S2:E2 "Forearmed is Forewarned: Nerve blocks for median, ulnar, radial and other distal nerves of the upper limb"

Would you like to spend one day with us while we look for Martin Gruber by the arcade of Froge? I'm Amit Pawa. Distal limb block in the middle of the night? Don't try this at home or maybe do. I'm Jeff Gadsden, and this is Block it like it's hot. 

Hey, Amit. How are you, man? Are you settling into 2024 yet? Hey, Jeff. I think so. 

You know, before the days of electronic patient records, this is about the time of the year when I would have been just getting used to writing the correct year in the patient notes and not having to scribble out last year's date, which I used to do all the time. How would you be? Yeah. Wow. Manually writing in a chart has been it's been ten years for me since I had a a pay applying a paper chart. 

That long? Ten years? Yeah. Yeah. Yeah. 

I've been fortunate to just to now we still have paper consent forms. So I I do the same thing for the first month I write, you know, last year's year. But, do you have electronic consents? Yeah. So, actually so both the hospitals where we've only just recently introduced Epic, they have electronic iPad based consent forms, which took a bit of getting used to, but actually they're pretty good. 

But, you know, we need to start doing nerve block consents. So I haven't had to do that yet because somebody else has done it for me. If we have to do nerve block consents, then I've gotta learn that whole different work stream. But, yeah, I kinda see the advantage of paper, but Yeah. We've we've gone fully electronic. 

Well, I don't know. I I think electronic makes sense. I mean, we lose papers all the time, and papers get Exactly. Covered in gump. So do you wait. 

Did you say you have a separate nerve block consent? No. So I I should clarify. If we're doing a nerve block as part of the surgical procedure, then that takes part as our, that takes the place without, with our oral consent we do when we see patients on the day of surgery. But if we are gonna do a nerve block for for a procedure that's unrelated to surgery, so, you know, rib fractures or fascia iliaca, for example, for hip fracture pain, then we do have to fill out a separate, surgical consent. 

So that's a that's gonna change the work stream for us. Well, speaking of fascia, when you say fascia iliaca, I have had a bit of a week. Oh, no. Tell what what's happened? So I think it's just I'm getting old, man. 

I I, I was on a I went and me both, brother. You and me both. Went for a run on the treadmill, just a normal distance that I'd normally do. One went great. I stepped off the treadmill and felt this intense pain in my the sole of my foot. 

I was like, that's really weird. I figured it's just one of those twinges that would go away. Didn't go away. It I think I've I've torn my plantar fascia acutely. Ouch. 

It it is I don't think of myself as a baby. Like, Corey might disagree in terms of my pain tolerance, but that night, I did not sleep. Like, I was I couldn't get comfortable. I was writhing and turning. Was I getting up every few hours and, like, looking for a new pain medication to add. 

Like, I had NSAIDs and I had acetaminophen. Oh, And here's the stupid part. Okay? So at 05:00 in the morning, I'm like, you know what? Why don't I just do a tibial nerve block at the ankle? 

That would You did what? Yeah. Yeah. So I found some I found some repivacaine don't ask me why I have repivacaine at home and some 25 gauge needles and that sort of thing. But suffice it to say, drew it up, did a tibial nerve block at the medial malleolus. 

With ultrasound? No. I know. I don't have ultrasound. So this is this is old school, baby. 

Oh my god. It's landmark. But it was amazing. I went from what Corey would call a man pain Right. Score of 10 out of 10 to zero, like, within about fifteen seconds. 

And this is with ropivacaine. And then the actual, like, sensory block, like, the numbness of the sole of the foot Yeah. Took, like, about ten or fifteen minutes. But I was writhing before, and then it just went away. So that was really interesting. 

Oh my goodness me. Well, I'm I haven't found myself in a situation where I've had to do that, but that sounds nuts. Now we we are probably gonna have an ankle block episode at some stage. When we we can we can relive this, but you what you just literally went in behind you felt the artery and went in right next to it. What did do? 

I don't wanna cause a big a big bloody mess in my home office. So I did palpate for the posterior tibial artery and just went posterior to that, went in a few centimeters, aspirated, injected about six mils, and it it worked. I it my the only thing I was regretful of was not having thought of that at 11PM instead of 5AM after having not slept for six hours. So Holy mo and how and how are you feeling now? Better. 

Thank you. It's it's, it it's gradually getting better. I it's gonna be a long unfortunately, I'm one of these long injuries. It takes a while to come back from. So but, hey. 

There there are worse things. I will I will Jeez. I will get over it, but just I'm part of getting old, I guess. My goodness. Well, we we normally say don't try this at home, but this is one of those situations where trying at home made a difference. 

Do try this at home. Okay. Well, you know, may maybe there's a reason for for having some, some local anesthetic at home. Well, gosh. That's food for thought. 

Well, I'm well, I'm sorry to hear that. I, but I I hope you continue, with your recovery. I'm guessing the backflips are gonna be put on hold for a while. Yeah. But possibly. 

Yeah. The landing might be a bit tough. Anyway, enough about me. How have you been? Well, you know, I've got to admit, it's not been a great week on the regional anesthesia front. 

I've kind of got some stories Oh. That I wanna share with you. And my fear is that when we discuss and dissect these stories, that could actually be the whole podcast. But Okay. That's one element. 

And then I've also been really upset by a TV drama that I watched that's got me totes emouche. That phrase Oh, no. Do I need to get a beer for this? Or Yeah. May maybe even something stronger. 

But bearing in mind what time in the morning we're recording this, perhaps that's not such a great idea. Okay. Tell me about the regional anesthesia stuff first. Okay. So it was one of those days. 

You know those days when, you know, you're gonna start doing a case. It's, I was with one of our new regional fellows, and we kinda suspected that the the patient may be a little bit difficult to place a spinal in. And in fact, they had what I call the power sign of difficult spinals, and I ignored it. Oh, we need to we need to publish a a little little manual of all the power signs and Gadsden signs and I think so. I think it'd probably be worth it. 

Let me tell you about the power sign. If you put your fingers on the on the spine or either sign of the spinous processes and all you can feel is really tough, strong paraspinal muscles Yeah. That's the power sign that it's gonna be a difficult spinal. And, actually, what that should have done was acted as a trigger for me to say, get the ultrasound out, but it didn't. So we kind of thought, and I'll be okay. 

But I felt that. Was like, okay. It's fine. And so, you know, a new regional fellow, kind of it was a bit difficult to get the spinal in. We eventually cracked out the the ultrasound and, you know, managed to find a space. 

And the fact that we got ultrasound there, we could see right the way through to the posterior longitudinal ligament Yeah. I kinda knew there was a path. And it was still tricky. Yeah. It was just demoralizing. 

So, anyway, that was that was case one of the day. Okay. But then the same thing happened on the last case of the day. Exactly the same thing. So Really? 

You know, some some days you just have those tricky spinals and you think it should be straightforward. And I can hear Robbie Erskine's voice in the back of my head saying, why didn't you do a paramedian approach to spinal laminate? Yeah. Yeah. I should have done. 

I should have It happens. Right? This you get tricky patients. But if it happens once in a day, it's it's tricky patient. It happens twice in a day. 

It's not me. It's you. Yeah. Well, I mean, I I I was I was starting to think maybe if I'd if I'd gone home and come back in again or started the day again, maybe things would have been better. So, anyway, that was slightly demoralizing. 

But you know what? That's not where the story ends, sadly. Oh, no. Okay. So for one of these patients, you know, we'd been going great guns with our total knee arthroplasties and and, you know, being really fast operative time. 

So I thought, you know, let me take a leaf out of the the Ganston book, the playbook here. So rather than using, lidocaine, I thought I'm gonna use a short, a acting spinal anesthetic. We used, intrathecal prolicaine, heavy prolicaine. Oh, speak speaking of Robbie Erskine. There we go. 

A little bell should go off. A little Robbie bell should go off every time we Yeah. He should get an alert on his phone when we say his name. Right? Paramedian. 

Ping. Exact yeah. Prolocaine. Ping. If we did two chloroprocaine, my gosh, you'd be getting, like, multiple alerts. 

But listen. So so we did this spinal. Eventually, we got the spinal and did the spinal, and it was all going great guns. And then there was a complication which meant that the surgery did not finish in the period of time that we thought it would. Ah. 

And exactly on the nose of two hours, the patient started complaining of pain and discomfort and had I had to convert to a general anesthetic. So this was, this was a sobering and a grounding experience that made made me realize that, you know, when you decide to do things like this, there are certain factors that you can't anticipate for. You can't you can't you you can't, you every time you do a total knee arthroplasty, you're not gonna expect a complication, but sometimes these things happen. And it's a calculated risk that you take each time. So it it's left me with a bit of food for thought, really. 

Well, I agree it is a calculated risk, and I think the I'm okay with it. The the because the benefit to those nine out of ten patients doesn't happen to is immense because they get up. They're walking in PACU, and they're they're home. And they've gained the benefit of the spinal, but then get the quick offset too. So for knees, especially, I I don't I don't know. 

I don't find there's a whole lot of shame in slipping an LMA in if you find that they're starting to wiggle a bit near the end. Yeah. But it was interesting because when I initially shared some videos in social media about this kind of, the benefits of doing short acting spinal anesthetics, so certainly we did get some comments, on social media on x saying, you know, why? What's the benefit? Why would you use a short tethings thing? 

What happens if the surgery goes longer? And it kind of that little bell went off, in my head when I was having this experience saying, you know what? There are risks. This is the first time this has happened to me, and maybe if you speak to somebody like Robbie who's done so many, he he he might be able to to recall none or maybe a handful of cases. I still think it's worth it, but it just leveled me a bit. 

You know, thankfully, the patient was fine. Everyone was fine, but it was just something to bear in mind. Yeah. So we we've had to be more what much more thoughtful about the timing of our spinal. Most of our surgeons do two rooms, and so they'll, you know, finish case a, come out or getting close to finishing case a, they'll scrub out while the trainees are closing, come and consent case b, and then go and finish case a. 

Yeah. And so when we used to pivot cam, we used to, like, just, oh, we'll just block them now because it's gonna last for three or four hours. Who cares? But now we're like, okay. Wait. 

Let's wait till the last possible minute before they're about to roll back to the OR, then our spinal goes in. Yeah. Timing is definitely key. Yeah. It's been a bit more tough. 

The other thing we've done, successfully for those cases where you think, ugh, I think this might be a little bit longer than two hours is add four of dexmedetomidine intrathecally. Wow. And that makes enough of a difference? Yeah. It just seems to add, like, thirty to forty minutes of sensory block. 

It doesn't really extend the motor block so much. So they're still able to garner the benefits of that short acting spinal the PACU. They're up doing a little staircase in the PACU. Okay. Interesting. 

Although, I just something I just heard you say that was interesting. So you used the term scrub out. I'm just thinking that's an odd thing because we I can understand how a surgeon would scrub in for a case. But why do we need to say scrub out? Because it ain't scrub to go out. 

I I so as you said that, it just I I it's not the first time I've heard that phrase. I thought it's an interesting thing. Yeah. Yeah. It's a good point. 

Anyway, that's an aside. That's an aside. Unfortunately, I do have one more bad or unexpected Oh, no. Regional anesthesia story. So the yeah. 

I the a reason I think this is important to share is we talk with passion about our love, regional anesthesia, and sometimes people can think it's always rosy. But when things sometimes don't go according to plan, you know, even things I I know you've never had a failed block. But I think it's important. I think Exactly. I think it's important to share. 

So I wanna tell you another episode. Now this was with our second regional fellow. So regional fellow number one had some some fun experiences. Now we had regional fellow number two. And on on on his first list with me, he did a beautiful single shot infraclavicular brachial plexus plot for hand surgery. 

My favorite. Admittedly, yeah, your favorite and and mine too. Admittedly, when we were looking at the cords of the brachial plexus, it looked like there was a slightly high riding cord next to the lateral cord. But, you know, we still managed to see two cords sort of super laterally and then something at the poster aspect of the artery. So a beautiful, single injection of local anesthetic, thirty cc's, good spread, and we didn't get a block. 

Really? Nothing? We just we we I mean, just like a very slow maybe something. We waited about twenty five to thirty minutes, and we got zip, nada, zilch. And the interesting thing is, at that point, I went back and I scanned the costoclavicular view of the infra infra brachial plexus blood. 

And you know what? There wasn't a lot of local in that pocket, which is interesting because on the standard infra clavicular view view, it went really well. So you know what I had to do? I had to do a mini auxiliary brachial plexus block with just ten cc's of lidocaine, which is all we had left in terms of the allowable dose. Sure. 

And that worked almost immediately. Oh, good. But the block only lasted an hour. So it looked like the block was purely due to the axillary brachial plexus component and nothing from the improper. But when we did review when I was looking at his, axillary brachial plexus plot, he had something really interesting. 

I just wanna know, whether you spotted this before. His median nerve actually had two components that were very obviously visible in his axilla. So he had what I would normally consider to be the median nerve, and there was a separate nerve right up to it, right up next to it, which is very different from the ulnar, very different from the radial, very different from the musculocutaneous. So he had two components of the median nerve. And then when I went back to scan his infraclavicular region, lo and behold, the lateral cord wasn't an isolated lateral cord. 

There were two components to it. So have you seen that before? What on earth was going on with that block, and have you seen that before? Weird. Yeah. 

I'm gonna blame the patient's anatomy on that one. That sounds like the nerve of power. Yeah. Exactly. Well, no. 

They well, there you go. Anyway, that that was my, my odd experience. I've got I've got no explanation for it, but, you know, sometimes these things happen. But what was really nice was that we had another plan, another approach, and and it was useful to have a little bit of local asset left over to do that. Okay. 

That's me done. Yeah. That's me done. Apart from my sad story Gosh. My sad TV show. 

Oh, man. You've exhausted me with these these regional anesthesia tales of woe. So maybe we we save the the sad TV story for the the break in the middle. Okay. Okay. 

Okay. Fair enough. Well, listen. We would do we definitely need something to balance out the jokes in that midsection just to bring people down. So so tell me, Jeff, after that sort of depressing start to the podcast, what have our pet our listers got to look forward to today? 

Well, so, you know, in the last episode, we got as far as the axillary brachial plexus block, and we finish up with what to do about, you know, managing an anticoagulated patient. Right? Uh-huh. Uh-huh. We still have all the other distal nerves to talk about. 

The brachial plexus, things in the arm, the elbow, the forearm, the wrist. Oh, so you mean the big small nerves and the small small nerves, all the other stuff? Yeah. Exactly. Okay. 

Let's do this. Okay, man. So let's start. So if we're thinking about distal blocks of the upper limb, so we're we're kind of talking, what would you say, antecubital fossa and downwards, that sort of area? Yeah. 

I think so. I I I haven't there was a time before ultrasound when I did some, like, mid arm blocks. You need to hit sort of hit the humerus and angle 30 degrees and try to get this, that, or the other thing. I don't know. I I haven't done a a mid arm block. 

So, let's let's talk about sort of elbow on down ish. Okay. But, you know, talking about mid arm blocks, I do remember there were some textbooks where there were chapters on the mid arm block and wrist blocks and elbow blocks. It was a it was interesting concept because these weren't things I ever actually did. So Yeah. 

But you did you've done them. So that's cool. Well and my landmark based skills came in handy two nights ago when I had Yeah. Well, I so yeah. So don't, you know, don't forget those is what we're saying. 

Right? Yeah. Why don't we start with the median nerve? Okay. So for me, the easiest way to think about the median nerve is when you start at the antecubital fossa, you palpate the brachial artery, and you know that it lies medial to that. 

And when you stick the ultrasound on, you could often see it right next to the brachial artery, as a general rule. Right? Yeah. I agree. I will say as a sort of a starting principle that I don't like to block at the elbow or at the wrist. 

Just Mhmm. Just simply because there's lots of confuse I mean, I'm easily confused. I'm an old man. Yeah. But there's lots of tendons and big vessels and other things to distract you. 

Whereas for the median ulnar, smack dab middle of the forearm, there's just muscle or nerve and and some small vessels. So Yeah. It's, it's a little bit easier for me to to pick out of the background. Well, also, I think if you if you imagine the median of sitting right next to the brachial artery, when you're gonna try and get in there and block it right near the artery, there's not very much space. So there's a lot of potential for bad to happen. 

Right? Yeah. Yeah. Exactly. But but I think it's a nice thing to do is to start off at the antecubital fossa, use the brachial artery as a as a ultrasound landmark, see the nerve lying medial to it, and then scan from the antecubital fossa via the forearm right the way down to the wrist. 

And there's that little tricky bit as the median nerve dives down undercover of the pronator pteris. It can be slightly difficult to see, and then it just pops up between the vegetaum profundus and superficialis in the forearm. Right? And that's a nice place to block it. Yeah. 

I agree. Now have you ever seen that, persistent median artery? Is that do know what I'm talking about? Persistent median artery. No. 

Was so there's an artery that so I well, this is this is exciting now. It's a very rarely that I get to talk to you about something that I'm that I've come across in my practice, that maybe you haven't seen. So so quite often, or not insignificantly, when you scan the median nerve in the forearm, you will see an arterial branch. And more often than not, those arterial branches are very small. But every now and then, you see a fairly large and significant arterial branch. 

And as you scan down the middle of the forearm, you'll see it there consistently. Now I'd noticed this a couple of times on when I've scanned on various fellows and posted videos on social media. People have commented on these really large arterial branches. And I worked with a nerve surgeon called Tom Quick. Shout out to Tom. 

He's a nerve surgeon, and he's told me that there's actually some evidence where patients who have this persistent median artery may be at a slightly higher risk of, carpal tunnel syndrome because that artery may cause some compression of the nerve. So Oh, is that right? Yeah. It's just an interesting thing to be aware of. And I think if you do see a sizable artery next to your median nerve, certainly, you need to take extra care when you're doing your sort of fascial injection around that median nerve. 

Yeah. Yeah. So my my technique is find the midpoint of the forearm between the wrist and the elbow on the volar surface, plop your probe down the transverse orientation, and just sort of scan up and down a couple centimeters each way. And then you'll see the median nerve as this hyperechoic little oval between the the superficial flexor compartment and the deep flexor compartment. And the trick I'll have them do sometimes with patients is say, hey. 

Can you wiggle your fingers? And the nerve will dance. That's right. It'll, like, sort of do a little Do a little dance. Sorry. 

Yeah. Yeah. Okay. So that and and and then you'll just pop in a small volume of local anesthetic, to surround it? Yeah. 

And and a a way that I failed early on in these, when I first started thinking about these nerves and sort of scanning for them, oh, there it is. And I I got my needle kinda close and it didn't work. And I I realized I wasn't close enough to the correct plane. So so it is a fascial plane block, so I'll I won't get my needle tip closer than nerve per se, but I want to definitely be outside the muscular compartments and in between those two those two muscles. So oftentimes what I'll do is I'll go through and through the plane and then come back as I'm putting a little bit of pressure on the syringe and it'll sort pop open that plane. 

Yeah. Do you do you do that? That's a really nice technique. That I do exactly. And it just it just reminded me of a statement that you made in one of our early podcasts when you said that famous line, all blocks are fascial plane blocks. 

And that's kind of stuck in my mind. Yeah. Right. Right. Now before we move on to another nerve, I just wanted to signpost the fact that the median nerve gives off a branch, the, the anterior, interosseous nerve. 

And that may well be relevant for part of our discussion that we're gonna have later on. I just wanted to signpost that here. Signpost. And that's responsible for muscle innovation and innovation of the radio ulna, and the wrist and carpal joints. So we'll come on to that. 

So what about the ulnar nerve? Where can you block this ulnar nerve then? So I do the exact same thing. So use oftentimes, what and the cool thing, just to back up, about doing these nerves is you can pick and choose. Right? 

So we'll have we had a patient with a fifth finger fracture, last week, And I asked a fellow, hey. What do you wanna do? And she thought about it and said, hey. You know what? I think we can do this entire case with four mils of local anesthetic at the ulnar nerve. 

What? Yeah. And and that's such a cool little elegant way to do it. But if you had, you know, if you had a third or fourth or, you know, thumb, you have to think about, okay, which of the three main nerves, median ulnar, radial, or do you need to to get that? And all that to say, sometime a lot of the time I'm doing median and ulnar together, which is convenient because I do them with basically the same probe position Yes. 

Middle of the forearm, volar side. The median I find is right in the middle. Yeah. And then I'll translate the probe towards the ulnar side and you'll see that same fascial plane. Uh-huh. 

In small patients, sometimes you can do one needle stick and get and just sort of redirect your needle over. But I'll find the ulnar nerve typically on the ulnar side of the ulnar artery in that plane. Yeah. And as you get towards the wrist, they stay quite close together. So the artery is immediately next to the nerve. 

And as you Uh-huh. If you don't if that kind of freaks you out a bit and you don't wanna be so close to the artery with your needle Yeah. If you come back just past midpoint of the forearm, they separate, and you'll see the nerve take off, and and that's that's kind of where I like to do it. How about you? So so this is really exciting. 

The two things I wanna say. As you were talking, I was I was imagining exactly what, what I do and listening to what you do. So if I'm getting people to do an ulnar nerve block, I generally get them to start scanning at their wrist, actually. Ah. What I say to them is, look. 

I say that identify the ulnar artery because you know you should be able to see that arterial landmark and look on the ulnar side of the ulnar artery, and that's when you should start to see the ulnar nerve. So I get them to get their eye in and they kind of Yep. Look amongst the tendons. I say, is there a tendon? There's a nerve. 

I said, right. Now keep your eye on the artery and scan proximal. Come towards the mid part of the forearm. And exactly as you describe, as you scan from the wrist of the forearm, you'll see the artery diverge from the nerve. It'll leave the nerve where it is right by flexor carpi ulnaris. 

Right. See the ulnar nerve standing separate. And, actually, if you're really clever and you and not in fact, not not at all if you're really clever. If you pay attention and watch that ulnar artery, you'll see it dive past the median nerve. So you often watch the arterial branch branch. 

It will swing from the ulnar ulnar artery ulnar nerve, and it will actually bypass the median nerve in the middle of the forearm. So I know one of my my, UK friends who did the fellowship with Vincent Chan in Toronto a long time ago, Matt Oldman, he published a little paper on this just showing or talking about how the there's an arterial branch that swings from the ulnar nerve to the median nerve. So that's something to look out for. Yeah. Nice. 

The other the other thing I wanted to talk about is the fact that there is a very or a couple of relatively common ulnar nerve median nerve cross innovation syndrome. So one of them is called Martin Gruber syndrome, and the other, I think, is called Roux Ganoush. I'm not making this up. Google it. Yeah. 

It sounds it sound wasn't Martin Gruber the the bad guy in Die Hard? Yeah. Do you know what? That also rings a bell, but I'm pretty sure Oh, it's Hans Gruber. There was a Gruber, though. 

Right? But but but check this out. I'm pretty sure one of them is a proximal. One of them is in distal cross innovation, but there are potential situations where you get fibers from the median nerve innovating ulnar's territory and vice versa. So Uh-huh. 

Sometimes if you try to be too smart and just, take out the ulnar nerve for ulnar side surgery, you might come unstuck. Okay. Yeah. Well, I feel better about some of those failures now. Exactly. 

But It's not me. It's it's Martin Gruber. It's not me. It's you. I do the yeah. 

Exactly. Martin Gruber did it. So why you know, just to prove it, I want somebody to do a bit of Google and see if they can find out some history. And I think there's another colleague of mine, Peter Majavi. I think he's all over these these cross innovation stuff. 

So he might he might know about this, but I'm pretty sure that's the thing. Cool. Okay. So we've talked a bit about medium. We talked about ulna. 

What about that radial bad boy? Where do you block the radial nerve? So there's a couple choices here, and I like to block it just proximal to the elbow crease. Again, it's it's a spot where I find it easily. It's in a muscular plane between brachioradialis and and brachialis muscle. 

There's nothing else really to hit there and you get both branches. So we're mostly interested in the sensory branch, the superficial branch. But in case you needed the deeper branch, it's there too. So that's one option. I like doing it there. 

So you so you're not you're not talking about higher up on the arm here. You're talking about antecubital faucet just a little bit above where you've got brachialis. Right? Yeah. And what I'll do is I'll say, I'll put the patient's hand on their belly and so their elbow's flexed. 

And so you can you can see the prominent elbow crease and just like a finger breadth above the elbow crease on the lateral side of the arm, you pop the probe on and you'll see, you know, a bunch of muscle and right in the middle is this, like, prominent radial nerve. So I think you might I found as I'm picturing what you're doing, I think especially if you've got the arm across the belly, I think you're doing it slightly more proximal than I do. So, actually, what I tend to do when I do the radial nerve is I get the arm out, soup pronated. Do I need know supinated? And I scan over the antecubital fossa. 

I scan laterally towards the radial side of of the antecubital fossa and I go slightly keflab, but not as keflab as you are. And often you'll see the radial nerve really nice and flat, between brachialis and brachioradialis above it. So I tend to pop it in there, it's really quite thin and flat at that point. And then if you would scan a little bit more proximal, then I can I think I can picture where you were doing it because I wouldn't be able to do my block with the patient's arm across their belly? So I do ever so slightly more distal. 

Right. Yeah. I mean, the great thing about most of these is you can just trace that nerve up and down and wherever you see it most prominently, it works. Yeah. The other place that I have done it for hand surgery is at the wrist. 

So right at the stylet process of the radius, you can actually if you put take your fingers and sort of Mhmm. Press hard on your radius, right, right, just approximate to the wrist, you can and move them back and forth. You can also oftentimes feel a little snapping sensation, like a little bowstring. Uh-huh. That's that superficial branch. 

You can actually I can elicit a paresthesia of my radial nerve there. Yeah. That's that radial nerve. Don't do it, man. I can see you do it. 

Don't do it. Don't do it. But, yeah. So that's that's really easy. You just put, like, a little subcutaneous wheel of local right by the styler process, and that gets that whole hand back of the hand. 

Oh, now listen. You telling me that as as give me two things I need to talk about. One of them is actually I didn't realize if you start following the radial artery up and down the arm without ultrasound, you can actually see that tiny tiny sea fish radio branch. I didn't I didn't appreciate that. You can actually see it. 

Right? Well, especially as ultrasound machines have gotten better too. Like, when I was doing this ten years ago, I don't think we had a hope of it. Like, we maybe there's a smudge, but now with the quality of the images, now you can really see, oh, there's a little honeycomb tiny structure right next to the radio artery. So absolutely. 

So, you know, you you could do that little flicking the little band of nerve doing it, but you could also do it without sound. And then I suddenly made me realize how many times when I was doing my blind radial arterial lines, how often I would have been actually quite close to that superficial branch. Yeah. I know. Well, for a time when I was a trainee, we had this prominent sports surgeon who did a lot of hand stuff. 

And our practice at the time was to do blind wrist blocks. Uh-huh. And we would do all three nerves. So we would Right. Take a needle, stick it in the wrist crease in the middle, go down and hit the carpal bones, and then pull back. 

I know. And pull back and then give, like, five mils there, and that was for the median. And you'd slip it underneath flexor digitorum ulnaris tendon on the ulnar side and get the ulnar nerve, and then do what I was describing, that subcutaneous wheel for the radial. But it I shudder to think about how many times that Uh-huh. Sharp 25 gauge needle went through the median nerve or the ulnar. 

Probably not zero. Dude, I've got one horror story to tell you. And actually, as you were talking about doing your, landmark radial nerve, it brought shudders because I remember, in my first year as a consultant, I was still learning, to get skillful at doing axillary brachial plexus blocks with ultrasound. And I did a block, and actually we'd sent it to Cook, and brought the patient back to theater just prior to having their surgery, and they were having their surgery in there Right. Which involved the radial territory. 

And I just did a quick check before we moved them onto the Operating Table, and the patient still had some preserved radial territory sensation. I was like, well, this isn't good. Right. Bearing in mind that's where they're gonna be operating on. So I thought, you know what? 

I'm here. I'll just quickly do a superficial wheel of local anesthetic around the radius. And I did, and the patient had the most massive vasovagal ever, which involved in having two screens of cardiac standstill. Oh, wow. No cardiac activity. 

So, yeah, they obviously had such a profound vasovagal. And then I don't know mean, I'm I used about five cc's of local anesthetic. As you were talking about that landmark based infiltration, I suddenly got nightmare. Thankfully, everything was okay, but it would just, again, another one of those situations where you think, holy moly. What happened there? 

Well, brings up a good point about you just reminded me, another way we failed when I started doing these forearm blocks. I thought I'd be really clever and do a median nerve and ulnar nerve block for a carpal tunnel. And they weren't always successful. And until I realized what I was missing was the cutaneous nerves of the forearm, especially the lateral cutaneous nerve of the of the forearm, and which I which I wasn't getting, obviously. So Yeah. 

But it's useful to to to kind of put all of that into context and realize that what sometimes when you try to be too smart and do something too isolated, you might be missing out other things. Before we move on to into some more complex discussion, I just wanted to take this opportunity to use a phrase that professor Philip Peng introduced to me, and that was the arcade of Froge. Are you are you familiar with this? No. At where so so I'll never forget. 

I was at a meeting, and if you speak to Professor Peng, he's one of these guys who is so remarkably intelligent as such in-depth anatomical knowledge. And he was talking about the radial nerve, and he talked about the arcade of frozen, spelled f o f r o h s e. And I was like, what is he talking about? Okay. So I had to go back and and look at it, it's actually this supinator arch where the deep branch of the radial nerve passes under the supinator muscle just as the the posterior interosseous nerve is is given off there. 

And that also gives some sensation or sensory innovation to the wrist. So I just wanted to use that term because it's a a cool anatomical term of the arcade of Froge. I mean, you got Euclidean in there somewhere, so I thought I'd I'd I'd add in some some some other anatomical terminologies. It sounds like a setting in, like, Lord of the Rings or something. Doesn't he? 

Meet me at the Arcade of Froge. Oh, I love this. Okay. Cool. Right. 

Right. So we talked about all the individual nerves and some and some kind of interesting components of it. And you've already said that you sometimes use them for very isolated surgery. You might have just, blocked these nerves individually. Are there any and can you think of any other situations? 

You know, carpal tunnels when you've done median ulna potentially. So do you use these individual nerve blocks sometimes, or do you generally if you're gonna use them, use them as part of, general anesthetic to supplement? A lot of times, these are used for hand cases when we and and particularly for you could do a brachial plexus block, but then you're committing that patient to having a numb upper extremity for whatever length of time. And so what's nice about these is that they can move their elbow. They can flex their elbow. 

They don't have to have a sling to go home with. Yeah. But their hand is numb for what you know, whatever duration you wanna make it. And a lot of people don't like that. Right? 

They don't like when the surgery's o over and that that arm is numb for hours. They hate it. Yeah. Yeah. Yeah. 

It's a it's a weird feeling. And as someone who recently walked around for twelve hours with a numb sole of the foot Yeah. It is it is unusual. So it takes some getting used to. So that's one one case use case is hand surgery. 

Another way we'll do it sometimes if it's more involved is to do a brachial plexus block with short acting local anesthetic or intermediate acting like lidocaine or mepivacaine, and then just touch up or supplement with these Uh-huh. Ice these, you know, radial or ulnar or median with bupivacaine. That way, they get their arm back quickly or relatively quickly, and then but then they have longer acting hand analgesia. So you're talking about this whole concept of differential blocks. Right? 

So you're short acting local anesthetic proximal, a long acting local anesthetic distally. Right? Yeah. Yeah. Yeah. 

And that's a that's a a nice way to go sometimes. That really is. But I, again, I've got to remember how to say how to say this. Froge. I want to introduce some no. 

No. No. Some controversy. Is that how I say it? I'm completely confused now. 

Well, man, I'm confused now too. Tanya Selleck has really got upset because I said controversy, and now I'm I'm I don't even know how to say it properly. But but anyway, so something controversial. So you will be familiar with this whole concept of single, double, or triple cut crush phenomena when it comes to nerves. So one of the crushes being the potential use of a tourniquet, causing, you know, an area for nervous ischemia, and then you do a proximal brachial plexus block. 

That be crush number two. Are we making it more complicated by by doing these differential blocks and having another point along the nerve where we potentially expose this nerve to nerve injury? Do you think it's more risky to do two approaches the nerve along different paths? Okay. So I have some I have some feelings on this and opinions. 

So listeners, if you're unfamiliar with the double crush phenomenon, it's the idea that along the course of a peripheral nerve, you could have a subclinical injury. So most commonly people talk about a compression injury at the clavicle or first rib or at the nerve root level in the neck. So patients don't notice it until they have a second injury at some other point in that nerve that's also potentially subclinical by itself, but the two together then unmask this. It's it overwhelms it and and you get this a clinical phenomenon, you know, numbness or weakness or whatever. So that has been described in a mechanical sense. 

So it certainly exists when you have compression or stretching or that sort of thing. It's been described in a chemical injury. This chemotherapy can do that as well. So it's been alleged to occur in patients with a metabolic neuropathy like diabetes or that sort thing. Uh-huh. 

It has been talked about in terms of local anesthetic blocks, and people get quite freaked out about this. But I I've never I've never seen it myself. And I have looked in the literature, and I and I've granted, I haven't done this in about a couple years, but I used to give a lecture on, like, blocks for trauma and that sort of thing. And I I made a point of of screen recording me searching in PubMed, double crush, nerve block, and the results were zero. There there is no there was at least no recorded case of a nerve block causing double crush because it's just a temporary application of a local anesthetic, and it goes away. 

I think it's overstated is is what I'm saying, the the risk of untemporary nerve block causing some sort of a longer lasting nerve injury. Does that make sense? It does make sense. And, actually, on two occasions at REK meetings, we've had surgeons speak most recently as Tom Quick, a nerve surgeon, spoke at one of our UK meetings saying he really doesn't think there are that many instances where, or it'd be very, very rare for a post operative nerve injury to be caused by a nerve block. That's not to say the incidence is zero. 

Right. But it's very unlikely that the nerve block itself would be responsible for for the majority of these cases. So, I hear. I hear. No. 

No. No. Just to be clear, you can cause nerve injury with a nerve block. Of course. Mechanical, you get if the local anesthetic gets inside the fascicle, that can cause a chemical injury and that sort of thing. 

But what we're I think what we're talking about is a safe, normal deposition of local outside the nerve, but somehow the nerve is theoretically susceptible to injury, and that causes a problem. I've never seen that, and I've never heard of it. Yes. Agreed. Agreed. 

Nor have I. But it's just it you know, it's something that I do think one needs to think twice about, you know so for example, another example I remember hearing about earlier in my career is somebody doing an interscalene nerve block and then intentionally doing a supraclavicular as well to and and so I didn't understand what the perceived benefit of that was, but they were blocking the brachial plexus as two separate points. Now each of those needle passes carries with it its own risk of nerve damage. Sure. So I so I guess what I'm saying is each time you do that, you have a risk to think twice before you do that. 

So if you think there's a valid benefit in doing a proximal and a distal, then the chance of you causing meaningful, impactful nerve injury is very low, but still don't take it for granted. Yes. Yes. Agree. There's one other thing I wanted to talk about before we hit up the break is, and that's a specific use of these isolated peripheral nerve blocks at the upper limb and why it's worthwhile knowing them in addition to, you know, using them as a rescue block. 

So, you know, you do your proximal brachial plexus block, you weigh and you see like I did that you get a bit of sparing, then you could top up the deficient territory. So that's one exciting use or one real life use of these peripheral nerve blocks. The other one is something that's quite niche. So I work with, with an upper limb surgeon called Sam Gudwani, and he, you know, he specializes in hand and wrist operations. But he gets a lot of patients who have cerebral palsy or muscle spasticity, and they come with quite quite significant sort of posturing of their upper limbs. 

Right. And they're looking for things to or they're looking for ways to increase function of that upper limb. So what we started doing, which is really exciting, is doing isolated peripheral nerve blocks with lidocaine. So we might do median nerve first and wait to see what effect it had on those muscles. And then based upon that effect, he would perform an ultrasound guided. 

So I'd hold the ultrasound. He does an ultrasound guided Botox injection of the relevant muscles and then follows those patients up over time to see what impact the Botox had to decide whether they have muscle lengthening surgery. So we've done that, and that's really, really interesting. Yes. It I I've heard of this. 

In fact, I think you're familiar with this too, but I have spoken to some people that are doing crown neurolysis of those nerves. And the stories are almost almost too good to be true. Like, haven't seen it firsthand, but reliable friends of mine that said that have said, I I watched the rehab doctor do cryoneurolysis of the musculocutaneous nerve, and now this patient who's had spasticity for months or years, I can at least extend their elbow to a point where they can be positioned a bit better or not have complications from that spasticity. So that that seems amazing. It in fact, you know what? 

I'm gonna give a shout out, to him. There's a guy called Paul Winston who's from, BC, Victoria in Canada. He has got some really almost unbelievable videos on on Twitter or x where you see exactly this. Yeah. Paul's the guy I'm thinking of, actually. 

He Yeah. So I've known some friends who've gone to BC to watch him do this stuff, so it seems pretty cool. Yeah. Absolutely. So so, I mean, what you can achieve and and knowledge and he's even talking about you about blocking nerves or or crying, urinalizing nerves are even smaller than we are. 

So that's, I mean, that's kind of mind blowing to think what you can achieve. Awesome. Okay. Why don't we head up why don't we head up that break, man? Are we I'm I'm so desperate to tell you about this this thing. 

Yeah. So so tell me about your your totes and mosh experience with the TV show. Okay. So on a streaming platform that goes by the or starts with the letter n Nemazon Prime. Not nearly. 

And HBO. Not quite. Nulu. No. No. 

No. But anyway, I think, you know, it's a limited series of 14 episodes called One Day. And, I saw some some posts on this on social media, and and most of the posts related to people crying after watching this. I'm not quite sure why I decided that would be a great idea. God. 

Why would you why would you why would you do that? I've no idea. But I decided I said to my wife, Kate, I said, you and I gotta watch this. So I watched all 14 episodes with my wife, and I have to confess, by the last couple of episodes, I was bawling my eyes out. I was crying so much, but it was incredible. 

You're, you're really selling this. Yeah. What's what's it about? With with with dude, it's a I I don't wanna give too much away because I want people to watch it, but it was in it was set in the late eighties, early nineties, and it's about friends and friendship and an unlikely friendship that develops between these two individuals. It was the vibe, the music Okay. 

And some excellent, excellent acting. And there's one particular actress I wanna give a shout out to, Ambika Mode, an a British Asian actress. She was just fabulous in it. So I don't know. I I think I I think it's worth, worthwhile watching. 

But if you're feeling particularly fragile, maybe not. But it's definitely great drama. Okay. Alright. Now the other thing is, did you see the comment? 

You you saw the comment from Tanya Selak about our last episode. I did a little promo, and I said there may even be some controversy. We talked about this already. So so can you just can we just clear this up? How do you say controversy? 

You're not gonna like it. I mean, it's it's my Yeah. North American accent. Controversy. So what is the right way? 

Is it is it controversial? Oh my god. Do you know what? I'm so confused. Implied it was controversy. 

Controversy. Yeah. See, so, basically, now we're all lost, so I don't know. Let's let's move on. I've got a I've got an episode themed dad joke for you. 

Hit me. Okay. Why did the median nerve go to therapy? Don't know. Because it was always under pressure. 

That's like that's like a carpal tunnel. They I got you. Yeah. Yeah. Yeah. 

Got it. Yeah. Yeah. On. Okay. 

Okay. I've I've got one more. I've got one more for you. Why did the nerve keep getting into trouble at school? Press that you have these nerve themed dad jokes too. 

That's that's impressive. Don't know. Because he kept axoning his impulses. Acton in his axon. No. 

That was okay. Listen. I've got a confession. Did you did you make that up? Chat GPT, my friend. 

Chat GPT gave me those jokes. Okay. That's that's a little scary. I think I'm gonna not gonna use that anymore. I might I might have I might have to use another another source. 

You got anything for me? Do you know that that dogs can't operate an MRI? Do but cats can. Oh my goodness. Why didn't I see that coming? 

Like that. I like that. I like that. Slightly slightly medical themed. Here's one that's totally not the medical themed, but it's cutting out with the theme of the the podcast. 

Why does Snoop carry an umbrella? Snoop carry an umbrella. Okay. Why does Snoop carry an umbrella? Dog pound. 

Something when it's hot. No. I don't know. Tell me. For drizzle. 

For drizzle. I love it. I actually love it. I think that's my favorite. That is actually my favorite. 

Yeah. So listen. We we also got some other question. I thought this might be a good time to do it. This is the first time we've managed to to respond straight away to a question straight after recording a podcast. 

So we've got a follower called Joel Shapiro, who I've been communicating with over a few years. He got a couple of questions for us. Yeah. And again, it fits in with our theme of brachial plexus blocks, but with a bit of a twist. So I'm gonna give you a little prelude to his question. 

I'll want you to let me know what you think. So he performed an infracluricular brachial plexus block for forearm surgery using twenty mils of two percent Xylocaine or lidocaine with adrenaline on a sixty seven 70, woman. No sedation. So twenty mils of two percent lidocaine with adrenaline on a sort of, let's say, seventy kilogram patient. Okay. 

And just as he was completing his injection, there was a loss of consciousness. Now what do you think about that? I mean, we've been talking about how infraclavicular block is so safe. So number one, lost consciousness. What happened there? 

And, you you know, was it the was it the dose that was incorrect there, or was this localized systemic toxicity? What are your thoughts about this? You know, I've seen this. I've I mean, you do enough blocks. You're gonna have last, but sometimes it is an inadvertent vessel that you happen to be in. 

You don't see it and it aspirates negative, but you end up getting some some local in there. There's some patient factors sometimes that predispose people to last in terms of the free fraction of local in the bloodstream. But I I have been burned with two percent lidocaine before too because it is so potent. I mean, it's so so concentrated. Right? 

So you very quickly eat up your milligram allowance with a two percent solution. So I have that's the other thing that surprised me. Just getting back to my my tibial nerve block that I did on myself. I used point two percent rupivacaine, which I did not consider to be a potent surgical anesthesia dose, but I had I had full surgical anesthesia. Like, I could've I could've sized the sole of my foot with that. 

With zero point two percent Rhopivacaine? You're right. Yeah. Yeah. Now it took it took probably twenty, thirty minutes to onset, but, you know, I I think we probably use more local milligrams than we need to, in a lot of cases. 

I'm not I'm not saying that Joel did here in this case. No. Because that seems like that seems like a a a fair dose. So interestingly, he was intending on giving another ten c's another ten cc's of local anesthetic, which I think would have taken her over the the the allowable dose inverted commas. So his follow-up question was, what are our thoughts on super toxic doses of local anesthetic? 

So doses above the recommended level because, you know, there are anecdotal reports of people using more than that and not having any issues. But I think you've almost answered that, which is often we use a higher dose of local antisokes than we require because we feel that we need to get close to that level. Yeah. I I agree. I've I think as I have more experience and and I I don't wanna say wisdom. 

I'm not there. I don't know if I'm there yet, but I have learned to use less and less. I I I have I'm guilty of using super toxic doses in some patients, and there have been times when I have paid the price. I can think of one case particularly. It was also brachial plexus. 

It was also it was mepivacaine in this case, but the patient had a seizure immediately afterwards. A principle we teach the trainees, use the lowest dose that gets the job done. And and just to add an interesting thing about that, I remember, a long time ago, that we were doing metacarpophalangeal joint replacements, with a particular surgeon. And I wanted it was gonna be longest surgery. I wanna make sure they're well analgesed, but the surgeon wanted to make sure the patient had decent movement afterwards. 

And I said, look. I've got a great idea. What I'll do is I'll just put a catheter in, and I'll run a really low dose of point one two five bupivacaine during the case. So I'll, yeah, run five cc's or so, five cc's an hour. So it'll be low concentrations. 

They're not gonna have a motor block at the end of the case. The case took, four hours. Fourth times five is twenty, so they would have had about twenty cc's of point one two five percent bupivacaine. I woke the patient up after surgery. They had a complete motor block, full surgical anesthesia. 

So so I think that that that speaks to what you're talking about here, and that would have been given over a long period of time. So, actually, we probably don't really need to use that much. And, if I use point zero six two five percent bupivacaine with the half the concentration, I might have spared some of that motor block. So just food for thought. Maybe we don't need to to push the boat too hard and try and use those high doses. 

And sometimes diluting the local answer and using less concentration, less dose will still get the job done. Yep. Follow on from that is so Joel was asking, you know, this patient lost consciousness and had maybe a small seizure activity but was stable. Would you administer intralipid to that patient? He did. 

But, you know, was it necessary? Don't know. Right? And so that and for that reason, I always do. Yeah. 

And, I mean, I would argue that is an alteration of central nervous system activity. So by definition is toxicity. So what have you got to lose from giving intralipids? I think, yeah, I agree. Give it. 

Right? Yeah. Little downside. Yep. Okay. 

I think we should get back into the pod. What do you reckon? I think so. Right. Okay. 

Cool. So this bit's gonna be relatively quick. You mentioned a bit earlier on talking about the lateral antebrachial cutaneous nerve and the medial antebrachial cutaneous nerve. So for those of you who don't remember, the lateral antibrachial cutaneous nerve is that terminal sensory component of the muscular cutaneous nerve. And the medial antibrachial cutaneous nerve or medial cutaneous nerve of the forearm is a branch of the medial cord. 

Do you block these nerves individually? And if so, when? Occasionally, when I have procedures that I want to do under block alone, so no GA, and they're gonna be involved the wrist or forearm. And and so to me, there's a there are a couple ways of doing it. A good way to do the lateral cutaneous nerve of the forearm is to block the musculocutaneous nerve up in the axilla, but that's gonna take out your biceps as well. 

Yep. So an easy way that I have come to do these is to use the veins Mhmm. Just above the elbow crease. So there's the basilic vein and cephalic vein, and the lateral and the medial cutaneous nerve of the forearm lie just beside these on either side of the elbow. And so you can just Mhmm. 

Scan and find those veins, and then just even if you can't see the nerve, just put in a of local but outside of those two big veins does the trick. Yeah. No. It it really works well, actually. The one thing I've learned is actually cephalic vein doesn't lie as laterally on the, on the adecubular fossa as you think. 

So, again, I use the the brachial artery and the median of as as anchoring landmarks, and then I scan medial to identify the basilic vein and go a bit more proximal. Sometimes you actually see the medial antebrachial cutaneous nerve lying by the basilic vein. If I don't, I just pop some local enzate around it. And likewise, I look for the cephalic vein, which often sometimes sits above, the midpoint of the antecubital fossa. And if you're really lucky, you'll sometimes see the lateral antebrachial cutaneous nerve there. 

You know what I have done before is I've actually scanned from the muscular cutaneous nerve in the axilla and traced it right the way down to the antecubital faucet. And the largest branch, the last branch that's left is a lateral antebrachial cutaneous nerve. So with a bit of practicing, you can see that. And do know what? Put a couple of videos on my my YouTube channel just to show how to identify those. 

So Oh, great. On this note, I so I had a have a surgeon who sometimes doesn't like us using brachial plexus blocks for distal open reduction internal fixation of distal radius fractures. So, you know, I when I first found this out, he was like, oh, you know, I don't want a proximal brachial plexus block, but you can do something peripheral. So I was thinking back in my early days when my anatomy maybe wasn't as good as it is now. I thought, distal radius fracture, that's gonna be radial nerve because where's what's that rule? 

Is it Hunter's rule? There's a rule about any nerve that passes by a bone will give innovation to that bone. I can't remember the name of that rule. Hilton's law, I think. Hilton's law. 

There you go. Well done. Thank you for being so I think Paris Hilton was the Paris Hilton. Yeah. I can't remember the phrase that she says all the time, but it's gonna it's gonna come to my mind. 

That's hot. That's right. I'm actually ash I'm ashamed I I know that. I mean No. You should you should show your age. 

Okay. Keep that in. So so Hilton's law. So so the radial nerve that made sense, and I was thinking, oh, it's radial and and it must be median. I was just thinking about where the median nerve innervated in their hand. 

So I did a radial and a median nerve block, and the patient woke up, and they were in agony. And very respectfully, the said and said to me after is, Amit, you know, I don't think the median nerve innervates very much in the wrist. If you look at the anatomy, you might find that's the lateral cutaneous nerve of the forearm, which comes to the muscular cutaneous nerve. There was a lesson learned. I changed my practice, and now if I'm giving a GA for distal radius fracture and I'm not doing a brachial plexus block, I'll add in radial and lateral a antebrachial cutaneous nerve, and it does make a big difference. 

Yeah. Agree. I mean, very occasionally, they do get some breakthrough pain and I'm actually wondering in those cases whether that breakthrough pain is because, you know, the and we mentioned the anterior interosseous nerve that comes from the median nerve that does supply some sensory innovation to that wrist joint. I'm wondering whether sometimes by not blocking the median nerve, I'm missing out that branch and maybe that would be useful. So, yeah, just something to think about. 

I still think the problem is Martin Gruber. Yeah. Yeah. Yeah. Tasas called you. 

If if okay. Stop. Stop, Amit. No accents. Okay. 

Listen. I wanna finish up. I wanna finish up on another controversial subject, and that is. So you're talking about wide awake local anesthetic, no tube. Is that two is it T tube? 

No tourniquet. No tourniquet. Tourniquet. Wide awake, local anesthetic, no tourniquet. No. 

That's what I'm talking about. Okay. Do you do it? I don't know. I've seen this this term tossed around. 

I don't really understand what what people are getting excited about. Okay. So what they're getting excited about is they take large volume of local anesthetic and, they dilute it. So large volume dilute lidocaine with hyaluronidase or hyaluronic acid and adrenaline to dilute, adrenalize, hyaluronic acididized local anesthetic, and they slowly infiltrate all of the planes they're gonna be operating in. And, essentially, the adrenaline can causes vasoconstriction, but not dangerous vasoconstriction. 

So there's no bleeding, and they've got full preservation of motor power or motor function, but no sensation because they're blocking all those tiny nerves. So they u they used this during COVID when there were no anesthetists. All the plastic surgeons did wallant and and and carried on without us. Wait. Why didn't they have anesthetists? 

Because during COVID? Are you joking? Because we were intubating patients, and we were running ICUs. And so if patients needed so we didn't maybe have enough, cover for as many operations as they needed to do. So they were able to get on with some trauma cases without Anesis being president because they were like, hey. 

We don't need someone to do a block. We'll just do Wallant. And the, you know, the patient doesn't get a motor block. They get surgical anesthesia, and they don't need to use a tourniquet. Okay. 

So I understand the no tourniquet thing now because this sounds like a beer block without the tourniquet. Well, except it's not meant to be intravenous. Right. Yeah. Yeah. 

Yeah. Sure. But but large volume lidocaine in the Yeah. In the okay. Alright. 

Yeah. Sounds okay. I I has there been a case supportive toxicity with this? Not that I'm aware of, but that doesn't mean, it hasn't happened. I haven't specifically looked for it. 

But, you know, people like, Vicente Roques, who we've shouted at a few times before, he does something similar for knees. And in fact, when I posted one of my my ambulatory spinal, knee arthroplasty patients, he then showed a a picture or a video of a patient moving their knee intraoperatively whilst having a knee replacement surgeon surgery because it had this this equivalent. Why you know, they put high volume dilute local anesthetic with adrenaline into all of those structures. This patient had their their surgery without what we would classically describe as regional anesthesia. But, yeah, it's it's interesting. 

It's it's it's it's cool stuff there, but I've seen it used for upper limb surgery a fair amount. But I was just wondering whether you had any experience of that. No. No. We, so one of the other principles that I I've always taught and observed is that local anesthetic placed at a named nerve will give you a longer acting block than local anesthetic placed next to nerve endings. 

And so this is one of the several reasons why I think doing peripheral nerve blocks for things like total knee replacement works way better than someone infiltrating squirty squirty squirty around the joint. And and I guess for hand surgery, it's not quite as big of a deal because, know, you wanna use your hand afterwards. If it wears off quickly, that's that's alright. Yeah. I I get the I get the reason for the innovation during COVID. 

That makes makes a lot of sense. But, but if you I think if you have the skill set to do a nerve block that will give you more consistent results, maybe. Listen. I hear you. And I also don't wanna lose a job. 

But you know what? I'm gonna invite, Vicente Roques, Matthijs Desmond, who I think does this, and maybe Sebastian Block as well. We I'd love to hear Yeah. What they think about Wallant, why they're doing it. Sometimes they're doing some of this with ultrasound. 

I'd love to get some engagement from them or anybody else out there that's doing it just so we can understand. I wanna know how Vicente is doing this for knees. That sounds amazing. Dude, yeah, I think I think the paper's coming, but there's a video. If you if you I'll I'll see if I can find the video and link it to one of our block it like it's hot post, but he is doing some incredible stuff out there. 

So, you know, it's just something to bear in mind. Well, listen, Jeff. That's a that was a I did not realize talking about those small, small nerves and those big, small nerves would have taken us this long. But, hey, what an exciting, an interesting episode. I I hope our listeners enjoyed it as much as we have. 

As always, I've learned some things from you. So thank you for that. No problems, Martin Gruber. So so listen, guys. If you want to have us do more of this, please please like and rate us on your podcast provider that helps us get to more people. 

And as always, follow us, on the socials, Twitter at block it underscore hot underscore pod. YouTube. Can I let me do YouTube, please? Block it like at block it like it's hot, and then I'm gonna leave Insta for you. Yeah. 

The block it like it's hot with underscores between all the words. That will make it sound so much better. Don't don't forget to use our hashtag, the full one, which is hashtag block it like it's all, or our new abbreviated one, hashtag b I l I h. Until next time, guys. We hope you all Block it like it's hot.