S3 E13: "Block Box 5: Our conversation with Ki Jinn Chin and Amanda Kumar!"

Jeff. Amit. I don't know what to say. This is if I had to to write a wish list Okay. If I could be in a glass box with two people that were were were big names at Regional anesthesia...how big is this box?  I mean, actually, we need quite a few people in this, but this is a dream moment for me because we are joined in the GE Healthcare glass block box by none other than professor Kijin Chin, who has, I'm very privileged to say, is a dear friend of mine, but has been an inspiration to me in the whole world of regional anesthesia, a mentor, a colleague, a friend at Inspiration. Chin, thank you so much for joining us. 

You know what, guys? The pleasure is all mine. And, you know, we're here at ASRA. Yeah. So I wanted to tell you all one of my ASRA origin story. 

Okay. Yeah. You know, the very first time I was ever a faculty at ASRA meeting was and, Jeff, you are gonna probably remember this. It was in Phoenix, and they put us out in this resort in the desert. That was amazing. 

I mean, yeah. So I was not meant to be on the faculty. I think it was Greg Ligori's meeting. Okay. And at last minute, Ricky comes to me and says, you know what? 

Somebody's dropped down the faculty. They're looking for somebody to do an ankle block and then because Ricky has the connection with HSS because that's where he did his fellowship. Right. My program director at the time. So he said, can you stand in and give this ankle block thing? 

And I was like, sure. Okay. I'll do it. Never having spoken before. And so that was the very first time I went there. 

And I went I didn't know anybody. I remember going to some of the faculty events and standing around and looking at all these sort of very sober, serious people and didn't know anybody. But one of my enduring memories of that was there was one night, and I just have this image in my mind. We were out in the desert. There was campfire. 

And, you know, me not knowing anybody. I'm standing in this little hill looking at this group of people around the campfire, and everybody's laughing and joking. And the center of attention is this guy, and I still remember wearing a cowboy hat. Center of attention. And I was like, oh my god. 

That guy is so cool. I wanna be that guy. And, yes, Jeff Gadsden. Is that right? Jeff Gadsden. 

I remember the campfire. I don't remember being the center of a township. You were you were were in this so cool. Cowboy hat. Right in the desert. 

Dancing or something. That was a fun meeting. And so was that the first time that you'd seen Jeff? You'd you had you guys thought, oh, wow. No. 

That's it. That was nobody, man. Well I still I'm still not. Well, number one, that's certainly not a mystery. But What what is what is wonderful? 

And you will be no stranger to the fact that we have been talking about you probably since episode number one. I I actually think there's probably not an episode that doesn't feature Jin Yeah. Somewhere in there. Now that's testimony to a number of things. Number one, his drive and passion for regional anesthesia. 

Number two, the amount of content, educational content he produces. Number three, the academic excellence. So I know it seems that we're bigging you up, but I cannot tell you. Number one, you've changed the the world of regionalities yet, so we're very grateful for that. Number two, we've been talking about you so much. 

It seemed only natural that we would have you as a guest. So so that's, I mean, we're we're very privileged. But tell me, I wanna ask you a question. You will have seen that a large part of what we do involves telling some jokes, and we'd like to to have fundutainment or edutainment. So education with a bit of fun to it. 

Do you have a joke that you'd like to share with us? Well, I've got then a question for you. Okay. And you're the you're the dad joke, man. Right? 

So what do you call a fake noodle? A fake Fake noodle. Like, oh god. Thing is, this is gonna be so easy that I should have got this. A fake noodle. 

Oh, I know. An impastor. An impastor. How did you get this? Wow. 

Okay. I'm very proud of myself. That was good. I'm just speaking to myself. I've never got the impostor syndrome. 

No. Not at all. Not at all. But, yeah, I'll give you a bonus one. Okay. 

Do you know the definition of a nerve block? Not the Not the real. Okay. No. No. 

A nerve block is a technique of local acid injection that when performed in either human or cadaver produces a scientific paper. Okay. Very good. Okay. Nice. 

And I see. That's it. Is all of my sort of paper thin reputation is probably built up. No. No. 

That's all. No. That's all. Listen, Jeff. Do you wanna start with the first question? 

Because I'm my mind is spinning on all the different questions we could ask Jim. Is there something you wanna start off with? Well, first of all, listen. I I am a huge fan of everything you've done. Like, I feel like there are a few people in this realm that, like, everything they touch is gold. 

Yeah. And and you're one of those people to me. Like, I I admire your teaching. I admire your incredible way of presenting stuff on your you amazing YouTube channel. I admire your the amount and impact of the scientific stuff that you have created. 

It's incredible. So congratulations on on so much. And I just wanted to tell you how much I admire admire you, as a person and as a as a scientist and as a educator. But Yeah. It's incredible. 

Well, it means a lot coming from you, and that that's serious. Right? Like Yeah. Yeah. So what what keeps you what keeps you going, man? 

How do you how do you do all this stuff? Great question. Well, I mean, you all probably know that regional anesthesia is fun. Right? Yeah. 

I can't think of too many other things we do where, you know, every patient is unique in their anatomy. And I think one of the beautiful things about ultrasound now is that you're actually looking below the surface at them, and it never fails to throw me when you put it on. It's like, oh my god. That's beautiful anatomy. Right? 

We literally say that. It's Yeah. Got beautiful anatomy. You know? Or, wow, that's really interesting. 

Right? And then the patient starts to get all worried. It's like, do you mean I'm there's something wrong with this? It's not the tumor. Yeah. 

And so that it never gets old for me. Right? Putting it on and looking at things. And then then I really view the performance of the block as as art. Right? 

It's, you know, again, the satisfaction of guiding the needle in, watching the little kind of aesthetic spread, do all the little Jeff noises. Oh, that is interesting now. The Jeff noise. Yeah. Yeah. 

Yeah. So, yeah, I mean, I think regional anesthesia really is and I think anybody who loves the interventional part of anesthesia, which probably isn't most of us, what's not to like. Right? Yeah. Yeah. 

And then I think beyond that, you're doing this not just for entertainment, but it's in service of the patient. And the other thing I really like and think about regional anesthesia is it gives you that latitude to be creative. So, like, building on that art thing. I mean, it's just one more thing you can do to craft anesthetic plan for the patient that's tailored to them. Right? 

Allows you to solve problems. I like that. And I I I don't think I'd ever thought about it in with using that word before, like creative. But you're absolutely right. Like, there are obviously different ways to do a hip fracture, but this gives you a way to regional gives you a way to be much more thoughtful, but but creative. 

Yeah. Or or improvisation. That's the other end. Right? You improvise based on, oh, that patient can't get into this position, or they're constrained by their cast or whatever, or, you know, they you know, oh, you got that bilateral injury and you wanna provide something. 

You know, this is the main side. Well, you can this and then you've got this sort of combination of techniques that you can draw from and Yeah. Piece it all together and create this, like, bespoke plan. Yeah. Yeah. 

Yeah. That I find that incredibly satisfying, right, when you can when you can do that. And and and, you know, that's why I tell the fellows particularly that, you know, you go beyond the planning blocks, but you wanna accumulate a of techniques because then when it gets sort of really challenging, you can sort of pick and choose a little bit. Yeah. And and beyond the techniques as well, what you're actually injecting, you know, there's creativity there. 

You don't have to stick to the same old rote recipes. So that's where you some of your recent work has developed, right, in some terms about varying intrathecal medication. And so I guess I've got two questions. First of all, I don't know if Jeff asked it or or whether we never specifically asked it. How do you manage to find the time to do all of the things that you do and to keep you you told us why you keep motivated and you're excited about it because of all of those reasons you described. 

But how do you find the time, number one? And number two, what is your current passion? Where is your current direction of travel? What's your current research interest? Okay. 

Well, second question first, I guess. Like, I don't really have a research interest, and I've never really had a research interest. I just do whatever I find is clinically interesting. Yeah. And it's like, yeah. 

There's there's an issue here. So, you know, you're talking about the intrathecal recipe, for example, like, the whole sort of hyperbaric, low kind of aesthetic thing, which I kind of, like, talk about a lot now, which, you know, to be clear, I didn't invent. Right? It's actually quite well described, but it's kind of, like, just an under the technique that they came about because we had a shortage of our short acting bupivacaine, and I said, well, we'll just use bupivacaine, but we don't wanna inject fifteen milligrams and have it last for four hours. And, you know, somebody told me, oh, yeah. 

These these old timers didn't literally use ten milligrams. They put a mil of water, and I was like, alright. I'll try that. And then then I sort of went and finally it was all well described. Right? 

And so, yeah, I'm always a lot of these things come out of, like, there's a problem to be solved, and you kinda think about that. Published so widely because he'll you know, what's the one question he's got this week? Okay. That's I need to get an answer to that, so then I'll do it. And then next week, could do something else and do something else. 

It's amazing. So that's the thing that you've most recently published on amongst amongst other things. Yeah. So we're building on that probably now and super interested in spinal anesthesia because we do a lot of it, and I guess it's also really widely published. But this whole business around you know, I guess the very start of my career was, like, the technical success of spinal anesthesia, and this was the whole ultrasound imaging part of it, like, get the needle into the space. 

Yeah. But I think people overlook the therapeutic failure a bit. Right? And it was a surprise to me to discover that, you know, it's pretty much three to five percent of spinals don't give you surgical anesthesia. Sadly, I have a lot of experience in this area, and maybe we'll talk about that afterwards, but I didn't wanna interrupt you. 

We'd the local. Must say bad local. Yeah. Bad batch. Bad batch or local. 

Bad batch local. Well, listen. You're gonna go there. Okay. Help me understand. 

How can you have a needle in the right place? You get free flowing CSF. You administer the drug. You get swirling. You're missing. 

You give the drug. And how can you have a situation where the spinal doesn't work? Because this has happened to me. Can you help explain this to me? If anyone can give me the answer, you can give me the answer. 

I guess you have to say, what did you mean by doesn't work? You know, was there complete absence of detectable block? Did you test all the way down to the sacral dermatomes? Did it just stop in mid thigh and basically not high enough, which is the basic problem? And I would say that's probably where most of those therapeutic faders come from. 

Right? The block just doesn't rise high enough. And when you look back at the papers, you know, it's all about distribution of CSF. And, you know, if you read a textbook, they'll, like, list the 20 different factors that were described. But, really, in my mind, it's all veracity and positioning. 

And I think those are the only things you can really influence. Now you can also administer a whacking big dose Yeah. Of it as well. But Right. It's really barricity. 

And so for the longest time and I think to to a large extent, we still use plain local anesthetic in Toronto Western, but I have sort of moved away from it because, really, it doesn't consistently distribute. And I think the word is consistently. You'll get it ninety percent, ninety ninety five percent of the time, but as soon as five percent of the time, it doesn't Right. Rise high enough. So we use a lot of hyperbaric bupivacaine. 

We use a lot of heavy bupivacaine, and I've had every single variation of failure in spinal anesthesia. So I've had needle go in, CSF, injects it, and nothing. Like, zero block, number one. I've had the soles of my feet feel a bit numb. I go, yes. 

It's gonna be great. Lay the patient down, and then nothing else. And then I've had a block which come two thirds of the way up the leg and then just stopped, all using appropriate doses with all the correct markers of success. Sometimes ultrasound guided, and I wanna blame the local anesthetic Yeah. Because I can't think of is that is that wrong? 

No. I think I mean, but everyone was like, it's never the local. Say, I mean, you're just rubbish at doing a spinal. But but I think it's not there's there must be another explanation. Yeah. 

Do you use a, like, whittaker or a sprat needle? It's with a Spratter. So you Sprrotter. Sprrotter. Sprrotter needle. 

Yep. You should do the correct So so so I use this So I wonder sometimes if you if the side hole is just You're talking about the hole there, and and there's like Yeah. This is flap thing. Right? A little bit for a little twiddle Yeah. 

Free flowing. Yeah. Always always. Always do that little thing. CSF's coming back. 

And yeah. I I almost to the point when I was gonna give up being a central neuraxial anesthetist. And I was just gonna say, do know what? I'm just gonna be a peripheral block guy because most of the time, I don't screw those up. You know what? 

Life is a bell curve. Okay. There are always gonna be outliers. Yeah. And he always makes me feel good about myself. 

Yeah. Jake, you all the Are you an artistic person in your non work life? Because you talk about regional anesthesia as an art and being creative and and improvisation. And I wonder if there's like a are you a painter or a poet or something? I don't think I'm artistic. 

Okay. But I admire Okay. Art. And I wish I was I wish I was I wish I was a better artist. Yeah. 

But so and it's not there's no, like, a hobby of mine, and I'm a terrible I I love music too, but I only need to listen. Can't play. Can't sing to save my life. Unlike you, another thing that I sort of idolize Jeff for Absolutely. Jeff Jeff sings a mean loose. 

But yeah. No. But but I I I increasingly value art. I mean, my kids are very artistic, and I guess I've also started to appreciate that just design. Right? 

Yeah. And and I guess where I'm indulging my art now is is in the kinda, like, YouTube videos. It's partly why I do I I it's become a bit of a artistic outlet. And that is that is a skill that is hard to get right. Right? 

There's a ton of content on YouTube. But what's fascinating, if you watch Jin's channel, it has morphed with time. Right? So he started off really in-depth, beautifully knowledgeable presentations that were the full length of a presentation you might give back in the days when you might talk for forty five minutes to an hour on stage to Jim who put this amazing presentation. And I can tell you, if you watched that presentation, sat down, spent forty five minutes or however long of your life, you would know everything you need to know about the area. 

But you've changed. Something has changed with your video style. Tell us about it. Why have you gone that way? As you know, there is just too much content out there. 

Right? And I've come to the reality that people need their information in sort of more digestible chunks. So I have made them a little bit shorter, a little bit more concise. And, again, in all seriousness, I draw inspiration from both of you. Your design aesthetic on your slides, I've told you this before, are amazing. 

Yeah. They are. And then your videos are, you know, the epitome of sort of A 100%. Concise without leaving out the important details. I just know. 

I just don't have a knowledge base to talk that long. I just Oh, I think so. As you know, it takes a lot you have to have all the knowledge to be able to distill it to the essentials. But, you know, I think there is that problem of people yeah. They they don't have necessarily half an hour to sit down and sit through something. 

I I came to the recent I I agree with you a 100%. Our attention spans are are decreasing. I came to the realization recently that my trainees were watching my YouTube videos on, like, double speed. Like, what? Well, I I hate to tell you. 

People listen to our podcast on double speed, actually. That Am boring that you have Can't even give me five minutes. And they're like It's a it's a generational thing. It's a joke. My my my kids are doing all that. 

Well, my son didn't know it. Yeah. Everything that's efficient, I guess. But yeah. Okay. 

So I wanna ask both of you this question. What is the optimal length of video to get the essential information across without causing shallow learning, without without skipping out the the important points. What is the optimal length of video where you can distill the crystal clear points? Is that two minutes? Is it less? 

Two might be hard for some of these concepts. I would say more like five to eight in my experience. I mean, I I maybe I'm just So I think you're right. However, you will still find that people do not if you give them a five to eight minute video, they will scroll through till they get to what they consider to be the golden content of the meet, which makes me wonder, do we need to give you yeah. You give you give the full version, and then what you do is you give people snippets. 

So if you look at, I hate to talk about it, but TikTok or Instagram, what draws you into a conversation is, well, like, the the, you know, the finale, the exciting bit. Now I wanna know a bit more and maybe drip feeding information in small bits. I I I don't know the answer, but I'm looking at some of my videos that have got the best traction have been the accidents. I recorded a forty five minute lecture on regional anesthesia for the trauma patient. It was a a thirty minute video. 

Right? So this is back in the days of putting all of my videos out. A masterpiece. I don't know about that. But the one bit of that video that didn't work right was just something about the supra inguinal fascia aliaka. 

That bit, the video loaded incorrectly. So I had to rerecord just the supra inguinal fascia aliaka bit and release that as a separate entity. That's one of my most viewed videos. Ah. Because, like, two minutes. 

Yeah. Yeah. Yeah. Not just that bit. And so I I don't know what the what the optimal duration is, I wonder whether we think five minutes is is is about right, but maybe for some people, it isn't. 

Maybe it depends on the generation that we're aiming at. I mean, I think there there is catching eyeballs Yeah. And there's actually influencing practice in a positive way. And I think it's important that we distinguish you between that. Right? 

We're not well, I'm not trying to naturally be an influencer. No. You just wanna put good educational content out there. There's no living to be made out of YouTube. But so so I my my my my my you'll have to tell me how. 

I'm sure if I'm Kardashian or something. Yeah. So I think then one has to decide where your emphasis is. And if people don't wanna watch your ten minute I kind of think now, like, ten to fifteen is you can get important concepts across, and I think that will be within the attention span of people who really wanna learn the block. Yeah. 

I think half an hour is much too long. But what is interesting is one of your Blocktober sessions, you put out some shorts. And, actually, like your suprascapular nerve, putting your hand on the back and drawing people to where to scan, What a great tip. Right? So you're not trying to tell them the whole thing. 

Right. You're trying to give them I guess you're right. Like, nugget. Just just that little tip that would I hadn't had that in the original Yeah. Video that I made because I didn't think about that at the time. 

Yeah. But I thought afterwards, kinda like you. It's like, oh, yeah. Kinda would be good to communicate. But just that one little I guess, yeah, that's that's I love like, three minute plug buzz. 

Does serve a separate trigger. Right? You're very clear that this is meant to be a attention grabber to draw you in to then explore. Yeah. It's the same thing they say about talks. 

Right? Like, if you have a talk, it shouldn't really be an information presentation because nobody's gonna really take it all in, but it should give them enough inspiration or or or intrigue them enough to say, okay. There's something I wanna read up about. And Yeah. It's like a gateway. 

I have to say. So Yeah. Jin changed my stress levels when it came to lectures. I would find myself getting worked out, and I still do, to be fair. Yeah. 

Every time I got a presentation for a conference today, I'd be like, oh my god. What do I do? And Jits said to me, Amit, obviously, when you're doing the talk, you're gonna do the reading. You know, you're have an idea of what you wanna do, but actually or what you wanna talk about. But people are interested in what you think having read the evidence. 

What do you think? They don't want you to present the tables and the graphs and all the charts from it because you could direct them to that. But, actually, what they're really interested is having read the information and that and and interpret it, what do you think is important? So actually tell them what you think and direct them where they go if they wanna read more of it. But, it's really important. 

And it just complete because I always spent ages trying to Such good good advice. Redraw the graph so I wasn't doing the copyright thing and and putting, like you know, having a table and putting boxes and going around it and colored in red. Actually, people don't always wanna know that. What they wanna know is, what's the headline? You've read the paper. 

What's your interpretation of that? Yeah. And how are you using that in your clinical practice? The moment you told me that, I started like, oh, okay. Now it's okay. 

Yeah. So I've read it. Yeah. I'm just gonna tell them what I think about it. And you know what? 

If they they could agree or disagree Yeah. But there's the evidence, you can go and read it yourself. But I've read it, and this is what I think. Change my approach. But then do you ever worry that you are telling them something that Yes. 

Is not true? Yeah. Yeah. Yeah. For sure. 

Or Yeah. I can say, do know what? I've read this evidence. And having read the evidence, this is what I think with it. You can you can believe what you want, but this is how I'm using that information. 

You're right. There is a potential that you give them an interpretation. Maybe that's not right. But I think what it made me do is think I I just chilled out a little bit more about it. You know, I don't have to summarize the paper and put it on a slide. 

I think that's the key. It's like, that's not what people could read the paper themselves. Exactly. Speaking of highlights, Jin, what what have been some of the highlights of the meeting for you? Are are there lectures or sessions that you've seen that have been, oh, that's that's amazing, or things that you're looking forward to later today or tomorrow? 

Yeah. I so I've been going to some of the lecture sessions, and, you know, I I'm always amazed at the quality of the speakers here at ASRA. They've you know, it just came out the sort of innovations one and peripheral neurostimulation. That's actually very, very interesting, I think. Yeah. 

You know, the combination of of of applying a current, a, as a sole modality, b, as Rakesh, Sundar Koplan was talking about, you know, maybe it opens up channels. And if you do it at the same time as you're giving local, it'll enhance the effect of local anesthetic. Yes. The source in dwelling things. But, again, I'm more about, like, what can the majority of people do, but, like, you know, can we just use the nerve stimulator you have? 

And and if it's not just to detect how close you are to the nerve, but if you're, like, applying it at the same time. Keep the current going while injecting local, will that actually Wait. It's hundred o'clock. I'm sure doctor Athmarja Thorntongel has talked about doing some of this in her pain practice. And we had Stuart Grant on earlier on. 

He was talking about his best in meeting abstract about using a high frequency radio frequency simulation of nerves, which completely blew my mind. And he was talking about twenty days worth of analgesia from this this technique. Yeah. Mhmm. Yeah. 

I think there's a whole area that we're I think that I I started to panic a little bit hearing about this thinking, like, I'm out of a job now, but but you still need ultrasound guidance to get some Yeah. Right. So okay. I can Yeah. I can still do this. 

Yeah. But are we gonna skip over the fact that Jin just said he uses a nerve simulator? Well, I didn't say I didn't say that. It's still tucked away in the drawer. Do you use a nerve stimulation regularly in your practice Not regularly. 

For Zikigi Chin? Not very good. Thank you. Not regularly. Also, I'm gonna ask Jin one last question. 

I don't wanna close on this question. Okay? So we like to talk about controversial subjects on the podcast. And Jeff and I often agree on things, but more interestingly, there's some things where we don't agree. And we don't agree on mixing local anesthetics. 

So he thinks that that people who mix local anesthetics are heathens, and he he said, no. That's not true. He doesn't say that. But but he's like, why should you do that? Do you mix local anesthetics? 

I'm I'm laughing because you know what, Jeff? There was a session on that, and you were quoted by the pro person because you have written articles and done research showing that mixing does produce that sort of accelerated onset show the duration. So you're like a poster child for mixing local anesthetic. I mean, yes, we do because and now I'm gonna I'm going to say Vincent Chan taught us to do mixing. It is the Toronto Western tradition and culture. 

Get this. Yeah. Okay. Okay. Mic drop. 

Yeah. We both learned from Vincent Chan. Mic drop. Yeah. Yeah. 

Yeah. Vincent like, level setting. Okay. Anna Heath Prolas, Ricky Bro all do two percent lidocaine, point five percent bupivacaine, and so I do it. Anyway, it's good enough for Vincent. 

Trying to get enough. I feel that's it. That's what I'm done. No. In all seriousness, it it does work as advertised. 

And, actually, for those people who were at that session, pretty much a consensus among even the Michael Pheater place who was on the con side is that it does actually do what is advertised. Then there's a whole issue around safety and, you know, calculating toxicity and stuff, but it works as advertised. It accelerates onset if you mix short and long acting, and it shortens duration. I feel I that's it. I've landed. 

I'm I'm done. Whether or you want to do this. This is the precon debate of all precon debates. Every time I ever talk about mixing local and say, I'm gonna quote this guy. I'm gonna take the video footage of of But this this guy is smoking you. 

Okay? Because he's he's done the research. Yeah. He's recanted now. Yeah. 

Yeah. Yeah. Exactly. Amazing. Professor Kijin Chim. 

So much. Yeah. That was amazing. What every time I speak to this man, I learn something new. The pleasure was all ours to have you here. 

Thank you so much. No. It was a honor to share this space with you guys. Sometimes on these on these, you know, high profile podcasts, the guests get, like, flown in. They get, like, four seasons accommodation. 

The bill's coming. They get it's coming. Yeah. The bill's coming. But we got something special for you. 

You get a sticker. So that's that's our that's our thank you token for you. Use it wisely. And and and you this is this is the name of the rep that we made. So if you're unsure how you're gonna block it, it's a it's a it's a like like, This a is gonna find pride of place somewhere in the Toronto Western Block. 

I love that. Amazing. Thank you so much. Thank you. Amit, I am so chuffed. 

Why are you chuffed, Jeff? Chuffed levels are at an all time high because we are in the presence of one of my favorite people. Really? Yeah. It's true. 

Wait. I mean, what about this person over here? Sorry. I couldn't resist that. You think yeah. 

Yeah. Okay. So so who how She got a lot other people. Thank you. I got Amanda Kumar, who is not only a anesthesiologist extraordinaire, but is the fellowship program director for regional anesthesia and acute pain at my institution, Duke University. 

Wow. And a good friend and just an all around amazing human being. That is amazing. Amanda, thank you so much for joining us at ASVA Spring twenty five. Over the next two and a half hours, the three of us are gonna explore some. 

It's okay. I wore my Depends. Ready. Ready for anything. Depends. 

I think that's like, something to help you with The adult diaper brand. The adult diaper. Okay. This is for The UK audience. I can't do any brand names. 

Okay. That's Oh, no. They're one of you can't. They're one of our sponsors. Do you have the same brand on? 

It's it's in our contract. They work us hard at Duke. But am I also correct in in thinking that you were a fellow at Duke as well? I was. I everything I know about regional anesthesia, I learned from this guy, even the parts that were incorrect. 

I'm just kidding. He knows no incorrect fact. Well, I I think there's a medal where supposed to come out the other side of the neck. Yeah. It's transcervical. 

We're all we're all about innovation. Yeah. Exactly. Yeah. More bang for your buck. 

It's called a BOGO. Yeah. The one needle entry bilateral blocks. Okay. And the brain block at the same time. 

No. But so I remember in the early days when we lots of people were using X and and Twitter. I remember seeing your name pop up and doing all the the fellow stuff at Duke, and it's amazing to see that that now you're looking after the future generation. Yes. It's such a privilege. 

It's amazing. I still remember when I joined Twitter the first time. I was a fellow, I wasn't really into social media. And Jeff just cornered me in the block area and said, are you on Twitter? And I said, no. 

You know, I'm thinking about it. And he said, don't we just sit down? And he watched me download the app and watched me create a profile just so, you know, like, it's a nice follow-up, you know, just to kinda make sure that, like, I'm I'm following up with these tasks. So he helped me create my first Twitter account. And, honestly, being on social media has been great to connect with folks to kinda follow the podcast. 

It's been really phenomenal and then amazing to be involved in fellowship now. Excellent. So everyone kind of develops an area of interest. I seem to recall that you have an interest in simulation. Is is is that one of the one of the things that excites you? 

It is. I love a good simulation. And so I think part of that is, you know, as a trainee, I was the product of some really great high fidelity simulation courses. And then coming over to Duke, Duke has a simulation center. It's run by our department. 

There's a lot of fantastic resources, some cool equipment out there. It's So been really fun to be able to kind of, you know, do a lot of simulations for our learners of all different levels and types and, get to practice some some really scary things out there Really? But in a safe, you know, environment on a plastic person. Can you give us some examples? Because I because I I'm one of those guys. 

I I think I grew up my training sort of happened before simulation was a real thing. Before Before the steam engine? Yeah. Before yeah. Exactly. 

And so Had antenna. Yeah. Yeah. You had to adjust it just right. So exactly. 

You had to point the t the antenna the right way to get the right signal. And then sometimes if you put your finger in your ear and, yeah, put the finger in the back of the TV, there are different things we used to do to get a good signal. The simulation was something that scared me because when it first started to come out, I was a I was a consultant. I was an attending, and they put me in a room and people were watching what I did, and I I found it scary. What it what type of simulation do you do? 

How can you get an old fogey like me to embrace that, and and why do you think it's important? Yeah. These are great questions. So we're really lucky in that we have a high fidelity sim man mannequin. And so you can change the vital signs. 

You can have them go into arrhythmias. The mannequin can blink their eyes. They can talk. Their mouth and lips can turn blue to simulate hypoxemia. They can seize. 

You can make it a difficult airway. You can inflate the tongue. You can, like, decrease range of motion of the neck. So it is still a plastic mannequin. So there are some facets that are not truly realistic, but it can be pretty darn high fidelity, which is fantastic. 

Can you do blocks on it? So we can't do blocks on this one, but we do have anatomic trash tax trainers that we could do blocks on, including one that one of our fellows presented at as a poster here, one that Jeff has been working on us with, but it's a take home task trainer. So it's one that you can plug into any computer. You put an ultrasound machine, and then, like, a trainee could say, hey. I don't really wanna spend another hour here at the hospital. 

I wanna go home, spend time with my family, have dinner. But once the kids are in bed, it'd be great to, like, plug it into my laptop and have a little bit of task training time, kinda figure out how to do those transducer needle, maneuvers. Oh, that's that's really important, I think, because to me, there's two major skills to regional anesthesia. There's image recognition. Right? 

And that just that's just reps. Scan yourself, scan your friends, scan your nurse, scan your patient, and then there's the needle driving. And that's also reps. But if you can't if you're only getting your hands on a needle five times a day at work, how do you accelerate that learning? So being able to take this home or take it on a subway or take it on a plane or whatever and just probably wouldn't let a needle get on a plane. 

Right. But, I mean, but this is the biggest barrier to practicing regional anesthesia is number one, having an ultrasound machine that you could take home. Now we may be starting to adapt to that with handheld, wide, or wireless probes that are out there in the market. So that's one facet we've dealt with. But then you sort of do the needling. 

And then what are you gonna need? Oh, yeah. You could get a piece of meat and have it at home where you could get a phantom. But this potentially is a game changer. So this is simulation. 

Right? And and and are there scenarios yet where you've integrated your sim lab with this type of stuff? So we have. So for example, we do a lot of high fidelity things, and our goal in the simulation center day is to kinda have this immersive all day fun educational experience. So the fellows are nonclinical. 

They get to all be together. So one, it's kinda just a fun day to hang out together and bond. And then it's a little bit of trauma bonding because then we throw them into some really intense situation. So we wanna expose them to crises that they may never see during their formative training years. So local anesthetic toxicity, a high spinal. 

Maybe they're doing perivertibals and then they have attention pneumothorax, and they have to manage that. We have one where they have to do a nerve block. For example, it might be a TAP block in a parturiant, and then it turns into a postpartum hemorrhage. So it's kind of like a one two punch of, like, I think I'm just going in there to do a nerve block and then wait a second. What are all these bloody chucks that we're pulling out from under the drapes? 

And so kind of you we catch them off off guard a little bit. Oh, and they they think I'm just here for a regional anesthesia simulation, and suddenly you mix it up like real life. Exactly. We even have simulated patients come in where they'd have, you know, hey. I have this peripheral nerve injury, and the surgeon told me that the block caused it. 

And you have to go through, you know, what are the studies we would do? What's the natural progression? How do you talk and disclose an error if there was an error, or how do you talk with the patient in an uncomfortable, difficult situation. It's really cool. I wonder if you've gotten any feedback from fellows that have gone through this program and on the crisis resource management stuff that you've done, and then two years later say, you know what? 

I had a case of this. Were it not for that day that we spent, I may have handled this differently. Totally. I think that sometimes this is the first time that they've dealt with that crisis, and the second time is in a real patient. So when they have that opportunity to say, hey. 

At least the first time that I spiked the intralipid bag wasn't today. At least I got to do it one other time even if it was in a simulated scenario. It's been really fantastic. The other thing is that we're really big proponents of the of cognitive aids, and so it kind of helps teach them. You know, when we talk about the principles of crisis resource management, using cognitive aids is one of those facets. 

And so during the simulation day, we talk a little bit about cognitive aids, what they are, and how to use them. And we know that if we're more familiar with the setup that we use them better in a in a crisis situation. So same thing. You know? Hey. 

Maybe I don't use a cognitive aid on a day to day basis, but when that crisis happened, wow. I'm really glad that, like, I've used this before. It's been a couple of months, but, like, I could flip through it pretty quickly. I could get to the page that I need it to be. I know the format. 

I know the steps. But this can also be a good way to test how effective a cognitive aid is. It may be that someone's produced something, when you put it into practice, you suddenly realize, oh my god. This is not usable, or it wasn't obvious where you needed to go. Amanda, can you explain just quickly what a cognitive aid is in case some of our listeners don't? 

So cognitive aid is basically like a cheat sheet. So it's kinda going through, like, the steps. Like, what do you need to do in sort of in a in a crisis? So in an example, like, local anesthetic toxicity, I'll talk about kind of briefly what are some of the signs and symptoms of local anesthetic toxicity. What are the immediate steps, the ABCs that you need to focus on? 

Stop any local anesthetic infusion. Start to call for help, call for your intralipid kit, etcetera. And then what are kind of the secondary node and tertiary steps that you should do as far as stabilization? It's also great for remembering uncommon things in uncommon scenarios. Like, the dose of intralipid can be, you know, oof, like, in an emergency, this patient's coding in front of me. 

Like, do I remember, like, what was the dose again? How do I do the math? He's sixty seven point five kilos. And if I have to carry the the one, oh, man. So this kinda takes all that math out of it. 

Just makes it really simple because it helps your brain work to its capability. Free format. Yeah. Free is great. So it's wonderful. 

So oftentimes, the one that we use at Duke and the one that I think a lot of institutions use is the Stanford Cognivy that you could Google and download for free online. And it's got some diagnoses like different, ACLS algorithms. It's also got hypotension, hypertension, hypoxemia, etcetera, and then specific diagnoses. For example, local anesthetic toxicity or anaphylaxis. So it's fantastic to use in a in a pickle when you're kind of like, alright. 

I went through the first four steps, and now I'm in a little bit of a a mind freeze situation. It's nice to kinda be like, ah, yes. The trip taste level. I should send off a trip taste level, or I should call in house or kind of those next step up. Alright. 

So I've seen the benefit of somebody having, gone to simulation training with a Cognizant a before. So I've unfortunately had, Jeff turning the volume down on me. Did see that I'm too loud? I saw that. He's like, just turn it down. 

Amit, be quiet. You've been talking the whole day. Now that's a plural dropping sound. There's power dropping sound. Also the power coming down. 

The power of vertigo. The of the Death Star. You know, in Ben Kenobi? Oh, yeah. Yeah. 

Yeah. Oh, you're right. Oh, wow. On so many levels. So I I unfortunately had five or six cases of anaphylaxis within a two period two year period. 

So my so I was actually relatively good at managing things because I've done it so I did I had my own simulation. Do you need to smear peanut butter on a laryngoscope blade, or is that just something you do for fun? Tastier that way. They're all different agents. Actually, it wasn't always the same trigger each time. 

But what I was gonna say is I was working with one of my colleagues who'd mentioned her a few times on the pod, Shelley Lee, all the way from Australia. Travel agent? Shelley Lee. Travel agent doctor Shelley Lee. She is is considerably younger than me and had done a lot of simulation as part of her training, including anaphylaxis. 

And what was really interesting is when I was having, I don't know, case number five or six of these, in my head, I knew what I was doing. But it's interesting. So even though you think you're good at managing a team, some of those steps I was doing were were were I wasn't articulating, I would say, outside. What's really lovely is she took the role. Yeah. 

She was she's coming gone back to a consultant job now, but she took the role. She's at right. She took the coming to the aid, and she dedicated responsibility to one of the team members and said, right. You're in charge of making sure we do all of these steps. And she read the steps out, she or got this person to read the steps out. 

So she nominated somebody being responsible to make sure we went through everything. And I spoke to her afterwards about the way the case is managed beautifully. I spoke to her. I said, you know, that was really lovely to watch. How were you so calm and so proficient? 

And she said, because I'd done simulation so many times with different techniques, and I had an idea for how I was gonna run this because I I never had she hadn't had her own case before, but she'd simulated it. And, actually, that's for me, that's proof that it works. I think cognitive aid is helpful for so many reasons, but having someone who's calmly standing just to step back from the chaos, reading out the steps, and saying, did you do this? K. Next step is never seen that before. 

Right. Because I I bore responsibility on myself as a Yeah. I've gotta nail this. I've gotta this. I know the five h's and the five t's. 

And I was happy I did things, and I was patting myself on the back when I was doing a simultaneous trip today. It's like, yeah. I got this. I treated them. And but, actually, we're all human. 

Right? And we can make mistakes, and we can get to do it. So this was a really cool move that, you know, using that that tool, but getting somebody removed from the situation to step back and say, have you done these things? And it's great because when you're kind of assigning those roles, the cognitive aid is in kind of you know, it has medical terminology, but it's also in in, like, kind of normal regular layperson's terms. So you can also designate someone. 

So if you've got limited anesthesia staff, it doesn't need to be an anesthetist or anesthesiologist who help that out. Yeah. You could be like, excuse me. Could you just hold this up and then what? Are they doing just compressions on? 

You should be doing those at a 100 per minute. Like, a medical student. It'd be a great task for them. Or a circulating nurse who comes in to help out, like, fantastic. Like, really kind of involve them and and use their skills to keep the team on task. 

Interestingly, in the world of regional anesthesia, they've looked at cognitive aids for local anesthetic toxicity, and they've compared kind of, like, different versions, like the AZRA version versus the Stanford Cognivate, etcetera, to see, like, which one was most effective. And then they then they were able to test out in a simulation lab based on which Cognivate they were using. How much time they spent I I believe in this one, they use eye tracking. I was gonna say this sounds like it's perfect for eye tracking. They, like, looked at it, and it was like, could you find the most important pieces, like dose of intralipid, like, next like, epinephrine dosing, etcetera? 

And, like, how long did it take your eyes to find it and which cognitive aid was, like, more effective? Like like, this one, it took x number of seconds to for you to get the the intralipid in the patient. And this one, oh, it took you twice as long, so maybe this cognitive aid is better. Which came out on top? Do you know? 

I I don't recall. Was it the block it like it's hot branded? It clearly was the block it like it's hot. That's another idea for merchant guys. Yeah. 

B I l a I h. On the back of the hoodie, can you imagine if you had, like The entire algorithm. Yeah. That would be great. Not that we think there's a high risk that this is ever gonna happen, but if we Wait. 

Look. Where's my hoodie? Can someone find my hoodie? Step one, find hoodie. Step two, call for help. 

Listen. Whilst we're laughing, it seems a shame for us to to to miss out on the opportunity for you to tell us a joke. I knew that there was a fee for entry to this place. Right. Okay. 

So I don't know if you know this about us at Duke Rap, but we have kind of a cat theme going on. A cat theme. So we have this group chat. So it's a text message stream. It Or is it a group chat? 

A group shot. Very nice. I love that. It's quite active. And I would say it's it's partly work, and it it's mostly kinda for fun. 

But we have a cat theme in that we send lots of cat GIFs. Is it GIFs? GIF? I think GIFs. I think you're correct. 

I wanna say GIF, and I say GIF all the time, but I think it is GIF. I prefer I prefer the French. Yeah. Because it sounds like your name. Oh, I see. 

Yeah. Got a lot of cat GIFs going on. So if it's your birthday, you get a cat meme. Oh, you get a cat. Yeah. 

Okay. Remember that. If something challenging is happening at work, we kinda cut the tension with the cat meme. Okay. And so I've got a cat themed joke. 

Okay. Do you call a pile of cats? Meow. I I got not I don't know. Is it a meowton? 

It is a meowton. I live for the applause. That was good. How did you do that? That was great. 

I love a one two punch. Yeah. That was Wow. Okay. That's brilliant. 

I lift the applause. Oh my goodness. Okay. I I I'm speechless. Jeff, where do we go from here? 

That was amazing. Is there before we wrap up, is there anything that you've different kinda scenarios. And so some of them are, like, the classical academic scenarios where it was like, hey. I'm teaching trainees, but others would be like, you know, I'm trying to teach my colleagues or, like, what do you do if you're trying to, like, deploy, like, a novel type of block, but you're trying to teach at a center that only has one anesthesiologist per day? So, like, they never have backup, or there's never anyone to kinda phone a friend or call for help. 

You could phone a friend, but you'd have to video chat them. Like, they won't be there in person. So it's kind of cool to see how they, like, gave advice in these, like, variety of different scenarios. The other thing that was really cool was the, cutting edge technology. So it's kind of cool to hear about, like, cryoanalgesia and, like, the role of music and, like, kind of these other different Music. 

Music. Meow. Yeah. Sorry. You just, you know No. 

No. I'm like love. Okay. So so and so music, so how are people using music in regional anesthesia instead of instead of, sedatives? Exactly. 

And and, interestingly, their, one of their take home points is that you have to choose a type of music that the patient likes. So if you have a genre that they enjoy, you're actually gonna decrease their pain scores. But if you pick the wrong genre and they don't like the music, you may actually increase their catastrophizing behavior. So it is music within asterisk. Ah, that's interesting. 

To it. That's really cool. Those both sound sound like great great sessions. Amazing. Well, Amanda, thank you so much for joining us. 

Thanks for having me here. It's been so great. You guys are just knocking it out of the park. We're we we enjoy what we do, and what has been amazing about this meeting is the fact that we get to to speak to superstars like you who are doing great things with education and delivery of regional anesthesia, and it makes us feel excited. The future of regional anesthesia delivery and education is alive and and fun. 

It's brilliant. So thank you for spending this time with us. Amazing. Yep. Thanks, Amanda. 

Thank you, guys.