S3:E3 "Somebody call 911! Nerve blocks in the ER 🚨"

This is an emergency. Is it too shellfish to keep blocks in the OR? We talked to a couple of blockheads to see what they think. I'm Amit Power. The best place to learn blocks might be in a brewery, but this podcast is a close second. 

So grab your tube and lube and join us as we talk blocks in the ER. I'm Jeff Gadson, and this is Block it like it's hot. Hey, Ahmed. What's popping? Well, hey, Jeff. 

You know, most of my joints are popping right now, especially my hips. I I think this is a sign of aging. Right? Well, you know what yeah. I hear you. 

You know what they say. Right? You're only as old as the man you feel. Wait. Are you how which man are you which man are you feeling? 

Well, truthfully, in my head How old do you feel? I feel like I'm 21. Right? I don't feel any different from how I was when I was younger, but probably my bones make me feel like I'm about 60. Now talking of bones, that may well be relevant when we introduce our podcast topic later. 

But before we get there, Jeff, what have you been up to since the last episode? Well, I I got up to Toronto to visit my family. So my parents, my two brothers, Dave and Brad, they both had birthdays in January. So took the kids up there. Wow. 

Yeah. It was good good little visit. It's been a while actually since I've been in Toronto. So Uh-huh. Got some snow in there and played some you know what road hockey is? 

Like, when you play hockey on the road? Yeah. Yeah. With a ball instead of instead of on a a rink with ice in a pocket. It's like on the road with a ball, but, had a epic game of road hockey, and, kids love that. 

But, like, what about the cars? Didn't you, like, smash the cars? Wasn't that, like, a thing? I'm I'm just trying understand. Would you so the road's empty. 

There's no roads on the cars, and you're just, like, hitting a a ball or a puck around? Or Yeah. So, ideally, you have have a friend that lives in the sort of dead end end of a street, and you can kinda, like, just sort of cordon it off. And every once in while, someone has to pull into their driveway, and so you everybody else, and you move the net and stuff. Oh my god. 

I think there's too much land in Canada. I mean, The UK, we could not do that, man. We used to play we used to play cricket on the street or football, but, you know, there were lots of cars that got damaged, man. Yeah. That's a hard ball, that cricket ball. 

Yeah. I I can imagine it get going through a few windows. And then this weekend, we're going to this indoor water park for Holt's birthday. So, called Great Wolf Lodge, which I it it it'll be fun. It's it'll be a couple of days of intense sound and chlorinated air to breathe. 

But Wow. So does that mean that the Gansden six pack is gonna be on show? The Gansden? Well, if we could take a time machine back to, 1988, perhaps. Yeah. 

No. I'm I'm probably gonna be just more supervising slash reading my book on this side. I got you. It's a weird crowd there though, man. It's we were there once before and that's the first time I've that was my first time seeing an ankle bracelet. 

Oh. Like, you know, one of those you you're a convicted felon and you can't go places. Oh, that type of bracelet. Okay. Okay. 

I thought you meant, like, the fashion outfit. Anklet. No. I've seen plenty of anklets in my life, but no. I was like, I and I thought to myself, you're allowed to go to a water park as a Well, I can't. 

Felon. But anyway, so Okay. Well, that sounds fun. Yeah. And it's not it's getting it's getting nice here. 

But one thing I love about North Carolina is the weather is Uh-huh. Is, like, we have buds on the trees now, like, just coming out. It's just February. Right? Uh-huh. 

So the other day, it was a nice day. I went for a walk. Uh-huh. Ended up in this little cemetery that was nearby our house. And I was standing there just kinda like just taking it all in. 

Birds are chirping and stuff. And this little girl walks up next to me. And like, she kinda looked a bit upset. She I I and she said, I'm really afraid. And so I took her hand and I said, I used to be afraid too when I was alive. 

What on earth was that? That is the weird I mean, what? Are you okay? Okay. Anyway, that was my attempt at a joke at the beginning. 

So how about you, man? What have been up to? Well, I'm I'm kind of lost for words to that, Jeff. I I was with you and I like, okay. There's gonna be this is gonna be a crazy story, and then you lost me. 

Holy moly. Listeners, I don't know what you think about Please feedback on the quality of Jeff's jokes as they go through the pod. I hope our guests bring something good. I'm so excited for this. But, anyway, since our last episode, what I've been up to? 

Well, I think my life has kind of been dominated for the fact I've got this conference coming up in Australia in just under a month. Yeah. I The Austra Australasian Symposium Of Ultrasound And Regional Anesthesia. I've got, like, loads of talks to write, and I haven't done anything yet. So I'm getting a little bit nervous. 

Oh, sounds fancy. I think you're gonna be great, man. You I always write my best talks under pressure, and I'm sure you'll be just fab. Hey. Are you gonna hook up with any of our, Aussie and Kiwi friends there? 

Well, it's really funny you should say that. So I'm hoping to meet, finally, Mary Anne Fox from X and her husband James Aspinall, a urologist. Yeah. Our friend Cass Andrews, Shelley Lee, he's been with me in London. Andrew Lansdowne and Lee White, who I published as well, but never met. 

So I'm really looking forward to seeing all of those guys. Amazing. Well, looking forward to hearing all about it. I'm sure you'll take lots of pictures. Wait. 

Who am I kidding? Of of course, there'll be lots of pictures. Of course, there'll be photos. Now speaking of photos, what kind of photos do lobsters take? Don't know. 

Shelfies. Oh, god. And you had the nerve to disparage my cemetery joke. Well, listen. If you think that was bad, here's one more. 

Right. Listen. I've been reading a book about sandpaper recently. It's a real work of friction. God. 

Okay. Let's move on. Alright. So The thing is what our listeners what our listeners don't know is I can see, the faces of our guests, and there's, like, no reaction showing on their faces at all. So this is, like, this is terrible. 

What are we gonna discuss today, buddy? Well, you know you know what? Just before we get into that, it's kind of relevant. I wanted to share something that is a little bit personal. So my last remaining grandmother, is 95, last week fractured her hip. 

Mhmm. So true story. This is no joke. She actually got a fractured neck of femur. She got a really nasty, intratrochanteric fractured neck of femur, and we got to experience the highs and lows of hospital admission. 

Thankfully, she's on the mend. Fingers crossed. By the time we release this episode, she'll be at home. I'm praying for that. Yeah. 

But I just wanted to take the chance, because it's very relevant to this episode today, to thank the whole team, that looked after at Norfolk Park Hospital, the ED team, the nurses, the health care assistants, the surgeons who operated on her, mister Rafting, mister Singh, and the team of anesthetists or anesthesiologists involved. So I've got a few shout outs. I have to do it as an anesthetist. I've gotta give them a shout out. So Sally l Ghazali from afar, doctor Chima Otti, doctor Dan McNaughton, and doctor Ruveni Gummage. 

All of them were involved in the care of my, my grandmother. So just wanna say thank you now. Well, we're all we're all thinking about her, man, and hoping that she's she's on the mend and getting home soon. Thank you so much. But now you'll see how that links into the subject of our podcast. 

I promise you, you'll see the link. So we've discussed lots of pure anesthesia related indications for regional anesthesia in the past, and the guests we've had so far, Johnny and Tanya, they've been anesthetists. But as we know, regional anesthesia doesn't just take place in the OR or in a block room, and it isn't just performed by anesthetists or anesthesiologists. It happens everywhere, like the emergency department. Exactly. 

And there's been an explosion of point of care ultrasound or regional anesthesia in the emergency room, so we figured we would get some EM physicians who are making great waves. Get it? Waves, ultrasound. Yeah. I know. 

In this in this arena on the pod. Yes. And I am delighted that we are joined by two physicians who are both members of a team of forward thinking emergency physicians with a passion for regional anesthesia, and the group they're part of has a great name too. It's called Blockheads. I love that. 

As as someone who loves puns and names and that's so great. Yes. We are joined by doctor Arun Nagdev, who's the director of emergency ultrasound at Highland General Hospital and a clinical associate professor at the University of California San Francisco School of Medicine. He has authored many peer reviewed articles and book chapters, won lots of teaching awards, and recently served as a president of the American College of Emergency Medicine, ultrasound section, and the AIUM, which is the American Institute of Ultrasound and Medicine, POCA section. Wow. 

Well, he sounds super qualified for this. Well, you know what? We are also joined by another expert, doctor Andrew Goldsmith, who is the current vice chair of academic affairs at the Lahey Clinic emergency department and previous chief of emergency ultrasound, of Brigham and Women's Hospital. Andrew has lectured widely at numerous international and national conferences, and he is also an avid researcher. Additionally, he was senior editor of the EMRA book on ultrasound guided nerve blocks as well as being a principal author in the new ASEP guidelines on ultrasound guided nerve blocks in the ED. 

Hey. Welcome, guys. Thank you so much for joining us. Yeah. Welcome, guys. 

We can't wait to hear what you have to say. Yeah. Thank you, guys. Hey, Jeff and Amit. Thanks for having us. 

We are very excited and avid listeners. We look forward to being on this podcast now. Well, listen. This for for us, this is a super highlight. I mean, Arun and I have met before we met at ASRA, but, but, Andrew, this is the first time we're meeting. 

So this is an exciting way to get all of us positions together and talk about stuff that we love. Right? It's a super hot topic. I've been on the Blockheads website, and I've seen the workshops you guys are doing, the live workshops. It's, it seems like it's it's just taking off like wildfire. 

So I'm curious how how did you both become interested in this particular part of your practice? Yeah. I can start off with that. So about twenty years ago, which seems like a very long time, as a young, emergency physician, we went over to UCSF. Andy Gray was actually probably the only person I knew or heard of who'd ever done an ultrasound guided nerve block. 

We literally sat in his office. He was like, who are you people? And I was like, why do you wanna do this? And had this large I think it was a GE or Philips system and showed us our forearm nerve blocks and just showed them, like just showed nerves. And we were like, this could probably really help us out because we're at an inner city county hospital, and there there wasn't a way to do hand lacerations, you know, palmar lacerations or Uh-huh. 

Or sole lacerations or big fractures that had to wait. So we kind of started learning ourselves. I remember buying Marhofer's small little book, throwing it in my bag, and I would just scan every brachial plexus and try to figure out where these nerves were. And That's awesome. You guys know that ultrasound technology has improved so much. 

It was still a little grainy back then, and that came from us then really trying to offer optimal pain control to patients that were waiting twelve, fourteen hours for optimal pain control. And so it came from the collaboration that I think is the central point of most of medicine. Right? Learn from each other. Yeah. 

That's that's amazing. So, Arun, you know, that probably means that you and I were learning regional anesthesia at about the same time on opposite sides of the world. That's fascinating. That's so cool. Yeah. 

Yep. Yeah. It was really it was it was really fun because, you know, back then when when you would I even mentioned that we're doing blocks, people were like, what are you talking about? Like, they had no idea what we're trying to do and trying to build. And so this has been a long time in coming. 

That's incredible. So you it must have been one of the first, if not the first, emergency department in the country to start really looking at this systematically. Yeah. 100 Unfortunately, people thought we were insane, and people thought we were completely I remember giving talks in various people leaving, just getting up and saying this is ridiculous that you're talking like this and would walk out of talks. Really? 

Happened numerous times. Wow. Wow. So speaking of learning from each other, mine's, only about seven, eight years. It started in residency, and it started specifically with fasciaeliacca blocks. 

We had a starting a program on fasciaeliacca blocks. And, you know, it's interesting. It only takes one or two to kinda get that hook. You get that positive patient experience, and there's many there's very few things in the emergency department that you have, like, this immediate patient satisfaction right back to you. That patient satisfaction of being in pain to not being in pain is kinda that hook that grabbed me. 

Wow. And so once I started with fascia iliaca blocks, by the end of residency into fellowship, I thought about the same thing when it comes to sciatica. Was like, why can't we adapt what we're doing here for something we see all the time? And so this relationship with Arun and I started out probably back then when I called him, and I was like, you are the expert in this field. You've been doing it for twenty years. 

I just started. What if we could do something related to sciatica? And then from studying from anesthesiologists like yourself, we picked up a block, applied it to the emergency department, and that's how I took off because we had some significant success there, which led to me then developing programs for the emergency department and doing the same thing, getting the same feedback as Arun and saying we're crazy, specifically from local institutions, and then actually gaining traction to where we are with Blockheads. That's amazing. When you when you go to an EM, like, conference now, like a national conference, is there are there lectures and chunks of time set aside now to teach regional anesthesia and you guys are the back saying, I told you twenty years ago this was gonna be a thing. 

It's so interesting. Over the last three or four years, we've put on a nerve block course at ASAP or SAM, which are two large conferences for EM, and they're full. Every Right. We we we we pitch this to the conference. They have a lot of reservation, and then it's the most booked of any workshop that they have. 

And then Arun's obviously next year lecturing the entire country, by being the main lecturer for these conferences now. You know, it's it's fascinating because I've I've been watching from afar the, the journey that you guys in the emergency medicine are taking. And it's fascinating because in many ways, it reflects the journey that I went through as an anesthetist, but I can see how you guys are showing the love. And I remember very early one of Arun's infographics came up on a supraclavicular brachial plexus block, and I saw it come out on on Twitter as it was back then. I was like, this is cool, man. 

This is how I went through the process. And I see he's got a very standardized way of of showing videos, when he put the two videos side by side that he's released on x. I've got you know, I can specifically remember how you're sharing, the love and the passion for regional anesthesia. So listen. It's so incredible to speak to guys like you who are experts in doing this, but I'm curious to know what proportion of emergency departments in The US are actually using regional anesthesia or regional box analgesia. 

Is it growing? Are we just getting a skewed opinion for you guys, or is this something that's happening across the whole the whole country? And what are the main drivers for this? So I'll take this, and I can reference two articles. First one, which is Arun published back in 2016 with Richard Armani. 

Basically, they took a 170 academic institutions, and they got a 120, academic institutions surveyed back to them. And they said that they had 84% had some type of nerve block program at them in academics. We fast forward to 2023 when me, Arun, and a bunch of other people repeated this similar study design. 100% in academic institutions had nerve work programs. That's just academics. 

It's hard to extrapolate what might be in the community setting. But, obviously, as we're training more and more residents, we can likely expect that that utilization is increasing within the community as well. I can imagine too, like, if you if you're training these the next generation and they're going out to a community hospital or private practice, then blocks are a force multiplier. Right? Like, they only help you and help your patient to help your job and maybe hasten things. 

And we'll talk a bit more about specific blocks near the end of the show and how you're using those to to do that. But I I can't I I would I would venture to guess that the numbers are similar in the community. I would expect so. Yeah. I I think this really is is is the key, and this is, I think, the hard part, and I think this is the impetus for us to start blockheads. 

And I think you're hitting it at the central point. The hard part is at the academic institution with seven providers and, you know, four friends doing a block is very different than doing it at a busy emergency department where time, resources, and the next patient is already coming through the door. So I think from from my point, the reason the infographics and the reason the teaching is so basic and it and and not to diminish the educational knowledge of clinicians, but to simplify a very complex tool so they can start the process and then allow that to be scaled. And that's where Blockheads comes in. No. 

I I I think it's so so important. I mean, we are definitely seeing more of our UK emergency department physicians placing single shot nerve blocks. Now whereas the past you know, in the past, if there was someone who was in pain or they were struggling with, they definitely would have called, anesthesia. But I've got a follow-up question that I wanted to ask at this point. And as you know, we don't shy away from controversy or contra controversial topics on here. 

So when I was an anesthesia resident, we used to get paged or bleeped to the recess or the Trauma Bay all the time to intubate patients. But over the years, our UK ED physicians are starting to intubate patients themselves a bit more. Tell me about the practice, in The USA because, you know, I I know I remember seeing on ER or on the, you know, the the the new versions of that, the resin or whatever else. What's the truth, man? What's the truth? 

So in in in most ERs and, actually, this is I I think this is very parallel to, where we're at with, with blocks. I think back in the day when I was a resident, we had that same issue, like who does this intubation, who's safer, how are we trained. And at least from my department, our anesthesiologists come downstairs for very, very difficult airways, and we tend to do 99% of these airways. If we need help, assistance, or if there's something very difficult, then they're at the bedside that can help us. But I would say that in most academic, nonacademic ERs in The States, the ED physician does the primary airways. 

And I can ask both Jeff and, Andrew this. Yeah. Ours is similar. So in fact, we'll have the EM trainees come up and do a rotation with us in, the OR so they get a chance to get a lot of reps in and practice using different airway devices and and talk to us about, you know, our thoughts on airway management and that sort of thing. But, but same here. 

We will get called down for the really, really tricky airways or things that that the EM physicians think might be might be difficult. But in general, they are really, really good, at our center at managing managing airways. Okay. That's that's the same for us. It's when you have time and you anticipate a very difficult airway, bring all your friends to the game. 

Right. Right. And so that just in case you have a lot of hands there if needed, it kinda draws back to our original conversation on NerveBox. Right? Yeah. 

When you have time and you have the ability to participate, anticipate that the patient's gonna be admitted to continue that relationship. And the two go hand in hand. Right. Right. Okay. 

Communication's important too, obviously. I remember one time, a couple of years ago, I was we were down there with this patient with a known sort of airway tumor came in not doing well, and so they called us to come down and just have a look. And it was touch and go, but we were almost at the point where the tube is through the cords, and all of a sudden I felt like wet, like there was moisture all over me. And I I I look up and the emergency medicine, like, chief had taken a a pot of Betadine splashed it all over the neck, and he had a scalpel in his hand. He was about to cut the neck. 

I was like I was like, dude, dude, I really appreciate your enthusiasm, and I and I'm not against the front of neck access surgical airway. I'm I'm a 100% with you, but we're almost there. So but Wow. Anyway, so, yeah, the, like, the communication back and forth is typically very, very good. That's amazing. 

Okay. And I I think that comes back to that that that idea, Amit, that, how do you scale blocks in the ED so that care happens and prevents you guys from being called for every hip fracture, which you guys can't come for. It's it's a it's a scale issue. It's it's when when you're working at a small hospital with anesthesia and a lot of the hospitals I've worked at in The US, anesthesia is not in house even. They're out of house. 

These small community hospitals I work at. So if I have a hip fracture in the Central Valley, which is, like, two hours from San Francisco, nobody's getting a block for the next after 8PM till eight in the morning. So the poor lady or man is laying there in pain. Instead, the clinician does a ten cc, even a lidocaine, just a small reduction in pain with multimodal strategies to get the patient through the night. So the expert or the person who's gonna put a catheter in is gonna be in the morning, is gonna be ready to do that. 

And and the the same applies to airways. Right? In these local community shops, when anesthesia is not available 20 four seven has to come in just for emergency operations, it's the ED that gets called to the floor of the ICU to go intubate somebody because they're in house. Yeah. Yeah. 

Yeah. Exactly. So that's fast fascinating. So you kind of your your skill mix is kind of adapted to fit the institution you're working in and the and the services that provide it, which is great. And, actually, there are so many overlaps with the with the skills that we need to take on everything we're doing. 

Listen. So kind of that sort of brings me on to my next question, which is, how important and you kind of alluded to this already, but how important is it for ED and anesthesia to collaborate together to improve patient care? I think I know what I'm gonna say, but I just wanna hear your viewpoints on this. It's as important as it is to collaborate with airways. It's the same collaboration that needs to exist for acute pain for a patient. 

Uh-huh. Basically, when you do a let's take a, for example, a fascia Liaka block. We all know that patient is not going home. There are some blocks in the ED that we anticipate the patient to go home, and we can act in a silo because we are the one owning that block when they discharge. However, eighty percent of the time for acute pain, they're gonna be admitted to the hospital, especially for fasciaelyaka blocks for acute hip fractures. 

Now who takes over control of that multimodal pain regimen as they get admitted? It's it's orthopedics, it's medicine, and it's in pain med anesthesiologists as well. And so that communication of when that block was done, what you used so that they can anticipate, do they need to put a catheter in place, do another single shot, or when to anticipate need for operative intervention before the pain returns. I think that conversation and policies that come with that is super important. Absolutely. 

Arun, do you have anything else to to add there? Yeah. I think it builds bonds. So so I think, as Jeff pointed out, his residents come upstairs and do some intubations. We call it tube and lube rotation. 

So in the morning, they intubate. In the afternoon, they they do ultrasound. Tube and lube. Oh my god. Sorry. 

It's it's it's a long standing rotation we developed years ago. But but I but I think it's, it's it's so important because it allows us to communicate both verbally in person. So they're doing blocks with our anesthesiologist in the morning. They're doing intubations with them. They're watching them do their various blocks. 

They come downstairs. We also do like, our interns do anywhere from 20 to 30 blocks in their first month. So they get block experience. They get ultrasound experience. So and then that communication that communication of of just knowing each other really facilitates this process. 

That's amazing. And I I had a question that that I just thought of. What, are there national and sort of college standards for number of blocks that EM trainees have to get or certain kinds of blocks, or is it just we hope you get some regional in your train in your core residency training, or how does that work currently? Currently, we hope that they get some regional training in their residency. However, our goal with all of this research, all of this educational platforms that we're developing is to get built into the ACGME educational requirements because then we it'll be required, obviously. 

And we're not there as a specialty yet, but we're learning from you guys and trying to take some of those key principles and put them in the ED as a result. It's it's it's definitely the our goal to get it into that process to the we have RRC or to to our standards in our college. We would love to have that tomorrow. The hard part is scaling that up with education, which I think the goal for blockheads and also for, you know, agreeing with everybody else who all have their own fiefdom in in the college of emergency medicine. And it's like anything else in medical school. 

Right? If we increase focus in medical schools, the nephrologist is like, why are you taking away my education? So there's this there's this pie that we have to somehow figure out how to get in a part of. It's hard. Right? 

When you have when when you're such an enthusiast and and an expert and a niche authority on something, you and you believe in it and you're like, this should be part of our training. But but to make that a standard means that everyone in the country is gonna have to live up to that standard and in terms of in terms of being able to train the trainees And that's just that's we we face it all the time. Yep. But I definitely think there's a lot that, anesthesia can learn from emergency medicine and vice versa. I mean, I think back to, the first time, and this is very niche. 

I'm so sorry for being a nerd about this. But the first time I learned about the lateral antebrachial cutaneous nerve and how to do that block, that was from Andrew Herring from Highland ultrasound. And there was that was the only resource I'd seen. And I didn't realize he was an emergency physician, but I I went and found some websites, saw this video. I thought, brilliant. 

Nobody else is doing that. And I saw one reference to it in one of the Nisora textbooks, but his explanation was so much easier. It'd be really great if we can work together to help each other get better. As you know, that was something that I learned for the first time. I looked at a lot of the papers on the rapture block. 

I've looked at the work that you've done, Aaron, from the early days. So we've got a lot of experience collaboratively, and I think it's, you know, it's it's great if we do work together. How did you just pronounce that block? Which one? This year, rapture? 

Is that what Why what if I done one? What do you call it? The raptor? I I The raptor block. Raptor. 

Raptor. Hey, man. Let's do us some let's do us some raptors today. Oh, no. God. 

Then why is is that another word? I'm saying we Let's do a raptor. No. That can't that sounds wrong. Okay. 

Raptor. I do love I do love your American accent. Hey. I I wanna know more about Blockheads. I think this is I I said I've I've perused the website and I think it it looks amazing and and fun. 

What is it? Tell us more about the role and and how the reach and the mission. So so I think this is this is the the kind of what really I think is the next step for us. And it was me just I guess, I will say the story about I was literally walking my dogs, and I was recognizing the fact that, like, internally, we were doing tons of blocks. In my institution, we're doing 500, 600 blocks a year through our residents. 

And I recognized there were a few people outside my space that were also doing blocks, Andrew in Boston, a few people around the country. But it was wasn't this group that was kind of progressing forward. And I felt the only way to get that is to have some group that was doing it together. And so I kind of came up this term blockheads because I think, like you, I have bad humor. And the goal was to have a group together and just meet once a month and just talk. 

And it was really just conversation once a month on a topic. So the first two or three, I would just essentially hold a Zoom and talk about something very simple, like how I do interscalenes or when I worry about front neck paralysis and how do I do hemofractors, and what do I do for that? So the idea was to build this small community, and then from that, it has just grown. It has been this monthly conversation around topics that we all feel is interesting from the recent one with the new billing CPT code, something very boring like that, or to, you know, how do you get anesthesia involved in your department? And we've had anesthesiologists on. 

Actually, Alex Stone out of the Brigham hopped on one time just to talk about the communication skills that have to happen. And from that, people are just like, we should do a course because we wanna increase populations that are doing this. And now we're just holding courses around the country for really inexpensive prices. I mean, we're charging I I don't wanna tell you the number, but we're charging $250 for a full day for a two hour course with CME and food and drink and the whole bit. And the idea is to really just bring them in because the goal is to scale. 

Yeah. Dude, I wanted to come to one of those courses. I saw some of those videos, and I'm looking at the beers, and I was like, I wanna be at that course. Yeah. We would love to bring you guys. 

You need to. We hosted at breweries. How much more fun can you have? I I saw that. I'm like, what are we doing wrong in our field that we're not having courses and breweries? 

We're gonna change that. Well, that's that's amazing. I know that you you both have published on regional in the emergency medicine context, and I wanted to hear more about the recent JEM open paper that was published. Yeah. This was a this was a multiyear process. 

Basically, it came up. We were having beers probably at one of these conferences, and we said, how do we advance the field? What what is holding us back? Right? And we ask the question of what a community doc is probably asking themselves is, can I do this? 

And if I do this, am I gonna hurt somebody? And that question, I think, has resonated with us, and we're we took it upon ourselves to try and solve it. And the way to do that was to get as much of our co researchers together at once and then start brainstorming how do we form this national registry. And it kinda takes the example of what Ron Walls and Calvin Brown did did out of Brigham, is the National Airway Registry. And we were like, this is how airway management got to be an ED skill. 

So can we adopt that methodology into this way we look at ultrasound guided nerve blocks? And so what we did was form this 11 hospital registry, for this one paper, and just took retrospective data collection, very simple, to look at complication rates as our primary outcome. That's amazing. Were you looking at all blocks or just primarily at the common ones, or was it, all comers? We looked at all comers. 

We took all the blocks that were performed in each and one of our emergency departments, mostly academic with a few scattered community hospitals as well. And we looked at not just the complication rates. We we group them into efficacy as well. And now there's limitations with doing retrospective data collection, but as somebody that was doing this at a labor of love and for free, that, we didn't have our RAs being able to get this prospectively. But in doing that, we get a trend that we're able to see that these blocks are both efficacious and have very minimal complications when you get down to the numbers. 

Well, listen. I got very excited, when you sent told me about this JAMA paper that's coming out. So the first thing I did, of course, is I searched for it and I downloaded it. And there's a really interesting data that came out of this. So you guys in that that that period was 01/01/2022 till 12/31/2023. 

Right? And in that period, you got 2,742 ultrasound guided nerve blocks, which is an impressive number. And and you said your primary outcome was complications, and so you you must have pre listed the complications that you thought was significant. But the thing I was most fascinated about when I looked at that was, number one, the efficacy was great, but also the spread of blocks. Jeff, had you had a chance to check this out? 

Yeah. So can you guess what the what the common well, you know now. This is not gonna be fun, but let's pretend you don't know. If you were guessing what would be the commonest block, what would you put your money in? Yeah. 

I hit fracture blocks. So, like, fascia iliaca. So that that was incredible. Right? So that guys, that was, like, 35% of your blocks. 

But what I think sticking with our controversial theme, block number two in that list is not one I would have predicted, and that is, of course, the ESP block. So holy moly. So that's fascinating. Right? So I'm guessing that's rib fractures. 

Is that was that the indication, guys? Yeah. Mostly. So so so your your your most common blocks were for, for hip fractures and ESP for some other indication, which is brilliant. But then it's interesting that Arun talked about it. 

He then talked about forearm blocks, and that was the first set of blocks that he they were. And that was, like, 8.8% of your blocks were forearm blocks. So let me guess. Was that skewed to your institution, Erinn, or was that across the board? Yeah. 

I think it's across the board. I think what we I think what we realize is that ED doctors are trying to reduce pain in in the area where the injury patterns are the highest or where the blocks are the highest. And and and for us, you know, our plan a blocks are generally thorax injuries or injuries in the thorax, excuse me, and pelvic injuries. And those are the most common that we see that we have no other technique to work with. And so clinicians are leveraging the skill set of doing those blocks because there's really nothing else. 

And I think that's why it popped up. That's cool. I was a little surprised to see that tibial nerve block was somewhat down the list because I I imagine there's so many foot lacerations that come in that need sewing up. And I think I told the story once before in the podcast. I remember as medical student watching someone try to infiltrate lidocaine into a plantar wound, and I nearly passed out because I was like, oh my god. 

It looks nobody was having fun with that experience. So just that simple tibial nerve block is so so great. I I think that'll come with our education because I think what's happening is the hospitals are getting those types of injuries are your local community shops, whether that's by the beach or wherever it may be, and it just takes expansive education to get to those. But I do think we will see that one increase drastically when we get there. We're seeing that. 

So I I taught two fellows that that now run the point of care divisions, one at Stanford and one at Children's Hospital in Oakland, and they do a lot of those. And it seems like it's just more a pediatric injury, and that's just my guess. And and they're they see a lot of it. Okay. Interesting. 

I I do have one more question about this list. There were seems to be two people that did a dorsal penile nerve block, and I'm just wondering what that indication was. What? You do a lot of those in the That probably came from us. So so we we get we get a a large number of private patients secondary to, yeah, substances. 

We do we do a ton of dorsal pina nerve blocks, and one of our faculty published a case series on this, which I thought was hilarious. So people get very excited because they look up our website, and and they do it. I think you know what? If if this is making your job easier and you're more comfortable with the anatomy, all you go for it. Right? 

Yeah. Yeah. Okay. Right. Well, it it's funny. 

I I I took Arun's article on this, and I did one in a community hospital. This is how it works. Right? You you look this up. You try to figure out the best pain management, and Arun's published on it, which is usually the case number in two medicine. 

Well well, the other thing, looking at that list, I'm fascinated about because I wouldn't have thought that that would have come into the ED. And again, Andrew, you made some reference to this, but the transglutial sciatic nerve block made your list, as one of the blocks that's performed. But I'm curious because you get a significant motor block with that block, which can, of course, affect the ability to ambulate. But also, if you look at your complication list, that block was responsible for what you would classify as some significant con complications. So tell me both what your thoughts are about that, why you do it, and whether you think it still has a role. 

I think it has a larger role than we're probably even using it for. Mhmm. The reason being is a lot of patients come in with acute sciatica, and the block isn't meant for everyone. The block is meant for someone that is refusing to get out of bed because it hurts so bad, and opioids and other medications are just not touching it. This is the type of block that will help them. 

And so when you take the risk benefit of it, you're you're talking about a hospitalization. You're talking about immobility versus a potential motor deficit. And when you go through that risk benefit, most patients want to just get up and walk. They want to be able to go home, and this is that type of pain modality that can bring it. Now we have learned a lot from doing it. 

The the complication rate is with the foot drops, like, five to seven percent probably, that we've learned. And now most of us are giving patients crutches to go home just on the off chance they get that foot drop. Because all of our complications from it are because they rolled their ankle or they got numbness and weakness and we're not expecting it. So it's it's really having that upfront conversation explaining to them that they may get this weakness and giving them proper return precautions as a result. You you just said something, Andrew, there that I really like that for controlled motor deficit. 

I'm gonna use that. That's great. Because we get it, you know, despite the fact that we've been doing this for twenty years in our, you know, personally, and then the field's been around for a 100, I still get the odd surgeon that's supposed to well, you know, we want them to ambulate today, and the block's gonna reduce that. And and so we have to have this conversation. I'm gonna use this term in that this hey, dude. 

This is a controlled motor deficit. I actually love this. I think this is the hook. Right? This that is the I've taken away so much already. 

Yeah. But that is the that is the phrase. Right? That's the phrase of the pause. That's a bumper sticker. 

Wow. Yeah. For me with these vlogs guys, I just tell them they're all gonna have motor weakness. I give them all crutches, and I tell them in twenty four hours if there's still motor weakness that they should come back in for a repeat evaluation to see where they're at. Yeah. 

Yeah. I agree. And it's it's all risk benefit too. Right? Like, the don't ignore the benefit that this block provides. 

You're avoiding it in a mission. You're allowing them to sleep overnight, you know, and with some with some appropriate counseling and durable medical equipment, you can, make it all safe. And we have a we have a study that's more of a observational study of this prospectively, and you'd be shocked how even two, three days down the line, how they've gotten on top of their pain regimen. And now instead of, like, being extreme 10 out of 10 pain, they're living at three to four, and they're totally okay with that, and they're just on ibuprofen Tylenol. It's a it's a big difference. 

So now I've kind of I've got a vibe that you got a decent number of blocks across a whole host of different institutions with the spread in the kind of areas that that we would expect apart from a couple of bonus surprises that we've discussed already. What about the complications? Tell us about the complications that you saw in this cohort of patients. So we broke the complications into two cohorts. One minor being that it affected it in some way, whether that was motor deficits, numbness, almost anticipated side effects of the block, and the second being your typical major complications, whether that's last PNI, stuff like that. 

When we divided those two cohorts, we got 10 total complications, nine being minor, one being major, And that major was a last complication with an ESPOC, I think, out of one of our institutions that I can't even remember. It's mine. It it was our institution. But they did okay. I didn't wanna mention it. 

We talk to everybody about how the ESP block is a relatively safe block. It's relatively avascular area, but, of course, there are blood vessels in there. So so tell me about it. Was that I was trying to read the paper and trying to get a vibe for whether you thought that was a real Yeah. Episode of last or not. 

Yeah. So I think I I think it's interesting. Actually, I was at Astra, I always tell this story, and it was Vincent Chan talking about the venous absorption in the ESB that causes this spike in last associated with it. He feels that thoracic blocks are more worrisome because of the venous absorption. It's really not a planar block, which is a really interesting concept, and it was really a fascinating I was really lucky to be at that talk. 

So our case was somebody giving a pretty high dose. It was it was a it was a sub max dose, but done not quickly, not quickly, but too quick for me, which which our protocol now has indicated. The patient started having some tachycardia, some hypertension, and so started having and luckily, he was using rupivacaine, started having some mild tingling in his tongue, numbness in his cheek. And at that point, they all got worried and just, reversed the patient with intralipid, which we have at the bedside in all of our blocks. So we consider that last episode, and we didn't wanna shy away from the fact that a complication could have happened. 

And I think, luckily, we were using ropivacaine and not bupivacaine for that block. So I think we had some CNS symptoms and we we did the right thing, I think. Yeah. Well, it sounds like it. That and then that's our experience too with those cases where you're like, well, it could have been, maybe it wasn't, but just treat it anyway. 

I'm glad there was because the the point one of the take home points in this paper is blocks are very, very safe, you know, and and if you're if you've got the right training, you're doing them consistently, and you got the the skills, and you're thoughtful, blocks are very, very safe. But I'm kinda glad there was one episode last just so that's in people's minds as they read this paper that, oh, yeah, that could that could still happen. Blocks are not a zero risk proposition. Yeah. And and so this this this kind of I'm sorry. 

This goes to the airway stuff that I still go back to. If you're an ER physician who is doing intubations, you should be comfortable knowing when to do a crike and not wait till the patient's o two sat's at 20%, and you're bagging the patient. So I think Splash that beta dime, man. Yeah. Exactly. 

If if you're gonna do blocks, you have intralipid ready to go. And not even ready to go, you know how to use it. And this is something that we're putting something up in ASAP now. It's one of our magazines on how to push this and, this medication quickly and rapidly and in a way that allows you to do it safely. That's great. 

So I just wanna say, first of all, guys, congratulations on the papers. It's great what you're doing is you're putting that information out there, making people feel comfortable. Exactly as Jeff said, the regional anesthesia in the ED is, is safe. There are not zero complication rates, and it's important that you're truthful and honest about that, but we should be encouraged about that. Now before we hit our joke break, I wanna ask another con question that I hope I know the answer to, but I'm gonna ask it anyway. 

When you're performing blocks on patients of any, age group of comorbidities, do you always apply monitoring? Yes. Ninety five percent. I wanna know why it's not a hundred percent, Andrew. What happens in that five percent of cases? 

It's low dose forearm blocks Okay. Or below the kneecap, so, like, posterior tibial. Okay. So so it's interesting because I, I do have some personal experience. I won't spread any more information about it, but we're observing a large volume fascial plane block being performed on somebody without monitoring. 

And I in ED by ED in The UK, and I I'm fascinated that that was even able to happen. So because if we had a big Royal College of Emergency Medicine, alert about a patient who had a fractured neck of femur, had been given opioids, was in a side room, had received then a fascia aliaca block with no monitoring and was found a period of time later, unfortunately, with you know, had had died because they'd taken away the pain driver for respiration, and it was a disaster. So you guys would say for the majority, if not all of your blocks, you would put monitoring on, so low volume distal blocks, maybe not, but certainly anything evolving, anything near the near the spine or high volume, you'd use monitoring. 100%. 100%. 

And that's been our we we've written position papers for us for ED, and it was clearly any like, a five cc block on a forearm, I can be okay with not putting on a monitor. Sure. Yeah. But once once you're getting above the elbow, above the knee, even at the knee, I think if you're doing a distal sciatic, you should place these people on a monitor for at least thirty minutes, and the thirty minute window is the minimal. Guys, did you hear that? 

This is such sensible information. So from whatever specialty you're listening to us from, you know, these guys are doing blocks, not in an anesthetic room, not in an OR. They're doing the NED, and they appreciate the importance of this. So I think this is really important. So thank you for sharing that. 

Jeff, I interrupted you. You wanted to No. I was gonna say congrats. Kudos on the paper. Really, really great stuff. 

And I think that's gonna that's gonna, I think, make a big difference to the adoption of of blocks as people realize, hey. These are great. They they're effective, and they're safe. Gina, hey. By the way, kudos. 

If if I say kudos to you, that's a good thing. Right? Yes. Yes. Yes. 

Yeah. Apparently apparently to Gen z or, like, my kids. No. Like, I said, kudos to somebody in, like, my my kids, like, snickered out. He said, kudos. 

Oh, no. He he he must he must hate that guy. I what's guys getting these kudos emails too from, like, your hospital where they've subscribed to this give your kudos to our colleague where you can electronically give kudos now? No. I've never gotten an electronic kudos. 

It's a new thing. Maybe it's just New England. Famously famously, one year, the administration at my hospital gave every nurse a rock as a gift. This is like during COVID saying, like, and it the little message was you rock. Oh my god. 

And the instruction was please take some paint and some googly eyes and, like, decorate this rock to and accept this as our as our gesture of how much we appreciate you. And there was a lot of, like, comments on Reddit and everything saying, like, I know exactly where I'm putting that rock. Like, where does the CEO park his car? Oh, man. Dude, I I'm I'm assuming that you have a new marketing department at Duke. 

I actually I said to someone the other day, I I wanna know where that person is now that thought of that idea because they're certainly not they're no longer at our hospital. New job time. Well, should we should we should we gone with the the jug break? Of course. Of course. 

Well, listen. So I I was down I was downstairs in the living room just just trying to relax the other day, and my wife shouts down from from the Second Floor. I said, hey, do you ever get like a shooting pain across your body? Like someone's got a voodoo doll and like of you and they're and they're stabbing it? And I I said, no. 

And she responded, how about now? Oh, yeah. Yeah. I hope you checked that joke with Corey before you told it. That's all I'm gonna say. 

I I finally cut ties with someone that was really dragging me down. Rock climbing with a friend can be so hard. Alright. That's all I got. Oh god. 

Okay. Okay. Guys, so so now you see the the level that we're bringing. You see that so okay. Aaron, Andrew, who's gonna go first? 

I wanna see what you got. Andrew. So it's funny. I asked I knew this was coming for the joke, and I started it. My friend texted Red. 

I was like, give me your best dad jokes. I was like, give it to me. This is the one that's signed, but it's, thirty percent of pet owners let their pet sleep in their bed. I tried it, but my goldfish died. Oh, Okay. 

I like that. That's that's simple. That's not dirty. That's clean. On every level that hits, boom, boom, boom. 

We can tell that. Great work. Great work. Okay. Arun, what you got? 

God, I'm gonna I'm gonna I'm gonna butcher this, but I'm gonna try to do it. So I apologize for the stupidest joke. So what's the difference between a general practitioner and a specialist? One treats what you have. The other thinks you have what he treats. 

Oh. That takes that takes some thinking. Yeah. I was like, yeah. Yeah. 

Yeah. Yeah. I like that. I like that. Listen, I'm gonna be I there's no way I can compete with that. 

So I'm gonna I'm gonna keep it simple. Right. So a neutron floats into a bar and asks the barman how much for a beer? And the bartender replies, for you, no charge. On. 

On. Come on. Yeah. Yeah. Yeah. 

That's that's okay. Not bad. It's not bad. Science joke. You know, I always try and make something tie in to the podcast episode theme. 

So here we go. Get ready for this. You know, I had to go to the emergency department the other day because the outside of my elbow was hurting so much. And the, the emergency physician said to me, we he said, when when does it hurt? And I told her it hurts sometime between nine and 11AM. 

And do you know what she said? This is the worst case of ten ish elbow I've ever seen. Okay. I like that one. That's good. 

That is good. Right? Yeah. Yeah. Yeah. 

That's good. That I think that that could could win. I don't know about that. There's no competition, but I would be very happy to accept the prize. And that's it for part one of our EM episode. 

Join us next time for part two where Arun and Andrew get into the nitty gritty telling us about their favorite blocks and how they use them in the busy ER. Till next time. Block it like it's hot.