S2:E9 "Block it Like It's Hot Down Under Part I: Two Regional Anesthesia Tragics and a Social Media Queen"

Wake up and prepare for a deep dive into training, expertise, and who should be doing procedures with our special guest. Oh, and an extra helping of jokes. I'm Jeff Gadsden. Join us Down Under as we get LinkedIn and excited about socials, stares, spinals, and shopping. I'm Amit Power. 

And this is block it like it's hot. Good day, Jeff. How are going? Oh, good day, Ahmet. Say, what happened to our narrow accent policy? 

Well, the thing is, Jeff, it's gonna be really tricky not to slip into that in this episode because I'm really stoked about what we got lined up today. Might. I am similarly stoked as. But, before we get into what we have in store for our listeners, let's check-in with you. What's what's going on, man? 

Well, holy moly. I'm gonna drop the accent now because I really don't I could make that work for the rest of the episode. This Yeah. It's probably safe. Best for the listeners. 

Probably safe for everybody. I guess the biggest news is that I just got back from the European Society of Regional Anesthesia meeting in Prague, which was so much fun. Oh, it looked like fun. Yeah. I saw it. 

I saw all your your socials and everything. And Sorry about that. No. No. No. 

It looked great. It looked amazing. It's always Ezra's a fun meeting. It is. You know, it was so cool to meet so many of our friends and colleagues and to meet a whole bunch of new folks who had not met before. 

And what was lovely is the amount of people that came up to me to feedback positively about the podcast was incredible, but they all wanted to know where you were. Yeah. One of these days. It it seemed like there were a lot of people that you had known on social media but hadn't ever met in person. Was I getting that vibe? 

Yeah. No. You you know what? Absolutely right. So I got to meet, a couple people that who hadn't met before. 

Actually, Claire Braganza and her husband Andy from The Philippines. Yeah. But I'll tell you who I did met. So Kavitha and Rasna from The Netherlands, the two people I'd interacted we both interacted with on on X for a while, but never met. They're they're friends and colleagues of Bob Funicottis. 

I actually got to met meet them. Got meet got to meet one of the people I mentioned a lot over here, Rafa Blanco, and a whole host of American dudes, Raj Gupta, Ed Mariano, Sandy Kop, Jan Bublek, Nadia Hernandez, Melody Herman, Robbie Erskine, and, of course, some of The UK crew, Alan McFarlane, and Mornay Wilmern. Dude, there were so many people there. Was so much fun. The usual suspects. 

Absolutely usual suspects. But do you know what was really scary? So I'm gonna do my best Spanish accent now. Vicente Roques. He Please. 

No. That was good. Right? No. Okay. 

Okay. Anyway, well, Vicente is a is a long time listener of ours and a and a expert regionalist, but he is like a whiz with video creation and AI. Yeah. He did a presentation where he got asked to feature in the presentation. He took our voices and made us say things we would never have said before. 

And in languages, we can't speak. You were speaking French. I was speaking Italian. That was crazy. I just assumed you could speak Italian. 

Yeah. Well, I mean, I I I do get mistaken for Italian, but no. No. Unfortunately, I I'm not I'm not able to speak. Oh, I did. 

So I saw that he sent me the the version where we were just doing our own English tracks, but I didn't hear a French one. How did I sound in French? You sounded, I have to be honest, you sounded pretty good. And there were a lot there were a lot of smiles and people getting so uncomfortable in their chair listening to how good you sound. I met it it was yeah. 

It was scary. It was scary. But I reckon I would I would I would sound pretty good in French. Yeah. I think anyone anyone sounds good in French, actually. 

I think so. I wish I could speak. I can only say, actually, I'm not gonna do any of what I was about to say. Keep in your head, Amit. Keep in your head. 

Keep the listeners. But, anyway, listen. It it was a great meeting, and it was great to see, to see so many people. So I hope I can see you on Ezra meeting soon. One of these days. 

We'll get there. Well, listen, the other other thing I wanted to say, the other thing that's happened to me, seeing as you asked me first, is that I've got something exciting happening next year. I can't tell you very much about it because it's not being launched yet, but I was, I had to book some, some long haul airline flights, and I was too scared to do it. And so I managed to rope in the help of an Australian colleague of ours who's with us at Guy St. Thomas'. 

It's called Shelley Lee. So she sat down for a good hour and helped me book my flight. So I did wanna say that I was gonna give her a big shout out. It's a massive shout out to Shelley for helping with my flights, and we will release more of that information later. But listen, enough about me. 

But what will you hold on? You you need help to find Australia on a map? Like, what was Yeah. Dude. Was the how Thing is, like, I know it's down under. 

I just didn't know exactly where was where it was. Yeah. No. I'll tell you what it is. I've got about, like, six interconnecting flights. 

I didn't know what the turnaround time should be and Six? She was like a pro How are you getting to Australia? No. Listen. I'm I'm cheapskate. 

I've gotta gotta get it with, like, the lowest amount of money. But, no, seriously, she, she was doing all this crazy stuff. She was googling where the best flights were, where the best seats were. She's like, I was like, is that a good seat? She's like, don't worry. 

She went to YouTube and checked out. So these young people know how to use technology in a way and that made me feel really old because she was doing all these quick touching keystrokes and then getting one website up and yeah. It's nuts. I feel like an old guy. But anyway, massive big shout out to Shelley Lee for helping me with that. 

I actually put a video on my socials about because she was, yeah, she was a legend. Now listen. Enough about me. How have you been, and what have you been up to? Because we're coming out to Blocktober. 

Right? Well, by the time this gets released, we'll be halfway through Blocktober. Yep. I can't wait. I cannot wait. 

Thanks. And I saw you you tweeted out something, about Tobleroc Tobleroctober? What's that? Ok October. Toblerone. 

Sorry. So I saw I saw this post coming out. I was like, I'm excited about Blocktaber, but hold on. Oktoberone, we need to do some of that. Do you see that giant Oktoberone bar I have? 

How much is left? No. That was that was a couple of years ago. None of it is left. It was basically I I got it. 

It was during in fact, was during COVID, but this thing was so big that, actually, I couldn't eat it. I had to cut it with a knife. It was massive. Tell me about you. It's not all about me. 

Tell me about you. What you so what you've been up to? Yeah, man. Good. Things are the usual at work. 

I bet you know you know what I've been doing? I've been cooking a lot more than I have been. Cooking? Yeah. You know, thought during this new school year, I would, try to develop myself more as a guy in the kitchen. 

You know? I I grill once in a while, and I can pour a mean bowl of cereal, but this is something that I've that I haven't explored all that much. So, yeah, looking forward to learning a new skill. So what's your what's your best dish at the moment? Well, I've liked them all. 

I mean Okay. Which dish has gone down the best with the family is I guess, what you talking about? This has become the issue. So Cory has, in general, enjoyed what I've made. Uh-huh. 

But the kids have not. And I we've realized that they've become just too used to the staples that are kid friendly. Right? So, like Steak and caviar? Yeah. 

Yeah. Right. Pasta, grilled cheese. Cory makes a great tuna melt. Really good tuna melt. 

So, like, we have our we have our usual stuff. But so I when I tried to stray off, like so I made these Moroccan meatballs with couscous one day, and I made a made, like, a Thai and Thai style curry one day over rice and just stuff that we haven't been making. And do you know what they did? They actually got a petition together. A petition? 

Like, Holt took the time to do this. This is after about two weeks. Okay. This is a petition to ban Jeff Gadsden from making any more nasty dishes or food for dinner all in favor of this argument signed below, and then all four all four kids signed it. Wow. 

Which was yeah. Yeah. I'm offended. Holy moly. But, I've met your kids. 

I can't believe they would do that. So the food must have been really bad. No. It was really good. I made this potato, bacon, and corn chowder. 

Like, does that not sound good to you? It does sound good. You know what? Okay. I I think I think you've just step by step, you just gotta broaden the kids' horizons. 

And, you know, may and you haven't paid attention to this petition. Right? No. No. Oh, they're children. 

They get to they will eat what I put on the table. Yeah. Okay. Cool. So that sounds like that's that's quite a lot to to be, to be focusing on doing all the, the foods, food cooking at home, and and having an audience that are not receptive. 

Receptive. So that sounds like a big challenge. That's been fun. Oh, and I I've, I've I think I've perfected crepes Oh, really? Which makes me realize I need to I need to perfect the the French Jeff accent. 

Yes. In fact, well, I think that would be something great for, like, a a a video video podcast is, you know, Jeff Cooking. Block it like it's hot cooking with Jeff. Something like that. And well, listen. 

Before we get into the mink thing, yeah, the other thing I wanted to talk about is I think Yeah. I have managed to get over the hump of my bad spinal juju. Oh, what what are you talking about? Dude, I had a run of about three or four cases where I got CSF back, injected the medication, and I never got a block, like, not at all. And I did all the textbook stuff, you know, I scanned, got pre procedure ultrasound, did a mark, x mark x marks the spot, got in CSF back, injected medication, nothing. 

And a few times where I could actually see into the space, and I never hit CSF at all. And I was so I was in such a bad place, that I was gonna I was gonna hang up my central neuraxial hat and say I'm only a peripheral regional anesthesia specialist. But thankfully, because I was working with a good luck charm, she was an Australian anesthetic nurse called Courtney, and she's like, I got you, Amit. You got this. And actually, the day I worked with her, everything came good. 

Thank god I'm over the hump. How many Aussies do you work with? So far, counting Shelley Lee, and then there's Do you know what? Quite a few. Okay. 

Shelly Lee Shelly Lee's a fellow, and then we got we got about four or five Australian anesthetic nurses that come over here. So Lucky you. Yeah. I I I think the Aussies bring us good luck. What do you reckon, Jeff? 

I remember in the early days of spinal ultrasound, Manoj Karmakar from Hong Kong telling me that he had the same thing. He every once in while, had a dry tap, but he could see it in real time. He said, look. I can see the needle is in the subarachnoid space. For some reason, we just cannot get CSF back. 

But if you inject it, it would be okay. Did you ever inject any of those, or did you? Yeah. Dude, so when I wasn't getting CSF back, clearly, I wasn't using ultrasound to do it real time, so I wasn't gonna inject it into nothing. Yeah. 

The ones where we got CSF back injected, they got no blocks. So I don't know. People said it's a whole host of things to be like a bad batch of drugs and but, actually, I I don't know if that's the case. But, anyway, the bottom line is, I guess if you do enough of these, these things are gonna happen. Okay. 

I can't wait other than I can't wait, any longer. Like, we need to reveal what we have lined up for today. Oh, boy. I can't wait. Yes. 

Indeed, Miel Koba. We are joined today by a special guest from Down Under who is a social media queen, a researcher, an international advisory panel member of Anesthesia Journal, and who goes by the name of Gongas Girl on Twitter or x. Amazing. Do you forgot to mention that Tanya Selak is also the ANSCA vice president. We better be on our best behavior. 

Holy moly. I think we need, like, some royalty music and a round of applause over Hello, boys. I am so chuffed to be here, chuffed back to 10 plus plus. I am so thrilled to be one of your guests. It will be quite weird, though, because I listened to you guys in the car. 

So in the future, I'll be listening to this back to me in my car, which will be a bit strange, but I'm very pleased to be here. Thank you so much for having me on. Oh, thanks for coming. This is amazing. Tanya, I can't believe it's crazy. 

Right? I can't believe we've actually made it happen. I feel like I know you so well, but I think we may have only met definitely once. I'm trying to work out if it's actually twice. I think we've met once at an at an anesthesia conference, maybe London. 

Was it maybe pre pandemic, post pandemic? Not sure. I I think it was at the Association of Anissa's meeting, and there's a picture with yourself, Rosie Hogg, and I. Yeah. So, gosh, just once, but but so much has happened since then. 

Have you have you met Jeff before? I have not met Jeff before IRL. But the thing is about Twitter. You know, there's that thing that people say, Twitter is truth to strangers, and Facebook is lies to friends. So I kind of feel like I know people from Twitter. 

That might be crazy. That might be crazy talk, but I think because it's just a few characters, you are quite sort of slimmed down with all the trappings. So I think we kind of have a better idea about people who are on perhaps Twitter than other other platforms. Yeah. I never heard that saying before. 

That's really interesting. But I I agree. I think I feel like I I feel like I know you. I feel like we're friends. Totally. 

It's totally normal. Yeah. I know. But maybe you're right. Maybe like that, you just get a sense of somebody's personality quickly over Twitter. 

I think you do because you you just strip away all the the trappings of who you are and what you come from and your hierarchy. All of that's kinda gone. Whereas sometimes on the platforms like Facebook, it's a little bit like, oh, everything's wonderful in my life, and my husband's great, and my kids are awesome, and I went on this awesome holiday. And it's sometimes not a 100% truthful Yeah. Where people tell you all the glossy bits, but not the the bits that aren't so great. 

I like a bit of Twitter. It seems a bit more real even though it's a crazy place sometimes. Real and gritty. But you know what? Looking at the three of us on this call, I'm reminded that we did this that piece the ASA monitor on social media education recently. 

So, here we are again together. Here we are. And it's amazing. Like, time zones really Yes. They just blow my head off when you think about it. 

Here I am in Australia. It's in the evening. Yeah. I'm at I think you're in the morning in London, and wake up Jeff is Wake very early. So Australians will know there's a children's band called The Wiggles. 

Love The Wiggles. And there's a character in that called called Jeff, and Jeff's always asleep. So it's probably not the first time you've heard wake up, Jeff. Wake up, Jeff. And it did seem a little unkind given it was horrible o'clock or it is horrible o'clock for you, and there's probably little chance anyone would get me out of bed and speaking so nicely at 4AM. 

I know my colleagues don't necessarily like to see me at 4AM, but impressive work to be so fresh at horrible o'clock. This is one of the most fun parts of my month. So this is I would get up at any any time for you guys. Oh. Bless you, man. 

Bless you. I remember The Wiggles. The Wiggles was a thing when we were when we were there in 02/2005, 02/2006. I remember watching we had no kids, but for some reason, we watched some of the episodes. But Jeff was a purple one, I think. 

Right? Yeah. So you're do you get people saying all the time, wake up, Jeff? Is that, like, annoying for you? Like, at work? 

Do your residents like, if you stuff up, do your residents go, wake up, Jeff? Now they're going to. Yeah. Stop giving them ideas. Okay. 

So anyone's working with the professor, he loves a little wake up, Jeff, when things aren't going well. Loves it. Wants to hear that every day. He would love that. You're welcome. 

Thank you. And I think I I think a lot of people that know you from from Twitter would under would know where you're originally from, but we're hearing a Kiwi accent here, but you're based in Australia. So tell us a bit about where you're, you know, where you're originally from. Yes. So I'm I'm a kind of mixed bag. 

I was born in New Zealand to immigrant parents in a not very fancy part of Auckland and did med school and my schooling there and then went to London after I had completed a couple of years of anesthesia training. So that's how I ended up in London for three years. I followed my husband. And that was just the time of my life. Three years in London in your late twenties when you have, you know, no children, no mortgage, no huge responsibility. 

We lived in a tiny little flat opposite Saint Thomas' Hospital, which Armin obviously knows where that is. And we lived in County Hall. The flat was about, you know, three meters square maybe, £285 a week. I was gonna say, but it's not cheap. We had to what was the cheapest one there? 

We had to hand over four weeks of rent ahead of time plus three weeks bond. And at the time, the New Zealand money was 4 to one. So it was, like, $16,000 we had to hand over just to get the flat. Oh gosh. Never been so poor in our whole life. 

And I recall when we first got there at Waterloo Station at the McDonald's wondering if we could, like, splash out and have some McDonald's, but we just couldn't. So we went home for some nine piece soup. Those are first few months getting sorted in London, but time of our lives. I'm sure. Yeah. 

And then we planned to come back to Auckland, but stopped in a place called Wollongong, which is South Of Sydney for one year, and that was almost eighteen years ago now. And in the meantime, got a house, three children, jobs, and we're here. So hence, the slightly mixed accent. I do recall my first job I do recall my first job in London, which was at Chelsea and Westminster Hospital, which is a very fancy place. And I would go on the two eleven bus from our flat, which was outside Tommy's to Chelsea and Westminster. 

And I do remember my bosses there could not understand a damn thing I was saying. I recall very care. This tall guy, big professor English proper doctor guy in that first week, and I was talking because Kiwis talk fast and we swallow our vowels. And I just remember the I will never forget the look on his face, and it was just like, what language is this creature speaking? Like, so polite, but so confused. 

So I had to slow down a lot. Well, I have to say, I mean, it's that's incredible. I feel like I've got to know a little bit about know, I didn't realize that you were that close to, to Saint Thomas'. And I also didn't realize that you worked in The UK for that long, but I can imagine back then, if you just spoke the way you did normally, it might have been a lot for people to take on because, I think probably British people are maybe not that patient. And if we don't hear an accent that we can resonate with, it it takes some time. 

So, you sound very different now. Yeah. Your accent is kind of a a mix of a whole host of things. Right? It was by necessity. 

And I think to be kind to the very fancy boss at Chelsea and Westminster Yeah. In New Zealand on the TV, most of the stuff we see on the TV is not. Or back then, there were only two TV channels, channel one and channel two. Kids listening at home, that was before the Internet. And so we would hear the only thing we would hear on the TV would be Aussie, various UK accents, various American accents. 

So we were actually very skilled at hearing different accents, Scottish accents, Irish accent. But the reciprocal was not true, so I made the assumption that I could understand all different accents. So therefore, people would be able to understand me was incorrect. That's really, really interesting. Fun times. 

My kids, they can't wrap their heads around the idea that we had three channels in Canada in Canada growing up, and it was and there was a little box that had we had an aerial outside our house. Did you guys have this? Where it where the the little thing on top pointed a certain direction, and if you're if the signal wasn't coming in, right, you'd, like, turn this knob by the TV and we go and turn, and you go, oh, there it is. There it And you go, too far. Too far. 

Turn the back. Turn back. I mean, kids of the eighties, we can handle anything. Right? We can dial up Internet. 

Right? We sat there while it made that noise, and it dialed up. We coped. We coped with antennas on TVs. We are really invincible. 

Listen. I used to watch I used to watch television in black and white, and I remember watching snooker in black and white. Now you tell me that is that is desperation. I mean, I've got no idea what color the balls were, and I watched Nick get in black and white. So we have this calendar thing on our kitchen counter that gives advice to teens, and you flip it every day, and there's a different thing. 

And one of them one day was embrace boredom. You know, don't have a device in your hand. Just get used to letting your mind wander, and that'll take you down a a cool path, and you'll end up, you know, climbing a tree or reading a book or something. But how bored do you have to be to watch snooker in black and white is the one I'm wondering right now? Dude, I got a TV. 

Or maybe you just love snooker. You just love snooker. There's a love for it. No. I didn't. 

I just got I got a TV in my bedroom when I was a kid, and, you know, whatever time it was, I used to go to bed right then. There was only, like, three or four channels, and there's only certain things that were on TV. So and, like, it was one of those TVs where you had to turn turn the dial around like a radio until you could tune into the right channel. So I'm talking about really basic time. But, listen. 

I'm just gonna give you some ASMR here. There we go. That's me opening my my root beer because I think we need to get down to the roots of Tanya's regional anesthesia experience. Tanya, are you a regional anesthesia fan? So this is a bit awkward given I'm on block it like it's hot podcast. 

You you you know this is a regional anesthesia podcast. Right? Uh-huh. And so I'm mindful of the audience out there listening worldwide, Regional anesthesia, Tragics, who live and breathe regional anesthesia. They listen to YouTube and tragic? 

Did you call us tragic? I mean, tragic's like It's tough but fair. Tragic's like a good it's a good thing. Like, you know, there's good there's good sigma energy in being a tragic with all the rims that you folk have. Here we go. 

Here we go. So I have a I have a mixed review of regional anesthesia as a concept. Okay. Okay. Do tell. 

So I think there are a lot of incredible things about it. There are a lot of wonderful advances that have occurred. And, of course, I listen to all that on your podcast, and I devour regional anesthesia education. But I think there are some downsides with regional anesthesia, and I think sometimes people who are enthusiasts can overlook the downsides when they talk about things. I think regional anesthesia is good. 

It has its place, but I think we need to, like all forms of anesthesia, have a balanced view on its place. So that's heavy. That's heavy, isn't it? I think that's I think that's I think it's fair. Right? 

That that that sounds fair. Yeah. That's fair. I think culturally, it really is very different where you are around the world. So for example, my first one of my first jobs in Auckland as a baby anesthetic doctor was there was a regional anesthesiologist. 

So it was hand and arm things, auxiliary blocks, obviously, no ultrasound. It was kind of like a needle through an artery blind technique to an arm, made the arm numb. And then as a junior anesthetic registrar, you could then supervise that list. So that worked because the patients were accepting of it. The service needed it. 

It was safe. That was great. But some cultures aren't accepting so much in terms of the patient population of being awake for things. So I'm just thinking of the classic example was prostate operations, spinal anesthetic. So depending on where you go, the men expect to be awake or asleep. 

Mhmm. And I recall very strongly when I first arrived in Australia, had a urology list. There's a prostate list, and I've been very accustomed to doing patients quite awake having a spinal TURP, transurethral resection prostate. And I would talk to the patients, and I'd say, well, he you know, here's what we're gonna do, and this is the advantages and disadvantages, and they're a bit reluctant. And I'd spend maybe twenty five minutes saying, here are all the advantages of being awake for this procedure, and we do it for anyway, at the end of all that, most of them would say, just do what you like, love. 

Yeah. Just knock me out. And I really I mean, I can talk, and I really tried. Because in that situation, I really did believe that it was the best form of anesthesia for the vast majority of patients. I believe that in my heart, but the patients weren't buying it. 

And I think that's cultural. So I think in those two examples, I think regional anesthesia is a real is quite a cultural construct about what the expectations are Yeah. Of the patients, of the surgeons, of the post op, and all the rest of it. So I think some units are very well set up for regional anesthesia. The teaching is really great. 

There's really good quality data. There's really good befores and afters. That's an because that's another beef I have with regional anesthesia. Sometimes we can be very focused on sorting out our log books and doing our blocks and getting our needles to nerve and what probe am I using and all this ultrasound is fancy. We get very gizmo obsessed. 

And sometimes I think that we fail to do the before and the afters. So the before being counseling the patient appropriately about the risks and benefits and what they might expect. So some patients might be really surprised to have a numb arm for a long time after. They might not like that. Maybe they weren't told that. 

Mhmm. And then the afters, my big bugbear is nobody wants to do a pain round. Everyone wants to do the blocks. No one wants to do a pain round. So that's my perspective as someone who was maybe past the real big wave of regional anesthesia training that's happening now and someone who has been a head of department and tried to run a service. 

I have a little you know, I think it's great, but I think we can just do better. Yeah. I think those are all fair comments. I think you're spot on with the preparing patients the right way and the expectation bit. The thing about knock me out is is universal, I think. 

Like, no. As much as I love regional and think that it's the best way to go in many cases, I get through this all my spiel and the same comment comes up. I often preempted actually and say, now, first of all, before we get to the blocks, you're not gonna know anything in the surgery. Surgery. You're You're gonna gonna be unaware. 

You're gonna not see, hear, or remember anything. Then you see that sort of relief come over their face and then say, but But is that because you're talking about GAWA? Well, sometimes yes. I mean, how great is propofolzation? If I was having any kind of operation maybe there's part of me that's curious and would want to see the screen, but I don't know. 

I think most people want that unconscious experience, but we and you can do it quite safely and cleanly these days as opposed to maybe when I was growing up. But, yeah, the expectation bit is is is important. And the thing about the rounding afterwards and and are these blocks actually doing what they're supposed to be doing in terms of longer term outcomes and not just not just getting somebody through the the surgical the surgical bit? Well, do you know what? I think so first of Tanya, I could listen to you speak all day. 

I love your accent. And I I and I don't think it's it's like so it's kind of sing so singy songy, but it's also it draws me in every time. So, anyway, I I love your accent, number one. Number two, I totally agree with you. And, actually, I'll tell you one thing that's so so I I did a a a knee list with my regular knee surgeon, Rags, on Friday. 

I came across two things. Number one, I went to see a patient who was just having a, a unicondylar knee replacement. I saw him in the morning of surgery, and for a number of reasons, this guy would have been better having a regional anesthetic technique, I. A spinal. And I when I presented it to him, he was like, gosh. 

That's a lot to take in on the day of surgery because he wasn't prepped for this preoperatively. And that's a big problem. Right? Because I'm faced with a patient who I believe would be better with a spinal anesthetic because of my own experiences and and and what I think would would suit this patient well. But he wasn't prepped for that, so I had to do the whole consent on the day of surgery, which isn't ideal. 

And you could argue it not informed consent. But, thankfully, because of the fact I was able to go through it with him, he was like, okay. Listen. Let's let's go for it. But it wasn't prepped to him pre op as an option. 

That was a bad thing. But with regards to follow-up, so, you know, whilst I didn't see him on the Saturday morning, what I was able to do, because we've got electronic patient records, is follow-up what happened. And what was really instructive for me is we do not have access to a long acting medication like liposomal bupivacaine at the place where I'm working. So I was able to pinpoint the point at which my blocks stopped working and therefore tell, when he started asking for, as required, the PRN medication. So I think following back patients is absolutely key. 

But even if you can't go in, you can't do a ward round, there are ways that you can get the information, and they absolutely should inform our practice. So I I I think everything you say there is absolutely true. But you know what I'm dying to ask? Now that you you sound to me like somebody who's very rounded in your regional anesthesia practice, you kind of you can do everything. You don't make a big deal of it. 

So what is your favorite block? Okay. So that means I'm faking it. Do have that do you have that impression? Most of my most of my work is I do a lot of head and neck cancer anesthesia, which doesn't lend itself to much regional anesthesia, gyne, obstetrics, emergency cases. 

So I don't do a lot of blocks. I tell you what, if you said to me, what's what's your best peripheral nerve block? I love an ankle block. For the vascular patients, I love a little ankle block when they're having a little nibble on their toes. Yeah. 

So with a little bit of sedation. And Uh-huh. I think a part of anesthesia that's really undervalued is the you know, we talk about a sing soggy voice, and I'm hoping that my search has never listened to this because there is something about someone having, you know, something under sort of, you know, local infiltration or an ankle block where you are aggressively and actively making them comfortable in the space. So, you know, the sing songy voice, lots of affirmation, well done. You're doing amazing. 

Bear hugger. You guys know what that is? The thing that blows warm air on a patient? Yeah. We got them. 

The bear hugger. Got bear huggers. Have you got those, Jeff? Yeah. Pillow under the knees. 

Forced air warm up. Super comfortable. How are you feeling on the Operating table? How does your body feel? Are you comfortable? 

I really need you to share any worries that you have with me. Don't you know, we'll we'll get through you know? So that, I think, is huge and not just what's coming out of our mouths, but everyone in the Operating Theater. So Oh, yeah. It is a theater, and the patients are sometimes really worried. 

You know, maybe they've got cancer. Maybe they're really stressed. Maybe they've been fasting for a long time. And the beautiful teams I work with create a beautiful vibe in the room. Little music, nice sort of gentle talking, not so much carry on about the weekend or your latest boyfriend or whatnot. 

Very patient focused. That's amazing. You could anesthetize me any day, Tanya. I could say gonna say that sounds like verbal madazzling. Completely. 

Wow. Getting wake up, Jeff. Oh, hey. That's right. Of course, my surgeons are sitting there going, would you hurry the beep up and get on with it? 

That's why they can never listen to this. Okay. Right. No one ever tell them they're not. This is just between block it like it's hot fans. 

Absolute so so then, Tanja, I mean, what you're what I'm getting from you is that you maybe don't do a lot of lists as a rule that lend themselves to regional anesthesia. But when, you know, when you have a patient in front of you, you could crack on with it. But as a general rule, in your hospital, is regional anesthesia popular? Is it a technique that many anesthetists or anesthesiologists are using? I would say in the last five to ten years, it has become very popular in my hospital. 

It was really unheard it was just unheard of really before, and it's the it's the training has changed, and a fresh group of anesthetists have come through. I think ultrasound has revolutionized how available and accessible blocks are for our patients. And that's not only in the operating theater, but also in the emergency department as well. And I think I think it's a combination of the the new anesthetist, new surgeons, ultrasound, and folk like you doing really great education to try and broaden the appeal of regional anesthesia. And I think that Sentinel paper, future directions and regional anesthesia, not just for the Cognizanti and the plan a, plan b box. 

When that paper came out, I just got screamed with happiness. Mhmm. Yeah. Because it really was these experts in regional anesthesia really drilling down that it's all very well to get more and more minute in all these different blocks. That's fine because some people get really expert at it, but it alienates everybody else, which has the effect of fewer patients having access to quality regional anesthesia. 

So that paper, I think, was was absolutely profound Mhmm. And so wise. So wise just to go, hang on. I don't think we've really appreciated the significance of that yet. Right? 

Because that was Turbot, Mariano, and El Bogdadley. And So important. Boyd, Kareem, and Ed Mariano for that together. And I we are now we've changed the way that we teach regional anesthesia off the back of that. And I think when we look back, in the future, we look back at that pay that will be the the the the key point, the key change in time when people like, you know what? 

Let's stop. Let's focus on the basics, and everything else is is is, you know, is additional to that. It was so great. So, I mean, you cannot say how that was a pivotal turning point. And I think from then, I don't know what is it. 

Was it the paper? Was it the ultrasound? Was it the new anesthetist? Was it the new surgeons? But regional anesthesia is very common in my hospital now, particularly when people do orthopedic list. 

I used to do an orthopedic list, and even I would do an adductor canal catheter and a spinal. Like, that's how simple the crew that were doing it made it. That warms the cockles of my heart to hear you say that. It's really profoundly different. The what's interesting about this is that where I work in this sort of quaternary center, things are quite siloed. 

And I think we've almost done this to ourselves with the introduction of the planned x, y, and zed blocks as opposed to the plan a blocks, whereas we had this small cohort of enthusiasts and experts. And we run a consult service, so a lot of our colleagues say, hey. Can you come and do this block for us and here, here, here, which we're, you know, thrilled to do. And then I it almost gets to the point where your colleagues become deskilled or or maybe lack the enthusiasm or training or education or opportunities to keep those plan a block skills up. Do you see that, Amit, where you work too or or or Tanya? 

Yeah. So so what's interesting is we have a a situation now where there are key small number of anises who are happy to do pretty much everything. And then the rank below them, there are some that are very skilled at doing maybe one or another block. And then below them, there's a whole host of other nieces who probably should have or probably do have the skills and ability to do these blocks, but they're scared to do it because they don't do it enough because the other people are doing all the blocks. So we kind of created a situation for ourselves where, you know, if if you have an anesis filling in for a list that they don't normally do, they're suddenly a bit nervous to do a block that they did in their training because they're not doing it in their everyday practice. 

So I think this is a problem, and this is gonna be something that's gonna be problematic moving forward when it comes to delivering training, for our new we don't call them junior doctors anymore now. We call them resident doctors in The UK. So for our new our new resident doctors in anesthesia, when they need to get the experience doing blocks, we now got fewer lists covered by people who are happy to teach. So this is a a big problem. I think we have created a bit of a problem for ourselves, and we need to address it really. 

I agree with both of you, and it's interesting. I'm thinking about Nevsidu's paper about trainees and who gets the block. And there was a big gender bias in folk that got the block. And male trainees got heaps of blocks, and female identifying trainees got not many blocks. And that was also for other procedures as well. 

You can explore the reasons around that. So we sort of thought out the trainee issue that we're not delivering equitable training to everyone who comes through the unit with us, but that does extend to consultants also. And it is. It's a self perpetuating thing because in the department and every department has probably the handful of folk who are guns at the blocks. Yeah. 

So everyone goes, oh, you know, Buggerlugs is there in Theater 4 today. Let's go ask them to go do the block. Let's go and ask Steve O. Steve O, can you do the block, But I think it's sort of it's almost analogous to the conversation about awake fiber optic intubation, about how many with the old advent of video laryngoscope, the numbers of awake fiber optics are not very many. And I know some have had conversations and saying, well, it's unrealistic to have every working anesthetist really be able to know how to do those not very common tricky airways. 

Fortunately I'm gonna I'm gonna stop you there because this is really, really interesting because Jeff and I had a conversation about this not so long ago. And, also, there's been a a bit of chat on Twitter recently recently about a, a little teaser that Jeff, promoted about awake head and neck blocks for, for awake tracheal intubation. Now I work in the center where there are some worldwide experts at awake and intubation. Right? And and then, yeah, everyone knows that. 

But the problem exactly in the same way with regional anesthesia that's been created is the expectation is if somebody needs to have an awake trachea intubation, you have to call one of them to do it. Was actually is that true? You know, surely, there should be a skill that is core same way as regional anesthesia. Surely, this should be a skill that's core to every anesthetist. We're all experts in airway by definition. 

So shouldn't we all be able to do awake tracheal intubation? And you're right now, with video laryngoscopy, maybe our requirement to do that is less. But but isn't a wait tracheal intubation something that we should all have a skill or a technique for? And I know I've gone off piece there, but as you mentioned it, it kind of it sort of got my head, my head going because I thought, actually, this is very relevant. I mean, my view is most hospitals aren't huge, and most hospitals can't have a twenty four seven airway roster in addition to everything else. 

You don't most places can't manage that. And, of course, after hours are most of the hours. After hours is most of the hours. I was I was a little bit I was I think I'd been head of department for a couple of years, and that, like, dropped in my mind after hours or after hours. Like, it's a small number of hours. 

Most of the hours are after hours. Yeah. That's true. Therefore, most of the bad things are gonna happen after hours when most people are not there. Yeah. 

So I would think that everyone should be able to do those really tricky airways because it maybe don't have time. Right? Or maybe no one's there. Exactly. Is that now you've got an official position with ANSCA now. 

Congratulations. That's amazing. Thank you. Congratulations. Yay. 

Thank you. Is that explicitly written out in the requirements or curriculum for a graduating anesthetic registrar to know how to do well, block we talk about blocks for one, but also the airway stuff. Like, does it say you are expected to know how to do an awake intubation? Yeah. But, again, it's the issue about, you know, recency of practice. 

Right? So you do your rotations during your training. So I might do my cardiac anesthetic rotation, and I'll have been through a normal rotation with a normal volume of practice. But in 2024, I couldn't then get spat out the end just with my Fanska and expect anyone to hire me as a cardiac anesthetist. It would be the expectation that you would do a one year fellowship Right. 

In that. So there's a sort of volume of practice that you move your way through and then demonstrate that you were able to kinda do that. But then it's that it's that recency of practice and that skills maintenance, which is which is pretty tricky. And I think if I was in a hospital with a bunch of, like, super duper international airway experts, it would be quite tricky. Right? 

Because everyone would think, oh, this person's the best person. But in ours is one thing, but you are taking that away from everyone else who'll be expected to provide the after hours service. Same thing for us for pediatric anesthesia. We do, I guess, what you call it community level peds here. So we don't do tertiary pediatrics in my hospital, but we do ASA one and twos having straightforward things, adenoids, tonsils, broken arm, that sort of thing. 

But there's not that many regular pediatric lists during the daytime. But everyone's expected to be able to provide a service in the after hours space where there is Yeah. Where that is most of the time. So it's really tricky. And, you know, health systems everywhere have got no money. 

Everything's getting more expensive. These kind of skills that we have to have, we have to try and fit in with all of that. It's not very easy. It's not. And and simulation's gonna help a lot with procedural stuff like the airway and block bits, but delivering a a safe, solid pediatric anesthetic may be trickier to keep people skills up over time. 

Yeah. And I mean, simulation is great, but it doesn't it does not replicate that heart beating fast when really there's a patient really sick. I mean, we've had that. Your heart rate's a lot. You've got rising nausea. 

You're trying to pretend that you're just a swan. Everything is fine. In my case, my sing songy voice intensifies. Intensifies. My team know that we're married because I get really polite, like super polite. 

That it kills them. And I go, oh, hey, Jen. Can you just turn the music off? Thanks. Hey. 

Could you would you mind grabbing can you press the bell? Thanks. Thank you so much. Like, that's super polite because I'm mindful. Because inside, I'm screaming. 

I'm screaming inside. I wanna vomit. I'm fearful for the person's life. I wanna do the right thing. There's no time. 

Things are going bad. Oh, that's that's funny that your your colleagues know, oh, when she gets calm and polite I get scared. Start doing chest compressions. Oh my gosh. That's hilarious. 

Okay. I could've so I'm kind of thinking I that you you said that phrase mindful a couple of times, and that reminds me there was a recent trend on on social media with from somebody called Jules Lebron, and this she was saying, yeah, I'm very demure, very mindful, very cutesy. Have you seen that? No. If you haven't, Google Google that afterwards. 

In fact, I did a little post on my YouTube channel when I'm saying, look at how I hold my ultrasound probe. It's very demure. I'm very mindful. I'm very cutesy. If you Google that, you'll know what I'm talking about. 

I thought you keep saying mindful. I thought you knew about that. But that takes us very nicely onto a little break here. Tanya, you know the way we roll and block it like it's hot. Have you got a joke for us? 

So I'd like to preface the joke with, I've been listening carefully to the jokes Uh-oh. You folk have brought to the table I can see where this is going. Over a long period of time. And, you know, they've been they've, you know, they've required a little bit of finesse, I think. This this feels harsh. 

Maybe when I review you on my podcast provider, I might provide some stern feedback on the quality of the dad jokes. Anyway, without further ado, here's my attempt. Okay. What do you get if you cross an octopus with a hamster? Okay. 

Hold on. Octopus. Don't know. Hairy Notetakers? Hairy leggy. 

Okay. The no. Arm arm hair. Arm hair. No. 

Okay. I don't know. I don't know. What you get is a strongly worded letter from the hospital ethics committee. Oh, gosh. 

You are welcome. I'm just getting up for chest infection. You could just hear that's brilliant. Oh my gosh. Darn, that was brilliant. 

That's I didn't expect that that was where it's gonna go. It's see? I'm lifting you guys already. I didn't I didn't spot that. I didn't see that at all. 

Well, listen. I've got a couple for you. What do you give a sick lemon? Don't know. What do you give a sick lemon? 

Lemonade. Okay. Okay. One more in the same one more in the same vibe. What does an escalator say when it stops working? 

I don't know. What does an escalator say when it stops working? Nothing. It just stares. Okay. 

That was better. Come on. That was good. That was that was okay. And I'm gonna finish up on the last one here. 

Okay. Okay. Get ready. This is this is I've been working on this one. Internet Explorer and Google Chrome went shopping together. 

After being in the shop for a while, the shop assistant came up to them and said, are you gonna buy anything? And they replied, no. We're just browsers. Yeah. Visceral groan. 

How how is it that your children will write a petition against bad food, but they will not... Gadsden powered children, listen up, and they will not write a petition That's the bad joke. These jokes. Ugh. How is that? That's a cognitive dissonance right there. 

They probably should. Children. Petition, your parents, please. Okay. Maybe I can rescue us with with a couple of jokes here. 

Alright. So a caveman and a bear walk into a bar. Alright. Bartender looks at them and goes, alright. What's what's the story? 

Caveman goes, bear with me. That's so terrible. That is so terrible. Yeah. The cooking gets a petition but the joke's don't?

I was waiting for this big thing. Okay. When your girlfriend comes home in a white suit covered in bee stings and smelling like honey, that's when you know she's a keeper. My god. 

Okay. That hands down. That's the winner. That is the winner. Oh my god. 

You know, in sad news, like, a guy down the street is is getting divorced. His his wife's leaving him. He had this accident, and he lost one of his toes. He only has nine toes now. 

Turns out she's lack-toes intolerant. Oh, it hurts. You're definitely gonna have to mute the audio of mine because I think my yeah. I've broken the audio with with with the noise I'll be making. Okay, Jeff. 

I'm afraid whilst Tanya's was completely caught us by surprise, and I thought that that punch line was great. I think I think Tanya I think Jeff wins. He wins what? Does he win that? What does he win? 

We No. What? The joke off? No. The joke off. 

Apparently, it's a it turned I only got one joke. This is the volved hanger from I only had one go. I know. Like, you guys are biased. This is biased right here. 

I can't believe it. He had multiple jokes. Multiple jokes. I had one I had one go. But it was a good one. 

You made it count. You made it Yeah. It was research But I didn't win because your mate gave you multiple goals. Uh-oh. Alright. 

We're just throwing volume at it. Okay. Just gonna write that down too. You you you you hit us with the good stuff. Thanks for listening so far. 

To find out if Tanya does win the joke competition and for much much more, tune in next month for the exciting conclusion of this episode. And remember to Block it like it's hot.