S2:E7 :Summer Regional Anesthesia Controversy Spectacular!"

To prevent the spread of diseases, please practice safe scans and save the mixing for the bartenders. I'm Jeff Gadsden. Bro, we are so excited to talk to you about mixing drugs, tucking your scrubs and probe covers, plus much more. I'm Amit Pawa. And this is block it like it's hot. 

Hey, Jeff. It's that time again. We are back for a summer episode. What's cooking, bro? Hey, Amit. 

How are you, man? What's cooking, bro? Have you been watching some old school movies like Bill and Ted's excellent adventure? You know, I haven't, but that's actually a great shout. Maybe I should. 

Well, no. The the reason I, I use that phrase is I've just realized I am so out of touch with the latest lingo that my kids are using. I just figured I'd try something different to kind of, you know, appeal to the kids. Yeah. I I think I know what you mean. 

Tell tell me more, though. Well, see, the thing is recently, Sienna, who's my youngest, has started calling me bro. She just started sentences really like bro. And then and then there's a next level. She'd be like, brozif. 

And I'm like, what? What are you talking about? And then they've been using phrases that I feel I should know that that I'd never heard. Like, they're like, oh, you know, spill the tea or she ate that. What? 

And and occasionally, Sofia, my oldest one, will be like, oh, that's giving. And then she won't finish a sentence. She should just say it's giving, and I'm supposed to realize that it's giving means it's giving vibes of something. Okay. Man, I'm so out of it. 

I'm such an old fart. I I know the feeling, man. I I mean, I've got four four kids the same age here. What she ate that. What does that mean? 

She so she nailed it. She slayed it. So Oh, slayed. I tried to use it my my own but slayed is not no one says slayed anymore, so I used slayed and thinking I was down. Wait. 

Really? Oh, I say slay the day away. Yeah. Well, I mean, it makes sense. Right? 

But they'll say, oh, she ate it or you ate it. And I tried to use a different variation of that? You make sure you eat it. And Sienna's like, no. That that's not what you say, papa. 

So yeah. I don't know, man. I'm really feeling out of it now. It's, I I get bra. Corey gets bra as well. 

She's like, why how am I a bra? Like, b r u h. Yeah. So that I've heard, but these guys have anglicized us. It's like bro. 

A bro. And then broziff? Yeah. And I've gotten broziff as well. Have you encountered Skibidi, Ohio, Riz? 

I'm so sorry. What? Skibidi, Ohio, Riz. Never heard that. What does that mean? 

Okay. This is oh, wow, man. This is I I'm happy to bring something Gen Z to the to the table here. So so apparently, Riz is short for charisma. Wow. 

So if you've got if you've like, you know, lots of game with the opposite sex, you've you got Riz, man. That guy has Riz or she has Riz and that sort of thing. Okay. And don't ask me the the providence of Skibbidi on Ohio because that's complicated and will be hard to explain, but Skibbidi, Ohio, Riz is like you suck at at Riz. So you don't have charisma. 

You don't have game. Oh, man. That guy has Skibby, Ohio, Riz. They just met these guys they're having you on, man. They're this is not a real thing. 

No. It's a real it's Google it. Okay. Well, may may you know, we've already discovered there's some things we should be careful about on googling because you end up on urban dictionary. Who knows what you'll find out? 

Well, the other yeah. The I might have used an expletive at home the other day, and I was told that I should have said sugar honey iced tea instead of saying what I said. Are with me on that? S h Sugar honey iced tea? Oh, yeah. 

Yeah. Yeah. Okay. Well, listen, man. What have you what have you been up to? 

Well, just had a call shift. Do you do you watch, are you familiar with baseball? Yes. I am familiar with baseball. Well, it's like cricket a little bit, but instead of running back and forth, you run to four points of a square and then and then come home and 23 innings. 

Right? Yeah. It it can be. Nine usually, but there's no ties in baseball. So you go until there's a winner. 

Oh my gosh. I thought it was okay. Okay. Okay. So there's a thing in baseball. 

If you if you hit you might get up four or five times during a game to bat. And if you hit a single, which means you get to first base, and then the next time you hit a a double, a triple, and then a home run, not necessarily in that order. But if you hit all four types of hits in a game, that's called hitting for the cycle. And it's it's pretty rare. Hitting for the cycle. 

Hitting for the cycle. Like, oh, Hit that you know, Johnson hit for the cycle last night. He got a double, a triple, a single, and a home run. Okay. So we have it like, I I have my mind, I have this anesthesia hitting for the cycle which is, you know, in the course of doing all your your regular stuff, you do an overnight call shift with cases, you get all four of these somewhat less common things in one night. 

And that is get called to the ED to do a pen block for hip fracture. Okay. You do a stroke code, so you rush down to interventional radiology and suck out somebody's clot in their brain. Uh-huh. You do an airway in the ICU and then you do an awake fiber optic intubation in the OR. 

Wow. Yeah. And so, like, you know, those things happen once in a while, but, like, not usually in the same twelve hour shift. So we we hit for the cycle last night. That was exciting. 

Wow. So so that was full on and you had to do all of those as, a first responder? You're you're on the shop floor doing all of that stuff? Well, yeah. We're supervising the residents doing all those all those things. 

Yep. Wow. So I'm privileged that you managed to to stay up and record this pod with me today then in that case. Well, no. No. 

I got a I got a bit of rest as well. Do you one thing that came up in the conversation was trainees are not getting the same numbers of awake fiber optics as they used to because of video laryngoscopy. Are you guys finding the same thing? Yeah. I think, again, this is one of those other areas that's that's pretty controversial. 

But, you know, certainly in my center, which is an airway specialist center at Guy's and St. Thomas', a lot of the weight tracheal intubations as they're now referred to in our place are all done on specialist airway list by the airway fellows and by a group of airway consultants. And so those opportunities are on certain lists, but not across the board. But, certainly, we are using video laryngoscopes for a lot of these cases. And, yeah, I I think probably those opportunities are few and far between, you know, similar in a way that know, our thoracic epidural training numbers are coming down. 

I think Right. We have specialist centers and specialist lists where you can do a weight to kill intubations, but it's not something that's a given that everyone will get access will everyone will get access to. Right. Yeah. And I wonder what the role of simulation is gonna have to be to to get those skills up. 

Because a lot of our trainees go off into private practice, and they're not gonna be an airway fellow, and but they're gonna have to manage a tricky airway at 03:00 in the morning. Well, and there are some phenomenal simulators out there. And, certainly, you know, we have a guy's airway management course, so they've got some amazing piece of kit. So I think Mhmm. Courses, workshops, and simulation are definitely gonna be key Yeah. 

For sure. So how you been, man? Well, I've been pretty good. If we're not careful, this this, intro bit could be the whole podcast, but I've got quite a few things that happened since I hooked up with you last time. Probably the biggest headlines are that we went to the Intensive Care Society state of the art meeting. 

So after our episode that we recorded with, with Johnny Wilkinson all about few sick blocks Yeah. We actually did a whole session at the state of the art meeting. Right. And there was Johnny Wilkinson, Jenny Ferry, Manny Barra, Ash Meta, Monica Jackson, and Justin Kirk Bailey. All of these guys who are big in blocks and in ICU were all together on stage doing some some demos and demonstrating the block. 

So that was that was pretty cool. That's so cool. How did it go? Did you talk about all the stuff we talked about in the pod? Yeah. 

A 100%. We we literally covered everything we talked about in the in the pod, but we also talked about something else. We talked about doing sell it ganglion blocks for VT. Mhmm. And that kind of divided some of the audience, some of the questions that come in. 

They're like, hold on a minute. Why are you talking about this? It's so rare. And I was like, well, hey. I know that in The States, there are some folks that are doing this. 

So, you know, we thought it was relevant to cover this as a topic. So that was really great fun. That could be the fifth thing in the hit for the cycle. Like, go and get called to do a stellate ganglion block in the in the ICU because the V tach that's unresponsive to medications. You were gonna say recalcitrant then, weren't you? 

I was gonna say recalcitrant. I was gonna say recalcitrant, but it didn't seem like the right word there. No. Do know what? But I knew what you meant. 

I feel you should embrace you know, we should we're all about making up words on this podcast, so let's just go with recalcitrant. Recombinant? So so you guys are doing that. Right? You are doing stellate ganglion box. 

Yep. Yeah. We are. Yeah. Fairly regularly. 

So, one of my colleagues, Arun Ganesh, has sort of taken the lead on this and developed the protocol with the cardiologists, and and, and so he or one of our regional team will get called up there to do these things. Wow. Okay. Well, that's cool. We and you know what else I managed to do? 

So some really cool things happened. So Ed and Carly Mariano made it over here on their way to Belgium. So Right. My family managed to hook up with the Marianos. We went for some sushi at one of our favorite places, and, you know, we hooked up with them. 

That was really great fun to see, the three Mariano boys as well. Amazing. And what was really interesting was that my kids and and their kids were, were sitting at the same table, and nobody got any devices out, and they played card games. They played chop trumps together. So that was pretty that was pretty cool to see kids from different sides of the, across the Atlantic, boys and girls mixing different age groups playing cards like the old days. 

That was good fun. Really great fun to see those guys. Oh, that's great. Oh, man. You're making me even more excited to to get over there in a few weeks and see you guys. 

Listen. It's not it's not long until you guys are here. We can't wait to see you, Corey, and the kids. It's gonna be great. And one other thing, if you were watching my Instagram feed, you might have seen that I got a chance to take my friend out for a date. 

My top hat I'm referring to, we went to Royal Ascot, to the Royal Enclosure at Royal Ascot. So my wife and I went out with some friends, and, that was the first time I'd I managed to get my, my top hat out in the open with my, with my, morning suits. That was good fun. I'm just feeling really chuffed that I have a friend that owns a top hat. Like, that I never thought I'd It's only a year old, man. 

And if you told me, this small town country kid growing up in rural Canada, that one day I'd have a friend that owned a top hat, and you looked dashing, my friend. It was it was inspiring. It was great. Looks like a really fun day, actually. Yeah. 

No. It was great fun. I'm not a big gambler, thankfully, but we did manage to to win some money on the horses. That was even better. Even better. 

Yeah. Yeah. No. You you and Kate looked just amazing, so that would look like a lot of fun. Well, thank you very much. 

Now before we get into the main crux of the of the podcast, I wanted to ask you something. So I was recently out with some colleagues of mine from Guy's and St. Thomas'. And we're having an interesting conversation about lots of things. One of my colleagues, Sanj Bhattacharya, from Guy's and St. 

Thomas' was telling me how he finds your jokes funny on the podcast, so that was noted. And he particularly referred to the snoop the Snoop Dogg faux drizzle, gank that had him laughing out loud on the train. But in amongst this conversation, people's I mean, Sanj, thanks a lot, man. Thank you. Your your loyalty has been noted or lack thereof. 

But the other thing the boys were talking about, because there's a group of guys talking about Instapot. Are you familiar with Instapot? This is something I'd never heard of before. Maybe. Is this, a countertop appliance that you can cook in? 

Yes, man. I haven't even heard of this thing. This thing can do, like, everything. They were talking about Instapot since one of the guys had a nine in one, one had a 10 in one. I didn't even know there were 10 different ways you could cook stuff. 

But yeah. Have so you'd heard of these things? I think it was popular during the latter part of COVID. People were really getting into their Instapot thing. But what I did find out is that Sunil Ramosur, one of my colleagues, was telling me you know Sunil, actually. 

Yeah. So he was telling me that Heston Blumenthal, one of our big chefs over here, has one of his kitchens using Instapot to do things so he can spare up the people power to do other things like, you know, stir this at, you know, 18 degrees centigrade or whatever it may be. Wait. You can you can, like, program oh, it is programmable, like you said. Dude, there's somebody has worked out a crack into these things, and you can override them, write your own programs. 

There's a whole host of things you can do. Rise of the robots. Here we go. Exactly. AI has taken over the restaurant scene too. 

Well, that's good. If you can free me up free me up from, from chopping onions, maybe that maybe that'd be good. Well, that would that would be easy for sure. Well, listen. I feel that I've digressed far too much, Jeff. 

What are we gonna be talking about today? So being no strangers to controversy or controversy and picking up on some of the online social media dramas that we've been involved with. I figured we could go We've been involved with a few. Yeah. And a few. 

We could go all out and have a controversy episode tackling some of the major issues and see if we agree or disagree. What do you think? Oh my goodness. I am so excited. Oh, one thing. 

Can I pick the first one? Sure. Yeah. Why not? Okay. 

Right. Let's get into it. So the first one that I wanna talk about is something that is really very close to my heart and is very, very relevant. It is all about scrubs. Should we be wearing our scrubs tucked or untucked? 

What are your thoughts on this? Well, I am a lifelong tucker. I'm gonna I'm just gonna say it. I do I do like, I don't know, the clean look, the clean lines, the the feel of a I don't like to have my my shirt hem sort of wafting around as I'm as I'm walking around, you know, catching on things. Yeah. 

I like a streamlined kinda how about you? No. Well, see, I kind of get what you're saying, but I think there's there's two things. In The UK, our scrubs have got a pocket. Right? 

And so that pocket tends to be in the front right. So if you tuck your scrubs, then you can't use the pocket because then the pocket is sticking out of your pants over the top of the drawstring bit. So that's one thing. But I've seen, I've seen your, your Matthew McConaughey esque, body. So I know that if you were to tuck your your scrub top into your trousers, you've got nice straight lines. 

What about people that have got different body shapes? Maybe tucking is accentuating the wrong part, and I'm speaking as one of those people. What happens if your trousers are too tight and you stick your trousers, your scrub top down your trousers and it bulges in the wrong areas? I mean, this is a problem. Right? 

Well, we're kinda getting into, like, the scrub tuck etiquette. Like, should you Yeah. Just just because you can tuck doesn't mean you should suck. That's that's right. Maybe there's a yeah. 

Maybe there's an unspoken rule about but having said that, I I have friends and colleagues at work that that do talk and, you know, doesn't leave a whole lot to the imagination as to the bits and pieces that are hanging over and It pulls things quite tight. Right? And it accentuates a lot of things. So yeah. So this is why I don't think it's a clicker answer. 

Well, I think your your point about the pocket makes sense. We don't have those pockets here. That's a do you do you have breast pockets? Yeah. Occasionally, but it's not a to Australia, I I don't know why I brought my own scrubs with me, but I brought scrubs that I had, you know, used in New York. 

Again, who know? I don't know why. Australia, like The UK, has has the longer top with the pockets in front that I just didn't love. And so I began wearing my own. Uh-huh. 

The the sleeves were a little bit shorter. So it was it wasn't quite a cut off sleeve, but it was not like mid arm length either. So they showed off your guns. Right? Well, I I don't have a lot of gun, but the the I just realized I was getting a nickname, the Todd. 

Like, you know, from have you ever seen this the show Scrubs? Yes. People started calling me the Todd, and then then I was like, okay. Message received. I'm put these away and just comply with the the standard uniform. 

I get the that there's a ventilation aspect too. Like, if you untuck, there's a bit more, you know, freedom of movement. And, well, the only thing I've gotta share is sometimes when you don't tuck, rest of the people in the room get to see a lot more than maybe they want to. And I certainly have some colleagues. I'm not gonna name anybody or any specialist. 

I don't wanna give it away. I know some people when they bend over and lean over, you get to see a lot more than you would do. You certainly get to see whether, you know, the brand of underwear that's being worn, and sometimes you get to see a whole lot more. So that's one of the reasons why I would advocate for tucking. But I, you know, I think it's I think it's a very personal thing. 

I just wanna share one anecdote, which is gonna make it might make me cry as I tell the story, cry with cry with laughter. When I was a medical student, the very first time, I scrubbed oh oh, no. I got changed to go into theater. We went to a a hospital in South London, and we're all sent off to go and get changed into scrubs. And so I went into the, the changing rooms, and there weren't very many scrubs left. 

I might have told this story already, so forgive me if you've heard it, but I've got to share it again because it's very relevant. So I, you know, I found a pair of trousers, which kind of just about fit. Okay. And there was only one top. And I put the top on, and then I realized that the top wasn't a top. 

It was a scrub dress. So it was basically a full length dress. Now there weren't any other tops there, and I didn't know anybody else in the hospital. So I tucked the whole dress into the trousers, which then gave me, like, a triple muffin top between the top of the drawstrings and my you know where. And so I came out, looking like a really interesting body shape. 

So That's amazing. Oh god. We So that is why I don't tuck. If only that had been time of, you know, smartphones and people would've there's no picture of that. I'm I'm imagining No. 

No. Smartphones didn't exist then. That would have been photographed for sure. Yeah. But thank god it doesn't exist. 

So listen. We we've we've I I know what's gonna happen here. We're gonna vote here. So, what is your vote? Tucked or untucked for Scrubs? 

I like a tuck. I'm gonna yep. You stick with that. And I'm gonna stick with untucked unless I've managed to hit the gym for a while and my six pack is showing, then I'm gonna tuck. But for all other purposes, I'm gonna untuck. 

Okay. Okay. I I think we kinda put that one to rest. Well, list listeners, we wanna hear your your opinions. Yeah. 

Please let us know. I I'm you know, every time people think they've kind of resolved this debate, somebody else comes back with some other thoughts on this. And I thought there was somebody who's been big on Twitter recently. He gives some sartorial advice, and somebody got him. I can't remember the guy's name. 

But somebody got him involved in the discussion, and he actually went for untucked, by the way. Just just heads up. So Okay. We wanna we wanna list this to chime in on this. Jeff, what's the next thing we're talk about? 

Well, there is some controversy about mixing local anesthetics. And so let's talk about mixing your locals versus not mixing. Okay. Well, I know we're gonna get lots of people involved in this conversation. This was a thing when I was a trainee. 

So I remember, my supervisors attending saying, here, mix a little bit of lidocaine or lignocaine and with a little bit of bupivacaine, and you'll get the best of both worlds. You get the the fast onset of the short acting local anesthetic and then the duration of the long acting local anesthetic. And it I thought, okay. That kinda makes sense, but we never really knew, did we? Did you? 

Well, so, before I thank god you stopped there because I know you're gonna then start citing all the evidence you have because I know you talked about this before, and I know you may even have written some papers on this before, and you can cite lots of evidence showing that the solution that you produce is one of intermediate duration. I hear. I hear. But most of the so I think the main objections so Bob Fonikoto is one of guys who happens to be married to a pharmacist, and he absolutely hates the idea of mixing. But so I think there are a couple of issues. 

Number one, part of the controversy relates to the fact that you are creating a pharmaceutical compound that hasn't been tried and tested either outside the body. You say you've basically got a pharmaceutical comp compound. You're mixing two components within a syringe, and there is no safety data officially about using these, this this compound that you created. Right? So that's one issue. 

But to counter that, we've got many, many, many, many, many years and anecdotal evidence of people having done that. And and what a lot of people talk about is they say, well, listen, if you've got bupivacaine, you know it's gonna last, for argument's sake, sixteen hours. Sure. I know that if I give twenty cc's of Bupiv going, it's gonna last sixteen hours. And when I mix these two solutions together, who knows what I'm gonna get, but it's certainly not gonna last for sixteen hours. 

Mhmm. That much is a given, and I haven't got a problem with that because the situations when I'm gonna mix it He's getting passionate here, folks. But when I because I just I feel that for those of us who do mix, I wanna explain why we do it. When I mix, and I do mix, and I I'm still a mixer. Sorry, boo. 

I know I know there's audience going nuts. The reason I mix is I want I don't have a block room. And for many of the operations, I'm not quite confident that I can get away with a pure lidocaine block. Certainly not a chloroprocaine block, not a forty five minute block, not a prolycaine block. I want something a little bit longer, and lidocaine may not be good enough. 

So I want an intermediate duration block. Okay. But I want it to cook in quicker. And, yes, although I have managed to get an auxiliary brake complex block to be cooked and set up within ten minutes, that's not the norm. And quite often, we need to do the block and go straight to the other, and I wanna know it's working. 

So that's why I do so I I know that it's not gonna last for sixteen hours because, in fact, many of our patients do not want to have a completely insensate limb for twenty four hours. They don't want to. So my defense of this is that it's not gonna last that long. It will last long enough to get you through a decent amount of analgesia, but the onset will be quick enough similar to the onset with lidocaine. I know what you're gonna say, but what what are your thoughts on that? 

So you're saying you're using this technique of mixing to create a different duration. Yes. A less a less long duration deliberately. Okay. Less long duration, but but also a faster onset, And that's probably the biggest reason. 

Yeah. So I have a problem with the faster onset theory because we because we tested this, and we we took patients getting interscaling brachial plexus blocks for shoulder surgery and did half of them with, I'm sorry, a third of them got bupivacaine alone, a third got mepivacaine alone, and a third got a one to one mixture. And lo and behold, the duration was as you'd expect. Lasted for six or eight hours, Bupivacaine lasted for eighteen to twenty ish. Uh-huh. 

And then the mixture was, as you point out, somewhere in the middle. Uh-huh. But the onset, the latency was the same for all three. Mhmm. And and I mean, roughly the same. 

I mean, that's that's in that's interesting. I I find it so you're telling me that the onset of the one to one mix of mepivacaine bupivacaine versus bupivacaine alone, the onset was the same? Statistically, and it was not different. And I'm talking so there might have been a difference of eleven versus nine minutes to to loss of sensation in all the dermatomes we checked. Well, listen. 

Two two minutes isn't a big difference. Well, that's what I think too. So but people will say peep I've and so you were kinda edging towards this when you were speaking a bit earlier about, well, we have, you know, awake surgery and, like, we do 10 cases a day in the in the theater, and we we can't put LMAs in everybody, and we need the blocks to work quickly, and I'm I'm putting words in your mouth now. But Yeah. That two minutes might make difference. 

And I kinda push back that a little bit, not not to your argument, but people say this to me. I'm like, wait. Really? Does it really make that much of a difference? And once in a while, we'll do a block, and it's time to go right back to the theater. 

And so we're rushing back there, and they are prepped and draped quickly. And it's only been seven or eight minutes. And I think, I might need to sort of temporize things here. So I'll just give them a little bit more propofol, and they drift off, and they tolerate an incision. And by the time, you know, twelve, thirteen minutes have elapsed, then the block is set up. 

Mhmm. Now I think case management in the OR, there's ways to temporize things. And I love an LMA. Right. Right. 

Right. Well, hold on a minute. So I'm gonna just stop you there. So I am talking about I'm talking about pure awake surgery. Now see, in some of the units where I work on, the whole premise is that we're gonna do awake surgery because we're not gonna use a PACU. 

So the idea is at the end of the surgery, the patient gets up off the trolley and walks to stage two recovery. So they they bypass PACU. So we have to have our blocks working effective. And if we give sedation, then they have to go to Pachy. They can't bypass it. 

So in those situations, if we waited Yeah. The full time for the block to be truly ready and not require supplementation, then a pure bupivacaine block wouldn't work. So in those centers, either a lidocaine only block or a lidocaine and mixed block tends to work quite well because then we know we can get the the the patient through without any or, in fact, very little sedation to the point they can walk off. So although what you're saying is supplementing with propofol or a little bit of profofol or a little bit of an LMA, once you start going down that path, yeah, I know it's okay. The outcome of the surgery won't be that bad, and, actually, patient may not be that different. 

But if you're trying to have a workflow that that avoids PACU, then that that process won't work. Yeah. I get that. But then again, we're back to the I don't know that your onset is gonna be all that different between bupivacaine alone and a and a mixture. But now that's for brachial plexus, and I will admit that most of the evidence is only for brachial plexus. 

If you had a sciatic, like, popliteal sciatic nerve block, maybe that's a case where Uh-huh. There would be more of a difference between a lidocaine versus a mixture. Oh, we see that in clinical practice. Unless you've got a diabetic patient who's relatively insensate to a certain degree anyway, we tend to see a difference with long acting onset with popliteal static. So okay. 

I think the other issue that I just wanna bring up, and this is, I think, what Bob has talked about sometimes is drug error. So anytime you are pulling up two vials, you know, especially in the you know, you're talking about a a busy practice Uh-huh. Where you're doing lots of cases very quickly, people get distracted, people get production pressure, and next thing you know, you've sucked up the wrong medicine, and there's rocuronium and lidocaine, for example. Yeah. No. 

Listen. I, I don't disagree with that, and I think that that comes you're right. That comes down again to safe practice of any form of anesthesia. You gotta check your products. You gotta check what you're drawing up. 

But the moment you're doing the moment you increase the number of drugs that you're using in your practice, I think it increases, the chance of drug error. Yeah. I'll tell you something. So I quite often use lidocaine with adrenaline. One of the hospitals I worked at recently had run out of lidocaine or xylocaine with adrenaline, and therefore, I had to make up my own one in five one in two hundred thousand mix. 

Now, actually, that made me feel nervous because that's not something that I usually do. So I'm thinking one in two hundred thousand adrenaline, that's five mics per mil. I'm use this many mils of bupivacaine or lidocaine. Mhmm. How much adrenaline or epinephrine do I need to mix? 

Then I then I can suddenly see when you're starting to mess around with medication like that, that's when it can be messy, which is why I like the premix lidocaine with adrenaline. It makes things easier for But I will confess, what I have started to do a lot more of recently, having said that I I didn't like the fact that I didn't get long enough duration with lidocaine blocks, Recently, I have been doing a lot more differential blocks, and we talked about this in our brachial plexus episode. I've been doing proximal brachial plexus blocks with lidocaine or with lidocaine epinephrine and distal blocks with long acting. And, actually, that's okay because I know I'm gonna get the fast onset. The only time when I might get caught out with that is if there's a long time between block insertion and starting the case and tourniquet time, but but I am doing a lot more of it. 

But I'm not gonna give up mixing just yet, Jeff. Okay. Alright. Well, there you have it. I think we need some more, more some more data. 

I think some smart people out there need to do some more, studies in different anatomic sites, different block areas, and and really characterize, is there truly a difference? Yeah. I mean, I mean, I guess but the problem is, again, if you see data that shows there's no difference, but clinically in your practice, you've seen a difference. How how do you deal with that? And that's one of the things about academic papers that are done under rigorous conditions, but they don't necessarily reflect what clinicians are doing practically. 

I I don't know what to do with that information. I think maybe I I I you know, it's difficult. Right? There's the answer that just comes to my mind when you ask that question what is an answer that we got from a a Scandinavian group one time when we were talking about QL blocks, and we had indicated that we weren't getting the same results that they were. And and the response was, you're not doing it right. 

Okay. So I'm not saying that, but, you know, that's that always it always comes to my mind. I hear what you're saying. Getting the same results. You're not doing it right. 

Yeah. I hear what you say. Okay. Well, one one last question on mixing before we move on. So I've heard somebody say to me, oh, I'm not prepared to mix drugs in the same syringe, but for some indications, I might use lidocaine in one syringe first, and then in the second syringe, add in bupivacaine. 

So aren't the drugs mixing in the milieu of the nerve? Aren't they aren't they mixing in the area anyway? Yes, absolutely. Yeah, so we it's funny you say that because we did a follow-up study with that question in mind. Like, so mepivacaine first then bupivacaine versus bupivacaine first then mepi to see if there was any difference. 

And it was Right. Zero difference. Same thing. Yeah. So mixing inside the body is the same as mixing outside the body, so no difference. 

Right. Exactly. Yep. Because because you're although in the first study, you were mixing in the same syringe. Right? 

Exactly. Right. In the same syringe. And then the second study, you you yeah. Yeah. 

Yeah. And then you did them a separate injection. Interesting. I I I think you and I probably so let me just get this straight. So you never mix, is that correct, in one syringe? 

Correct. Wow. Well, listeners, I think, you know, we're gonna have to get you guys to comment. Bob, we know what you're gonna say, but please join in. But everybody else, I wanna hear from the mixers. 

Please tell me why you mix and why you're not gonna change practice, because I'm feeling all alone here. Well, I don't think you're alone because I've I we we had this discussion. I've seen this discussion on social media. So there are mixers out there that would support that will support you. So I think we need to do more study. 

Because I because I think part of what guides our clinical practice is that feeling of you wanna hedge your bets Yep. And not have a block failure in a high stakes time, and you you wanna get your latency and your duration just exactly right. So I I know that feeling. I I really do. And to your point, our clinical workflow is not the same as what you were describing with the wide awake, getting up off the trolley, walking out the door sort of thing. 

So, you know, yeah. I get it. I will say though, if I had regular access to a block room somewhere I can cook and I'm not under time pressure, I think my need or requirement to for mixing would disappear. So I will acknowledge that. Not yeah. 

But I don't wanna ignore the fact that, again, some patients really don't like to have that really, really heavy feeling for twenty four to thirty six hours. So maybe there's still a role for the mixing. But, you know, if we're gonna vote now, you're gonna what's your vote for mixing or no mixing, Jeff? I still I still know mixing, man. Mix the mixing. 

Okay. Well, I'm gonna carry on with my mixing. Let's see what what folks have to say. I think this one's gonna probably cause the most controversy. Alright, Jeff. 

Moving on to the next win. The the this is topical. Right? What are we gonna talk about next? Well, Ariana Prinsbach, who's one of our fellows, and I just wrote a pro piece for part of a pro con looking at the use of single use probe covers for single shot blocks. 

I think we can all agree for continuous catheters, we want to be as aseptic as possible and have a nice long probe cover, etcetera. The question here was for single shot blocks Uh-huh. Do you use a probe cover or do you use something else? Or nothing. Or nothing. 

Do you go bareback? Which I think is just I mean, I'm gonna show my cards here in a second anyway, but I think that's just disgusting. There's been enough infection control studies looking at the vector capacity of an ultrasound probe, and they are just loaded with germs. Even if you think you're, you know, cleaning it well with these these chlorhexidine wipes or bleach wipes. Uh-huh. 

There's little nooks and crannies and cracks and stuff. And and Yeah. So so I so I think when I think about this question, somebody somebody said to me, what would you want to happen if you were gonna be doing a procedure or have a procedure done on yourself or on your or or a loved one, your wife or your child, what would you want somebody to do? Would you want them to just pick up the ultrasound probe as it was, as it was presented to you, and plunk it directly on the skin, clean the skin, and do a nerve block, or would you want something else to happen? And I think that kind of really channels my thinking. 

So I know for a fact that I don't always religiously pick up the probe and inspect it thoroughly in all the nooks and crannies to see if there's any, blood residue, if there's any glue residue, if there's any muck or I I don't do that. Sometimes, I might remember to wipe it down physically with a prop proper wipe, but I don't always. Sure. And I might assume that my block nurse or my anesthetic nurse might have done that, but they don't always do that. So we're often presented with a probe, and we've got no idea what's happened to that probe, where it's been used, what orifice it's been stuck in prior to us using it. 

I think using a probe cover, some kind of probe cover, just acts as a physical barrier between whatever's happened with that probe and and the person it's gonna be in contact with. So I'm kind of the idea is to protect the person who's having the block from anything that may be on the probe. That's why I don't wanna use a probe cover. So I think I think there's a role for it. But I do wanna say that there are many of our good friends and colleagues that we have in common that we like, hey. 

Why is this any different from any other procedure that we're doing? When we're doing it, you know, an ultrasound go to IV, we don't always use a probe cover. So, actually, why do you need to use a probe cover? Just clean it. The needle doesn't touch the probe. 

What's the big deal? That makes me feel uncomfortable, man. So I kind of I understand the need or requirement to put a probe cover. So I kind of I'm always gonna do it. But for me, the controversy relates to what that probe cover should be and the whole impact of sustainability and what how that will impact sustainability. 

Well, yeah, I mean, just just to set the record straight here, I also use a probe cover for ultrasound guided IVs and arterial lines and that sort of thing too. I think that's even more likely. See, the problem is that we'll see people puncture the skin with a needle, block needle, IV, etcetera. And then, you know, the they lose their image, so they're sliding the probe around, and then there's a bit of blood in the skin, and then that gets drawn up by the gel. And then the at the end of the whole debacle, you're hanging the probe up back on the ultrasound machine and it's all got this bloody jelly mess all over it. 

And what some have argued is that, well, that's okay because we then go and clean it with a bleach wipe and and so it is sterilized for the next person. And my my problem with that is, how do you know? How do you know when you go to pick that up that the the person that used it before had the same practice as you? Or or were they in a hurry and said, I'll get to it later, but, you know, I'll give it a quick wipe with a paper towel now, I'll I'll clean it properly later and that sort of thing. Yeah. 

Using a probe cover takes away the guesswork and and just establishes a standard that means, like, I please understand, I also clean the probe with a bleach wipe. So we're also doing that too. It's not in lieu of a bleach wipe. It's you clean it properly as is advocated by the FDA and whoever else is your regulatory body. Yes. 

And then just as a double protection layer of protection, you use a probe cover just in case you didn't get everything. Agreed. But, you know, but remember, this is all preceded by low level decontamination. So that is using a probe. If if you were subjecting your probes to high level decontamination, they're getting autoclaved or getting stick to one of stuck in one of those UV cleaners, and you could guarantee it was inverted commas completely sterile, then, hey, I can kinda see the argument for it. 

Although using a probe cover makes cleaning the probe afterwards a bit easier, I can kinda see the eye argument for it. But when you don't have to use high level decontamination for these probes. This morning classification that's that's been looked at, decontamination of medical equipment says you don't need high level decontamination for these ultrasound probes. But the problem is, Jeff, many of the societal guidelines are inconsistent with what they say, or they allude to using a probe cover saying, we know there's not much evidence, but we say you should do it. But then they don't necessarily say whether a probe cover should be sterile or nonsterile or just a physical barrier. 

I think that's where a lot of people are getting heads up. And I think the moment you have on your block trolley a set of non sterile probe covers versus a set of sterile probe covers, there's gonna be confusion. Right? At one stage, you're gonna use a non sterile probe cover for something that should be sterile. So I think if you're gonna use a probe cover, it should be sterile. 

The question is and the next question I wanna ask you is, is a dressing cover such as a Tegaderm type of dressing, is that as good as using a probe cover? And if not, why not? I think my answer to that is no because unless you're using a big long one, and we have some of these long ones that we use to secure epidural catheters to to the people's backs and that sort of thing, and and you folded it over and it covered the handle as well, then you're then the handle is still a problem. Right? And and the proximal bit of the cord. 

And so I think what what a good solution is that we've adopted is to use a 30 centimeter cover, and that covers the probe surface, the handle, and a little bit of the cord. And and really, that that means if you're if you're moving your probe around as many of our trainees are during the course of any kind of percutaneous procedure, you are not dragging the cord or the handle and you're not so as you're switching hands or something, you're not, you know, touching some part that's that's not clean and then transferring that those microbes to the to the patient. So I like Yeah. So that's an advantage to a 30 centimeter short probe cover, a shorty versus just a Tegaderm. Make no mistake, I have used Tegaderms lots and lots of times, but we didn't have these short probe covers then. 

The more I sort of think about it and the more things I've watched done in my block area, the more I love the idea of a short probe cover for everyone just standardizing it. Yeah. You know, I I still use Tegaderms, but I have to be honest. The reason I use Tegaderms is we don't have the short probe covers. We only have the long ones. 

And opening a full long probe cover for a quick single shot into scaling brachial plexus block seems a bit over the top or an auxiliary brachial plexus block feels over the top. I totally agree. Yeah. But when I look at my practice of how I apply the Tegaderm to the probe, the action of applying it means that I'm not inverted commerce sterile anymore. And now you could argue, and many people will argue, you don't need to be sterile when performing a single shot regional anesthetic block, and I don't disagree with that. 

Essentially, for most of the time, it can be a non touch technique. But the truth is, I used to wear sterile gloves for these procedures as a matter of course, whereas maybe now I am less worried about that because I don't tend to touch the needle as much as as, you know, as you used to in the past. So there may be some more controversy associated with this. Sometimes for single shot blocks, I'd use non I use clean, but non sterile gloves. So that's a the unintended extra controversy added to the mix. 

But I do think a probe cover is useful. I'm using Tegaderms at the moment, but if I had short probe covers, I'd use those instead. Yeah. And and, again, I think some of the discussion got a little bit off track, and people in the con group have said to me, well, yeah, maybe your ProCover is sterile, but like there's lots of other parts of your procedure that's not sterile. And and as soon as you breach one of those, then your whole effort has been shot. 

We're not trying to be sterile with these. No. We're trying to prevent the transmission of bugs from the previous patient to this patient. That's a really big point. Right? 

That's a really big point. Right. Yeah. Like, I the peripheral nerve blocks, they're it's a clean procedure, not a sterile procedure, a single shot block. It's about transmission of of microbes. 

I think there's also a bit of an optics issue too. Like, if I were to get down back to your point about your loved one, if it was your daughter coming in for a block and you were in the corner watching that procedure and someone pulled the probe off the cart, you would be wondering how well did they clean that thing before? Yeah. Uh-huh. And and so I don't know. 

It just seem it just seems in 2024, we can do better than than bareback probes. Yeah. No. I agree. And also, if I that's gonna be a quote that's gonna be someone's gonna use, I'm sure. 

There's gonna be a sound bite or maybe I'll make a little audiogram of that sound bite. I'm also trying to think you imagine trying to get those curved array probes. I have never successfully managed to apply a Tegaderm to a curved array probe without making a complete ass of myself. There's no way I can apply that. Yeah. 

You get a there's wrinkles and yeah. I know. Oh, I wanna it and it splits. And, of course, these probe these takederm type dressings, they can tear, they can sheer, they got perforations on them. I see some people trying to overcome the size by stretching them. 

Well, the more you stretch them, the bigger the perforations become. So I kind of whilst I am currently using Tegaderm, I would like, I really would like to move across to the short probe covers, but I'm waiting for some guidelines to come out that will give me some reasons to start doing that. And I know there are some big guidelines coming out from the American Society of Regional Anesthesia talking about infect preventing infectious complications of regional anesthesia and pain procedures. Yeah. When they come out, that will hopefully give us some reason to buy them. 

Well, I wonder what they're gonna say. I mean Yeah. It'd interesting to see what they recommend on this particular issue. It would be. I would say I know the answer, and I wouldn't be lying by saying that, but I'm not gonna say anymore. 

So let's see what happens when they come out. But the only other thing I would I I think we do have to talk about it because it's relevant. And I know there was another there's another study that I've been involved with, which is a Delphi consensus study looking at sustainability practice in regional anesthesia. Right. What about the plastic cost, the environmental cost of the plastic, the carbon footprint, all of that about suddenly going from a place where either you don't use probe covers because you think you're clean enough or using Tegaderms versus these shorties. 

What do you think about that? Well, it's it's not it's not nothing. Right? Like, it's an extra piece of plastic that goes in the in the trash and contributes to landfill and environmental waste and all that stuff. So I understand and appreciate that argument. 

I think when trying to put things in perspective, I look at all the disposable stuff that we use in the course of a single lab cole, and it is shocking. I when I was a medical student, we had nondisposable drapes. Like, okay, boomer. I don't know if places still use this. Yeah. 

I've seen them. But now everything is disposable. Right? So you, like, you lay there, and that gets washed and then reused. Maybe we can't go back to that. 

I'm not sure. But there's lots of things we do throw away that maybe we don't need to. And I I think that if you're going to start with something, there are bigger targets for your efforts in terms of reducing the amount of landfill waste that comes out of a hospital practice. Listen. I think that was a very I think it was a very political answer, but actually, I support that. 

I think we could review as a whole what we do, and there may be other ways we can offset the use of this. I think the financial cost hopefully is gonna be small, but just because we haven't done it some way and just because the incidence of infection or transmission of infection from one patient to another is small, it's not zero. And you don't wanna be that person contributing to transmission of infection. If probe covers help, I think there's a role for it. But I I think we're both gonna vote for use of probe covers. 

Right? It sounds like that. Okay. We agree on something. That's good. 

That's the first thing we've agreed on. But there is two things I wanna talk about. Okay. I'm gonna I'm gonna say the phrases. One of them is condoms. 

Why? And the other is gloves. I hope this is going in the direction I It is. Okay. It's going in the it's going in the right direction. 

So people have talked about using condoms for probe covers. Have you seen this practice? There are, yeah, specific condoms that you can stick on a probe. Have you is that something you've ever done or ever used? Are you talking about, like, a condom that's actually meant for Well, so so I think this is a condom that's actually meant for regional anesthesia, but I've seen somebody else use a condom used for another region, a reason for this practice, and using it as a barrier because it's cheap and accessible. 

This may have been in a developing country. What are your thoughts about that? Well, listen. The title of our ProCon piece was practice safe scans, use a probe cover. So we I I think the illusion is is similar, and the concept is is the same. 

Right? Like, wrap it or regret it. Yeah. That works a lot of different ways. But yeah. 

No. I think I think a a barrier works as long as it gives you a good image and prevents transmission of microbes, which is what condoms are meant to do. Yeah. Okay. So so maybe and the other thing I've seen people do, which is clever, right, is they've taken a sterile glove, and instead of unpeeling it, they've popped some gel in the side, and they've stuck you know, the sterile gloves often come folded, and they stick the probe in the area, and that creates, like, an instant cover. 

So that that's a a clever use. You're gonna use sterile gloves. They'll be knocking around anyway, so why not use that? Does that work? Is that good enough? 

Yeah. I've done that too in a in a pinch. And specifically at, like, three in the morning when I'm in the OR and I and I need a line right now and nobody can find me a probe cover in in that operating room. So I'm like, fine. Sterile gloves, sterile gel, that's gonna work. 

Let's go. Okay. So it's still advocating for use of a probe cover, but sometimes maybe you gotta be a little bit, a little bit inventive with our solutions. Before we close this out, so I think we both voted pro probe covers. And ideally, in an ideal world, not a Tegaderm type dressing, but we would use an official one. 

This is a a random one that came up. Now I'm curious to know your practice. Single shot spinals intrathecal injections. Do you use a gown or not? No. 

We don't use gowns. Although we did in Australia. I was I was taken aside and spoken to because I didn't do a spinal with a gown. Well, I think the whole of my training, we got fully scrubbed for spinals, and that includes hat, mask, gloves, and a gown. And that was standard. 

I think to a certain degree, it still is standard, but people are now questioning that. And if I look at my current practice over the last twelve months, for every single shot of spinal I put in the last twelve months, I've cleaned my hands, scrubbed my hands, washed them, put sterile gloves, had a hat and a mask, but I have not worn a gown. And I think that, you know, I use a drape. I must confess, I do use a drape. So I do use this the the spinal set that we get given, but I don't wear a gown. 

So that's my one bit of contribution to minimizing use. Think, actually, it's not it's not necessary. Talking lots and not wearing a mask is a bad thing, I think, which is why I wear a mask because I do tend to talk, being sensible with how you touch. I think there's there's a role for perhaps not even using a drape, but at the moment, I haven't got to nondraping. But I don't use a I don't use, a gown. 

Yes. I think that's then seems reasonable to me. I mean, I'm I'm not up to date on the evidence behind gowns versus no gowns for neuraxial, but but if you're talking about sustainability, like, look at the volume of material in a disposable gown compared to like, I can crunch up one of those shorty probe covers into the size of less than a golf ball. So if you're looking at ways to make an impact environmentally, that might be one of them if there's no difference in terms of safety. Okay. 

So that'd be interesting because I know that's also done the rounds on social media. Right. Well, let's get a little bit light hearted or they would I don't think we've been too serious so far. Let's head into the joke break. So I've got I've got a couple of jokes for you. 

Are you ready for this? Okay. Hit me. Okay. Did you hear that Aladdin was banned from the magic carpet race? 

Oh, no. Yeah. He was caught using performance enhancing rugs. I got it. I like that one. 

I think you're gonna get props for that one this week. I think you're gonna win you're gonna win the joke the joke off. I hope so. Sandge, please, vote for me. Okay. 

So I've got another one. This one has come from regular joke provider, Charlotte Salisbury. Are you ready for this? I love a Charlotte joke. I look forward to my Charlotte jokes. 

Okay. Well, here you go. Why don't you spell dark, d a r c? Thanks for the American accent on that one too. That was nice. 

I don't know. Why? It was unintentional. Because you can't see in the dark. Oh, good one. 

That was good. Right? That was good. Yep. Yep. 

Charlotte? Intellectual level as well? Charlotte never disappoints. She's good. She's on fire. 

Thank you, Charlotte. Miss Sulsey, you're on fire. You got something for me, Jeff? I do. You know, it was a hot day yesterday. 

Got home Uh-huh. From walking the dogs. I went to the fridge, and I love a root beer. So do I. I love root beer. 

It's good. Right? Yeah. Yeah. The only glass I have is a square glass. 

So I poured the root beer into a square glass, and now I just had beer. Very good. That was a I love it. Little mathematics little mathematics joke there. Right? 

Yeah. I had to think there. Root beer. Oh my god. Okay. 

Very good. You got another one for me? Yeah. Yeah. I had, last night, I I told you I got some rest last night and had these weird dreams. 

I had a dream about being a a car muffler, and I woke up exhausted. A car a car muffler is the thing that makes your exhaust quiet. Right? Is that what is that what that is? Oh, you don't have mufflers in the oh god. 

I'm not Totally fell flat. No. We didn't. I got it. And and you're still probably gonna win the joke off with your two jokes. 

Oh my god. Okay. Well, thank you very much, Jeff. I I kind of feel that's taken the tone of the podcast to where it needs to go. So now let's get into something that's gonna be a bit I think we're definitely gonna disagree on this. 

Okay? Oh, okay. So this oh, I just realized we haven't had any sound effects. Johnny Wilkinson had lots of sound effects for us. This is one that has no relevance whatsoever. 

Here we go. That was the wrong one. Wanted I actually wanted this one. I've got a bad feeling about this. That was c three p o. 

Okay. So I have got a bad feeling about this. So what I'm talking about is awake versus asleep blocks. Do you ever perform regional anesthesia under general anesthesia? Yes. 

Frequently. In fact Okay. Good. Yeah. Okay. 

So all blocks? I think so. I think there's no specific block that is on the prohibited list while asleep. When I was training, it was very much sort of frowned upon to do neuraxial while asleep. But then the worry that people have expressed is that if you take away the patient's ability to respond to you and the needle and say, oh, that hurts. 

I got this electric shock failing, Then you might be at risk of needle nerve contact or needle cord contact and provoke an injury or be less likely to to to prevent yourself from causing an injury. The problem with that argument is that there is virtually no correlation between paresthesia and resulting in nerve injury. So in other words, you can have no paresthesia and have a devastating injury. Yes. Or you can have you can have paresthesia and nothing happens. 

Right. So it's very hard to know what to do with that. So that that the sensitivity of that monitor is very, very low. And also, the thing I always use as a counter to this is I know that in North America, as we've talked about before, many regional anesthesia blocks are cited with the patient in vertigo is awake and can be using a spectrum of sedation from lightly sedated to relatively heavily sedated, and sometimes with more than one agent. So I know some people use midazolam and ketamine, or you might use a an opioid of midazolam. 

So I think to a certain degree, the the safety that's offered by being awake is kind of removed in those sedation scenarios. So so I see I mean, I'm surprised, actually. I thought you were gonna give me a hard no on something. And I thought you might give me a hard no on interscaling brachial plexus blocks. Because that's certainly in The UK, there's this this belief that's held by consultants, many trainees that, you know, interscathing brachial plexus blocks must be done with the patient awake because of the potential, in catastrophic injury. 

So it it's interested to hear I was interested to hear you say that. And I thought from a litigate litigation point of view, a lot of American hospitals were very hot that patients should be awake for those type of procedures. Well, it's interesting. It I I thought you're gonna go that way with the inner scaling, and I think that comes from a a case series that was published in 2000 by John Beniamoff from California that showed or or outlined four cases of catastrophic cord injury with a sleep interscalenes. And they had cord syrinxes and and paralysis afterwards and that sort of thing. 

But the difference then is they were not using ultrasound. Right? So this is a nerve stimulator alone block in a patient that was was asleep. I'm not sure why there was no they got a twitch. They got a really, really good twitch in some of those cases, those four cases, because they were stimulating motor fibers of the cord. 

So I think things are really different now. Right? Because we're it's hard to imagine if you have an understanding of the sono anatomy of the brachial plexus and you can see the c five and c six nerve root going so deep as to cause a cord injury or or jamming it right in the nerve root and have the local flow into the cord is kind of difficult to see, right, if you're if you're relatively careful. Well, I think this is the key, though. Right? 

What you're saying is, it's not just about having ultrasound. It's not just about having the tool in your hand. You have to know what you're doing. So I think that's it's I think it's important to make that distinction. So if you've excuse me. 

If you've performed regional anesthesia before using an ultrasound and you know what anatomy you're looking at, then I think you're pretty safe. If you know what you're doing, you can see a needle tip and you understand the anatomy, you're safe. If you've never done a nerve block before and you got a patient asleep and you stick a probe and you think, hey. I'm gonna have a go. Well, then I think that's danger. 

I think that's dangerous territory, but we're not talking about that situation. I think it's important to make that distinction. And and I wanna say two things. One one is that I like having patients awake for all kinds of reasons. I like having the conversation and hearing about what they're feeling and experiencing during my needle placement, etcetera. 

I think there's value to that, notwithstanding the lack of sensitivity and specificity of paresthesias. But so there's there's good reason to have them awake. I will so I choose to do them awake or lightly sedated when I can. But on the other hand, I don't get put off if I have, say, a trauma case, they're already intubated and and I've, you know, gotten consent from in some way of doing a popliteal block so that they wake up feeling comfortable while while they're asleep or or blocks for rib fractures while they're asleep, that sort of thing. The the other case that we do this literally daily is for our total joints. 

So we'll do a spinal and then we'll do the blocks for the knees. Yes. And some sometimes I get the comment like, wait wait a minute, they can't feel that. Yeah. And I said and I'll say, well, yeah. 

That's the reason we do it in that order so they don't feel it. But we are using so paresthesia is a subjective monitor that doesn't work very well, but we're using ultrasound and nerve stimulation, and in some cases, injection pressure monitoring as objective monitors to keep us safe. Yep. So that's really interesting because I've got some colleagues who a 100% will insist on doing certain blocks awake except for anything they do after spinal. And then they'll do it after the spinal, and they don't see how the two are are similar, which is interesting because I think, you know, if you're doing it after spinal, it's the same as doing it under GA. 

What I will say, however, is the further away from the neuraxis I go, the less worried I am about doing these blocks under GA. So, you know, an ankle block, I don't have a problem with doing that under under general anesthesia. Popular sciatic, I don't have issue with. But if I'm using Landmark and it's near the near the neuraxis or at the neuraxis, I'm a little bit nervous. So and and I think that's historical. 

And as you say, maybe I don't need to feel that way, but I don't like doing a sleep spinals. So I don't like doing spinal anesthetics to sleep because if the patient were to wake up afterwards with some neurological symptom, I can't say that I I can't say hand on heart has nothing to do with me. I I feel that the same. I feel the same. So I I doesn't I don't love it. 

There's certain cases to your point. I mean, it's everything in anesthesia is risk benefit ratio. So the the the case might come where, alright, the risk of me doing this neuraxial procedure awake might be greater if the patient's got, you know, behavioral issues or cerebral palsy or is a child who's gonna move and squirm and and Or even if it's an adult that's super anxious, you stick a needle and then move their head whilst your needle's in the skin. Right? Yeah. 

Yeah. Yeah. For sure. So weigh the risks and benefits. So do you think if we are gonna do a block under general anesthetic, we need to alter our consent to say there may be a slightly higher risk if it's done under a general anesthetic? 

I'm not sure we can say that, but do we need to alter our consent when we do that? I don't think so. In fact, there are data from Germany that looking at and that's retrospective, but they looked at twenty one odd thousand cases in three different conditions, under GA with sedation and wide awake. And the group that had the lowest incidence of nerve injury afterwards was the group that had a GA. Then the the wide awake group had the highest incidence. 

So Wow. What that tells me I'm not now you can't say, you know, you are safer under GA. No. But at least we're probably not putting patients at higher risk if we do it under GA. That's really that's really interesting. 

Because I know some people have have written in their notes, patient prefers to have block under GA, discuss the risk of nerve injury may be higher. But that statement doesn't have any evidence to back it up. So that's that's an interesting thing. Yeah. Yeah. 

So I'll I'll leave a we can leave the, links to that article and and those better as we talked about in the, in the show notes. Yep. So okay. So we're gonna vote, awake. So would you perform I guess the question is would you do you slash would you perform blocks under GA? 

And both of us seem to be saying yes. Is that correct? That's correct. That's what you said. Winner, winner. 

I, and I do have a slight anxiety about asleep spinal. So that's where I'm gonna, I'm gonna leave my my negative on asleep spinal. That's probably where I draw the line. Yeah. Agree. 

Okay, Amit. Well, why don't we wrap, up this controversial episode? Yes. I mean, Jeff, there's I kinda feel like there's so much we've left out in the air there, but that's it's quite good to kind of leave something for us to come back to and maybe to dive into a bit more. There's so many more things we can talk about. 

Maybe there's gonna be a controversies part two if we have, if we have people suggest some topics. So Yeah. Yeah. Thank you so much for for entertaining me and and for giving us some jokes and diving in on that. Likewise. 

I I'm hoping I'm hoping our listeners enjoyed that. So, folks, you know what the deal is. Please like, subscribe, and rate our podcast from a usual podcast provider, and, and you know where you can find us. You can find us at Twitter at block it underscore hot underscore pod. Where else can they find us, Jeff? 

We got YouTube at block it like it's hot and also Insta block it like it's hot with underscores in between each word. And don't forget our hashtag hashtag block it like it's hot or the abbreviated one b I l I h. Please get involved with all the conversations online. This is the best part to me is is after we release the episode and we can we can see, oh, you know, we've touched a nerve there or, hey. They they they like that or Touched a nerve. 

But that's that's the the most rewarding part apart from just spending time with my top headed friend. Absolutely. And I wonder how many people heard the little blooper reel that you added at the end of our last episode. It'd be interesting to see if people found that. But I guess Right. 

Until the next time, we hope you all block it like it's hot. Bruh. Natalie was doing a block and totally ate it. I mean, she slayed. And I was like, you have mad Riz. 

You must listen to block it like it's hot.