S2:E4 "Top Tap Tips for Tums: Abdominal Wall Blocks (Part 1)"

Planks are used to make cabinets and to tone up your six pack. We'll talk about both types here, so grab your seven layer bean dip and settle in. I'm Jeff Gadsden. Wraps, taps, two pack, and carpentry. There is so much in this episode you won't want to miss. 

I'm Amit Pawa. And this is Block it like it's hot. Hey, Jeff. We are cruising through our season two. I'm doing great, man. 

How about you? Did you realize you just wrapped that intro? I don't know what to say, man. Sometimes it just comes naturally. Yeah. 

And when you got it, you got it. I know. Well, of course, I planned that. But how are you, honestly? How are you doing? 

I'm I'm a good man. Thanks. What have you been up to? Tell me. Working a lot. 

We're getting most of the way through our fellow years, so we're trying to wrap up or, you know, push forward some projects. Kids are busy on the home front. We got sports, soccer, lacrosse. It never it never ends. Right? 

There's so many things going on. Yeah. I'm building some doghouses for our three months. You're you're building them you're building them yourself? Well, we have three Shih Tzus, and so they're they're small dogs. 

They're eight pounds each, but they sleep overnight in these little crates, these wire crates in the kitchen. But it's not that attractive, and they're kind of the wrong size. Now that we added a third one over Christmas, that the third one kinda sticks out from the alcove a bit. So I'm making custom doghouses for these little guys Wow. That are just gonna fit just nicely in that little area. 

Oh my god. Okay. That, I mean, I I knew you had skills, but that's, like, next level. There's no way. I was I was you know, there was one time when I, we had an old desk at home, and, my wife, who wasn't my wife at the time, she was my girlfriend, she said to me Kate said to me, oh, are you gonna are you gonna get, get rid of this desk? 

We're not using it anymore. I was like, no. I'm gonna turn it into a drinks cabinet. Oh, nice. She went away, for the afternoon, and all I had at home was a junior hacksaw. 

And this thing wasn't really up to, up too much. So I spent about an hour trying to to trim off the lower part of a door. I went through three blades, and then I gave up, and then she came back and just saw all this sawdust on the floor. So I think your your, carpentry skills, that must be must be legendary. Oh, you haven't seen them yet. 

I mean, they could be a total travesty, but I just hope the dogs are safe inside them. Yeah. I'm sure they will be, man. Yeah. How about you? 

Well, Jeff, you know what? It's been quite a week. We were initially planning on recording this podcast a couple of weeks ago. So, initially, I kind of thought we would talk about how nervous I was for REUK, but you know what? It's happened. 

REUK's happened. We we've had the conference. Well, Alan McFarlane, Toby Ashkin, Maria Passebastian, and Nat Haslam, these are the guys that organized that along with the whole of the REUK board. They did an amazing job. It was, I think, it was our best conference yet. 

And I say hour. I'm not part of REUK anymore, but, know, I still feel like it's part of part it runs through my veins. The conference was great. Amazing. They treated me very well, and, you know, everything went according to plan. 

So I'm I'm feeling on a real high, actually. That I I bet you are. I mean, I was following along on Twitter different lectures and workshops and stuff that was going on, but, of course, the crown jewel, as it were, was the Bruce Scott They talk about my crown jewels like that. Was the was the Bruce Scott lecture that you delivered on Friday. Yeah. 

I haven't yet seen it. And I'm looking forward to the recording when it comes out. But what was really cool was to see the reactions of people on social media react to your lecture. And it was it was it was clearly of an an incredible lecture and emotional and personal, and people had amazing, amazing reactions. Well, listen. 

Thank so much. It's really kind of you to say that. What all I can tell you was I've never quite given a lecture like that before. So, it was very different from what what I've done before. It's like, this is it's not how this is how you do this block or the evidence for this block says the following. 

It was very much a kind of, I decided to present it as a my personal journey. Yeah. Of course, that, you know, that there were some emotional components to that. You suddenly realize that you're not as young as you think you are. And then you most importantly, you go back and realize how many people have influenced your career. 

And, actually, for me, it was really great to be able to to give certain people the thanks, and recognition they deserve. So, yeah, it was cool. I wasn't expecting the reaction that I got, but it was it made me feel very special. And they were you know, as you know now and as we can reveal, there were a few cameos that made it into the, into the lecture. Tanya Selak, Agongas girl made it in there. 

You recorded something very nicely, and Claire Braganza from Behold in The Philippines. And, actually, although I couldn't have planned it the way that it went Yeah. All the video, they just came in at just the right point, Gave me a little chance to take a breather. Oh, that's good. Nicely introduced the podcast. 

Actually, Claire's video very much summarized my talk. So Oh, that's great. I I'm very great I'm grateful to everybody for their support, and I'm happy it all went well. So it was a blast. And if you're if you're still interested, I'm sure you can, you can still purchase some access to the conference. 

But you know what? At some stage, when I had a chance that it all digest, I might record the Bruce Scott lecture in a slightly less emotional manner and pop it up on my YouTube channel. I can't wait to see it. That's that's amazing. Congratulations again, man. 

You'd well deserved. Thank you so much, and and thank you to everybody else for their support. But you know what? On a non REK subject, the other thing we did that was quite cool Okay. Was we live right by the start of the London Marathon. 

And so we, our friends at Salisbury's, who featured nearly regularly on this show, they live on the road where where the the marathon runners for one particular start run down. So Oh, very cool. We went to stand there with a cup of coffee and a croissant for the start of the London, marathon. Actually, we saw Nick Gillfillan, who's one of my consultant colleagues from Cleveland Clinic London. We we knew who's gonna be on that run, and I managed to track him on the app. 

And I got a video of him running passes right at the beginning of the race, So that was super cool. Oh, that's amazing. I hear it's a good course as well. I do you run? Do you run at all? 

Yeah. In my mind, thoughts run through my mind. That's the extent of my running. I've never done a marathon before. I keep thinking, like, one day. 

I've done a half marathon. In fact, I I did a I did an event with my brothers once in in Lake Placid where Uh-huh. It was an out and back half marathon, and then you could do that again and make it a full marathon. And so I knew I wasn't gonna do a full marathon, but they did. Right. 

And so I did the half, and then I said, see you. And I went to the went to the bar and then I knew you could have saved me. Of course you did. Well, that's how you recover from a half half marathon. It was enough for me. 

But ever since then, they were they refer to themselves as athletes and me as a half late. Oh, half late. I like that. Yeah. Yeah. 

So You know, there's one last thing before we get into it. One last thing that I've been looking forward to and planning. So we're being visited, by two North American families this summer. Number one, the Ganstens, and the other, the Marianas. So, actually, I've been looking forward to planning some entertainment for those families and can't wait to see you guys. 

Yeah. Yeah. I know. Suss. We talk about it every day. 

So we're we can't we just can't wait. Yeah. Well, you know, and one of the, one of the things that I've planned for us is to go and to check out some Indian food. I'm not gonna give away free advertisements for the, for the location, but maybe we can do it afterwards if we get some sponsorship. Although, yes. 

Unless they wanna sponsor us. Yeah. Sure. So you like Indian food. Right? 

Oh my god. It's my favorite. And I know that London is is the best. Chapel Hill Indian is okay is okay, but, yeah, really looking forward to it. Yeah. 

We think you're gonna like it. But listen, I know you've got a lot of, you've got a lot of connections to Indians. So how is it that you've become an. What's the story here? I don't I don't know. 

I just I had this affinity for, all things Indian for for decades. And, guys, what you can't see is as Jeff is saying that, his head is just slowly rolling from side to side in a way that you only know if you know. I might have a small Bollywood collection of DVDs. Oh my god. Well, in that case, you're ahead of me, man. 

You're ahead of me. Well, yeah, we we can't wait. We're we're looking forward to, hanging out with you guys and finally meeting, Kat and the girls. I've I mean, I heard so much about them. I feel I feel like they're almost family. 

So Exactly. Likewise, man. Likewise. Okay. So what what are we gonna talk about today? 

Well, you know, it's another controversial area that was kind of triggered in my mind by something that Lloyd Turbot once said. And I remember he he he did this on social media, and he put a tweet out, and it was like, the tap block is dead. Who? And it kinda got me thinking, should we take on the whole abdominal wall thing? It's like, it's a really big deal. 

Are you ready for this? Yeah. That's a that's a massive topic, but, oh, it might be a two parter. But, anyway, let's let's let's try. Okay. 

So so, Jeff, tell me when you think abdominal surgery, in The US, in your hospital, and when you're thinking regional, what's the reflex first thing you think about in terms of analgesia? It's funny that's changed over the years. Right? So when I was growing up in anesthesia, it was thoracic epidural. That was what you did for every major abdominal case unless it was laparoscopic. 

So that that would be reflex. Open abdominal surgery, big midline ins big midline incision, automatically, the you think about thoracic epidural. Right? Yeah. Yeah. 

And you're telling me that's now not your reflex reaction? Yeah. That's changed. I mean, that we I mean, thoracic epidurals are amazing, and it and if I were getting a big belly whack, I think I would want a thoracic epidural because I I think it's a gold standard. But they have baggage. 

Right? So and the big problem that we have had at our institution is that the hypotension on the floor is problematic. So, you know, you're running these patients on the the brink of euvolemia, and then you can get them through with a bit of phenylephrine in the OR. And then by the time they get to the floor, the epidural is still running and their pressure is sagging, and then someone turns it off, and then they have pain, Uh-huh. Etcetera etcetera. 

Now there are ways around this. And I I wish that I worked in a hospital where you could run a phenylephrine infusion on the floor, but you we can't. So thoracic epidural have gone really by the wayside and we're doing way more fascial plane blocks. How about you? You know, I think The UK practice hasn't quite made that full shift yet. 

So I I remember probably the the gold standard for use of thoracic epidurals in my career was when I did my, liver transplant fellowship at King's College London. And they had a phenomenal so when we used to do a hepatobiliary cases, the default now you might cringe when I say this, but the default used to be GA, flip them on the side, asleep thoracic epidural. That was that was the way we did it. They then have the surgery. They'd wake up, you know, euvolemic, perfectly analgesed, and they'd be nursed in an HDU setting for twenty four to forty eight hours. 

And you would go and see these patients the next day, and they did not look like they'd had surgery. These were the, you know, the hepatectomies or Yeah. Yeah. The whipples or those cases that were slightly long. They were done by the transplant surgeons, but they weren't liver transplant. 

The big juicy Yeah. Hepatobiliary cases. You look at them the next day, and they looked amazing when the epidural worked well. That's what I mean. Like, mean, that's what I want as a patient to not look like I've had surgery. 

But you said something interesting there. You said when it works. So tell me more about that. Well, you know, I've definitely had you know, you remember those days when you you put in a journal and it kinda feels okay. You get that, you know, you get that meniscus drop when you hold your catheter up. 

You think, yeah. I'm I'm pretty sure that's there. And you give the bolus, but then you you know, do you get a drop in blood pressure prior to the knife to skin? And then, you know, the surgeon will stick a knife and you get, you know, a rise in blood pressure and a rise in heart rate thinking, is this gonna work? Is it not gonna work? 

And I said your whole day's stressing about it, and then you wake them up, and then they're great or they're not great. And sometimes they're one-sided. If it doesn't work first time, once you gotta start fiddling, then I think it's a nightmare. Or if you get your level wrong. So there's a lot of planning. 

Right? Yeah. Yeah. And sometimes I just think the epidural space is finicky in terms of where the local goes. Yeah. 

I have a slide I get I put up sometimes. I'm talking about this showing fairly contemporary literature, a overall rate of epidural failure of twenty five percent. That could mean patchy or one-sided too, not just, like, oh outright failure, but, you know, that's high. That's really high. That is really high. 

Now I've now I've just suddenly got, something coming to my mind. Do you remember this whole talk about the Tzuyu there was it the Tzuyu test? So Gordon Lancelot and Kwesi Kwofe talked about using stimulating epidural catheters or converting an epidural catheter into a stimulating one. So you pop it in, you put some electricity through it, and you can look at the intercostal muscles twitching to work out where the where the catheter's placed. Have you ever done this? 

I've never done that. No. It sounds crazy. Right? But also sounds like, why aren't we doing this? 

I mean, my admittedly, I haven't, like, used a catheter that would show up on X-ray and and then fluoro or stuff. But my impression is that these little nylon catheters that we use coil up a lot and don't head straight up the epidural space towards the head. Mhmm. I mean, the SUI catheter was different. Okay. 

Well, Jeff, hold on a minute. There was a little throwaway comment there that I wanna pick up on. You mentioned the term fluoro. Now I remember ASR did this. I believe it actually may be at Brian Sites' institution, the editor in chief of RAPM. 

They use fluoroscopy to identify the epidural catheters. What do you think about that? That seems like a lot of work, but but maybe one way of definitively knowing where your epidural catheter is. To me, it seems like a lot of work in ionizing radiation and for something that we get in routinely and works well most of the time. It seems like a lot if you weren't gonna be using fluoro for part of the case. 

So what so one of my colleagues does a list in the endo endourology unit, and they got fluoroscopy there because they use it for the case. And if he's gonna do an ESP or a paraveral Uh-huh. He'll do it ultrasound guided. I mean, just before he administers the drug, he'll give a bit of contrast and look at the fluoro to double check. Now that's cool because it's set up, and, actually, they're gonna be using fluoro for the case. 

The flip side is he does it in an anesthetic room and says, now, let me move them to the Fluoro suite to test that I'm in the right place. That seems a bit much if it wasn't part of your practice. But I I don't know. It's it's interesting. I'd be interested to hear what people think about that. 

Yeah. It's it seemed to me like people that were using fluro routinely, like pain positions, were quite comfortable with it, which makes sense. And and saw it as no big deal. Whereas someone like me is like, wow. That's I don't know. 

Wouldn't even know how to turn the machine on and, I gotta put lead on. I don't know. It just seems like a lot of work. You know, it may be fear of the unknown as well. You know, it's not standard practice. 

Yeah. Now, see, one of the advantages of the epidural is, of course, is the ability to continuously administer the medication. And and if you do a which compare compare that with a spinal, of course, we've got a shorter duration of action. But has anyone ever done have you ever considered doing a single shock epidural? Is that something that people do? 

I've only ever heard of epidural as being done as part of a you do the epidural, you thread a cast, and then continuously administer the stuff. But is there a role for single shot epidural? I've never heard anyone doing them. I god. That's pretty rare. 

Right? I I no. I don't think I have. So so I know one guy that used to he didn't want to have the hassle of dealing with a lumbar epidural. This is back in the days when we used to do lumbar epidural a lot for gyne surgery. 

Right. And so he didn't wanna have to to deal with the hassle of of having lumbar epidurals running on the ward afterwards. But he would do a single shot lumbar epidural and put in some opioid. We'll get onto that. And and then he was like, listen. 

It's so much better than doing a single shot spinal. I get prolonged duration of analgesia. And then tomorrow, the next day, by the time the epidural bolus and the opioid is worn off, the patient's up and about, and they're through the worst of the pains. That was one indication we've heard people using it for lumbar epidurals, but I've never heard people use it for thoracic. So I was just wondering No. 

I've never I've never seen that. Okay. So, Jeff, so listen. I'm worried here. Right? 

You're saying that you're doing less and less thoracic epidurals for major abdominal surgery. So if you're doing less, that means you're teaching less. And then so who's gonna do your epidural when you need to have your major abdominal surgery? God forbid you do, but how are gonna train people to do them? I'm getting on a plane and coming to London, I guess. 

Now we still we still do them. They're at just far less I think we were a very, a high user, centered when I first arrived at Duke ten years ago, but, it was it was really part of our ERAS protocol. Everybody who was even the even the laparoscopic stuff that may have a small incision to deliver the colon, got an epidural. And so those have gone away. And we've we're reserving them for the kind of the stuff you're talking about, like the big hepatobiliary cases and and so on and so forth. 

Uh-huh. But you're right. I mean, it's it's we're doing less of them now. I mean, obviously, it's been a long time since I was a trainee, but what I can tell you is that, yes, the centers where it's really key slash useful to have them. So people are doing esophagectomies, they tend to get thoracic epidurals. 

A lot of our thoracic surgeries are either getting surgically administered paravertebral or anesthetist administered paravertebral. And then the major abdominal surgery, it depends very much on the anesthetist and the institution as to where they get them. So I am seeing a fall off in the training opportunities for thoracic epidural, which makes me nervous. And it used to be a rite of passage. You knew you were good enough to be a senior registrar on call overnight when you could do that thoracic epidural by yourself. 

And once that was a tick, you're like, yeah. Now I can do everything. But now it's not a given. I don't think it's a given. I want the trainees who are listening to correct me if I'm wrong, but I think you sometimes have to search for those. 

I I still think it it's something that people aspire to make sure they've got, and we could they feel complete as an ethic unless we can do it. But I'm definitely worried that the training opportunities are diminishing for that, and that used to be something you say, yep. I know we're gonna have enough of those done. And you know what we're moving to, man? For most of our procedures, we are moving to single shot intrathecal slash spinal injections with varying doses of opioid in there, and that seems to have taken over. 

Really? Yeah. That see, my my hot take on that is it seems like that's a step backwards from moving away from opioids and keeping patients in hospital because they have pruritus and nausea and Well, this is the whole thing. Right? So there's a big push slash desire to get this opioid free anesthesia, but, you know, sometimes we don't really need to be completely opioid free. 

Maybe we need to reduce opioids, but the intrathecal route of administration is something that I still don't really understand. What's fascinating is I was listening to Eric Albrecht present some of the evidence on intrathecal opioids for hip arthroplasty, for example. And if you're talking about intrathecal, morphine, there seems to be a ceiling effect at about point one milligram, a hundred mics of morphine. And he's like, if you go any more than that, you don't seem to get analgesia, but then you do tend to get side effects. Now flip that to dimorphine, and I have been working at Cleveland Clinic London and learning from one of my colleagues, a chap called Jeremy Proud, who incidentally is the only triple fellowship qualified anesthetist I know. 

He's got the physician exams, the surgeon exams, and the anesthetic exams, like, bright. Woah. And he and he's got a law degree. Anyway, so so Does he have time to work? I mean, getting all those Well, he I would I don't know how he does it, but, anyway, he he's a legend. 

And Wow. Impressive. So Jeremy has been using, varying you know, increasing doses of dimorphine to the point where he's been putting in, you know, a milligram or milligram of a half and a half of dimorphine in the spinal space. And these patients have got, like, twenty four hours plus of incredible analgesia. Now I don't know where the ceiling point is for dimorphine, but I suspect it's different from morphine. 

And I remember, an old fellow of mine, a chap called, Tom Wojciekovich, he did some work in patients with obstructive sleep apnea having bariatric surgery and looking at the various dose of of opioids. So I think there's something there, and I don't think you need to be as scared about it in the same way that, you know, you think of The US, you think of opioids and get nervous. I think there may be something there, man. Well, I I I don't disagree. I think that they're you know, use the right dose, right route can be very, very safe. 

And I think for the neuraxial opioids, the reticence is not so much about the opioid crisis that we've been going through here and and getting somebody hooked on Uh-huh. On opioids postoperatively. It's more about the side effect profile. Right. And because as you mentioned, if a 100 mics is the ceiling effect, anything over that is just gonna increase your side effects. 

You're gonna start to get nausea and vomiting and itchiness and all that stuff. The only place we still do that a lot routinely is in, OB. Well, you know, this this kind of segues very nicely in what I wanted to lead on to next because my understanding from there's some great work being done by Neil Desai, Kareem Desai on Wachey looking at fascial plane blocks in cesarean sections. And my understanding is that if you add in an intrathecal opioid into your spinal, there's less clear benefit to adding in a fascial plane block after, cesarean section. So I I I'm sure you're familiar with those with those papers and the things I'm talking about. 

So that kind of leads us nicely onto our fascial plane block. So you said when you're moving away from thoracic epidural, fascial plane blocks sort of come to the forefront. So what options have we got, Jeff? Well, that is a that is a loaded question because there are tons of options. Right? 

So we got the old the old tried and true tap block. Mhmm. The one that Lloyd said is is dead. And that was an interesting comment. Obviously, he did it to be controversial, but I think I think he felt that to a certain degree. 

I think a lot of us have felt that. And I'll say it. I don't enjoy doing tap blocks. And I'll get into I'll get into that more a bit later. But so to me, I when I think about the abdomen, when I'm called to the room and they say, hey. 

The surgeon had to open. We wanna do a fascial plane block. Can you guys come and do one? My first question is, was it midline? And if it's midline, I breathe a sigh of relief. 

I grab my team, put my cape on, and I run to the room and do a rectus sheath block for the for the midline, which I love. Love a good rectus sheath. And if it's lateral, so out like a Pfannenstiel incision and below the umbilicus Uh-huh. That to me is a good indication for a tap. If it's above the umbilicus exclusively, then we used to do subcostal taps. 

Now we're doing more external oblique intercostal blocks. And then if it's all over the place, rather than do a combination of those, which, you know, we used to do this thing called a four point tap, which is tap tap, and then again a tap tap, subcostal tap. So one, two, three, four. Uh-huh. We're more likely now to to put them on their side and do a QL or an ESP. 

Holy moly. So, like, that what did I say? Like, that's six or seven different different blocks you could do. It's almost as if you knew what I was hoping we would be talking about in this episode because you basically ticked all the boxes that I'm looking at over here. So this is great. 

Okay. So let's, let's let's wind it back. Let's wind it back. So when we're doing I was waiting. That was the first sound effect we've had so far. 

Thank you. So when we're doing these abdominal wall blocks, what are we aiming to target? We're we're aiming to get the the intercostal nerves, right, and say somewhere between kind of t six down to t 12 l one just to get that abdominal wall analgesia. That do you agree? Am I missing anything out there? 

No. That's that's that's good. Yep. Good summary. Now tell me, do we expect our fascial plane blocks to give us both somatic and visceral analgesia? 

Because, of course, when we're doing our thoracic epidurals, we're hoping to take the whole kaboot kit and caboodle out. But when we're doing our fascial plane blocks, we're not gonna do the same. Maybe. Mhmm. Okay. 

Uh-huh. So I I would I would say there's a line you can draw and say, on on one side of the line, you've got tap, subcostal tap, rectus sheath Uh-huh. External oblique intercostal, and those are just somatic. Right? They just get the They kinda round the front. 

You get everything around the front. Yeah. Lateral and an anterior and possibly anterior cutaneous branches of the intercostal nerves as you mentioned. And then QL and the ESP, there have been some cadaveric and clinical data to suggest that those do get the visceral component because they get into the paravertebral gutter and so on and so forth. And so you might expect a better response from those blocks, from that point of view. 

So I remember speaking to John McDonald about his because, of course, he didn't invent the TAP block. There was this Raffy block that had described before, but he was working in a in a hospital where if you were gonna be doing a major abdominal midline surgery, you want to put an epidural in, the patient had to be nurse in intensive care afterwards. And they didn't have intensive care beds for this particular operation, so he was asked by his professor to go and research a different approach to doing some abdominal wall analgesia, and he sat there with, with some research and some textbooks. And he he sort of looked at this landmark approach to the TAP block, which at that stage was called the Raffy block, but he then called it the TAP block, going through the triangular petite. Now the story was amazing. 

So they did this block, and, this lady had a surgery. And the next morning, he went to go and follow her up on the ward, and she wasn't there. Uh-oh. I was like, oh my goodness. What's happened? 

And she was outside the front of the hospital smoking a cigarette because she felt so good. So so so I guess what I'm saying by giving you that story, which may well be a story of fiction, but he tells it with such truth, I believe him, is that, actually, it can't just be a somatic block if you do it where he did it for the lady to feel so good afterwards. So the landmark tap block that was done at the Triangle Of Petit, was that the same as the old Sangare tap block that we all started doing afterwards? And if not, why not? Yeah. 

That's a good question. I've I've never done the landmark one in the Triangle Of Petit. And let me just say this at the at the outset regarding TAP. It may be it's just me, but I find it difficult sometimes to get that plane to open. So I'm using a really good ultrasound machine, best needle we've got, and all the skills I can muster, which may not be all that good. 

But, you know, trying trying to land that needle in the plane between transversus and internal oblique, I struggle many days. I'm like, oh, I'm in the muscle and I pull back and then I'm in the other muscle and then, you know, back and forth. And then you do a little bolus. The way we failed with taps initially, we were so excited. Right? 

We read McDonald's papers and thought, oh, this sounds great. We'll we'll do tap blocks for everything now. And we didn't have good success. One of the reasons was because we were putting the needle in at one spot, injecting a little blob of local in one spot. And sure enough, we got this weird pattern of sensory analgesia that didn't correspond to the incision or or may not have corresponded to incision. 

And we learned over time that you you really gotta work to open that plane up and move your needle and move squirt, move squirt, move squirt kind of thing throughout that plane. I think this is a real thing that's coming to the forefront now when we're thinking about fascia plane blocks. It's not the case of popping into the plane, keeping your needle static, and doing nothing because fascia is kinda like a spider webby type thing. You kinda gotta work your needle through and and and break open some of those, those adhesions and open things up. So I think that's a really key point. 

You gotta keep working your needle. Right? You did a cool little thing with your hand there when you said spider webby. Kinda makes me think you're just watching Spider Man. You got the I feel I I I, you know, I couldn't help myself from doing that. 

That's that's I talk with my hands maybe too much. So I so I think I I was guess I guess what I was leading you to say is I think that the the landmark tap block that John McDonald did back in the day was basically a quadratus lumborum block, and we're gonna maybe talk about that in another episode. But I think when we when we brought ultrasound to the foreground for the foreground, we were like, okay. We gotta three see these three muscle layers. That's what we would describe, and it's much easier to see them all anteriorly. 

So if you can see them anteriorly, you get great. That's perfect. Then you gotta work on getting in the plane. But maybe all we were doing was getting this kind of surface infiltration type analgesia, and the local anesthetic never went where the landmark tap or the posterior tap should have been, and it never went into the paravertebral space. So why I think we're getting that difference and also why we weren't seeing good coverage with a ultrasound guided tap above the umbilicus. 

We were basically getting t ten and below. Right? Absolutely. Yeah. And I'm I I kinda distracted there with my with my diatribe against the tap plane, but I what I was gonna say was I've I can't imagine where where John's needle was blindly to get to get a great block. 

But I think you're right. I think he was he must have been doing something much closer to the neuraxis and the sort of thoracolumbar fascia than we were ever doing with the ultrasound guided tap. So, yeah, totally agree. Okay. So you you've highlighted some interesting things there, which is, you know, we've heard a world famous expert in regional anesthesia, k Jeff Gadsden, say he doesn't find it easy to open up the tap planes, and that should give all of us some guidance. 

Oh, not some guidance, some reassurance. You know, if we find it hard, even someone like Jeff can find it hard. But where do you think the perfect location for the tap block is? I have in my mind that I know what I teach were at workshops for people to do. But if you were if you had to teach in a workshop people to find the correct I'd I'd number one, find the correct plane, but number two, find the correct injection endpoint, what would you tell them to do? 

And by the way, wanna give you a shout out to one of your, your YouTube shorts this year, or last year about plate tectonics and moving your your probe up and down and seeing the abdominal wall muscles moving in different directions. That was super cool. Man, I I like simple tricks to keep me honest. So another way we failed early on I'm telling you all my failures here. This is this is like a constant running theme for the for the podcast. 

But was again, we got excited about John's reports. I was yeah, do a TAP block. We put the probe relatively close to the umbilicus, like on the anterior abdomen, not on the side. And of course, you can see the three muscles there fairly well. And we got excited and we did our little thing and didn't get great results. 

And over time learned, a, we were downstream of the takeoff of the lateral cutaneous branch. Uh-huh. So really what we were doing was a complicated rectus sheath block. Yeah. So we kinda learned, oh, I guess I'm gonna get I gotta move the probe back further posterior, further posterior. 

Where I tend to like to do it now is I'd still start on the ant sort of anterolateral abdomen because I can see things nicely, and then I'll move the probe around the side of the flank until I see where transversus abdominis ends. Phew. Thank goodness. I was hoping you're gonna say that. Is that what you did too? 

Yeah. Yeah. Yeah. So so so that's where you aim for it. Right? 

Yeah. Because I feel I I feel like the bulk of the evidence and our clinical experience and possibly yours as well shows that the further back you are, the better it gets. Yep. Cool. So I so I mean so I I I in my mind, I call that the posterior tap block, and I think I think the key is you gotta go back as far as you can. 

Although the thing that you said there, I we can't underestimate how useful it is to start off on the anterior abdomen because patients with different, body mass index or different, body habitus can provide some slight confusing, sonographic images where you place the probe on the abdomen. You're like, woah. Where is the right layer? And sometimes starting at the midline allows you to identify the rectus sheath tethered to the three abdominal muscles, and then you can work out where you are. Right? 

Oh, thousand percent. Yeah. So we'll put the probe on sort of closer to the midline and often see rectus or sometimes see the the three tap muscles. But, mean, you look at some of these videos and it's a very nice three layer cake with a little bit of adipose tissue. But, you know, the reality is where I work, it's more like a seven layer bean dip. 

And so you're trying to figure out which Seven layer bean dip. Which one's the which one's the nacho cheese and which one's the sour cream and which one's the lettuce and everything. But so so to pick up on what you said a second ago, what I'll do is fan the probe cephalocaudad and all the fat kind of stays the same and those two oblique muscles which are naturally oriented at 90 degrees to each other will appear to move in different directions. And it really amazing how much that that little move maneuver Yeah. Brings those two planes out of the background. 

Right? Uh-huh. For sure. Now listen. Before we head into a little joke break here, I want to just touch on this subcostal oblique tap. 

So I understand. I think Peter Hebbard was was instrumental in describing this. This is starting from the midline along the costal margin, identifying rectus sheath, and you see the transverse as a numbness muscle just sneak underneath the rectus sheath in the midline and use a long needle from the midline gauging or, you know, directing out laterally to open up that plane, but, just above transverse abdominis. It seems like quite a long needle path, and it seems like a relatively aggressive, aggressive block technique. Does it work well? 

And do you think with the advent now of the external oblique intercostal where we can put local anesthetic between the external oblique and intercostals on the on the costal margin, do you think that's gonna get rid of out the use for the subcostal oblique tap? So short answer, yes. I do think I do think the subcostal tap doesn't have much of a place anymore because a) we're often being asked to do this in exactly the place the surgeons are operating like for upper, you know, epigastric surgery, you know, they've converted a lap chole to an open chole. Well guess what, now you're dressing or your glue is right there where you want your probe to go. Whereas external oblique is up on the ribs and so you're well out of the way. 

The other thing that that has been shown in cadavers and clinically is that the subcostal tab, a lot of the time, really only gets the anterior cutaneous nerve. So you what you're really doing is a rectus sheath block, essentially, like the the midline, you're missing that lateral part, whereas the external oblique intercostal block gets both the anterior and the the lateral cutaneous branches. So you do get the whole upper quadrant. So I kinda see what you're saying. If you got a full midline incision, rectus sheath block is basically a go to. 

Right? Because the moment you break it down into tap blocks, you need something for the upper component, and maybe the subcostal oblique tap isn't isn't the answer. Yeah. I I I do think so. I will say though, Peter Hebart, absolute legend. 

Oh, complete. And he visit I've known Peter for, man, over ten years, I think. And he came to visit us in New York once, and he showed us well, he didn't he didn't do the block. He kinda talked us through it, but he goes, he's alright. Mike, take out the longest 16 gauge IV catheter you you have. 

So we so we pull out this thing. Swear it was, like, 30 or 40 centimeters long. He goes, now put a good bend on it. And he started he started with a bend up, the tip so that you go in near the rectus and the tip is up. And then he goes, now flip it a 180. 

Yeah. And then as you go down along it was it was incredible. It was, you know, he got the entire plane in one thing, and then you pull that whole thing back and inject it. Wow. Wow. 

I I agree. It seemed it seemed aggressive at the time, but but kind of a cool experience to see. You know what that reminds me of? Brian O'Donnell does a transpectoral serratus anterior plane block, and he gets the longest needle he can, and he goes in from pep majors. If you're doing a standard PEX block, and he then passes it through pep major, pep minor all the way down the lateral chest wall for his awake breast surgery, that's how he does his serratus plane block. 

But but with a long needle, I've I've never managed to go longer than an 80, but that's, that's an interesting thing. Now before we before we go to the before I'm not doing an Irish accent today. Do know what? As I was doing it, was like, don't do it, Amit. And that's the first time I listened to my inner Amit. 

So there we go. That's such a such a hard accent. I mean, I can't that that in South African. Gotta I work on that. South African, I can't do Irish. 

I think I can, but but I know a few people that may differ, on that opinion. Before we go to the joke, Brett, I we we talked about the external oblique intercostal rather flippantly, but we didn't really explain to people what we're talking about. Now this is a relatively new technique. If I remember correctly, Hashem El Shakawi was one of the one of the people that that described it. Right? 

Yeah. Tell tell us a bit more about it, Jeff, from your understanding. So this is, a technique designed to get the lateral and anterior cutaneous nerves of the upper abdomen. So sort of t six down to down to about t nine is I think where most of the clinical and cadaveric evidence has has led us. But the cool thing about this is I didn't realize the the external oblique muscle and abdominal muscle comes up over top of the ribs and and inserts on the superficial surface of the of the rib cage. 

Absolutely. Nor nor did I. Still learning. Still learning. So he so, Heshem and colleagues took advantage of this and said, well, look, if we put put a needle about the level of the xiphoid process on the lateral rib cage, just sort of lateral to the nipple line, hit a rib there, usually like seventh or eighth rib, deep to the external oblique muscle and layer it out between the rib and the external oblique. 

It'll it'll flood that space and and the anatomy is a little complex here. It took me a while to get my head around this, but it gets into the space that gets both of those components, the anterior and the lateral cutaneous branches. So essentially with one easy injection, because remember it, as I keep saying, anytime you the direction is hit a bone, it's an easy block to do. And it and it works great. We have so now we're doing this for a lot of our hepatobiliary. 

As I said, some of them still get epidurals, but liver transplants, loving them. Like, they're we are waking up many of our liver transplants much earlier than we normally would have and sort of, you know, would take them to the ICU, intubated. Many more are being woken up on the table and feel great right away. Those cases where you have an incision that gets up into the the lateral upper abdomen and you wanna do a combination of we haven't talked about combinations of blocks, sometimes we'll come in and we'll go, well, let's do a TAP block on this side and we'll do a rectus, a high rectus on this side, and we'll touch it up with the external oblique. So you can kind of pick and choose depending on the pattern of Uh-huh. 

Of what you're doing. But, but this is a this is a good one. It's, it's been really effective in our hands. We know one of my colleague another colleague from Cleveland Clinic London, chap called Mark Edsall. He's, a cardiac a cardiothoracic anesthetist. 

He, his institution does rib plating surgery for rib fractures. And he was we were talking to him about this technique. So Ravi Naya and myself from Cleveland Clinic were talking to him about it, and he he he watched your Duke video, your Blocked Over video. He's like, okay. Do know what? 

Let me try. And he started using it for rib plating. He is not a he wouldn't consider himself to be a classic. It's a technique he learned from these, you know, digital education, and he said, wow. Actually, he's getting great analgesic outcomes. 

So I think we're finding more and more potential, uses for this technique. Oh, that's great. The other since you mentioned cardiothoracic, the other place we're using it is for epigastric chest tubes. Oh. We started with parasternal blocks for, sternotomy as a as an analgesic technique for for midline sternotomy. 

And and that was great. Except that and we'll have a whole different episode on cardiothoracic blocks or at least at least one. But that didn't seem to be the place that hurt them quite as much. It was the epigastric chest tubes underneath the xiphoid process. And so we would do put them to sleep, come in and do the parasternals, then do a high rectus sheath block with a little bit of local in that rectus sheath and got that. 

And that was that was fine, except that couldn't do it postoperatively. Like if your choice was, let's do this at the end of the case, well now the chest tubes are there. So we have gone a lot to the external oblique to to, again, get out of the way of the abdomen but get the same effect. That is fascinating. That is really fascinating. 

Well, listen. You know what? Before, I think I'm just looking. We're probably heading for about an hour here. So it may be that we that we do a little joke break and then call the episode, a done deal there. 

And what do you what do you think? Return for episode part two of Part two. There may even be part two and a part three. Who knows? But listen. 

There were too many good gags that I saw on social media that I had to I had to share. So so I'm gonna move on to this one. Right? So Andrew Lovett from Twitter, he's Andy Russe 22, gave us a joke from his daughter. Why do people say break a leg for acting auditions? 

I don't know. I've always wondered that. Because I wanna see you in a cast. Oh, god. I think that was very clever. 

That's a good Good. Well, thanks. Thanks, junior. Love it. Exactly. 

And and listen. I've got another one. This is from Bob Funicotte, who I've met for the first time in person and had a really great catch up. I met Bob F. You met Bob? 

I feel like I I feel like I know Bob, but, you know, just virtually. Well, I felt like I knew him, and and he's exactly as he appears, by the way. But this is one of his jokes from x. Okay? And I asked a barista why they were wearing a surgical mask. 

They answered, it's not a surgical mask. It's a coffee filter. Coffee filter. Oh, cough like Coffee. Yeah. 

Yeah. Yeah. Oh, yeah. Yeah. Yeah. 

Sorry. You had to see it written down to get No. No. I I yeah. It took me a second, but that's good. 

Oh, dear. Oh, dear. I'd see look. It's all in the delivery bump. It was funny. 

I think it's funny. You blame the No. It was good. I no. No. 

No. No. It took it just it's 05:00 in the morning here. So Okay. Have you got anything for me? 

I do. Have you tried blindfolded archery yet? This is a new thing. Blindfolded archery? Yeah. 

Have have you been have you heard of this? Have you tried this? No. I have not. I absolutely have not. 

It sounds very scary to me. You don't know what you're missing? Okay. Okay. That is very good. 

I've got I've got this is my last one. This is my last What do you call a rapper with small abdominal muscles? Okay. I can't believe you found is this another one of the social the, AI ones? I did Google this one. 

Okay. I did Google this. I'm impressed that you found a a related joke. Okay. No. 

What? What? Two pack. Two pack. As opposed to six pack. 

Right? Oh my god. Okay. Okay. A I'm a one pack myself. 

Yeah. Whatever. I'm a I'm a I'm a 12 pack. Anyway, we won't get into that. Listen. 

Jeff, I didn't realize that we're gonna get so stuck into talking about taps and everything at the front. There's so much more that we can cover. There is so much to talk about here. But so let's wrap it up for this week, and then we'll we'll carry on with our abdominal magical mystery tour. That sounds great. 

I'm really excited. And now it means I've got, less to think about in terms of producing episode notes because, you know, we're halfway there. So this is brilliant. Guys, you know what to do. Please do like, subscribe, and give us a rating from your usual podcast provider. 

Let us know what you want us to talk about next. Jeff, where can they follow us? Well, we got Twitter, x, at block it underscore hot underscore pod. We've got, YouTube at block it like it's hot. Aye. 

And we've got Instagram, block it like it's hot with underscores in between each word, no apostrophe. And don't forget our abbreviated hashtag hashtag b I l I h, or you can write it out full hand if you want to. But we hope you enjoyed this episode. We've got lots more to come on Abdominal War Blocks. Until next time, we hope you all block it like it's hot.