S2:E5 "I.C.U. Baby, Blocking is Class: Blocks in Intensive Care with Jonny Wilkinson"

Mangoes, sleeping pills, and ICU blocks. Come and join us for another stimulating episode. I'm Amit Pawa. If you want your patient to dance out of the ICU, just drop the needle and play that funky fusic. I'm Jeff Gadsden, and this is Block it like it's hot. 

Hey, Jeff. How have you been? We're we're back for another episode. How are doing? Hey, Amit. 

It's been good. It's good, man. Yeah. It's been a it's been an interesting week. You know, worked a lot. 

I got those doghouses finished. You know, I was talk telling you that Oh, yes. The ones you were working on. Are are they done? Yeah. 

They they're good. They look good. Yeah. They're all done. Then they all fit perfectly in a little little corner and stuff. 

So and the dog and the dogs like them. No one's complained yet there. They're not refusing to use them and stuff. But, you know, it's of dogs, last night, we're taking the dogs out for their, you know, for their pee in the backyard before bed. Uh-huh. 

Thank you for sharing. That's lovely. Yeah. No. No. 

There's never too much information in this podcast. It that was not that was not your that wasn't your pee. That was a dog's pee. That would be that would be too much information. Okay. 

Okay. But, but Fudge, our middle dog, raced over towards the fence line because we're back onto this forest. Uh-huh. That's unusual. So I something was moving back there, and we get deer and that sort of thing. 

So I I take my I go back to the back fence, look over with my iPhone flashlight, and there's a possum. Uh-huh. Nosing along along the and there have you ever seen a possum? No. Never. 

I don't even I don't know if they have them in The UK or not, but they are evil looking creatures. It's, like, pointy little face with these little fangs. Are they like raccoons? Like, scary raccoon type? They're like scarier, pointier faced raccoons with this pink tail, and they're they're not really afraid of all that much. 

Like, they'll come right up to you. And so I'm but there's a fence between me and this possum. And so I'm looking over, and I'm like, hey. I'm taking a little video Uh-huh. So I can show show the kids. 

Look. There's a possum behind our fence, and then all of sudden, I feel something moving next to my foot. And I turn around, and there's a second possum. Oh my god. They did what the raptors do to you. 

They they triangulated you. That was it. That was exactly it. The one faked me out, got me got me to drop my guard, and then the next possum comes and he's sniffing my foot. And, anyway, so we made a hasty retreat. 

No dogs were because Fudge has fought a possum before. Oh my gosh. And and won. And won, by the way. Fudge Fudge did beat the possum back in the day. 

But, anyway, everybody escaped. That was that was a highlight of well, not a highlight, but that was the exciting part of my weekend. How about you, man? Well, hold on. Before we get on to me, I think there's one other thing that we kind of have to talk about. 

I happen to know that, it was a special weekend for you. So I'd like to just to to dedicate a little thing to you. Happy birthday to you. Happy birthday you. Happy birthday, dear Jeffrey. 

Happy birthday to you. Happy birthday, man. I heard you had a big one. Thanks. 21 again. 

Right? 21 again. Again. Yeah. It's amazing. 

I just I don't know where this gray haircuts coming from. But, yeah. No. It was a nice I had a nice relaxing day Cool. Yesterday with the with the fam. 

So thanks, buddy. No worries. Well, listen. As to what I, did, well, you know, we kind of I'm right back into the swing of things after r u k and the last podcast that we only recorded recently, but I do have one confession. Oh, this sounds Are you ready for this? 

Hey. What happens in the podcast stays no. That is not really true, is it? No. That's not right. 

Okay. Well, here's here's the confession. I used a nerve stimulator, man. Woah. Shock horror. 

Yeah. There you go. Way to go, man. Welcome to the club. No. 

Don't get too excited. You know why? Do you remember when you tried to beat me but failed at last year's REUK debate with that? You showed that really clever demo of using a nerve simulator to get intramuscular twitches in QL. Yeah. 

And as you pass through, it stops here. Yep. So that was something you've been talking about for ages, but I'd never seen it published. Well, after you had done that, I'd always thought it's a good thing to do. And then, you know, Lee White just published the use of that, in the erector spani plane block. 

So Yes. I tried to use that and had, had some interesting results. So more about that on on another episode, but that was my that's got my kind of my confession. So James White, Wright, my regional fellow, got me into using that, and that was it was interesting. But so how did it work for you? 

It worked well. It kind of did what it said on the tin. We use it for a number of different fascial playing blocks of the chess wall, but we had some interesting results which we're hoping to write up when it came to doing the interpetual playing. But I will when we do a special chess wall episode, I'm definitely gonna touch on that. Okay. 

And the last bit of news I wanted to share is I got a personalized delivery from mommy power of my favorite fruit. Oh. Do you know what that fruit was? No. I don't think I do know your favorite fruit. 

Mangoes, man. Mangoes. Oh. Oh, man. She personally delivered some mangoes to contacted me and said, can you come and meet me at the station? 

She came with two boxes of mangoes. I've already had five. Aw. And that was just for me. Amazing. 

But, yeah, that that that's kind of me. So, I think that's kind of our prequel. Yeah. What we let's get into it. What are we doing today? 

Well, Jeff, you know what? I'm delighted to say that we're doing something a little bit risky and a little bit exciting. So let's just say it's risk citing. So not only do you make out block names, but you're now you're making up random words as well? You know me too well, buddy. 

Always innovating. So it's risky because number one, we're inviting our first guest onto the podcast. Yes. That's always risky. But it's also risky because I've worked with this guest before, and there were usually a lot of giggles and sometimes, in a uncontrollable manner. 

So I'm excited because this is about an area that is rapidly expanding and developing, and that is nerve blocks in the intensive care. Would you like to introduce our guest, Jeff? Absolutely. I've been looking forward to this episode for a long time now, and I'm intrigued as to where this conversation is gonna take us. So listeners, Haley from Northampton in England, it's my absolute pleasure to welcome doctor Johnny Wilkinson, who's an anesthetist, intensivist, pocus, and regional anesthesia superstar Whoop whoop. 

And social media social media guru. Johnny, welcome. Hi, guys. It's really good of you to invite me on. I hope you can hear okay. 

Yeah. We can hear you perfectly, man. Oh, good. And, yeah, I think Amit's very, brave to have me on this podcast because usually, Amit and I, when we work together, things descend into laughter, humor, and a massive bloop is real. It's what tends to happen. 

So so, yeah, I'm really privileged to be on your podcast. And can I just congratulate you for how successful it's been? And you did feature on the vlog heavily. Yeah. We saw your recent vlog featuring us. 

Thank you so much. Thanks, buddy. Yeah. No. It's a pleasure because I I think what you're doing is fantastic. 

It's right up my alley, and I I think this is the such a excuse the phrase. This is the best way to get education across. A bit of humor, I think, goes a long way with everything we do, to be fair. So, yeah, I'm at 09:02 there. And, Jeff, I met you at RA UK, I think, last year. 

Yeah. That's right. And it was really good to see you because you're a bit of a legend, obviously, as well as King Power there. Well, don't know about that, but, yeah, it was great to finally meet you in person, Johnny, last year and and hang out and share some laughs. And, also, thanks for inviting me on as the first guest to come, but I feel so privileged. 

We were waiting for the, we were waiting for the right moment and the right person, and you, you fit the bill. Now, Johnny, it's amazing to have you as part of this podcast, and I've been lucky that I've known you for a good few years. In fact, we met online before we met in real play. That sounds a bit dodgy. Sorry. 

We met virtually via via Twitter before we met in real life. But for the benefit of our international audience, please tell us a little bit about yourself, your background, and your passion. So, yeah, I've got so so I'm into a fair bit of stuff, really. And I think, again, the advent of social media, Twitter, and we, yeah, we did get we got to know each other through that, as did, I get to know many people through this platform. And it it is all stodgy to say we got to know people online, but there you go. 

Anyway, so, yeah, I've developed a bit of a passion for point of care ultrasound, and my background was always in regional anesthesia. I've also had a passion for regional anesthesia, that's funny enough how I got my job at Northampton. But it seemed like a really sensible and easy, actually, transition to move the probe from looking at nerves down onto the chest and and elsewhere. And I think as anesthesiologists, as Jeff would say, anesthetists, gas men, women, I think we're in prime pole position to do this, sort of thing. Points of care really adds to your, clinical armory when you're treating patients. 

And as I've always said, doing an icy ward round without point of care ultrasound would be like doing a ward round without my underpants on, which would be awful for for all kinds of Have you done that? No. I tend to only do that on Tuesdays between nine and ten, but, I haven't done that recently. So, yeah, it's all about, intensive care, ICU, point of care, sun regional anesthesia for me. Amazing. 

Yeah. It when I when I see your name come up in my Twitter feed, I'm expecting to see one of those things, POCOSR. And I I you know, one of the best parts of RA UK last year when I was there was the the POCOS session you did on stage live. That was great to see that. It had to have been a bit intimidating. 

Right? Like, you're in front of this auditorium full of people, and you're saying, alright. I'm gonna put the probe on and hope I see what I'm gonna see. Yeah. Yeah. 

I mean, you guys are well versed in this. It is a little bit of a heart sync moment when you can't find the heart in someone's chest. And, you know, there was a there was a time I think it was RA UK, Belfast, where there was Nadia and myself, and there were loads of there. It was a it was Steve Haskins and people. And I had to do session on DVT. 

Could I find any of the veins in this chap's leg? No. It was quite embarrassing, but, you know, I managed to get all my way through some bad jokes, etcetera. But, yeah, it is. It can be a real challenge, and I had to get up at o eight hundred, thanks, Hamit, at RA UK. 

Well, actually, it wasn't your fault, to be fair. It wasn't my fault, be fair. That was the girl at dinner where we all had great fun, and do a similar session that was literally just me, a stage, a model, and a crowd and some online people. So, yeah, I was a bit worried about that. But when it goes well, it goes well. 

When it doesn't, you have to tell bad jokes. That's, that's been my way through. Okay. So in this episode, what we're gonna be talking about, Jeff? Let's get into the let's get into the nuts and bolts. 

Alright. So I guess a question that comes up is why do we need blocks for ICU patients? I mean, I think just to set the stage, I think, you know, a lot of my at least history in intensive care medicine was, you know, these patients are really sick. We're trying to get their sepsis under control or, you know, correct all these metabolic abnormalities and get them back to, you know, living, breathing, etcetera. Pain is not top of our list of terms of priorities, but that is that is changing now. 

Right? Well, it is. I think and I've mentioned this on the vlog, and, actually, funnily enough, know when there's a a topic that's close to your heart, and you seem to hear and see things about it all of a sudden that you didn't before. I suspect it's just situational awareness thing. However, there seems to have been a lot recently all about courses in intensive care blocks, thoracic wall blocks, avoiding epidurals, etcetera, and also just generally the fact that we're perhaps we're neglecting pain on the ICU because we're all obsessed with tube tolerance, sedation, keeping the patient stable, all those things, looking at the numbers and fiddling about. 

But, actually, somebody there in pain, that's the cause of their delirium. That's the cause of their distress, the tachycardia, the hypertension, and or hypotension indeed. So for me, I think, you know, when there's a gap in the market, you're an entrepreneur, you, you know, you develop something you can scratch your dog's back with that becomes revolutionary. It's a bit like that, really. There's a gap in the market at the moment with regional anesthesia on ICU. 

So I think we gotta pounce on this as soon as we can. But but, Johnny, I need to ask you a question because what has changed? I remember when I was a trainee, if we had a patient who was septic and ill enough to go to ICU post laparotomy, for example, we never used to bother putting in thoracic epidural because ICU never used them. All they got pulled out. So number one, what's changed? 

And the other question is, as you're as an intensive, I wanna know, is it ICU or ITU? When I was younger, we used to call it ITU, the intensive therapy unit, and now everyone says ICU. So is there a difference, and what do you use? To be honest, I wish my Twitter handle was ICU on ICU. Also, at not the fly heart would have been good because, obviously, I get mixed up with Johnny Wilkin. 

Jeff, you know who Johnny Wilkinson is, the famous rugby player. No? No. No. No. 

It's an oval ball. It's like an egg that we kick around past to each other, and we have little scraps together. Oh, that one. Yeah. Yeah. 

Yeah. Anyway, so yeah. I'm going off topic standard. So, yeah, the I think the situation is interesting because thoracic capsules on ICU, I think they're not the new kid on the block anymore. No. 

But going back, you would have your patient with rib fractures. Get a thoracic epidural. They come to us because usually, maybe there's no other place to monitor it correctly, and you'll obviously, the morbidity associated with mal expansion of the lungs, poor cough, leads to mortality. So avoid that. But the septic patient and epidurals, do you know what? 

It does my head in a little bit this because, you know, oh, they're septic. They're white counts here, blah blah. They're going to get an epidural abscess. Well, how many of those really occur? I mean, probably gonna put my foot in the tears. 

There's gonna be loads of chat now. People going, you careless, careless man. Because, actually, the incidence is this, but I don't think we use them enough historically. Now, though, avoiding a sympathectomy, ease of placement of a block, ease of placement of a catheter and the pumps associated with minimal nursing care, you got the same results. So this is really what we're trying to push. 

It's getting the education out there about this, getting a structured way of learning and teaching and becoming accredited in it. Because unless you've got an SR on overnight who's regional happy, indeed, if you're not a blockologist but you're an intensivist, you're gonna have to go to anesthesia. If be lucky enough to be both Brill, but we aren't all like that. So that I'm not shining my own halo here. But, you know, you you patient may not get a block for a fracture. 

So thoracic epidural or nothing at all because she can't. So are you guys working on units where citing regional anesthesia and intensive care is a thing? Yeah. So certainly at Northampton. So so we've got quite a good little thing going. 

We've got a reasonable number of regional anesthesiologists. I I keep saying that for Jeff's benefit because I I just got a better ring. I appreciate that. To be honest. I think it has. 

We've got a good cohort of people who do lots of upper limb, lower limb orthopedics, so they're very good with the regional. And indeed on the unit, there are a few of us who are pocus happy in RA. So Okay. It's more common for us now. And in fact, the rib fracture patients who come in, we sort of rub our hands a bit and go, right. 

Let's bring him in. Let's go. Let's get an ASP done or a sat done, and let's get them on a pump and let let's show everybody that they don't escalate their f I o two and actually things improve over time. And you've got someone who comes in distressed, and then the smile appears on the face. And you just have this it's a bit like obstetrics. 

When you go in and you're you're almost been having your lights punched out by a lady who's highly distressed, you go and wang the lumbar epidural in. Wang the lumbar epidural. I love that. Wang. With care. 

And they just think you're the greatest thing since sliced bread. And it's a bit like that with this, actually. It's it's remarkable, and it's really satisfying. How about you, Jeff? The the rib fracture thing is is amazing. 

Like, we I I remember this case when I was still in New York where we had a patient who was admitted for multiple rib fractures to to the ICU was looking like he was gonna need to be intubated within the hour. We did a paravertebral block, a catheter, and then within about within about an hour discharged him home. That's the only time I've ever heard of What? Like, we we we thought, well, he looks amazing now. He looks perfect. 

Why would we send him to the floor? I guess he's good to go kinda thing. So he he went home, and he had his catheter for three or four days. And by that point, you know, by the time it the pump wore off, he was sort of through the worst of it. And, that was the only time I've ever heard of a patient going from ICU needing intubation nearly and right to the taxi. 

So I don't think I've ever heard of that. But speaking like, just to Johnny's point, like, the immediacy of the effect of good analgesia for rib fracture pain and the effect on ventilatory mechanics and that sort of thing is is outstanding. Okay. So that's rib fractures, I think, you've got me on, and I can see that. But the other experience that we had, and it came very much before around, around the c word, around COVID nineteen, was when we had a Can I just interject there? 

That was very well done there. What was that? Because that could have gone very downhill, that comment. Yeah. Yeah. 

Yeah. What my call? Well done, Eric. Well done. See, I I I yeah. 

I knew I was doing. No. It's only that was for your benefit, Johnny, obviously. But but we we used to get a lot of sternal fractures post CPR, and we got a lot of people, or our intensive care unit wanted to free up beds. So they would ask us to come and sight parasternal intercostal plane blocks. 

And, actually, they work really well. So that was the first time that I've kind of seen a bit of a sea change in our intensive care unit, which had traditionally been relatively anti blocks when they started to ask us to come and do that. And now rib fractures are regularly, regularly part of The that. Other thing we tend to do is, we tend to do a lot for, critical limb ischemia, but that's not so much in ICU. Are you guys doing any upper or lower limb blocks in your intensive cares? 

So that's a that's an interesting one because a lot of us are bread and butter upper limbless, weight regional anesthesia and things, shoulders, blah blah. I've done a couple of interscaling blocks on our unit for patients who have been suffering, you know, the trauma patient who comes in and ends up with us. I mean, we're not a major trauma center MTC, but we do get, you know, the you know, quite often, you'll do your secondary survey on a patient. You'll pick up something, there's a clavicle fracture there, or they've got some damage to shoulder, dislocated shoulder, whatever. So once or twice, but I've gotta be honest. 

Upper limb blocks rarely. Lower limb occasionally. Uh-huh. So interestingly, looking at the Oxford regional course that I mentioned on the blog but couldn't get the image up Mhmm. Does have lower limb, for example, fascia, iliac, all those things are in there as part of their teaching. 

So that was interesting. But, yeah, not very often, if I'm honest. I I think ours we have a similar experience. Like, it's not it's not the priority. And oftentimes, we'll get the polytrauma patient down to the OR who's been admitted overnight or the day before Uh-huh. 

Coming down for their ankle procedure, RAF. And they also have broken ribs, and they also have, you know, a forearm fracture on the other side. And so we'll address those with a serratus plane catheter and a infraclavicular catheter and then send them back to the ICU with those catheters in place. But it's rare to see them come down with those sort of preemptively placed. Sorry. 

I wanna ask a question though, getting back to the ribs. What is your favorite block for rib fractures, and are there limitations to those? Right. Johnny, you mentioned the epidural abscess issue with with sepsis, and I I agree with you because well, I wanna hear your both of your answers to that first. This is really good one, and Amit and I I think actually are in agreement, whereas the lovely JKB, our good friend Justin Kirk Bailey, isn't. 

So for me, and Amit will interject, I'm sure, the the ESP block Oh. Is the king. And the reason is, as Amit's described it before with a lovely graphic somewhere, it's a paravertebral light block. So if you can get a good ESP in, then you're covering all bases for me. Whereas, yeah, I get it. 

If you do a serratus anterior sat block, you can have the patient lying on their back still. You don't have to move them, all those things. But you're gonna miss in a cohort of patients those posterior rib fractures. So for me, it's simple. It's ESP. 

It's doable. It's easy, you get a good result. I mean, I don't know what you think about this. So so I think my answer is partially in agreement. So I I do think paravertebral is the best block, but if I'm being practical about the availability of expertise to cite these blocks twenty four seven, I think we're much more likely to have a large number of people say, yep. 

I could do an ESP Sure. Than than there are people to do a perverse. And therefore, we've talked about it before in the podcast, there's potential for pepper potting that fascia, the erector spinae plane muscle. If you if you do a little cheat and you go through in the intertransverse tissue complex and get a bit of local there, think you can enhance your ESP and then still pop your catheter in the ESP plane. But I think I think Paravage was the is the gold standard, but I think an ESP is a is a good second. 

And I think you'll get a lot of people through with an ESP block. Serratus anterior plane, yeah, great for anterolateral fractures, but there'll be a proportion of posterior fractures that it just won't seem to do enough for. So I think that's my rationale behind that. Amit, you went into some, anatomical detail there about, into something or other something. Thought, what did you say? 

Can you just please, Amit, say it again. Say it again. So when when Jeff was, was joking at the beginning of the podcast episode about making up blocks, I was very lucky to be involved in a publication with a clever anesthesiologist from, from Canada called Iwana Costash, and we we coined the MTP block, the midpoint between the transverse process and the pleura block, which is now being reimagined as the intertransverse process playing block. So, essentially, what I'm talking about is you do your ESP block as you would do normally, but then either at the beginning or just before you finish, you drive your needle deeper in between processes into an area which we call the intertransverse tissue complex. If you pop pop a little bit of local anesthetic in there and do an ITP block, what you'll see is local anesthetic will cross the superior costotransverse ligament. 

You will get a bit of pleural depression, and it's a way of supercharging your ESP block. So there you go. That's that's that's what I would do. I'm just a huge fan of the the phrase pepper potting. Yeah. 

Yeah. So that sounds like you said you used a phrase, Amit, enhanced ESP. Is can we call that the small e and then capital e s p? The e e s p, the enhanced ESP. Oh. 

Yeah. I mean, I I'd called it I'd called it the supercharge, but I like the e e s p. Yeah. I like the e s p. E e s p. 

Or supercharge would be cesp. Oh, yeah. CESP block. Yeah. Yeah. 

I I'm gonna go for yeah. Listen. We're making up more block names, man. This is crazy. Yeah. 

So, if I described, during a block, for example, on the unit, and I said, I'm doing some pepper potting now, team. I think there'll be questions raised. There'll be people googling it on the urban dictionary and finding out what was going on because it's obviously I'm sure we shouldn't look it up on there. No. I'm sure we shouldn't look up pepper potting. 

But, nonetheless, pepper potting is topical because it did come up, and I think I've, bookmarked it for the the the next vlog, actually. So, yeah, pepper potting. There we go. But okay. So so for paravertebral and now this is something that comes up in our center routinely. 

You'll have someone comes in, they're on a DOAC or some other anticoagulant or they're got altered hemostasis, and some people will shy away from doing pervertebrals and some won't. I know which camp I'm in, but what do you guys think about that? Because that's this is relevant to ICU practice. I don't think I'd shy away from it because I think the benefit outweighs the risk, actually. And interestingly, the description of pepper potting for me Yep. 

It's really interesting when you're describing the paravertebral space on an image to people you're training because their immediate thing, is, my god, that is really close to the plural. But, yes, it is, but you can see it. That's the key, isn't it? Yes. So yeah. 

Absolutely. For single shot block, I wouldn't think twice if they're on anticoagulation. For catheters, I would do a risk benefit, and I think, you know but probably on the side of doing it. But, again, the whole concept of performing the ITP block on the way to doing a paravirtual is as you inject low clansing in that area, it will often highlight the pleura. So it'll make it easier for you to see. 

It actually pushes it away. So a sort of a safer way of advancing your your needle. But, I fear that we're gonna make this another ESP episode, and we'll, we'll we'll generate some some some some talk about it. Johnny, what I wanna know is when you're looking at your unit, and and Jeff, saying, who's performing these blocks on ICU? Is it anesthetists? 

Is it intensivists? Is it consultants or attendings, or is it trainees or residents? So who's doing them? So we, obviously, if I'm on it, it's me. I've got several ultrasound fellows who are now trained up, so they will do it. 

We are we also have a RAD, r a d, regional anesthetist of the day in our trauma theaters. Oh, cool. So they are eminently callable to come and and help, but the problem comes after eighteen hundred hours when the the day cold faced guys go home. It's a bit of a lottery then. It depends who's on. 

So that's my I think that's the problem. So identification of a patient with rib fractures and complications thereon, out of hours could be a a bit of a problem, less so in the daytime. There's usually always some help in the daytime. So that that's my experience with our unit. How about you, Jeff? 

It's similar. It ends up being so we have a we have a a slightly different situation, I think, here in intensive care medicine in US as you do in The UK. There's, I think, a broader variety of people that get into intensive care medicine. So there's pulmonary medicine specialists and internal medicine and, and surgeons. And and the proportion of anesthetists that go into intensive care is is less compared to to my way of thinking anyway. 

Uh-huh. I I I take it, like, most of your intensivists are anesthetists. Would that be fair to say? Well yeah. Yeah. 

That so that's interesting, isn't it? Because my last employment round, we've had, we employed an ED intensivist. Yep. We've got an acute medical intensivist, and in fact, we're about to hopefully employ another ED intensivist. So it's ED intensive care, medicine intensive care, anesthesia. 

In our place, it is majority anesthesiology based, but not going forward, particularly with single tier ICM training, it may be. But but then here's the debate which Amit and I have had together with our group on Fusic blocks. I'm gonna talk about it in a minute, I'm sure. But we've had this debate as to who should be allowed to do these things. Could it be an advanced nurse practitioner, ANP, or one of our ACCPs, advanced care practitioners, does it have to be a doctor by definition who does these or not? 

There's a massive debate over this, and I don't know the right answer to that. I mean, this is gonna this is gonna be another controversial area because we're here. We've got a cohort of patients with whom we want to give the best treatment possible, because of the potential to reduce the morbidity and or mortality associated with their primary pathology. But we've got a deficit in the number of people who are able to deliver that. So so, Jeff, you may or may not be aware. 

So we're kind of having a discussion in The UK now about a situation that you're already, well within, which is nonphysician administration of extra anesthetic skills, including regional anesthesia. So I I don't know the answer. Ultimately, there needs to be some kind of regulation, some kind of clinical governance to make sure that it's it's it's well performed and done within the safe environment. But I personally think if you can treat or sorry. If you can teach intensive care physicians whatever their specialty base may be to do regional anesthesia properly, well, hey. 

That's brilliant. So whoever's covering that unit twenty four seven, if they've got the skills as part of their armamentarium, then then we don't need to worry about anything else. I mean, Jeff, we have advanced nurse practitioners who are PAs in anesthesia, physician's assistants. They do that. So so what what's the problem equally? 

You know, we we have this. I don't know about The US. Yeah. Yeah. And I think it is similar here. 

And I think there's no there's no magic to putting a needle in the right spot and and hitting go. I think the bigger question is, what how do you practice acute pain medicine? And so the diagnosis, the considerations of the risks, the risk benefit analysis, dealing with the complications, if you cause a complication. So that's that's Yeah. If you're gonna just stick a needle in someone, you have to do all the other work as well. 

And that's all part of acute pain medicine and not just being a needle jockey. So Right. I guess the other point is that, I'm all in favor of broadening this scope of practice of nerve blocks so that, you know, we we happily teach our emergency medicine folks when they've asked us for guidance how to do blocks. Because I want everyone's gonna do them anyway if they feel like this is the right thing to do. So at least part of my job is to make sure they're doing them correctly and properly and giving them all the tools. 

Yeah. It's been a while since I've been a trainee, but is this part of an intensive care fellowship training now, or is it going to be? It's almost like you set Johnny up for this here, Jeff. So so, Jeff, does a training program exist for regional anesthesia in ICU? Good evening, gentlemen. 

Thank you. Yeah. So that that was that was really well placed. And so Briefly, as not to bore anyone, we know there's a gap in the market. We have focused ultrasound intensive care in The UK, Fusic, within its multimodular training scheme, heart, lung, abdomen, DVT, advanced lines, and now Fusic blocks, which hopefully we are going to release in the next, let's just say, six months. 

We've got a working group. The lovely Amit sits there, Jenny Ferry. We've got Monica. We've got we've got loads. We've got almost a fifty fifty split of intensivists and regional anesthesiologists mainly associated with RA UK. 

Within this, we're discussing which blocks we're gonna train people to become accredited in. For example, controversy. How many do they need to do to be deemed competent? How Yeah. Practical is that in the real world? 

You know, they're not all gonna be able to do some of these blocks because we're not all gonna get refractory patients in every day. Loads of the logistics around, the subject. So so, hopefully and we've also got a really good session coming up, haven't we, in Liverpool in June, all about this. So that'll be amazing at the ICS. So, yeah, we're there's a lot going on, Jeff, on this front. 

Oh, that's amazing. Well, listen. Before before we get into, the nuts and bolts, because I really want to understand a little bit more about Fusick blocks and and what it entails and and how, you know, we're discussing what to do. I think it's time for a joke break, and I'm gonna try and see if we can get this ASMR thing to work. I'm gonna see if you can hear my Diet Coke open. 

Here we go. Oh, that was amazing. I think that might have worked okay. You you almost should have a recorded sound effect on that one. Do you know what I mean? 

Sound effect? Sound effect. Yeah. Like this. You know, I did that just for you two because it's I wanna block with you, really. 

Yeah. I couldn't I couldn't edit that. Really sorry. Little MJ in the morning. That's that's perfect. 

Oh. Wait. So I'm gonna go I'm gonna go straight into a joke here. Why did the pharmacist walk on their tiptoes? I don't know, Amit. 

Why did the pharmacist walk on their tiptoes? Because they didn't wanna wake the sleeping pills. Oh, dear. Sigh that's like silence. God. 

I mean, quite sadly, about a month, before my grandfather died, we covered his back in, in Lard. He slipped downhill from there. Sorry. I thought that was an actual story. I I felt really bad there for a second. 

I was like, oh, man. This this got dark very quickly. You'd probably edit that one out, won't you? I'm so glad that your faces did what they did, and no one on the podcast is gonna be able to see that. It was absolutely phenomenal. 

I was like, oh, man. I feel so bad. Sorry, Johnny. Okay. Well, that that took me by surprise. 

Jeff Jeff, do you have a joke before before we get back into it? Yeah. You know, the other thing that happened to me on the weekend was a book hit me on the head. Oh, no. I only have my shelf to blame. 

Oh my god. Oh my lordy. I'll tell you what, Ryan. I think they progressively got worse. I think they progressively got worse. 

The thing is, guys, Ryan, the old ladies in wheelchairs with blankets over their legs, I don't think so. They're just retired mermaids. Where do you do you get this stuff? I I should play a drum roll sound effect now or a trumpet or something. Okay. 

Let's hear it. Oh. Okay. That Oh, you want me to play it? Well, I've got some other sound effects you could play like this one. 

Criticalcarenorthampton.com. I mean, that was a complete accident. Unashamed, self promotion. I like that. Yeah. 

Here's another one. Here you go. Here's us. I just wanna check the best on x. Well, Batman. 

Anyway, there you go. Yeah. Yeah. It's it's good work. We need to up our game, Jeff. 

I know. I I'm I'm where where is our little collection of audio bits and pieces? Well, get this one as well. Listen to this one. This is for YouTube. 

Drop it it's hot. Drop it like it's hot. The pigs try to get at you. Fark it like it's hot. I already feel I'm I'm I'm feeling very, very chilled and relaxed. 

Thank you, Johnny, for that. That's alright. And I wanna broadcast the fact that the RODECaster Pro two mixer is the one to buy. Seriously, we'll talk about this later because it it'll probably bore everybody to tears. People have probably gone off the motorway now. 

They're dozed off in the car. You know? It's just I hope not. I hope not. Well, listen. 

Let let's let's get into it. So few sick blocks. What are the blocks that are featured? Start from the top. Tell us tell us what the what the important blocks are that you're thinking about featuring in this module. 

So, we do a lot of invasive lines on the ICU. There are times that I've certainly seen I'm not labeling my units as being like this necessarily, but people are guddling around a little bit in the neck. The poor patient's critically ill tilted head down as a sheet over their face. It's not pleasant. So the first one we wanted to train and talk about is the superficial spherical plexus block. 

If you're scanning to put a line in and you're looking at the jugular vein anyway, it's literally there behind the belly of sternocleidomastoid, a simple infiltration of 10, fifteen mils of local there. I'm telling you, it makes such an enormous difference to patients. And I'm told, Jeff, that it is relatively common in The US to do this as a routine. We certainly don't do it here, but we should be because I think it's a distressful circumstance for patients, you know, having their, neck guddled around with and like that. Yeah. 

When I was a trainee, we used to do all the lines for the cardiac cases in the pre op area before they head headed back just to save time. And and putting in a huge cordis into somebody's neck, you know, wide not wide awake, but they were aware of everything that was going on. It's just it's just, you know, cruel and unusual. So I think this Hold on. Help me out. 

When you say cordis, like, what's a cordis? I'm being serious. What's a Cordis? Is it like a PA sheath? A oh, yeah. 

Cordis. It's it's like a yeah. It's a it's a big big fat sorry. That is brand name, I think, actually, Cordis. Yeah. 

So it's a big fat, I think, seven and a half French line that goes in, and you can float a Swan Ganz catheter through it. Or So like a PA sheath? Yeah. Yeah. These we call them sheaths in The UK, Jeff. 

Yeah. Yeah. Yeah. Sheath. A good old sheath. 

Well, I'm gonna ask for a cordis. You know what? You're Okay. Sorry. I interrupted your flu, Cordis. 

That was a good American accent, by way, Ahmed. I you had me fooled there. I thought I honestly thought that was one of Johnny's sound effects. Like, how did he have that what's a chordus? Can I have a chordus, please? 

Anyway, you did ask me a pointing question. I've gone complete isn't that funny that we've gone off topic with that? So, yeah, suprasorbicular plexus block. Next one, debatable whether we do parasternal because I think within the group, there's been a bit of chitchat about the morbidity associated with puncture of vessels and all those things like that. If you make a bit of a moment when you're putting one in. 

And, also, clearly, we're talking about all the thoracic wall blocks throughout this anterior SP. We're training paravertebral. We're also gonna talk about spinal ultrasonography or sonography. Really, somebody said, do you need that for? Well, if you've got a challenging patient with a scoliosis who needs a thoracic epidural, there's a reason. 

If you're trying to do an LP and someone who's got encephalitis, whatever it is, there's another reason. So I think it's worth teaching. We're not necessarily gonna make people actually do a procedure with it. We just wanna know that they're competent. Then we've got abdominal wall blocks. 

And as he mentioned before, we we've we've we haven't talked to any lower limit at all. Actually, we stop at abdominal wall. So, really, it's about five or six main blocks. Yeah. That seems like a great start. 

It does. But, know, I wanna just rewind. This is when Jeff normally does a rewind sound, but it's okay. We'll There we Thank you. I wanna go back up to parasternal intercostal plane. 

Johnny, why is there so much anxiety about this? Because I don't think I can recall ever having seen damage to the internal mammary vessels, which line that plane between the internal intercostal and the transversus thoracis muscle, but that's because I always go superficial. And I know if you look at one of Jeff's videos, he he shows a a neat little trick where he turns the probe 90 degrees and actually scans transverse across that plane and comes in and does the deep block because he can see the internal mammary mammary vessels in cross section and avoids them. So I still go superficial, but what is the anxiety about about this block? Why are people nervous about it? 

So it I just wanna say, just to polish Jeff's halo a bit, his if you haven't seen his his YouTube channel, it's absolutely unbelievable. And and and and you should check it out because I've learned so much stuff from Jeff and his channel. Oh, good with the. Thank you. Anyway, so what's the problem with these? 

I think well, I don't know is the answer. I don't have a problem because if you put color Doppler on, it makes it let's face it. Color Doppler doesn't exclude a vascular puncture. It doesn't it necessarily depends what's in the way like the sternum. But I think there is a generic fear about this, and it's for the reasons you've said. 

But for me, I don't feel it's a big issue. I certainly don't feel it's an issue enough to not do these things when it could make a big difference to the patient. Okay. Jeff? Yeah. 

I I agree with with both of you. I stay superficial. I don't I've done both. I've done both on myself Oh my god. I see if there's a well You've actually what the You've done them on yourself in the kitchen or at work? 

No. That was the ankle block. A tibial nerve block he did by himself in the kitchen. That's true. That was yeah. 

But, no. I at work. We'd one day, we I said, right. Shirts coming off. This is not an uncommon scenario in the in the block area around 04:00. 

It's like it's like Matthew McConaughey. This is this a good time for me to oh my gosh. But the we did the superficial one on one side and the deep one on the other side to see if there was a difference in spread. And I know there's papers on this probably and that sort of thing, but nothing replaces your own clinical experience. And so we didn't find a difference. 

I kinda had this, like, Batman sign of sensory block on both sides of my chest. So on the basis of that, I have to say, well, I'm just gonna do superficial from now on. Jeff, you've just revealed that you are Batman. I am Batman. Yeah. 

To everybody now. That's the secret completely gone. There you go. That's yeah. Actually, Jeff, to be fair, I think you would make an amazing Bat man. 

I mean, you could. Yeah. He's an absolute god of a man, isn't he? Look at him. He really is. 

He really is. I think he'd be great. Thank you. Thank you. Okay. 

So that that's the parasternal intercostal. Now regarding chest wall blocks for rib fractures, are we gonna teach or get people to do ESP and serratus anterior plane block because they're both kind of very similar in concept? It it kinda doesn't seem that that big of a a jump. No. I think I think that's a good point. 

I think what we should be doing is perhaps deciding which one we want them to demonstrate competence in. Jenny Ferry made a very good point on this. If you're really competent at doing your serratus anterior, you're gonna be pretty good at doing your ESP. It's the same kind of principle of playing block and all those things like that. So, again, within this, look. 

You know, when you do lung ultrasound, we require 30 scans. Some of them are supervised. In this situation, getting everybody to do every single one of these is gonna be nigh and impossible. Some people may not do some of these in their entire career. So we've got to find a good middle ground of deciding competence. 

I mean, you can see straight away someone who's got their hand eye coordination and the psychomotor skills down to a t. So in those people, it'll be a lot easier. You know? And the ones who are perhaps not belittling anyone who's not an anesthesiologist here, just FYI, someone who's a medic coming into it isn't that familiar with ultrasound like this. I think we're going to have to give them a little bit of the benefit of the doubt and decide what's important. 

So, yeah, good point. I mean, I with that in mind, I I kind of I kind of think that maybe the serratus anterior plane is is the easier of the two potentially. But I don't know. We'll we'll have some discussions about this. Now with abdominal wall, Jeff and I just recorded, and released our recent episode on the first part on abdominal wall blocks, and we kind of made a throwaway comment that one of our, mutual colleagues, Lloyd Turbine, said about the tap block being dead. 

Oh, Lloyd Turbine. I love that man. Yeah. He's an absolute phenomenon of a man. Isn't he? 

But, again, a lot of people in the year Ed Mariani got involved in this. I'm like, hold on a minute, guys. If you like the Rector sheath block, then you'll like the tap block. And then he pulled out a paper that we were both involved with that that had our, had our names associated with it. But I think if we're gonna teach one, rectus sheath block's gotta be the one. 

Right? It's gotta be. Because if you can do a good rectus sheath block, you can take out the major, the big unzippering midline incisions that are the are the big problem. And then that principle and if you've got a principle of a serratus anterior plane block, you can adapt that to all of the other things. But those seem to be I I think rectus is a easy one. 

Right? Yeah. Absolutely. And I think that the majority of abdominal incisions that you're seeing in an ICU setting are gonna be midline laparotomies, which which brings me to a question. I I remember being at a EPOM meeting a a number of years ago, and there was talk about sort of an ERAS pathway for the emergent laparotomy. 

So are are you guys working at centers where they Mhmm. Do blocks as part of an emergent laparotomy before they go back to the ICU? You go first, Johnny. Yeah. So, we've got the National Early Laparotomy Database, NELA, it's called. 

I'm sure we're all probably aware of it certainly in The UK, and there's absolutely zero. Did you hear that? What? No. Good. 

Nothing happened. Anyway, I pressed a button, it made a cash register noise. Epic fail. Every time we hear the word laparotomy, Johnny gets five pounds. Can we hear the cash register noise again? 

Here we go. Here it is. Yes. That's exactly what just happened there. So, yeah, we, are advocating certainly tap blocks within Nella, within our surgical cohort. 

The surgeons are often placing them under direct vision. So that's one thing. Blocks. Say? They're placing they're placing tap blocks under They're placing tap blocks in, for example, in the laparoscopic guidance. 

They're looking and they're looking for the, the the end of the tenting between the muscle plane you can see. The thoracic surgeons used to occasionally do those with paraverteals. They used to do that. The majority probably come through to us if they come to ICU certainly with a tap in. But Jenny Ferry's point again, why are we teaching those when they don't cover the superumbolical area with reliability such as erectus sheath. 

Yeah. Yeah. Yeah. We've tried to do that more more and more trying to protocolize it with one of our fellows and make sure that any urgent or emergent laparotomy at the end of the case gets a rectus sheath block. So it's it's been a a moderate success. 

It hasn't I'm not gonna say it's been an amazing success. It just again, it depends on the time of day or night or middle of the night and who's on and what else is happening if there's four other cases that are demanding attention and that sort of thing. So it's it's trying but slowly. Well, you know, I've gotta say at my, NHS base at Guy's and St. Thomas', our general surgeons have been really good. 

So we've kind of got, a protocol whereby at the end of the case, they will do surgically administered rectus sheath blocks. And those that know how to do it properly do a really great job of this. They'll use our standard, nerve catheter sets, do, an initial bolus, then thread the catheter, and then they seem to do really well. Some of our urology surgeons are doing the same thing, but there's a bit of variability out of hours. If it's not someone who's familiar with doing it, then they tend not to do it. 

And, of course, if you're doing it, it's meant to be under direct vision, but the endpoint of that needle can be variable. So we do have some mixed success. But, actually, what we've said that's so lovely about the rectus sheath block is you can do that post wound closure, post dressing application because you can come in quite laterally. So I think, yeah, I think rectus is a no brainer for me. Yeah. 

We definitely actually need to have we have got that one in, Fusick blocks. It's it's it's actually whether we narrow, Amit, that mainly for you this, whether we need to ditch TAP altogether or just it's the same principle with the SP and SAP. You can do rep to sheet. You're gonna be able to do a TAP. Right? 

So just one or the other. I think what's interesting about TAP, we've recently had this conversation where we had a new regionalist join our group, which was very exciting. And he got called to the OR because a surgeon had requested a TAP block at the end of the case. And he he came into this discussion with the surgeon about, well, actually, a TAP's not gonna work for that incision. And then the discussion went on from there. 

And what what I think we came to the realization of was when surgeon when that surgeon or a lot of our surgeons say tap block, what they really mean is, can you guys do one of your fancy abdominal wall blocks? I don't care what kind it is. Just make sure it covers the incision. And so because TAP was the only one for so long. So they think TAP abdominal wall analgesia is TAP. 

But I still don't understand why the Recto to sheath block has lagged so far behind. Why did the tap block get so popular? And, you know, we may we'll cover this in part two of our episode on abdominal wall blocks. It's o b as Jeff would call it, I I think, is correct phrase, OBGYN. So it so within our obstetric anesthesia cohort, they're all getting taps before their Pfannenstiel incision's done. 

It's become Yeah. So popular, so doable. I think that's part of the reason. I don't know about the rest, though. I I don't know. 

Because the rectasheet is not a new block either. Like, it's been around for a long time. It's, you know, landmark based, but we're here to push that block through FUSIC. Yeah. Exactly. 

And I think I think if you make the rectasheet a core part of the FUSIC blocks, curriculum, I think you'll suddenly produce a whole host of of this of the future who are able to do something really valuable for patients, especially if they're not getting in theater. I I think it's a great idea. Got another one from my daughter here. Stop before you block regional anesthesia. Nice. 

What so what accent was that? That was great. She could she can speak almost fluent American. I don't know. She just goes into Yeah. 

These You were saying that. When she was very, very small. You know, you the moments where you can hear something going on in the bedroom, you you just listen, and she's she's talking in this. It's probably from Disney films. Yeah. 

Yeah. Yeah. That sounded like a prerecorded like a prerecorded voice or one of those AI voices, actually. It was yeah. I I could've I could've fallen for that for sure. 

She's done all sorts on here. It's hilarious. But there we go. And and then lastly, I just wanted to talk about, I think, spinal sonography. I think this is key, and I and I definitely remember forget anesthetized patients. 

I remember in regular patients trying to get a spinal in, and I've again, I've confessed had many confessions on the podcast about difficult spinals. And actually, if I just put an ultrasound probe on at the beginning and understood midline and level and depth, I think it would have saved a lot of pain. And you imagine if you're doing this for CSF pressure monitoring or sampling to be able to have the skill and knowledge to say, well, hold on. You know what? The spine looks like it should be here, but actually that's where I'm gonna go. 

I think that's really cool. So I think that's a good idea. Yeah. I think it's I think it's really it's quite hard, though, I think, to teach this, because I think getting the perfect view is often quite tricky. I think that's just from a personal standpoint. 

I think spine if if anything, if somebody goes to me, can you demo spinal, sonography? It would probably be the weakest of my cohort, but there you go. That's me. But but probably very useful in that setting because, I mean, imagine, you know, having my patient who's an elective hip patient coming in and they're sitting up and they're leaning forward and they're in the optimal position, that's probably one thing. But having an obese ICU patient in a lateral position who's intubated and unable to participate in the positioning in a big old ICU bed that's not that's kinda cushy and so everything's sagging a little bit. 

That, I think, would be where I'd wanna pull the probe out every time. I mean, at the very least at least for the midline. At least because because that because sometimes, you know, you get a scoliosis or a kyphosis and things don't look quite so straightforward. So at the very least, midline and level, and you can get a rough idea. And I think I think it's worthwhile doing, but I agree, Johnny. 

It's not something that certainly nonanesthetists feel that confident with when you give them a curved array probe and say, stick that on the back. People are like, ah. Yeah. I'm not very familiar with this. It's the usual stance. 

But, you know, you've really had the I'm sure you've had the situation where your ODP, your operating department practitioner, your assistant, whatever you call them, Great people, by the way. They're in front with the patient, and they then walk around the back to do something and have a look. And it's sort like, oh, that's that's an interesting one, isn't it? Because it looks like you're doing a renal biopsy. But in fact, they've just got such a bad scoli, you have to go paramedian off to the right where the scoliosis curves. 

So, you know, in that circumstance, phenomenal to use because you you probe sort of four centimeters from the from the midline, and there's the the there's the view. So, yeah, it's, easily good for those sorts of patients. Well, I think we should also give a shout out. Kijin Chin's got some great videos on spinal sonography. So check out Kijin Chin's video channel as well as Jeff's, put some great videos there on spinal sonography. 

Yeah. Chin's done some amazing things with this. I was gonna say the the our block nurses have a good sixth sense about when to pull the probe out. So we'll be, you know, having having a go and the the trainee has a go, and then I have a go. And then some point, you'll hear somebody's voice say, doctor Gadsden, do you want me to get the ultrasound probe out? 

And I'm like, yes. If you yeah. If you if you're saying that now, then yes, please. Thank you. That's a bit like the consultant who starts to glove up. 

Usually, that one where the glove packet opens, the the trainee will Gets it. Will be successful. Same with the drug vial. You know? At the end, if you have really good anesthetic and they're just not breathing properly, you reverse them. 

Go for the Doxopram vial, and you're just about to crack it open and they breathe. There you go. It's Don't give the secret away, Johnny. Oh, this has been great. Well, Amit, should we wrap up this fun episode? 

Absolutely. Johnny, thank you so much for being our first guest. It's been really interesting and really educational, and I love the sound effects. So so lots of us to aspire to improve the next time. That's been amazing. 

Yeah. Johnny, big thanks for me too. No. I've had I've had a fantastic time. And, again, complete. 

Was still phenomenally. That was an immense progress, to be fair. So if my vlog can do as well as your podcast, I'll be a happy gentleman. We need that we need that machine, Amit, whatever that machine is. Yeah. 

We need to get it. I just wanna put a plug in, a shameless plug for criticalcarenorthampton.com. If you're at all interested in anything critical care, this is an amazing resource that that I've used, and, lots of our trainees have too. So just full of great information, videos, tips, tricks, all all that kind of stuff. And those infographics, those Wilkinson infographics are all over that. 

They're amazing. Yeah. We'll put a link in the in the show notes for that if if you haven't, been there before, but, amazing resource. So great great job, Johnny. Thank you, Jeff. 

Thank you. That's really kind of you. Here we go. It's another awful jingle on the website. It's the best out there for foam med and all things critical care, ain't it? 

Oh god. So that's kind of a, well, a London rebel take on it. Yeah. There you go. But thanks for the plug. 

It's very kind of it. So thank you very much. Thanks very much, Johnny. So okay, folks. You know what to do. 

Please like, subscribe, and rate us on your usual podcast provider. And you if you and let us know what you want us to talk about next and if you want some more. So please do follow us at We have Twitter or x, at block it underscore hot underscore pod. We have YouTube at block it like it's hot. Yes. 

And, also, we have Insta, block it like it's hot with underscores in between each word, no apostrophe. And don't forget to use our new abbreviated hashtag hashtag b I l I h, or you can do the full version. Get involved with conversations online. Until the next episode, join in with us, Johnny. We hope you all block it like it's hot. 

So forgot what I was gonna say there. That that does sound amazing. That sounds to me a lot. Yeah. You know, we get we get these uncomfortable pauses, but we're all friends here. 

So we we shouldn't worry about these things. Nobody else is listening. It's it's like we're having a beer and a pub or coffee. And that's Isn't it? Well, isn't that the best way to get your points across over alcohol?