, I don't feel good. 

I've this is hurting more than it ought to, comes back to the ER, and they immediately diagnose the Yeah. Compartment syndrome. So his feeling and my feeling, I share this feeling, is that blocks actually facilitate the diagnosis because it takes away the somatic pain and gives you unhampered access to the patient's first recognition and perception of that ischemic pain. And so a question I ask my surgeon sometimes when we get the new surgeon who's who's, you know, been indoctrinated with the the old dogma, and I under and I understand why. I understand why is, okay. 

If we're not gonna do a block for this intensely painful fracture, what are you gonna do to manage the pain? What's the plan? And they'll say, well, we'll give them PCA. And I say, well, have you thought about the I go into the that idea. So it it but it is a hard conversation to have because the outcome is so bad. 

Uh-huh. I do agree with everything you said, but there's one scenario. But. I hear a but coming. Yeah. 

There's there's one scenario which I don't know how to manage. Right. So I want you to picture a situation where you've done a single shot nerve block for a patient having distal orthopedic trauma surgery, and they are pain free, pain free, pain free, pain free, and then the block wears off. And then they go, ow. Now I know and you know that's because of the resolution of the block. 

But it has happened to me in the past when this has happened to patient on the ward. The ward nurses have gone, oh my good goodness. They called the on call orthopedic resident who's come and they were like, oh my god. This could be compartment syndrome. And they take down the dressings and they, you know, and they're not measuring compartment pressures, sadly, but they just make this diagnosis and they go, oh my goodness. 

And they get the boss in, and the boss does examination and says, no. This is just the block wearing off. So how do you deal with that? That's tough. I mean, I I getting to your point about the dilute local anesthetic, I think given my druthers, I would put a catheter in and run, you know, a dilute solution so that they it takes care of the somatic pain Uh-huh. 

But it'll it allows that ischemic pain to break through. And that way, you can get them through the sort of the first two, three, four days if you need to. Now I know not every place can do catheters, so that's a tough one. You have to sort of have a good conversation and with whoever's gonna be looking after that patient on the floor and say, this is our expected time course for the block. Understand that they should be getting some, you know, increase in their pain experience at time x, and let's be careful, and let's let's do evaluate them as we would for a compartment syndrome. 

But So that's that's all about com communication and expectation management, and that's really key. I I I like that. And and also, you do give a good argument for using a dilute continuous local anesthetic technique there, and I'm and I get that. Okay. I think we've probably given Andy some food for thought and given our listeners some food for thought. 

So I'm gonna move on to our next question. Okay. Our next question is from doctor Dave Price from X. And his question is a spicy one, which may also lead into or link in with what we've just talked about. He said, given how pro block we are, can we have some discussion around when you wouldn't do a block, Where the time or the risk outweighs the benefit? 

How you're not gonna block it? Or how you're gonna not block it? Yeah. So I don't know. So so do you wanna start off with this one? 

That's a different podcast, Dave. Go ahead. You you tell me. What what what situations I wanna hear from you? So so clearly, patient refusal, that's going back to our standard, you know, board exam or FRCA question. 

If you offer offer somebody a block and they say no, then I'm not gonna force them to do it. So that's an easy one. And I'm still a little bit nervous about doing spinal or neuraxial techniques asleep. So I have would have a a careful consideration about whether I'm gonna do a sleep spinal. Given the choice, I'd rather not. 

But, you know, so if if a if a patient said to me, it was fifty fifty as to whether a spinal technique was gonna be beneficial, and they said, well, you can only do it if you're gonna do it when I'm asleep, then I might not do it. Where I have a slight concern is in patients with preexisting neuropathy. So an elderly patient with diabetes with a preexisting neuropathy. You gotta have a clear risk benefit discussion with them. And if they're on the fence about the benefits of a block Mhmm. 

And then not prepared to accept the risks of, you know, potentially worsening of their neuropathy afterwards, I'd consider it, but I'm not still still not saying a hard no. So actually, although I've given you lots of of waffle, I don't think I've given you a hard no yet. Get off the fence, Amit. Anticoagulation. Okay. 

Listen. I I'm gonna need some time to think about this. Okay. Have you got a hard no? I've got I've got a good so I wanna give a shout out to Malika Latmore who is a good friend and the fellowship director for regional anesthesia at Mount Sinai St. 

Luke's, Mount Sinai West in, in New York City. Malik and I worked at the same institution for a number of years, but, I I was with her at a workshop recently, and we were talking about sort of approaches to this kind of problem. And she had a very simple rule. I don't block crazy. So Oh, okay. 

When a patient What does she mean by that? When a patient is asking for weird things or clearly not understanding the risks, benefits, and that sort of thing or is is behaving in a way that you just is unpredictable. She's like, not not worth it. I'm not blocking that. Uh-huh. 

Just like how she summarized it. But, I mean, that's one answer. I like that. I do like that. Where I start why I walk away is and you got to this point as well, is when the patient starts asking a lot of questions about the block and I don't know and that sounds dangerous and that sort of thing. 

And I'm like, that's cool. I because that's the situation where Mhmm. I feel I'm just tempting fate. And if I if I push someone into something Yeah. Yeah. 

And then there's a complication, eve even though the likelihood of that is very low. Right? Like, regional is so safe. I'm gonna feel, ugh, I should I should have listened to my gut. I should have listened to the patient's gut and not done this. 

So so I tend to that's when I kinda said, no problem. We have other ways of managing your pain for you. Okay. So what I like about that is you tie in very nicely into the consent process for anything we do as physicians. You say to somebody, I would like to do this, but you've always got to present the alternative options. 

Right? The do nothing or the alternative options. And so when I consent somebody for a paravertebral or paravertebral regional anesthetic technique, I will say, in my experience, this is what I think is a benefit. This is the thing I'd recommend and the reasons why are the following. But you have a choice of either not having any any technique or having the following. 

What do you think? If they say, oh, I don't like the idea of a needle in my spine. Oh, I'm really nervous. I've got a friend who was paralyzed or I've got you know, once that process starts happening, I say, okay. Do you know what? 

It's it's better not to go there because as you say, that will be the one patient when if you inverted commas coerce them to have a technique, they'll end up with a pneumothorax or they'll end up with a hematoma or they'll end up with something random. And I had I remember very early in my consultant career, we used to it was and those were in the days when it was used it was normal for us to do an epidural for somebody having an open total abdominal hysterectomy. Sure. I remember speaking to a patient and and saying to her, you know, we'd really recommend you have an epidural. And this particular individual said, no. 

No. I really don't want one. I said, that's really something I'd recommend. I went on and she said, oh, okay. Fair enough. 

And I was with a a junior resident at that time and they were having an attempt. They had few attempts, didn't go so well. I took over, got it in. I remember about ten days later, this lady had come back to follow-up clinic with some persistent lower back pain. I was thinking, why did I do that? 

That was the one patient where maybe if I hadn't pushed them in that direction, we would never be in that situation. So, yeah, that's that's a good reason. But you haven't given me, and I haven't either, a a hard situation or a clinical circumstance where you wouldn't do one. So what about the tibial plateau fracture? You know, if your surgeon was ambivalent about it, would you do a block there? 

I'm guessing the answer is yes, but I don't know. Would you do a block there? Yeah. The answer is yes there. Because to getting back to Andy's question about the actual risk of a block delaying the diagnosis, I don't believe that is Yeah. 

A risk. So I I think that only helps the patient and helps the surgeon, but understanding that a ton of communication has to happen there. So Fair enough. The neurologic preexisting neurologic stuff doesn't put me off as much. What about Ehlers Danlos type three or type four, the one with local anesthetic resistance? 

Because I have had some very bizarre block outcomes in patients who have Ehlers Danlos. I've had some that have been that have been perfect, and I've had some where I do the regional anesthetic technique, and this is a historical thing. They'll say, well, I'm not sure it won't work, and I'll say, no. It'll be fine. And they get into PACU, and it's like I've not done anything. 

Or I've had blocks that wear off very quickly. So in some of those situations, I'm kind of left thinking, you know what? Maybe I should just say, don't take the stress and give them a bit of local infiltration for what it's worth if it does anything, and give them something else, multimodal and opioids. Yeah. Did did you have you had issues with any of those patients? 

A couple of times. Yeah. But it's it's it's kinda rare that we're seeing these patients. So I mean, I've I've had a fair few of them actually, and they can have slightly odd. That's I I guess that's going back to were were there something where I've got a I've got a doubt? 

I've now, as I've become older and growing, I started to listen to my doubts a lot more, I guess. But I'm I'm I'm disappointed. I thought you're gonna give me a a hard no. Dave, we haven't we haven't given you a whole host of no's, I'm afraid. I think this this is reminding me of a feeling that I've had in the last several years, which is when I was training, we kind of I kind of thought of regional as, okay. 

That's an additional something you can do for the patient if it's appropriate, if it's acceptable, if you have time. Yeah. All the if if ifs. But, of course, our default is to do Yeah. A GA and systemic pain medications. 

And I think I think that's changing. Right. I feel like as you see some of the outcomes differences that are being published and we see with our own eyes, hey. This patient does better, gets out of hospital quicker, does not use opioids or as many opioids. However you wanna slice it, I would love to think that and this is getting back to Dave's question. 

Maybe the reason we're not finding a lot of hard nos is because we're not seeing it as an optional add on in the way that we used to. Do what do you think? Yeah. I think you're right. I think and, again, our friend, you can hear that little Robbie bell, ping, Robbie Erskine. 

He he's saying, why why are we all obsessed with GA being the first choice? Why aren't we thinking regional first and GA as an alternative? And because, actually, traditionally, we always thought GA is always the way to go. And as exactly as you said, regional is a supplementary thing. But I think in some circumstances, people are considering regional as the first choice, and therefore, you really have to think hard as when not to do it. 

I'll tell you, I've I've got one reason why I've got one indication why I wouldn't do a block. It's just come to me as we were talking about this. Okay. So this is relatively topical because we've got some very expert, very niche regional niches in India that are doing this technique, thoracic spinal anesthesia. So TSA, and they have created a society called NADS, n a d s, I believe. 

So neuraxial I do not I don't remember what the acronym stands for. But there's they've got a society when they're talking about neuraxial anesthesia. But thoracic spinal anesthesia makes me feel a little bit nervous. And thoracic spinal anesthesia in a patient on anticoagulants makes me feel even more nervous. So that would be a hard no for me. 

And at the moment, because I'm maybe I'm too scared, I'm not experienced, I wouldn't do a thoracic spinal anesthetic, but that's I guess that's that's my no, but I definitely wouldn't do a thoracic spinal anesthetic in somebody who's on anticoagulants. I've got a no in there. I yeah. That's one of those things where my comfort level is there had to be a very specific situation for me to want to do a thoracic spinal, I think. My hat is off to those to those people and I've seen the videos and watch what they've done and I think that's a really cool They're very experienced and and, you know, I didn't know it's not a new technique. 

This has been around for a while, but I don't know. I'm not there yet. And maybe I never will be. And that's okay because, you know, different strokes for different folks and you do what's in your comfort level. So I'm happy not being that wise and not that clever, but but good. 

Okay. So now a question from our good friend, doctor Raj Gupta. I don't know if we're gonna be able to answer this before the joke break, but let's see how we go. Raj asks us, how do we manage nerve injury after regional anesthesia? This is a big one. 

Oh. It's a big one. Because first of how do you know the nerve injury's secondary to regional anesthesia? Right? That's that's almost a whole episode, but I can I can give you Give us tell us what you do? 

Yeah. Yeah. You know, you will have a proportion of patients that have persistent numbness or or hopefully not weakness, but a a variety of sensory and motor changes after anesthesia. And part of that is after block. So Uh-huh. 

When I get the the heads up that, hey, this this block is not resolving. Number one, communication. Super, super important. If only to reassure them Yeah. That someone is caring about them, someone Yeah. 

Is on top of it, and you're not being ignored. You know, the medical legal I know this is not a medical legal question that Raj has asked, but it is a concern in our country that sometimes affects the how care is given or at least the discussions are are had. So people tend to sue you less if they feel like you're addressing their concerns and hearing them, which is just, I think, basic human kindness. So anyway, my first question is, is there any motor component? And if there is, that is urgent. 

And so that's a immediate referral to neurology and a follow-up by the surgeon immediately to see if there's something fixable. We have had surgeons put plates over radial nerves. We have had dressings that are too tight and there's acute compartment syndrome. Right. And so there are fixable things that you can address quickly that resolve But assuming that it's a nerve injury from positioning or stretching or or the nerve block itself, then if there's motor stuff Uh-huh. 

The neurologist has to get involved. If it's not motor, what I'll tell the patient is the vast majority of these postoperative neurologic symptoms, and PoNS is what the the current nomenclature is, will go away in the first two weeks. Of the remainder, the vast majority of those will go away in the next six weeks. And then with a small sliver of people that still have some numbness at six weeks, the majority of those will go away by three months, and then you're left with a very, very small. So and and a good reassuring sign in my experience and in people that I've spoken to, if there's any ongoing resolution early on, that's a very good sign. 

Wow. It me usually portends complete resolution or near complete resolution. So if you say, well, it was three fingers for the first three days, and now one finger's come back and the middle part of the second one is starting to come back, I say, okay. Perfect. That's good. 

We think that that's gonna completely resolve over time. Just well, let's I'm keep gonna calling you every couple days, and we'll get through this. That sounds really, really logical. So after the expected, resolution of the block, persisting motor, you're worried about. Persisting sensory, effects perhaps less so. 

Communication is key. You know you'll refer to the surgeon neurologist quite soon when you get motor symptoms that persist after the block resolution should have happened. When would you order nerve conduction studies? At what point would you consider doing that in in your algorithm? This sometimes depends on the nature of the injury, but there are some neurologists that will want to get a baseline right away because if there is a nerve injury, let's say you've got a mechanical or chemical injury to the nerve because of the block or the tourniquet or the whatever Yeah. 

It takes time for that vullary and degeneration to occur and then start to resolve. So there are some neurologists that will want a baseline to see if there's any preexisting neurologic issues going on, which I think is not a bad idea. But typically, they'll get one at about three to four weeks. And that will tell you, okay, what is our picture right now with the injury having fully evolved. And then after that, it's it's sort of every few months Gotcha. 

If if it lasts that long to see how things are. And you you wanna get nerve conduction studies to try to locate where along the pathway of the nerve the lesion is. It won't tell you what the lesion is, like, what in other words, the etiology. It could be surgical. It could be positioning. 

It could be nerve block, but it'll tell you where. And then the electromyography will tell you which motor units are involved, especially for a plexus, like if you an arm injury, can say, if it's this muscle and this muscle, there's no one peripheral nerve that explains that. So it had to have been at the level of the cords or something like that. So those two are complementary. And then, unfortunately, don't help heal the patient faster, but at least can help you identify where and what structures were injured. 

And and I just wanna give a shout out to a few people here. So mister Tom Quick or associate professor Tom Quick, who's a nerve surgeon who I work with at Cleveland Clinic London. He looks a lot at nerve injuries, and he's spoken regional anesthesia conference before and said it almost never is the nerve block that was responsible post operative nerve injuries. He's gonna have to say that on the record, so I think that's really nice to hear. He sees Is that right? 

Okay. That's good. Yeah. He sees a large proportion of patients with nerve injury because that's his subspecialist area of interest. And he says it nearly never is the nerve block. 

So that's great to hear. And, of course, we are now about to start a national audit project, in The UK called NAP eight headed up by our good friend, professor Alan McFarlane, and we are gonna be looking at the incidence of postoperative or post anesthetic nerve injury, and we'll get to see just what that incidence of nerve injury after regional anesthesia is. So that will be amazing when that comes out. Yeah. That's exciting. 

Yeah. The other thing is that REUK also have an algorithm on their website for management of post operative neural dysfunction or nerve symptoms. So there's an algorithm available on the REUK website, so do check that out. That's right. And we can leave a link to that in the show notes as well. 

For sure. Okay. Last question before the joke break. This is from sleep doctor or Surab Suri from X. He says, can we think about any of the times we've run into complications or had near misses with regional anesthesia? 

And then what are our tips and tricks to avoid them? So Jeff, has anything ever gone wrong with a block or nerve blocks you've done in the past? I can't think of any. Really? Yeah. 

I mean, how much time do you have? Yeah. I mean, give us your top two. Okay. Wrong sided blocks. 

I was gonna say that's gonna be mine. Okay. Tell me about yours. Well, tell me about one of yours. So one that comes to mind is patient was getting a block done in the recovery room, post operative, a doctor canal catheter. 

Yes. So the trainee gets us supplies in the machine and calls one of my colleagues attending to come over and help him do the block. And then just as they're about to start, the attending gets called to another OR for some urgent reason and and he so he he taps out. He says, hey. To another colleague, can you go supervise this resident doing this block? 

Uh-huh. Sure. No problem. So that attending walks in, doesn't really know the patient, doesn't know the situation, the context, just knows there's a block to be done, and they go ahead and they block the wrong side. Now you may ask yourself, how do you block the wrong knee postoperatively with all the dressings and bandages and stuff? 

Yeah. That's great question. Yep. We ask ourselves the same question. But it just goes to show you. 

Right? Like, we're the human aspect of it, you will never eliminate. This is probably a good topic for another whole episode or half episode. But Yeah. Suffice it to say, we changed some of our processes and requirements for what has to be done before the needle can hit the skin. 

Okay. So I also had a wrong sided, but I you know what? I don't wanna tempt fate. In my consultant career I'm just gonna make sure I'm thinking really long and hard before answering this question. Yeah. 

In my consultant career, I have not performed a wrong sided nerve block yet, and I hope I never do. But I've got one that stuck in my mind when I was a resident. So I was assigned to a theater, but I was able to walk from one theater to another because I think it was on call or was it quite was it one one case on the list. So the consultant said to me, have her see if there's anything exciting happening. And I walked into the room of another consultant colleague, and that consultant colleague said, oh, hey. 

Good timing. Do you wanna do a nerve block? And she just tapped a leg. She said, oh, you know, why don't you just do a pop the seal nerve static nerve block on here and just tap the leg that was closest to her while she was doing something else. So I was like, oh, okay. 

Cool. So, you know, the drugs are drawn up. So I just went ahead and and did the block on the leg that was tapped. This is before upsound. This is with nerve stimulator. 

Stimulator. Right. He scrapped on and did it. Yeah. And then as soon as I'd finished injecting, because that one said to me, why are you blocking that leg? 

And I said, because that's the leg you tapped. And she's like, oh, no. I meant just to tap the patient, but it's the other leg. So that was the one time I've done myself done one. But Yeah. 

Interestingly, in The UK, we've got this we've got a new process called prep stop block, which is part of the stop before you block process. And whilst I don't agree entirely with what it says, I have become pretty meticulous about making sure at some stage in the process, I've checked the consent form, I've checked the surgical mark as visible. And in fact, at one of the institutions I work at, the thing that we've changed to is at the sign in in wherever you're doing the sign in, but generally in the anesthetic room that we have, if we're gonna be doing a nerve block, if the surgical mark is nowhere near the needle insertion point, then at that point, we've got a little anesthetic mark here to write block. So we will make sure a block mark site is visible near the needle insertion point, which is goes against what the prep stop block says, but that's something in one particular institution I work at we've modified to make sure that we would do not commit a wrong a wrong sided block. Because sometimes these things happen by accident. 

Right? I'll I think that's wise, and I'll take it one step further. We we had the same thing. We said if the block site is not like, for example, if you have foot and ankle surgery, I'm not blocking the ankle. Yeah. 

Most of the time, I'm blocking the popliteal sciatic. So the surgeon's mark isn't anywhere near my block site. And so if block site Yeah. Not near surgical site, you make your own mark there. And then we we realized Yeah. 

That's not good enough because it it every time you you put a decision tree into that algorithm, there's room for error. So we just said, every time you do a block, put your block. And and sometimes it looks so weird and artificial because you're you're making your mark right beside the surgeon's mark, and you're like and then the resident looks at me and goes, is this really necessary? And I said, look. If you do it every single time Wow. 

You shouldn't have a problem. So you now every time you're gonna put a block, you have your anesthetist block mark for every situation even if the surgical site is visible surgical mark is visible. That is our policy. Wow. Does it get followed every single time? 

You know, I All you're saying is that's what the policy is. Just mark every single time, guys. And that way, you don't have to think about it. Taking the thinking taking the decision trees out of these algorithms, I think I think is important. Well, listen. 

Jeff, we talked, a bit of fun stuff. We talked a bit of serious stuff, but I think it's time for the joke break. And I've got as it's our Christmas special, I've got loads for you. You ready for this? Okay. 

I am ready. Hit me. Okay. Well, listen. With Christmas in mind and all the spending on presents that my wife is gonna be likely be doing, I've got a joke for you. 

What do you call a woman who sets fire to all her bills? Don't know. Bernadette. Bernadette. Bernadette. 

Oh, that's good. I like that. It's good. I it took me a second. Bernadette. 

Yeah. Okay. No. This Dead. Good one. 

So this is this is a a joke actually that came from one of the surgeons at Cleveland Clinic London. Her name is Rima Nasa, and she was so impressed with her with her music video and her rap, and she's like, I've got a joke for you. Okay. This is gonna and I modified it slightly from what she told me, but the essence is is Rima's joke. Okay. 

So you remember Planet Hollywood. Right? Yeah. Yeah. Yeah. 

And you remember when Sylvester Stallone, Bruce Willis, Arnold Schwarzenegger, they got together. They set up this whole thing, and they were some of the early investors and promoters. Well, they were planning their fancy dress outfits for the Christmas party at at Planet Hollywood. And they decided, you know what? We're gonna dress up as musical composers. 

So Bruce says, I'll be Mozart. And I don't know what sort of accent that was, but that's what Bruce says. And Sylvester says, oh, cool. I'll be Beethoven. Oh my god. 

That's the wrong accent. Okay. But let's let's pretend that Sylvester came from I'm thoroughly enjoying this joke so far without even without the punch line. So Sylvester says, cool. I'll be Beethoven. 

And Arnold Schwarzenegger, he says, oh, man. I guess I'll be Bach. Okay. Oh. That's a Russian Arnold, but I think I think on every level, the accents were terrible. 

The punch line was terrible. Rema, I'm sorry. I absolutely destroyed your joke, though. No. I think the essence got through and I I That was the worst joke I've ever told. 

Okay, Jeff. I think you gotta put me out of my my misery. Can you give me can you give me a couple of jokes? Well, you know, this is I don't wanna get back to serious stuff right away, but, I was reading this news item. Speaking of Christmas and Christmas foods, I don't know if did you see that Germany is issuing a warning Oh. 

To stock up on, yeah, to to stock up on, like, cheese and sausages? Because they're they're they're expecting a big shortage. Uh-huh. They're calling this the worst case scenario. Oh my god. 

That's that's pretty bad. Come on. That's a that's a that's a Okay. But that that that that involves a little bit of knowledge of German language to get that, but I I like that. I think that's very Verst cases. 

Maybe it maybe it looks better on paper than it sounds. No. No. I got that. I got that. 

And some of our German listeners will enjoy that. I'm sure. I so. My my German accent's horrible. Mind you, your Arnold accent was yeah. 

I I'll be back. That's what I was going for. But then used that for Sylvester Stallone. And then when it came to Arnold, I don't know what happened. You boxed yourself into a corner there. 

Yeah. I was too I was out of accents. Okay. Have you got another one? Did you hear about the chameleon who couldn't change colors? 

No. I didn't. He had reptile dysfunction. Sorry. Okay. 

That's okay. Do you know, just I I I just was reminded of something else, but the we live in a pretty safe neighborhood, and we let our kids kinda roam all over the place. But someone was talking about hitchhiking the other day. And Oh, no. I actually I don't know if you've ever hitchhiked. 

I have not. I have not. Yeah. Nor have I. But, I feel like you know, again, we live in a pretty safe part. 

I I picked up this hitchhiker last night. What? Yeah. He I was on my way home from work, and this guy, he looked he looked legit. Like, he looked like a student that was just trying to get home, whatever. 

So, anyway, he but but he seemed surprised that I'd pick up a stranger. And, you know, he gets in the car and everything, and he's like, he's like, thanks. I I kinda wasn't thinking he was gonna stop, but, like, he's like he said, look. How do you know I'm not a serial killer? And I told I told him, well Oh god. 

The chances of two serial killers being in the same car is astronomical. Okay. I know somebody's gonna like that. I think I think I know Nav Baha is gonna like that joke. Very good. 

Very good. Okay. Well, listen, I'm just gonna close-up with one. Do you know that during Christmas, there are only 25 letters in the alphabet? Do you know why? 

No. Why? Noel. Noel. Oh my god. 

That was such a disappointing one. Thank you. That was I thought I thought I'd end on a positive note. I'm gonna have to work on my accent. I'll be back. 

Okay. We're gonna work on it. Okay. That was Right. Listen. 

Let's get back to the point. We could I could Go on. I could edit that and put that that version back into the joke you told a few minutes That would be my but see how see how it goes. See how it goes. Just let me just destroy my my accent. 

No, mate. Okay. Listen. We've got this is a really good one. Okay? 

So this is doctor Evan Yates. He's an emergency physician from X. And k. He wants to know, tell us about motor spurring blocks. In fact, initially, he just said, can you talk about motor sparing blocks? 

I was like, dude, that's a big question. What was your angle? And his angle was doing blocks in the ER that patients can be discharged home with. So he gave us a few examples. But have you got any ideas of ideal motor sparing blocks that our ER colleagues could be doing that could help with patient discharge? 

I think a great block in in the emergency medicine world is interscaling for shoulder dislocation because it just relaxes the musculature and and sort of pops back right back in. But, but, you know, I wouldn't care so much about motor sparing in the upper limb because they can just go home in a sling if you needed that to. But, lower limb, I mean, ankle block is amazing. And that's motor sparing, but yeah. Yeah. 

But but what are the indications in ER when you do an ankle block? Because you wouldn't do that for ankle fractures. It would really have to be forefoot stuff. I guess lacerations, foreign body. Lacerations of the of the sole. 

I think that's I I remember watching someone try to infiltrate local into somebody's soul as a medical student in the ER, and I nearly passed out. I nearly passed out from the, like, just imagining it. So a little, you know, tibial nerve block right there behind the middle malleolus. Yeah. So good. 

Yeah. Yeah. That's it. And I like the fact you didn't say posterior tibial nerve block because I've heard people say that. Come on, man. 

There's no anterior tibial nerve. I don't want to get into a little bit of controversy here, but I have seen both. And I'll be honest with you. I think my ankle block video calls it the posterior tibial nerve. What? 

See Yeah. Yeah. No. I I I I remember there's a firestorm of outrage that that I would call it that. And I had to I had to, like, check myself and go, what? 

Wait a minute. And I go back to some other sources, and there are sources that say posterior tibial nerve. But do you it's not that there's no anterior tibial nerve. Yeah. Yeah. 

Yeah. I get that. I get that. Listeners, if you have a a firm position or if you have some evidence to help solve this this apparent controversy, like, where did it came from somewhere. Right? 

Like, I don't Because there's a posterior tibial artery. That's why. And there's an anterior tibial artery. So people go posterior tibial artery, therefore, it must be Nerve must match artery. Yeah. 

That means Okay. So sorry. Sorry, Evan. We got sidetracked. So I like ankle. 

Geniculars. I'm hearing more and more about geniculars for knee injuries, for knee pain. So but, dude, we've also seen patients with chronic knee pain who come in with exacerbations to the ED for analgesia, and people are doing geniculars as, you know, acute on chronic rescue blocks. And so that's that's something we've seen the ED guys do. But what I haven't seen is you've you've seen it for acute knee injuries as well. 

People are doing geniculars, have you? Yeah. I think I think people are just saying, well, the geniculars innervate a large part of that knee joint. Uh-huh. Would why wouldn't they help for deep knee pain Yeah. 

No matter what the what the cause? Absolutely. So, you know, I'm just trying to think there's a doctor Stone who's a a very well known Yeah. Emergency Mike Stone. Yeah. 

Physician. What's his first name? Mike Stone. Yeah. So so Mike contacted me a long time ago about using ESP blocks. 

There we go. I got ESP into this episode. Hello. About doing ESP blocks for for renal colic. And, actually, there's a case series of people doing this with really great effect. 

I saw I've seen those. Yeah. There you go. Another thing that ESP is good for. Yeah. 

And adductor canal, people, again, can be doing for, I guess, medial knee pain, again, or somebody coming in with some sort of knee analgesia. You know, the other thing I've seen the emergency physicians do that was really cool and it kind of you you every now and then, if you're looking on the same sort of pages I look at on TikTok or Instagram, you see these horrendous kind of pimple popping esque videos of people's, like, get squeezing pus out of different body orifices. Yeah. Hard to hard to look away. I'm revealing a lot about my algorithm on the but people have used interpectral and pector serratus blocks or even serratus anterior plane blocks for doing axillary abscesses. 

And so, basically, put a little nick in the axillary abscess in the ED and squeezing all the stuff. So I've seen emergency physicians using either straight to center of plane block or as they were called in the old days, PEX blocks Yeah. To help with auxiliary abscesses. That's a really great way of being able to do something relatively painless. And that, again, goes against that because you're not infiltrating the urinary itself with local anesthetic. 

You you don't have to worry about the aesthetic environment and local anesthetic action. So that's one thing. The other thing I've seen, and in fact, I learned how to do my lateral antebrachial cutaneous nerve blocks, so lateral cutaneous nerve with the forearm blocks from an emergency physician. I believe his name is Highland Herring. He showed us actually, he was doing lateral antebrachial cutaneous nerve blocks near the cephalic vein just at the antecubital fossa to deal with forearm lacerations. 

So rather than having to put lots of local anesthetic along the wound if someone had a nasty forearm laceration, he was doing one of these latched antebrachial cutaneous nerve blocks plus or minus the medial antebrachial cutaneous nerve blocks. And, actually, that's makes it really easy to sew up a laceration. So that's another cool example. Yeah. Great example. 

And and then in in the legs as well, I think in the lower limb, if you knew how to do the anterior femacutaneous nerve blocks with the cuties and the lateral femacutaneous nerve, that'd be great for, you know, all that kind of thigh, knee type laceration. Absolutely. Yes. Yeah. So I think I think we've given Evan a few examples there. 

Yeah. And we even managed to squeeze ESP in there. Now we are getting towards the tail end of the session here, but this is a really interesting and it's it's slightly academic thing. There's a chap called Salman Naim who he's on X, and he published something recently in anesthesia reports. And it was all about a sternal hematoma infusion catheter for for a manubrious sternal fractures in the ED. 

And actually, we could link the the link to his article in the episode most Put that in the show notes. But this is a really interesting patient. This this patient presented to the ED with rib fractures, a clavicle fracture, l three fracture, sternum fracture, and and a and a wrist fracture. So they reduced the wrist fracture in this patient, and the only thing that was left over was pain from the sternum. So because they weren't sure what else to do, they essentially took a Tuohy needle, went right down to the periosteum, and put a catheter right into the fracture site, and ran this as a continuous infusion and really helped with the patient's pain. 

So this is a polytrauma patient. What do you think about this? This is like the hematoma blocks of old Yeah. For wrist fractures, but of the sternum. What are your thoughts about this? 

I think, first of all, congrats Salman on getting this published and showing people your work and giving us an opportunity to talk about it here on the podcast. But I wanna know what Jeff about this. Absolutely. I mean, there's different ways to skin the cat. Right? 

So if you don't want to get into things like a paravertebral or an parasternal intercostal, etcetera, etcetera, etcetera, which requires, you know, ultrasound expertise, multiple punctures in in some cases. This sounds like a cool way to solve that problem. If you've got a broken bone, two raw edges, and you put local in between, that's gonna that's gonna help. So I I think it's a I think it's a cool solution. I think it's very cool. 

But because we don't shy away from controversy here Mhmm. As I was reading and he's got some great images on there on on the case report if you click on the on the on the article. As I was reading and looking at the the images, the thing that makes me feel nervous is it's kind of like putting local anesthetic directly into the bloodstream. Right? Because you're putting a catheter right near bone raw edges where the marrow is and leaving a catheter there. 

So I am slightly worried. Although not crazy worried, but slightly worried about the systemic absorption of local anesthetic there. And surely that's got to be a consideration in the context of multiple blocks. Yeah. I I feel the same way. 

We went through my head as I was imagining this bloody, fairly, you know, vascular bone. It's got a it's got a wry edge. But It's it's it's consideration. Right? But I think sometimes you you've just gotta you gotta make the most of the of the issues you have. 

And actually, if you read the case for this patient was really starting to be decompensate from the pain from their sternal fracture, so they had to do something otherwise. They were looking at a tube and a ventilator. So, you know, if in their skill set, in their wheelhouse, that's what they had as a technique, I I salute them for doing it. But I would always just as a caution to our listeners say, whenever you're administering administering continuous doses of local anesthetic, you just got to think about the risks of local anesthetic systemic toxicity. We've already talked about what we think about intravenous lidocaine as a as a therapeutic option here. 

So just something to bear in mind. So thank you very much, Salman. Yep. And now, Vadim Sisov from X asked us a question which is totally topical. And again, we're not gonna be able to do justice, but as we're coming towards the end of the podcast episode, I wanna make sure we covered it. 

He said, what do we do to deal with rebound pain after a block? If that triggers some people, me saying rebound pain, I'm gonna say again, rebound pain after a block, and multimodal analgesia. What are your thoughts about this whole massive topic in two minutes? Wait. Wait. 

I wanna hear more about why it's a trigger for some people. Because some people I mean, but but answer the question first, and I'll tell you why. Okay. I don't believe this thing. I think I think Well, that's why it's a trigger, basically. 

Maybe I'm the triggered one. So I I've seen people describe this phenomenon, and lord help the surgeon who gets a hold of this information and starts to use this as a way to say, well, blocks aren't good, and I've seen this happen. Saying, well, look, you do a block, the pain is actually worse when the block wears off. It is not. It is not. 

What you're what you're not comparing it to is untreated surgical pain. And so, of course, if I have a block and I have an insensate upper limb and then I go home and I watch my Netflix and I'm drinking my coffee and I don't take any multimodal or other systemic therapies like I I would have been had I not had a block. When the block wears off, of course, I'm gonna have rip roaring pain, but it's not worse pain than had I done all the right things without a block. Does that make sense? It does, but I wanna tap in exactly to what you just said. 

So I can tell you about what I see in my knee arthroplasty population as an example. So I've got two populations. Those have a spinal and blocks and those have a GAM blocks. And anecdotally, for many of reasons we've described, as a general rule, the patients who have the best outcome in my hands are those who have had a spinal anesthetic plus the blocks. They do great. 

They feel comfortable. They have expectation management. They know what their pain is gonna be like when they go home. So they don't have rebound pain from the spinal. The spinal doesn't make things worse. 

Well, the spinal wears off and there are blocks in the background which is kind of, you know, soften the fall from complete analgesia and anesthesia to partial analgesia to blocks wearing off. But by that stage, they've got their multimodals working, etcetera, etcetera. And in the same way we talked about our GA patients, if you do a GA motor bearing blocks, we talked about adding in the femoral nerve block with lidocaine to kind of soften that landing, then that gradually wears off and everything else has a chance to take control. But I recently spoke to an orthopedic surgeon who went to the American Orthopedic Society meeting, and they have been told I don't I wasn't there, so I'm quoting it third hand here. But they have been told that blocks can be bad for patients having surgery because Oh god. 

I'm shaking my head here. Because of this issue. Because of this issue. People in our community, the regional anesthesia community are putting this term out there, rebound pain. It is hurting us. 

Please stop doing this. It's not a thing. It's untreated surgical pain. Absolutely. And actually, there's you know, we know that appropriately and carefully administered multimodal analgesia throughout the perioptive journey from preop to intraop to postop is key in managing the situation. 

Rebound pain, I think, is badly managed postoptic pain, exactly as you said. Because the the the the orthopedic surgeon argument is if they've never had a block at the beginning, just dose them up with all these drugs, and they're okay, and then keep dosing them up the whole way, and then they've never had an issue. But that's nonsense. Yeah. We'll take a time machine back to the eighties. 

Yeah. Let's do it. So there is actually I will give a shout out. There's a nice multimodal analgesia paper out. I haven't can't remember the link now, but Vishal Uppol at Repatha Kane on X has has written a nice paper on this covering a whole host of issues. 

So I think rebound pain, Jeff said what he thinks about it. I agree entirely. We should not let this this term carry on. We need to stamp it out. So the reason I was talking about trigger pain, as I know, there's a few people that would get triggered when they even hear the word yourself in I guess I'm one I guess I'm one of them. 

Exactly. Now now the final question. The final question of the episode, Jeff, is our good friend, Cass Andrews from X, wants to ask about pediatric regional anesthesia. Now this is interesting I didn't do any peds anymore. But she's talking about doing regional anesthetic blocks on kids asleep. 

And the questions are so I'm not a 100% sure I get what she's what she's asking, but she's saying, are the orthopedists or orthopaedic surgeons on board? Yes. It takes five minutes to do, but it prevents crying and screaming and pack you. What would they want for their kids to discuss? So I guess this is talking about orthopaedic surgeons being nervous about or pediatric orthopedic surgeons being nervous about doing blocks in kids asleep and the extra time it takes. 

What are your feelings about blocks in kids, for orthopedic surgery? I think it's a wonderful thing. I think I would hope that a pediatric orthopedist would be sensitive enough to the to a child's pain needs that they would not blink at five or ten minutes at the beginning of the case or the end of the case to do a block before the kid wakes up. Uh-huh. But, you know, but I think they're they're not immune to the same pressures that adult orthopedists are in terms of time pressure and that sort of thing. 

I you know, to to Cassie's point, most young children, and I I think I'm putting anybody under sort of 15 years of age into that category, don't wanna have an awake block or in the pre op area. So we'll we'll do those asleep. And so Oh. Part of getting buy in for us has been make sure everything is set up and ready to go. And so, you know, if you can put the tube in or put the LMA in, and then as that's being taped at the head of the bed, you are positioning, probe is on the skin, prepping the skin, doing your time out, and and blocking before. 

Yeah. Just trying to make things efficient. That that'll help the buy in. I think you're I think you're alright. But I would I would go one step further and actually say, with any regional anesthetic technique you do, I'm a bit of a control freak. 

I like to have things prepped in advance and because I I like to have things streamlined. I think if whether it's a patient under anesthesia waiting to start surgery while, you know, you know, waiting for you to do the block before surgery can start or whether it's an awake patient waiting to have a block, I don't think I think you wanna minimize the preparation time so you have everything everything safely prepared and set aside, then you can go on and do it nice and efficiently. And I know Kee Jin Chen, I mentioned this before. He talked about this when he's doing his ESP blocks or t lip blocks for spine surgery. They do that once the patient's been positioned prone in the OR. 

He has everything set up so that the the technique of putting the block in doesn't take that long and all the preparation is done. So I listen. I can't speak from experience with pediatric orthopedic anesthesia, but I think I'd want my kid to have a block of sleep and be comfortable. And I would hope that our surgical colleagues would be patient. Certainly, they don't see the kids screaming and packing necessarily. 

And maybe you just need to get the whole team involved. Everyone communicates and saying, well, we think this is worthwhile. It's gonna save you giving us opioids to this child in in PACU. I hope everyone comes on on board and does the same thing, but I'm kind of guessing Cassie may have had an issue with this, which why she's asking the question. You know, we we have a different, lens looking at opioids in The US as as compared to other parts of the world, but we have lots of data on teenagers and opioid use after ACL or something like that. 

And the numb the proportion of those vulnerable teen patients that then go on to use and abuse the opioids. And I did a panel recently at a meeting with my friend Paul Sethi, who's a a shoulder surgeon in Connecticut. And he has a has a a very powerful set of stories and perspectives about this. He said, look. You're an you're a student athlete. 

You get an injury. You're out all a sudden off the team. You're sitting on the bench. You're watching your friends play. You are depressed. 

You're anxious. You feel like you're alone. You're outside. All you need is a sprinkling of oxycodone to send you down a very dark path. And when he said this in in this panel, was like, yeah. 

Exactly. If my kid is getting any kind of surgery, I'm doing everything I can to not go down that path. I love hearing that from his perspective as a surgeon. So That's a very powerful message. Alright, man. 

As they say when I wrote a hip hop song about a burrito, that's a wrap. You had to end up One more too. Love it. Okay, man. Listen. 

That sounds good. All that remains for us is to wish you all season's greetings, merry Christmas, and a happy New Year. And we look forward to coming back in 2025 with a new season. Season three dropping January 25. Absolutely. 

Happy holidays, everybody. Hope you have a a restful break. And if you are working over the holiday season as I am, please look after yourselves and be safe. Listen. We look forward to welcoming some new guests next year. 

We've already got some great ideas and some potentially interested individuals. We've got so many more ideas and maybe even some more music, Jeff. For sure. There will be some more. Maybe they don't wanna hear more music, but they're gonna get it. 

Well, listen, folks. You heard it. You heard it. Till next time. Please remember, guys, like and subscribe to our podcast from your usual podcast provider, and let us know if you want more. 

Please give us some reviews. We really count on those reviews and those ratings. And, Jeff, where can they follow us? We've got a new one as well, haven't we? Yeah. 

We've got we've the x or Twitter at block it underscore hot underscore pod. We have YouTube at block it like it's hot. And we have my favorite one, Jeff, Insta, block it like it's hot with underscores in between each word and no apostrophe. And our new one on blue sky, which is much easier to remember. It's at bilih@bsky.social. 

The standard thing on blue sky. Yeah. It's good. Right? I think it's Exciting. 

Think it's gonna be cool. Let's see what happens. Amazing to see how many people have jumped over. Absolutely. Listen, we we wanna see you guys on all of those platforms. 

Leave comments. Let us know what you're thinking. Until the next episode, we hope you all Block it like it's hot.