S3:E4 "Spinal anesthesia with Robbie Erskine!"

Of all the backstabbers we know, our guest is one of the sweetest. So get ready for some regional speed dating. I'm Jeff Kadston. We've been waiting for you, mister Bond. We hope you're as keen as us to get into this special episode. 

And don't be nervous. Nervous. It's gonna be just fine. I'm Amit Power. And this is Block it like it's hot. 

Good day, Jeff. Hold on to your wallabies and chuckers a boomerang, mate. How are you going? Oh, god. Straight in with the accent. 

Brave start. Brave start. Does anyone in Australia actually say that stuff? I'm I'm pretty good, mate. How are you? 

Well, thanks for asking, mate. I'm Bonzer, and, of course, nobody in Australia says any of that. But but before I explain why I'm doing the world's worst Australian accent again, Tell me what you've been up to since we recorded our ED episode with, Aaron and Andrew. Oh, that was so much fun. Right? 

And we got and we got some great Blockheads merch from that too. Thanks, guys. Thanks for sending us the, the awesome mint green YETI mugs. Yeah. Thank you. 

I can't wait to get ahold of mine. Jeff promises me he'll give it to me, but let's see gonna meet up in Florida sometime soon. Yeah. I've I've been good. Thanks, man. 

I same old. Same old. I did teach a a gastric pocus course to to a group in New York City. Are you I mean, we're we are finding we're doing this more and more and more. It is it's a daily thing now. 

The need for especially with the GLP one Yeah. Agonists. I mean, it's it's it's definitely topical. Yeah. We're we're it's coming up the whole time. 

We'll get into this maybe another point, but whether or not this truly has a role remains to be seen. But people are asking about this all the time for sure. Yeah. Well, it was interesting. I got the feedback. 

So I taught the course to this group and then, you know, I had had some feedback over the over the next few days as they were implementing their new skills. And they they were saying, it's amazing. Like, we have had cases where they ought to have waited another four to five, six hours Right. By the guidelines, but we scanned them and they were empty even though they ate a cracker, like, you know, an hour before. So off to the OR. 

And so they they're it's not just a safety thing from the point of view of, oh, there's a full stomach. Let's delay that case. It's like, well, now we can move forward. And that that really I think that was an impactful observation for this private group that's doing a lot of cases. So Oh, for sure. 

Anyway, so that was that was fun. Oh, and I while I was there, I had some time to myself, and I thought, yeah. I'm I'm in the Big Apple. Yeah. Let's let's splash out. 

Let's do something exciting. So I rented a limo. Oh my god. It was yeah. Like, I thought, I'm gonna cruise down Broadway through Times Square, like, you know, head out the sunroof, waving at people. 

Who's that guy? Well, no. This is my plan. So I paid $500. $500 for this thing. 

Didn't come with a driver. What? So yeah. So I spent all that money and had nothing to show for it. Oh, god. 

Oh my god. Oh, god. Okay. How are you doing? And how is Australia? 

Oh my god. Wow. I don't know what to say. If only you could see the face of our guest right now. Well, thank well, thank you for finally asking. 

I think he's ready to click stop on the recording and just walk away. Well, thank you for finally asking. I I just got back from the ANSRA meeting, the Australian New Zealand regional anesthesia group meeting. They had this meeting called Asura twenty five, which was held in Hobart, Tasmania. Yeah. 

I remember you were writing, like, it's eight or nine or 11 talks or something. How did how did all that go? You know what? It was amazing. The course convener was doctor Katrina Webster, and she put together this amazing conference for about four hundred and fifty to 500 people assisted by her colleagues, Rian and Rachel. 

They made us work hard, but you know what? It was so much fun. I shared the keynote position with doctors Nadia Hernandez and Maggie Holtz from The US who were incredible. We had such a blast during our our joint sessions too. Oh, it's amazing. 

Any standout memories? Well, yes. Actually, a few things stand out. I met my best man for my wedding, Nick. He's based in Canberra, and he's I spent a day and a half with him. 

So traveling up the coast of Tasmania, that was good fun. And, he showed me bits of Tasmania, which is great. There was lots of strong female representation on stage with a really diverse faculty and plenty of new fresh speakers. That was really evident, and they were really high quality talk. So great role models for all of us. 

Amazing. You know, the other thing I did is I went to a place called Mona, and I'm not just referring to what my wife calls me every day when I come back from work. Not the Mona, but Mona, which is the museum of old and new art. Morphine, oxygen, nitrates, that's all. Oh, I remember the acronym. 

No. Yeah. So so Mona is absolutely crazy. All I'm gonna I I don't wanna spoil it. Because I'll be in Tasmania next week probably. 

Right? Quite. Right. But listen. This this guy this museum is owned by a guy who made all of his money gambling, and he bought this piece of land and dug down into, like, the the depths of Tasmania and this underground museum with some crazy, crazy bits of art. 

There are lots of references to anatomical body parts. I'm just gonna leave it there. It is weird. But in amongst all of that, they had some stuff from Charles Darwin. They had some stuff from Shakespeare. 

It's the it's like the biggest private owned collection that's open to the public out there apparently. So that was great. And I learned about wombat poo. Okay. Say say more. 

Now I was unaware, and and our guest is actually doing this. This is so funny. I I wish we had a video podcast. So our guest is doing what I'm about to say. Did you know that wombats poo cubes? 

They they they they force cubes out of their butts. Did you know that? I don't actually I recall hearing that at some point. So what how? Why? 

Why? I don't know I don't know why. Is it so they can make little, like, wombat igloos with the cubes? This conversation we we maybe will ask, I guess, when he when he comes up, but but we were having a a faculty dinner on our first night there, and this came up in conversation. We had this whole discussion. 

I spent ages trying to work out how you push something square out through a circle hole, And then I was wondering about a whole host of questions that I don't think we need to take. This is getting too anatomical here. Yeah. Okay. Anyways, that was cool. 

And I met so many people, but one of the people we did meet from Twitter, he he gave me a joke that he wants me to tell. Oh. So Andy Roos from Twitter is Andrew Lovett. His daughter, Josie, is nine, had a great joke for us. I thought I'd come straight in with it. 

Hello, Josie. Hello. Was that your Aussie accent again? Oh, man. Okay. 

No. It wasn't meant to be. Hello, Josie. Good day. So why do ducks have back feathers? 

Don't know. To cover their butt quacks. I thought that was really good. Sorry. Well done, Josie. 

That's good. Josie, well done. And I I met so many friends, Alwyn Chuan, Mary Anne Fox, and James Aspinall, Cass Andrews, Andrew Lansdown, Andy Roos, Joe Tan, Michelle Chong, Shelley Lee, John Carney of Tap Block Original, Reg Edward, Peter Hebbard, Yin, Chin Lim, Horn Trinh, Liz Maxwell, Matt Levine, Ken Yee Liu, David McCloud, Chris Mitchell, Ash McKajee, Tony Ng, Wesley, Roger Leland, Divya Sharma, Nav Sidhu, and Lee Zimmer. That's a, that's a lot of names. Wow. 

Do we might need, like, a separate part two just to get all your shout outs through, but, that's amazing. Dude, I wanted to I wanted to get them all in because it was just incredible to see them all. We we need to move on. Right? What's today's episode about? 

Well, we have a guest today that almost needs no introduction. Firstly, because he didn't present with a bio by the time I was preparing for the episode, although it's not entirely true, but it it works for the joke. But secondly, because we talk about him all the time and even considered having his own sound effect, a ding. Right? Yes. 

So this guest studied medicine at University College London and qualified in 1984. He trained in anesthetics at Leicester, Derby, and Nottingham in The UK and has had a career long interest in regional and spinal anesthesia. He has a big orthopedic limb practice and has lectured extensively on day case or ambulatory spinal anesthesia and motor sparing knee blocks. And he can boast a Belgian grandmother, a Scottish father, an Irish wife, three daughters, and a particular interest in rebuilding and driving classic cars. Who are we talking about, Jeff? 

Amit, we are, of course, talking about doctor Robbie Erskine. Robbie, welcome. Welcome, Robbie. Hey. Hey. 

Hi, guys. So what what This is so exciting to have you here. I'm I'm beyond excited. I mean, thanks for so much for inviting me on your show. Is it a show? 

I guess it's show. I'm I I think it can be whatever you want it to be, Robbie. It is it is now. Yeah. I'm a I'm a I'm kind of tad nervous, but kind of excited at the same time. 

And, yeah, I'm from a little place in in well, I'm from London originally, but I work in a place called Derby. It's pronounced Derby, Jeff. Oh, okay. Derby. Derby, darling. 

Derby, darling. Thomas Darcy from Derby. Dar absolutely. Yes. Absolutely. 

Jane Austen's favorite county, I believe. Anyway, it it's this is a career highlight for me, clearly, obviously. But I feel like a bit of an in bit of impostor in this sort of erudite regional company. Nonsense. I'm I'm a huge I'm a I'm a huge fan of you guys. 

You do so much for education, and and you make it fun, and you make it cool, and, you know, you make it real and accessible, and I think that's great. By the way, I love I love the phrase big orthopedic limb practice. It sounds like I only need sized people with huge, huge legs and arms. Is what I you're the big limb specialist. Big only big limbs. 

Yeah. You specialize in gigantism. Yes. Know. Carolina's like, but we have some big people in Derby. 

But, you know, it's it's a challenge filled ultrasound. But, anyway, there we go. But so, no, this is this is great fun. So fantastic. Thanks, guys. 

Do they have a an equivalent of we call it the the biscuit belt where I live. No. It's just it's just normal here. It's it's it's it's it's just it's it's fine. Yeah. 

Anyway yeah. I just done my Monday afternoon special with my with my Monday afternoon surgeon. It's it's quite a case. The legs are usually so big, you trouble with your 100 needles. So so, anyway Right. 

Punish. Yeah. Yeah. I've had a great block day today, so that's good. Oh, nice. 

Oh, wow. Blocktastic, I think you were saying earlier. Blocktastic day. Awesome. Yeah. 

Yeah. I love that. It's great. So I think I I want to get a bit more into your history and get to know you a bit more. Oh, sure. 

I know our listeners do too. So tell us, yeah, tell us a little bit more about your early anesthetic career, Robbie. Yeah. So oh, do know when did I start? When why did I choose it, really? 

Well, I was working in London with Stuart Ingram. I don't know if anybody's heard of the guy. He was the guy who set up CPOD. A great guy, lovely man, great really calm under pressure. I remember I remember thinking, oh, this guy's really cool. 

Okay. And then I went I've done a bit of general medicine, bit of ED, and I was down in Chichester doing ED. It's very posh down there, but they call it chai. They call it chai too. So yeah. 

Yeah. Yeah. They met loads of loads of Aussie anesthetists, and they were just so laid back, and they'd happy. No clinics to do. No writing to do. 

No notes to write. You know? And every time, basically, shit happened in ED, this cool Aussie guy would turn up and just calmly, quietly sort it all out, and I thought, that's what I'll do. So Wow. Yeah. 

Isn't that funny how you, like, find your tribe? I know. Yeah. Like, you just okay. I'm not like that person. 

I'm not like that. I that's who I wanna be like, that person there. Yeah. Do you know I'm immensely privileged to do my job. I just love what I do. 

Always do. Always have. Always will. It's just terrific. Great. 

Yeah. I feel the same way. And we we we get, you know, med I'm sure you get med students and trainees and stuff come through, and I detect a certain amount of skepticism about the quality of the future of the career in medicine in general maybe or anesthetics specifically. But I'm like, I just kept saying, like, look. I I've been doing this for twenty years. 

I still get up every morning and Mhmm. Cheerfully put on my clothes and drive to work because I'm looking forward to my day. Jeff, you know, I've never ever not wanted to go to work. That's that is so lucky. I mean, it's such a privilege. 

The patients are the patients are always there. They're always terrific. You know? The staff are just awesome. The surgeons are Yeah. 

We've got some of the best surgeons in the world in our in our hospital. They are just fantastic. I hugely admire what they do. The ODPs are great. We'll talk about them in a bit. 

And it's just it's magic. Absolutely magic. I just have great and the trainees, well Mhmm. What do you say? They're just thirsty for for knowledge, aren't they? 

It's wonderful. Especially these days. Yeah. It's cool. Yeah. 

Yeah. Well, they're they're they're lucky to have you. Well, that is for sure. That is for sure. I mean, I started I don't know if you know where know where I started anesthetics. 

I was Tell us. Tell us. Yeah. I mean, I did a kind of one off job to see what it was like. I'd done a bit of medicine stuff. 

So I I have a taster in a place called Kettering, the middle of middle of The UK. Right. And I started, and I just I was just hit by this whole kind of team purpose thing you have in anesthesia. Everybody was focused on just taking care of the patients. And I came as I said, I came across these people called o d ODAs or ODPs. 

Jeff, do you know who these are? I do. We had them in Australia, I think. The the these are the assistance type. Yeah. 

Oh, they just old days, they were ODAs. Right? They used to be ODAs. But they started as they started as theater orderlies. They were like porters. 

They like, often ex army, and then they've they've morphed into this amazing bunch of people. They're not nurse trained. They're not anesthetic trained, but they're just really cool. They just know, and they know all your tricks. They know all your errors and your tricks. 

You cannot hide anything from them. They're just great. And they and, boy, do they help you out when you're in trouble. And they're a bit like how can I they're a bit like grommet to our anesthetic Wallace, I would say? Does that like, do you know what I mean? 

I I know what you mean. Are you familiar with Wallace and Grommet, Jeff? I I am. Yeah. Yeah. 

So they kind of like the other day, Jeff, when I tried to do a block on somebody that I'd I'd I'd I'd pickled in rockuronium, I was doing a duct canal, a femoral triangle block, and I was trying to tickle this nerve with a nerve stimulator. Oh god. So so so Sam pipes up, Robbie, he goes, do you think maybe that's why it's not working? And I was like, oh, Jesus. And I I so rarely give a GA, but that was like, I didn't think. 

You know? But there we are. Right. Right. Right. 

It keeps you honest. Yeah. Well, I remember when I started ODAs, they generally tend to be big guys with big muscles and tattoos and mustaches, and they would kind of they they guess your every move. They knew what you're gonna do next. Oh. 

Oh. And and the best line I had was I was gonna go and see a patient on the emergency I was in my first year in anesthetics. I was gonna go see a patient on the emergency list who's meant to be having a neck abscess drained. And they were, you know, quite an unwell patient from what I recall. I was a bit nervous. 

I was like, oh my god. I'm gonna go and see the patient, and and and see, you know, what, you know, what they're like. And this ODA said to me, well, this might be a good one to do a spinal for. And I went, yeah. Great idea. 

And I walked down the corridor, and then I got halfway down the corridor. I was like, ah, very funny. Very funny. I mean, I I you know, I used to get this, but at the same time, they used to help you when you're a trainee, and they say, oh, doctor So and So usually does this. You're like, oh, right. 

Yeah. Okay. That's what I'll do then. Yep. That's fine. 

So yeah. Yeah. That's really good. Yeah. Anyway, so that that was how I started. 

And then I got into regional. Yeah. Well, how tell us how you got into regional. I know. That's what you're all begging to know. 

Oh, well, in those days, it wasn't very sexy, was it? I mean, it really wasn't. You know? I was just it was weird being a regionalist. It just was not normal. 

I mean but, anyway, so, yeah, I I said having said that, I mean, my first four anesthetics were, of course, spinals. I mean There you go. What a surprise. Probably, you answer a lot, doesn't it? The mall was cast. 

We have this guy well, I was in catching. We have this guy called Willie Sellers, who a lot of the guys from Bucks RA know very well. Great guy who, he just he he he talked I thought it was some kind of dark magic art. Yeah. I mean, you know, what you could do with a villa loco, it was phenomenal. 

And I was I was just hooked. I was hooked. And you could chat to the patient. And I you know me. I'm just a chatty, nosy guy. 

So and a lot of old blokes having pro states done. You're have a good old chat. It's great. And then I sort of went off to Leicester to do a few exams. We had about three in those days. 

They were very entertaining. And and regional regional was, like, really rare. But weirdly, we did loads of caudals. Yeah? Adult adult oh, kids caudal. 

Adults. Yeah. Adults and kids. Yeah. For TRPs and gyne stuff and kids and loads of epidurals and spinals and and the old retrobulbar blocks and stuff. 

Remember? Yeah. Big fat needle behind the eye. Yeah. And then I was so lucky. 

I got my second part of fellowship when we had three parts. And I went off to Derby, which is I mean, never know what that what's the hell Derby is. They make aero engines there and stuff. Yeah. It's a beautiful part of the world. 

But, actually, it's a it's a one of these fantastic, like, massive teaching general district general hospitals. So it's got a really good reputation. Fantastic bunch of people. And I can only describe Derby as regionally permissive. Right. 

I mean, basically, it's just easy to be a regionalist. And people say to me, oh, how did you set up your regional hand service? And my my answer is, well, it was just there. Yeah. There was no setup. 

I mean, we it's just expected. But I'm sure and I'm sure you played a role in developing that attitude and and coaching new orthopedic surgeons who came in, like, is the way we do things and that sort of but did did it sounds like it it partially existed before you came. You're so right. I mean I mean, the great thing is, you know, you get a place like that, and everything's done under block, and then that attracts more surgeons, and it's sort of it's a it's a sort of self fulfilling cycle, really. So we just have surgeons who are just used to having patients awake, and and it's normal. 

I'm very lucky like that. I love that term regionally permissive, by the way. It seems every time we do a podcast, we hear these new phrases. We had controlled motor deficit last time. This is I I work in the service that's regionally permissive. 

I love that. Yeah. I mean, you're very lucky. You're very, very lucky. We are I am I know that. 

I know that. And when I talk to all the people around the world, I realize how lucky I am. I mean, I was doing a course recently at the Ezra winter week. Oh, yes. And we had this kind of speed dating every evening. 

Like, literally speed dating? Oh, it's it's that kind of course, is it? It's yeah. Quite. I know. 

No. All the keys going to bowl and yeah. Okay. You know you know missus Erskine listens to these podcasts. Right? 

Yeah. Yeah. She's away. It's okay. I'm gonna tell her. 

Listen. No. No. We she was there, actually. We we sat around well, I sat at a round table in a room with four other people, and we had to sit there, and people rotate around, like a group of five to eight, ten people. 

Oh, really? And I do a talk on, like, fast track knee surgery, and I do the same thing four times. And it was fascinating because I asked them what they what they thought about it and what they did and the range of different techniques and things. You know? Oh, my surgeon doesn't like this or doesn't like that. 

Fascinating. I learned so much. That's really neat. Awesome. What a what a what a really interesting Yeah. 

Way to kind of do education. Yep. Like a rapid workshop, but rapid lecture. Oh, that's very that's very interesting. Yeah. 

Very interesting. And probably sounds would it be more interactive? Yeah. Yeah. Sounded with the smaller groups and such. 

Very, very interactive. Great fun. It's my sort of thing. You know? And we could all chat. 

You know? It was great. Really good. Loved it. Now that's given us quite an interesting insight to your early anesthetic career, and it's it's very fitting that your first regional technique would be a spinal. 

Do you remember the first block apart from a spinal that you did or the or the thing that happened that made you think, do you know what? This is gonna be me set up as a regional anesthetist. Do you remember that ping episode or that thing? Yeah. I mean, yeah, obviously, spinal's because they're so cool. 

But as you say, having left that behind, I think I think you know, weirdly, I got to Derby, and we have this hand center. It's a pull the top hand center. It's a world renowned center. We have 10 surgeons now just do hands. 10 hand surgeons? 

Three hand theaters dedicated and 10 surgeons. They are just phenomenal. Oh my god. We have fellows from all over the world. It's a great center. 

Anyway, so I was there. We do about five, six thousand blocks a day just for hands. Uh-huh. So but in those days, they were, I think, three hand surgeons. But we had some great regionalistas, a guy called Paul Lehmann, who he taught me how to do interscaling blocks. 

That was my first block I did. Wow. And that was with nerve stimulator or paraesthesia? Listen. I'm not that old. 

Okay? Listen. I I know I know I know I'm ancient, but yeah. So Landmark and nerve stimulator. I never did paraesthesia. 

But, you know, it was great. We use these what you call now is kind of out of plane approach, I suppose, which is why I still I still use the out of plane approach because you you can go tangential to the nerves. Yeah. And you you between Yeah. The scalene the scalene's medius and the nerves instead of poking through the muscle and hitting other nerves. 

And I still do that. And it's it's a great approach. We use these little one and a half centimeter needles, and we used to put forty mils in. You put a you you look for the biceps twitch, 40, 30 till you got a big a big bulge in the neck because, you know, to make it work. And then off of course, you'd miss the ulna usually. 

So you just drop a little ulna block at the elbow. And for hand surgery, it was just magic. I thought that was my first block, and I thought, wow. That's awesome. So hold on. 

So you did forty mils in the interskip Yeah. Crazy. And then and then added in an on the back surgery. Mean, that's but it's but it worked. Right? 

I'm get I'm you know, it did work if you if you saw the bulge. Oh, that's right. Yeah. I had the same experience. And our attendings used to say, like, look for the sausage. 

Yes. Sausage on the neck. Get the sausage. The sausage on the neck. Got me hungry. 

Yeah. But now now you're like I mean, I did a I did a shoulder surgery the other day under GA. Five mils of point seven five on on the nerve and a bit behind the the suprachycal plexus, and, you know, 10 mils total. It's just changed so much. It's so exciting. 

What we've happened in the last ten, fifteen years has just been awesome. Yeah. So, yeah, that was my first block. Yeah. So Interscaling was your first. 

If you were to give us the top three blocks that you love to teach. So you're you're your perfect block tastic day. You're sitting there. Trainees come up to you. Hey. 

Yeah. Doctor. Perkin, show me how to do x. What are what are those blocks? Okay. 

Yeah. That's a great question. Oh, wow. It's so hard, isn't it? Because don't you find your block your favorites change all the time? 

For me, they do, actually. And I thought I'd be fairly fixed, but, actually Yeah. If I haven't done a block for a while and I forgot about it and you do and you're, oh, they were cool. I I like those. I know exactly what you mean. 

Yeah. Yeah. And then you and then you kind of things move on. I would say, you know, if I'm if I'm doing the same block as I did five years ago for this, I'd be wrong. Yeah. 

And if if I was doing the same in five years time, I'd be wrong. But that's cool. That's fine. Because growth mindset. Wow. 

You know? It's it's I'm always trying to get better every day, and that's why I keep doing what I do. And when I stop doing that, I'll stop, but that's fine. Anyway, so top three blocks. Well, I think do you know? 

It's it's gotta be the axillary because it's beautiful. So back in the day, we didn't do them very much because it didn't work very well. Because still use a huge volume. You just press distally to try and get the musculocutaneous. That was a thing, distal pressure. 

Right? So yeah. Yeah. And now we can do it with, like, you know, twelve, fifteen mils of local, and it's a dream. I mean, why are they so good? 

Because they work so beautifully. They're really, really safe. I mean, there's not a lot you can do wrong. I mean Yeah. You could stick a stick a needle in the vessel. 

We used do that anyway. It doesn't matter. Right. You know? I would say to the trainees, better to go, like Jeff says, scrape the paint off the artery or poke a fascial layer, but don't aim at the nerve. 

And then you can you can separate everything off. And it's just a lovely block. Great for teaching needle direction, great for getting them comfortable with doing a really good block. And then you could teach the other stuff later, but let's get them competent at that. So yeah. 

And I love the I love adding nerve simulation to that too just I do it. To show the the like, Wes, where is this what an ulnar nerve twitch looks like, or here's what a median nerve twitch looks like? I just coming to that, I use them all the time for teaching just to not not to find the nerve, but to just gently reassure the trainee that that's what looking at. And they love it. They go, wow. 

You know? Yeah. Yeah. It's really fun. Yeah. 

Yeah. So that's that's it. So it's transformed. I mean, ultrasound's transformed it. Anyway, so number two number two. 

Do know can I talk about just knee blocks? Yeah. I mean, just just the evolution So you're basically cheating. You're just gonna you're gonna lump your number two as everything will I mean I think as is your episode, you can have it. You're very kind. 

You're very kind. But you're looking after the old man. You're so good. Listen. I I I I just look at the evolution through epidurals we used to use and the patients have a catheter in. 

They'd be stuck in bed, and then we go for the heavy femoral sciatic blocks to the beauty, the sheer beauty of the ultrasound guided motor sparing blocks we do now. They are I mean, all work Jeff's done on them. I always quote his stuff, you know, on the geniculars, on on, you know, the difference between the two and everything. And it's just been immense. The change has been monumental. 

Yeah. I mean, I have seen it every single year, and it's been recently, the change has been amazing. So It's crazy, the evolution of how how we've done this. Awesome. And and then we've this little thing about this lovely thing about when you do a femoral when you do a femoral triangle. 

Mhmm. As Jeff always teaches us that you you know, femoral triangle is great, but it's a compromised block as he demonstrated in one of his studies. You're missing out some bits, which you can then add in, of course. But, ultimately, a femoral nerve block is is a beautiful block and, of course, very appropriate for a lot of nurse knee surgery. Yeah. 

So don't knock Yeah. The femoral block. Oh, I like there's a that's a bumper sticker right there. Oh, I like that. Don't knock the femoral block. 

We That's a t I'm making t shirts. We are we are suddenly getting a lot of merch ideas here. Right? It's it's all I was sort of the trainees. It's not about just doing a block. 

It's about looking at the trajectory of the patient, looking about where they're going, what they need to achieve, what the surgeon expects. Oh, trajectory. Love that. Do you know? It's all about it's like a dynamic scan. 

It's like watching the patient's progress. And that's why sometimes the femoral block is just peachy. It is peachy. I totally agree. Beautiful. 

And then, you know, it's funny. I I was following a conversation you were having with somebody else on on X Friday, I wanna say, about ACL repairs. Yeah. And what's the best approach to that? And I was too busy to chime in. 

Was running around, but I wanted to say, and I might still chime in, what about a femoral catheter or a femoral block in that instance? Because does it need to be motor sparing for ACLs? And maybe this is a whole different episode that we can come back for this, but all our young teenagers go home with knee immobilizers and think a femoral block is more complete for that operation than an adductor femoral triangle block. Mhmm. What are your thoughts? 

We our patients all even the ones with lateral tinidesis, they all mobilize. No no no, they get no, brace at all. Nothing at all. Oh, really? Okay. 

So very free, very mobile, so we need it. Is that right? Isn't it interesting how we have different you can't always translate one person's experience to another. You have to be a little bit careful about precisely, as I said in my ex comment, about precisely what you mean by an ACL repair for a start. Yeah. 

So understanding that surgery is fundamental to what we do, and it's it's that's that's part of fun. Yes. Yes. Well, at some point at some point, I am gonna come back and ask you about the lateral tenodesis cause that's a thing that Mark said and started adding recently, and it's kind of changed the analgesic outcome of what we're doing for obvious reasons. But I just need to I'm gonna be headmaster here. 

So Yeah. Yeah. So was femoral an add on to your knee blocks, or was that your block number three? I'm just trying to work out what oh, what It was an it was a kind of it it was a block number three. I'm just Oh, okay. 

Okay. So oh, good. Okay. Good. So that is your three then. 

Is that right? No. No. No. I excuse me. 

I'm gonna throw in number three, which is apparently the spinal and spinal tricks in general. And that's it. You have to make make allowances. Okay. That's it. 

I've I've done that. You you know you know that we're gonna come back to the spinals later. So so there's gonna there's gonna be a whole whole discussion on spinals, and and we save that just for you. Now listen. It's been very evident from the lectures that you've given and the articles that you've written with infographics that have been used all over the world that you have extensive experience with short acting intrathecal medications. 

So how did you become the nation's expert in ambulatory spinal anesthesia? Oh, expert. Yeah. I well, I listen. I'm gonna say I think I think Jeff's gonna say it. 

Well, I I mean, we talked about this topic, and we we just looked at each other and both said, Robbie. I mean, Robbie has to be the one to talk about this. So Yeah. Okay. Okay. 

Well, I've done a lot of it, and I'll and and and I've kind of, yeah, focused on it. I prefer to talk about, like I I I I like to talk about it as you guys in The States called the ambulatory spinal anesthesia. Are you are you copying his awful American accent on purpose? Or Well, I'm trying, mate. I'm trying I am trying to make it Canadian. 

It's not working. My god. Was brilliant. So so, yeah, I've done a lot of it. But I don't know. 

I do rabbits on about it a lot, but my colleagues all laugh when I give a GA because I think it's really funny. But, you know, there's not much to a GA. It's not really that hard, is it? But so I I I realized it started years ago, didn't it? When I realized that spinals are actually, if you think about a day case anesthetic, the ideal features, spinal's are pretty high on the list, really, except for the bloody, you know, mobilization retention stuff you get and numb legs. 

And we used to use lidocaine. We used to use four percent lidocaine, heavy lidocaine, way in the day. It was made by Torbay Pharmaceuticals, and that all went out, of course. So it's it's great stuff. And then then I was using the Ben David regime, you know, the the low dose bupivacaine with fentanyl for many years. 

And that was ideal, but, yeah, you know, not not fantastic. And then we moved on, and we I was contacted by this is before I met you, Amit. I think I gave a talk in London for you. Yes. Mercury Pharma back in 2010. 

Guy called Darren Fergus. Lovely guy. Yes. Know Darren very well. Super, super guy. 

Senior marketer then. Ollie Tweedy, who you probably know. We did a podcast with him, didn't we? And they said, oh, why why this we've got this Pralocaine stuff coming out, which, you know, you really need this in North America. It's just a dream of a drug. 

And it was $20.10, so I thought, well, I'll try it. So I got all the sum. So you hadn't used it until they contacted you? No. It was just come out. 

It's just been licensed in 2010. And I thought, this is amazing. And I didn't tell the nurses one day I was using it. And they went, this is amazing. What have you done? 

And, actually, that was a that was a that's like, who needs a study? You know? Exactly. Exactly. Real clinical feedback. 

Yep. Absolutely. And then I came I came together to talk to you in London at Elsora. I remember. I even remember the Thai restaurant Yeah. 

The Thai restaurant right by Guy's Hospital. And there was this really excitable, very knowledgeable man jumping up up and down talking about something, and it just seemed crazy to me. I was like, what? I I don't understand what's happening here. And he was so so clever and so knowledgeable. 

Was about that. I'm never gonna be able to do that. Oh, you're so much better now. So much better. I you're still not paid by train fare for that. 

I'm you know, wouldn't tell if you get to. But it was a joy it's a pleasure. It was a pleasure. So, I mean, then chloropropane came out 2013, and I mean, it's just a dream of a drug. I remember the first time I gave five mils in the spinal of chloroprocaine. 

It was like, woah. But it was it's a pleasure drug. And I I've hardly used bupivacaine since, to be honest. Really? And then what happened was what happened was I was getting all these phone calls from my colleagues saying, oh god. 

You know? How much do you use for this? What do you do for that? They were still trying to use small doses, you see. And I said, no. 

Just use a big dose. It's fine. That's the point. So I thought, well, I've got to sort this out. So I I thought up a little flowchart because I thought, what do I do what do I do every time I go and see a patient? 

What questions to ask myself? Yeah. Yeah. Yeah. Yeah. 

And that's how my brain works. I'm a bit weird like that. So I go, I want this, this, or this. So I've done a little chart and drew it. And then I got my wife and my number two daughter, Ellie, to make the chart, and they made that chart as it is now pretty well. 

And that's the thing that we see posted around on social media and published in articles and shared around the world? Yeah. They've actually been credited as well in the BJ journal, so it's nice. So they they great job. That's cool, isn't it? 

That's great. Anyway, so the BJA article was fun. That was fun. So I thought, well, nobody had written on spinals since Tony Wildsmith about 02/2005. Oh, right. 

Yeah. So I wrote to BJA just I said I'd to write an article on these new spinal drugs. And it was rejected as being not relevant to anesthesia. That's hilarious. Wow. 

Wow. So I so I knew John Thompson because I trained with him, the editor. So I wrote back to him and said, don't be a Sorry. Don't be an idiot. And he said, well, can you change the name to ambulatory spinal anesthesia? 

Because that's what the Americans like. And I said, well, that's fine, but it is the British Journal of anesthesia. You know? Apparently, you had to be asked. So who's this little guy from Derby writing an article in in the what is he in? 

Anyway, got this amazing trainee of mine called Will Rattenbury, He's now in Nottingham. Really, really great guy. Oh, yeah. He's a brain size of a planet, and he did all the work, of course, because that's what trainees are for. And, you know, it kind of grew up from there, really. 

So I've got to know so many fabulous people around the world, around Europe, and everywhere, and it's been such a such fun, really. We'll be right back after this word from our sponsor. Hey, buddy. I'm so sorry I'm late. I just got back from doing a blood patch for a posterior puncture headache. 

Bummer, bro. You know, I've been using the Sprott needle from Pahyunk for years, and honestly, I can't remember the last headache we've had. I'm a Sprott fan too. Fewer PDPHs, and it's just blunt enough so it has a great tactile feel. You know I love my clicks and pops. 

Preaching to the choir, dude. I tell my residents, if you're giving patients headaches, it's not the Sprott's fault. It's yours. Oh, tough, but fair. And you know the most recent consensus guidelines on how to prevent PDPH recommend the use of non cutting needles like Sprotz. 

That's right. It's all about causing the least amount of trauma to the dura. And you know what still drives me nuts though? During combined spinal epidurals, I go to attach the syringe and the spinal needle moves a few millimeters. Yeah. 

Blink and you're no longer in the space. Exactly. It's like playing operation, but the patient's awake. Well, see, that's why I love Pyunk's EpiSpin CSE system. That sounds like a spin class anesthesiologists. 

Well, there's far less sweating and groaning. The EpiSpin kit has the same trusty Sprott needle, but with an easy mechanism that holds the spinal needle exactly where you want it. So no shifting when you hook up the syringe? Rock steady. No drift. 

No accidental advancement. No wait. Where'd the CSF go? And it's available for both lure and NR fit. That does sound luxurious. 

Kinda like the business class of spinal epidural kits. And throughout this month, Payunk has a special bonus for our listeners. Email info@payunk.com and put b I l I h in the subject line, and they'll send you a set of block guru posters for your block area. Jeff, it does sound like the EpiSpin means fewer headaches for everyone. I see what you did there. 

What can I say? I'm all about smooth blocks and smooth lines. And now back to our show. So when you are using these short acting intrathecal agents, you've got to have a lot of ducks in a row lined up to make it a success. So can you give us a little insight in how you ensure the operating room and the theater are set up for maximum success with these short acting or targeted intrathecal agents? 

I mean, it's a team thing, isn't it? So you've got to tell everybody what on earth you're up to. Yeah. Because otherwise, they get caught out. You can't let your surgeons dawdle. 

We don't you know, they have to be not in the coffee room. They have to be scrubbed and ready. You know, we position we help position the patient. I know my surgeon. I'll position the patient's leg. 

We'll do it all for him. So when we come to theater, he's ready to go, and the staff know it too. So I think that's fundamental. And, actually, the great thing is, you know, if we're efficient like that, they often get an extra case done, so they love it. Yeah. 

Yeah. There's no turnaround time. They just go straight out of theater. That's a win win. You know? 

It's a win win. I mean, it's fundamental that you get your regional anesthesia right as well. This is this is really, really important. You gotta make a combination too. It's essential that the follow-up is good from regional Yeah. 

Teamwork, making sure everybody knows. Jeff, you had a couple of follow-up questions for this. Right? Yeah. Yeah. 

No. I that's I I think it's that's super important. Yeah. If you had if I presented to your theater today and I had one of my knee done, what would be your recipe for the spinal anesthetic for me, for your for a knee? Great question. 

So what have you done, Jeff? Oh, great quest see there? You have quest answers the question with a question. See, that's that's the nuance. And I loved that it reminded me. 

I loved your answer to that ACL question because you're not like, hold on a second. It's not an ACL. It's not just an ACL. It depends on what they're doing. Let's say a total knee replacement. 

Oh, poor Jeff. Okay. Yeah. What a what a horrible, horrible, horrible operation, my first thing. Yeah. 

So what would I do? I'd I'd give you a Pralocaine spinal for a start. So I'd I'd Okay. I'll tell you what I'd do first. I'd sit you straight up on the trolley. 

I don't turn people around or anything like that. Just straight up. And I give you some midazolam because you're a man, and you will faint at some point. I'm a wimp. Absolutely. 

You know? Yeah. The people who don't give it before the spinal end up with with bradycardias and faint. So always a bit of a dazzle out, and they just feel so cool. Love that. 

Para median spinal, 27 gauge spinal needle, straight in, three three and a half mils of heavy Prolocaine, lie down, ultrasound machine out, straighten to the blocks. I do a femoral triangle block with a nerve stimulator, of course. Love that. And I've been talking about this today with my trainee. We did three, and he's done all three. 

And they were all in the nerve to vascular medialis were all in different place in each patient. Yes. Yes. Yes. Yes. 

Yes. You have to do it. It's great. And he just loved it. So that you know, a bit of local 10 mils for those two nerves, ten mils total for the deep sartorius. 

Then your QTs, I learned originally from Thomas Benson, and then you Oh, yeah. Promoted it too. So yeah. Great blocks. Very easy. 

Same same place. Yeah. And then I do I do three druniculars and a nerve to pass intermedius, sometimes lateralis as well. But I don't often do the infralateral Mhmm. And then an iPac with about 12 ten, twelve mils of of local. 

But that is it. That's great. And so straight local for the spinal. No adjuvants. No fentanyl. 

Oh god. No. No. No. No. 

No. No. Yeah. Okay. No. 

No. No. Listen. Simple. I'm as simple simple as best. 

The great thing about these new agents is you don't need to use any agents. You just use use the drug that works for that and keep it simple. I think the more we start messing with stuff in spinals, the more we make mistakes. Yeah. And I worry I worry I do worry about it. 

I'm a fan I'm a fan of that too. And we Yep. Yeah. Of course, part of that is having surgeons that can complete the procedure in the right amount of time. But yeah. 

So that's key. Right? You've you've gotta make sure that the surgery takes place within the length of the spinal. Do know you say that? I was thinking about this the other day. 

You can get a good ninety, a hundred and twenty minutes with a with an aesthetic with that, but the regional block helps. It does. Yes. It it smooths your landing. Jeff, if you would ask me about a uni knee a uni knee, which I more expect somebody of your age, I do them with chloroprocaine. 

Wow. That's that's impressive. I mean, yeah, forty five minutes. Forty five minutes. But they land in recovery, and they can move their legs. 

They're mobile. I had a guy the other day. He got up for a pee. He went to walk for a pee in recovery, but he was comfortable. So the the regional anesthesia is fundamental, but it's a great combination. 

It's a beautiful combination. But you do you use intravenous dexamethasone? Yes. Absolutely. Two mics per kilogram. 

Okay. Yeah. So that's about 16 in the average big band. Yeah. So that's that's much bigger than we as a reflex will do if you just Yeah. 

Open up an ampule of sick we you know, we've got six point six milligrams. It used to be different. Right? That that that you consider that to be nothing. Bob Funkotta goes, why do you have the six point six three five seven milligrams? 

It's just four. It's two lots of four, isn't it? It's eight, isn't it? Because we used to have four and eight, and then it became a 6, 3.3, and 6.6. And it's so it does my head in. 

But you would give you would give sixteen milligrams Four ampoules. Yeah. To everyone. It's quite European. Pretty much. 

Pretty well. Yeah. Yeah. Yeah. Steroids make you feel good. 

They do. We usually typically give, like, four for p o n v prophylaxis. And then one day, I was that aesthetic center and made a mistake made a mistake in the dosing because they had a new a new vial or ampule there, and I ended up giving sixteen or 20. I forget what it was. And then realized that afterwards, my own geez, what am I gonna what am what am I in for here? 

Patient woke up and they were so happy and so pain free. And I was like, what? And I know I did you know, Henrik Kellett and all those Danish people have published a lot of stuff on tons of milligrams of hydrocortisone and stuff. So there's something to it. Yeah. 

I know. It's it's made a difference, I think. Yeah. That's good. It it's it's I get this from a lot of European stuff because the guys in Europe do all this, and they they're using these sort of doses. 

And I thought I could do I'm allowed any shout outs for any of my mates who have, you know, in the Go for it. Go for it. Why not? I mean, you know, I I've got my my neurots to your brothers, Pete Mojave and Steve Coppins. Yeah. 

They've been just terrific. Great support. And Pete's fantastic support staff. Great friends of ours. Absolutely. 

All the Barra team. I mean, Barra, I mean, the Belter's Association are just the most fabulous bunch of people. They they are just awesome. You know, Matthias, Sari, Stefan, Chris, Mark, Admir, that they're amazing. Love those guys. 

And, of course, all you guys in region I see is UK. All you crazy, crazy North Americans who do all sorts of strange things that that don't necessarily translate to here. But we we watch them with interest. You know? So but, you know, it's and they're also warm and encouraging. 

I just think our regional athenist is just nice people. Yeah. Yeah. I think so. Yes. 

For sure. I think because we care we care. We go and see our patients post op and care about an outcome. They're just a sweet bunch. And then you got all the you got my lovely friend, Bob Funkotta. 

You know? What a star. He's been a bit poorly recently, but he's doing great. Okay. He's much better. 

We're sending you our love, Bob. Oh, do. Send lots of love and and big hugs to Bob. Yeah. 99% of my experience of everything has has been awesome and and positive. 

And Tanya and Mary in in the in the Antipodes, I'd love to meet them. You've obviously met them, so it's great. Yeah. Yeah. And, you know, COVID wasn't that bad. 

We got to know everybody. You know, talking about blocks, I've actually been blocked, as you know, but not not not anesthetically. I got blocked on Twitter, which is fun to say. Now what? Oh, really? 

Who who blocked you? I won't say who by. Yeah. Who would block Robbie? I know that's what Steve always says. 

That's Steve Cocker. I'm sorry to hear that. So so my trainee oh, and it's just funny, actually. It's a it's like a point of it's it's a sort of a badge of honor, really. But it was apparently, my my trainee, Matt Sherman, said I ought to say that I've been blocked, but not aesthetically. 

So thanks, Matt. But no. No. Honestly. So it's been a really positive experience. 

Jeff, don't know about you, but I wanna put my shoe take my shoes off and sit down the sofa. This is the Robbie show. I'm handing over the ring. I love that. Sorry. 

Is not an accept. No. Don't bother. This is like an accept. I'm I'm I'm you I'm absolutely in awe. 

You've got so much enthusiasm, Robbie. I I could listen to you all day. I wanna know what Robbie Erskine has to say on Twitter that gets unblocked. Oh, I know. Yeah. 

That I wouldn't know. I'll I'll share it quietly with you sometime. But Okay. You know me. I'm never rude. 

I'm never rude. I'm never horrible. I'm never horrible. I mean, suck. Sweetest guy ever. 

Yeah. Anyway, so I'll shut up now. You can ask me something else. No. Don't shut up, Robbie. 

Don't shut up. I would I was just in awe of your enthusiasm. I can imagine what it'd be like to be one of your residents, one of your trainees. We have a ball. You'd you'd come to work excited. 

You'd be like, yeah. This is amazing. I love it. I I I love I love to express confidence in my trainees because that's what you need to do. You need to tell them they're good, and you need to just For sure. 

Encourage them and support them, but not do things for them. Just just, you know, go, oh, yeah. Do that. When I'm doing my paramedics finals, I'm like, yeah. I can see what you're doing. 

You just need to be 10 degrees, not 15, and you're fine. They go, alright. Okay. And they oh, yeah. And their little faces when they get it happy, and I do a little jig around the room. 

You know? It's great. It's great. It's great. Yeah. 

It's a joy. Yeah. Hey. I had a question about the spinals still because one of the we have witnessed, an evolution in this country, from at least in our institution from bupivacaine, which was what we did for everybody to short acting medications. And we don't have Prylicane, but we use a lot of lidocaine and mepivacaine and sometimes some chloroprocaine if it's a really fast surgeon. 

Yep. We've had to solve sort of different problems as we've navigated this. One of them, for example, one of them was urinary retention. And so culturally, our PACU nurses were very sensitive to patients having distended bladders and would routinely scan their bladders when they first arrived. And anybody who had a bladder, you know, volume of more than 500 mils got a straight cath. 

As we've moved to more short acting agents, we've had to sort of encourage them to say, hey. Just wait if wait a few more minutes. Is this gonna wear off and things will be okay? And that brings up the question, do you even need to have somebody empty their bladder before they go home? How do you guys do it in Darby? 

Oh. Great question. No. The answer is no. If they so we have a short answer, no. 

I mean I mean, if I've given a private cane spinal, we if they've got a history of retentional issues, then we do perhaps keep a slightly closer eye on their bladder volume. But we don't give huge amount of fluid in those cases because we give sip till send anyway. They all drink till they come to theater. So the fluid volume of theater is minimal, really. So you don't have a pee before you come down. 

Don't fully butter up too much. We occasionally, with Prilocaine, get an issue with urinary leakage sometimes, but that's a slight issue sometimes. Chloroprocaine, I've never seen a case of retention. I mean, they're literally up and about. It just melts away because it's an ester. 

So we don't have we don't have a pee before you go in policy unless there's an issue with the patient. And the majority of patients who do have retention tend to be patients who are having, know, bladder work done or, you know, men having urinary work done or or sometimes, inguinal hernias, which have an incidence of retention anyway. So yeah. So the answer is no. We don't, make them have a wee before they go home. 

Yeah. And if there's a problem, they can come back, and that works fine. Yeah. Yeah. That's very very reasonable. 

Yeah. Yeah. Good. Good. That would be a really big, a big change in practice for us, but I can see I can see why. 

It's good. But also, I think it's incredible that you've got a significant volume of orthopedic knee surgery that you could do under a chloroprocaine spine. I'd love to have that. And I think It is beautiful. Yeah. 

Honestly, I love it. Well, listen. Before we get too into regional anesthesia, we always like to have a bit of a joke break here. Oh, god. So I'm gonna hand the reins over to Jeff to start. 

Well, here's one for you. I'm already nervous. I don't know why I'm nervous. I'm not telling the joke. Once you've been to one food court, you've been to the mall. 

Oh, nice. Okay. Do know, Jeff? Jeff, you know, I like the way Jeff sneaks them in Yeah. Yeah. 

When you're not expecting it. That's his his Amit's the light. You know? You it's coming. That one. 

Yeah. Playing Bondor. Yeah. You know? I'm Amit. 

I'm This is a joke. Unknown. It's great. No. No. 

It's it's it's just different style. Yeah. Absolutely. One more for you. This I think you'll like this one. 

Who does Beyonce call when she needs her roof replaced? Hold on. Wait. Wait. Wait. 

Wait. Wait. Wait. Wait. Wait. 

Who does okay. Put a ring on it. Halo. He'll get there. He'll get there. 

I can don't know. Did they go go? All the shingle ladies. All the shingle gosh. Cool. 

That's that's an American angle there. The shingles. Yeah. I like it. I carried I like it. 

Oh, very good. Oh, what what do you call what do you call them in The UK? Yeah. Shingles. Oh, tiles? 

Tiles. Yeah. Tiles. Tiles. Yeah. 

But I'd but it it still don't worry. It's good word. It's great. Oh, god. Okay. 

Very good. Very good. I'm musical. And so, Robbie, that's the standard that you're playing with. So let's hear what you got. 

Do know do know? I I've got nothing, really. I mean, I've got a is any do you know professor Alice Roberts at all? Yeah. Not personally. 

I'd love to. She's You'd love to. I would very much love to. I mean, I'm a big fan of her. Do you know who she is, Jeff? 

I I don't, I'm afraid. Oh, you need to follow her. She's awesome. She's so clever, so amazing. She's everything a mature intelligent man would want, which is basically she's incredibly bright. 

She's a doctor. She's an anatomist. Ah. She does she wrote an article in BJ education. She wrote one of the cervical plexus a little while ago. 

She did the illustrations for that. And she does a thing called digging for Britain. Okay. So she's a really, really interesting woman and a rock chick as well, and she has pink hair. Wow. 

Anyway, she's amazing. Okay. So she's got everything. Anyway, she was doing this this digging for Britain, which is this thing where they do archaeology, they dig up all this stuff, and she talks about the history of it and everything. Okay. 

And they found obviously, it's amazing. They found the biggest tibia bone ever ever found on a dinosaur Wow. Ever discovered. It was phenomenal. Wow. 

And it was so impressive. They had a party to celebrate. And, apparently, it was quite a shindig. Oh. Oh, gosh. 

You led us along the garden path there and then just you channeled your inner Jeff. I love that. I have to credit my daughter number three, Charlie, for that one. She she fed me that one beautifully. That's very beautiful. 

Anyway, listen. Listen. I remember the other thing is I was this is when I was a young registrar, fresh young registrar in Derby, I was in theater one day, and, I just popped this spinal in the sky, and, we we lay him down. And life is such fun sometimes in theater, including the patient. We're we're having a great time with this guy. 

He's an old fella, and I had I was with my boss, George McLeod. He taught me how to do he taught me how to do thoracic epidurals, paramedian, when I was a registrar, with a hanging drop, of course, which I still use for my spinals Yes. Just for the sheer bloody fun of it. Anyway, so there was George. Now George, dear chap, only had one leg. 

He had a he had a tumor when he was young, and he had to remove. Great guy. Lovely man. So there was George limping around the anesthetic room. You know? 

I'm doing my limp here. You can see, guys. You can see. I can see the limp. The ODP was a guy called Ivor, who was the funniest guy. 

Dry. He only had half a leg at one side. Seriously, this is funny. Okay. Picture picture picture the understanding room. 

Okay? It's so funny. I can hardly speak. So this is, like, thirty five years ago. And then and there's Tony. 

The he was the charge nurse, and Tony had severe hip arthritis. So there was there was this guy. Me, I've put the spinal leg, lay the guy down, and there was George. I we're getting around the room like this, and there was there's either hopping around doing this, putting the on, and there was there was Tony at the far end doing this. Anyway, so so we honestly, we went the sheets back. 

It was a vascular list, and the guy only had one leg. And the patient said he said, bloody hell he said, all we need is a batten ball, and we can have a game of cricket. Three stumps. Oh, dear. That joke was a bit it was a bit wicked. 

Sorry. Wicked. Oh, got that. Got you. Okay. 

That's it. I'm done. For those of you who don't follow cricket, Google cricket and you'll understand. That was a very good joke. Thank you, Robbie. 

That's a good one. Listen. Listen. I I was so I laughed so much. I was weeping with laughter, and the guy's disappeared. 

The young and I was left with my boss who was quite a serious guy. But, anyway, it was but And that was that was actually a true story. Oh, yeah. Oh my god. It was the best. 

Oh my god. The patient was so funny, honestly. Alright. Anyway, there we are. Well, you know, listen. 

I've Jeff, I told you I've got a friend called Joe. I know if I've talked to him before. But like me, Joe is trying to lose some weight, and he finally came across the Dolly Parton diet. Have you heard of it? No. 

I haven't. So so Joe Jay came across this this Dolly Parton diet. And you know what? It really worked because it made Jolene Jolene Jolene. Jolene. 

Oh, yes. I love it. That's awesome. Two musical punch lines in one episode. Wow. 

Okay. Oh, awesome. And you know what? This morning, I woke up and I found stir fry vegetables all over the bed. Oh, no. 

I was so confused. I said to my wife, Kate, and I said, what is going on about this? And she looked back at me and said, oh my god. I must have been sleepwalking again. Oh my god. 

Oh, sweet. They get Oh, dude. They just get better and better. Oh, poor Kate got dragged into that one. My wife will be cringey when she hears this. 

I'll tell you. When we go walking with a friend of mine, my my friend and I are we're allowed three puns or five puns, and that's it. No beer. But we just do the we do them in secret, but I guess she can tell anyway. Anyway, brilliant. 

Love it. Love it. Okay. Now I happen to know that Robbie and I are both James Bond fans. Robbie, you were telling me when we met we first met actually in Greece Yeah. 

Yeah. That you had this tradition with your girls when you watch them every Friday night and you have a curry or a pizza or something. Is that is that yeah. Chinese. Chinese. 

Chinese. Chinese. That's right. Yeah. So I want to know what is your favorite Bond film, and who is your favorite Bond? 

And I'll tell you mine after. Oh, great question. I've always been a fan. I mean, the thing about Bond is each each bit of Bond is a slice of each era of politics and and attitude to women and cars, everything, politics, everything. And so I think which Bond you like depends on how old you are Okay. 

And what first impresses So I think that's the so I would have to say it's gotta be Yoni Lived Twice, which is it's it's got everything for me. It's got Connery. I mean, he's the archety pe bomb for me for me. Not too corny like Like Roger Moore. Yeah. 

Yeah. And he's just he was just he was he was brutal, actually. It was brutal, but but but elegant. And it was peak gadget. They had X-ray screens. 

They had little Nelly Autogiro. They had rocket cigarettes. They had in car video conferencing, a safe cracking device, and exploding lipstick, of course. And to top it all, the Honda 2,000 GT, of which they made only ever two soft top models, especially for the Bond film because he was too tall. No kidding. 

The coupe. No kidding. And that great car. And Ugh. And having said that so, yeah, that's my favorite Bond. 

Having said that, I have a total man crush on Daniel Craig. I mean, he's I have a Daniel Craig calendar behind me on the wall. My daughter get You do. Yeah. Yeah. 

Yeah. He she gets me a calendar every year, Charlie, with various smoldering shots in different outfits. And, you know Just wait till we replace that with our men of block it like it's hot calendar 2026. Yeah. Can you imagine? 

So much better. So much better. What can I say? Great. So there we are. 

So tell me yours. Mean, I I gotta hear this. Daniel Craig is a good is a good pick. Yeah. Yeah. 

Amit, you you go ahead. I wanna hear it. Well, know, as you know, no stranger to controversy. Mine is is gonna be the cheesy guy. It's Roger Moore for me. 

And I'll tell you why. Man with the Golden Gun, I was born in 1976. Oh my god. I've said it out loud. Man with the Golden Gun came out in '74. 

So around my house, those were the kind of the copies of Bond films that we had on VHS cassettes by that stage while I was growing up a bit. So it kinda it sounded cool, the golden gun. It had Brit Eckland in it, of course, one of my early crushes. Scenes from Bangkok. I was born in Bangkok, so I felt that connection. 

There was Thai boxing in there. Then And there was a whole thing about Scaramanga's three nipples, which was, like, just really Are we allowed to say nipple on this? Oh, it's medical, but okay. Yeah. Paul has bleep it out. 

And and and, you know, Roger Moore, for me, he would just he was I thought he was cool. I thought he was cheesy. But but, you know, I I liked I loved it. That that was that's my answer. Cool. 

Yeah. No. It's a it's a great one. Christopher Lee, right, was the man of the golden gun. Yeah. 

Yeah. And that that opening scene where he's in the hall of mirrors, in that one, that was and he's shooting the whole line. Yeah. Slightly sort of psychedelic sort of, you know, late early seventies, late sixties sort of, you know, weirdness. Yeah. 

Yeah. Yeah. Yeah. Right. And Roger Moore was cheesy. 

Like, he had some cheesy lines, but I I did like them. Like, it was it was fun. Right? He made it fun. Yeah. 

For me, it's gotta be From Russia With Love. Oh, nice. The the second one. Yeah. I just I yeah. 

Yeah. I did like the song, actually. From Russia with love. It had the great villain. Right? 

Rosa Kleb. Yeah. Rosa Kleb with the with the old knife that came out of her shoe and she tried to kick you. Yes. Yeah. 

With the venom tipped spike and then the big guy, the the beefcake guy that was her henchman kind of thing. Yeah. With blonde hair. With blonde hair. Yeah. 

Yeah. Yeah. Yeah. That's right. Yeah. 

Nice. And then Dan Daniella Bianchi was the, you know, the blonde girl. And yeah. And then it had the, like, the the belly dancing stuff and the stuff in Turkey. Great one. 

Great one. Like it. Oh, do you know that they're all good? They all have their own little thing. And they like I said, they're each they're each a cross section of society. 

You could almost write a sort of PhD on it. But none of you said Timothy Dalton. I did notice that. Let's just move on. So listen. 

We have understood a little bit more about your practice and the medical part of your life, Robbie. But we're we're interested about you as a person. Yeah. So tell us about what are your biggest passions, and what do you do outside the, Blocktastic OR? Do you know? 

I have a beautiful, really smart wife. Amit's met my wife, haven't you? Yes. She's absolutely lovely. And she's great. 

She's she's I've known her for forty four years. She's a radiologist with special ultrasound skills. And, actually, my first images of my median nerve and radon and anal nerve were all done on her ultrasound machine in her office back in 2002 or something. Crazy. Long time ago. 

So that she's she's a she's fabulous. Really, really bright. And she puts me in my place. She's I would describe my wife as as mostly unimpressed by everything I do, which is, you know, it's fine. But that's good. 

It's you know, I'm so enthusiastic, and she's like, yeah. Okay. I did this today. Oh, alright. Okay. 

Yeah. Great. Well done. You know? But that's fine. 

Yeah. So she brings she's my best critic. You grounded. Oh, yeah. Absolutely brilliant. 

And I have three amazing daughters. Honestly, I know all dads are proud of their daughters, but they all get their brains and work ethic from their mom, clearly. The eldest ones, she's a dentist up in the Northeast. She does the the difficult dental cases, you know, the community dental work. Alright. 

And she's a skilled seamstress just like her mother, very good fine motor skill. She's a delight. She's married. I cried all day at the wedding. You will do this, Amit. 

You will do this, Amit. God. Number two, number two, you've probably seen her a bit. She's the physio in the scrum half. Yeah. 

Yeah. Yeah. She's the little Sheffield Tiger scrum half. Yeah. Wow. 

Unbeaten this season, and they've they've just been, promoted. They they won the top of the league. So, she also she also plays she actually plays the auction. She's played at Twickenham. So she's she's a little star, small but powerful. 

And, she designed this final chart, so she's a little darling. Number three is just amazing. She's she's a hell of a girl. She's did a genetics degree, and then she did she did genetics and microbiology, and then went she's a fourth year medic in Glasgow now. Oh, man. 

Yeah. Responsible for the dad joke. She's got drive since. Exactly. Just been selected for the GB training squad for American football too. 

So she's she's Wow. Plays in a men's plays in a men's team. No idea how that works. You say American football? Yeah. 

Wow. Okay. I know. Yeah. Chef Glasgow Tigers, she plays for. 

Yeah. Yeah. She loves it. She loves it. Interestingly, she spent a month with the lovely Steve Coppins in Lourbon. 

Oh, yes. And and Danny Hookmer too, his research, and he did some research there last summer. So Steve loves her even though he's kind of slightly scared of her in equal measure, which is perfect. So am I. So that's fine. 

Anyway, so that's my passion. And That's amazing. I'm I'm running my first half marathon in September, the great age of 64. So Wow. Great north run. 

So my 54, you said. 54. 64. I don't believe Yeah. Afraid. 

Don't believe it. Was that part of the Paul Mahertony song? I'll run a half marathon when I get to the when I'm 64. Do you know? I think that's right. 

I like it. I like it. Yeah. So no. No. 

It's fine. Yeah. Yeah. Nice try, Jeff. Nice try. 

So that's the great North Throne in Newcastle, which is Wow. Congratulations in advance. Well, my main aim is is survival. Yeah. Second aim completion. 

So, yeah, that's exciting. So and, yeah, I love hill walking. I just I I could walk forever up hills. Wow. Do and I'm running. 

But yeah. And I like building cars and and and driving them. E type Jags is my thing. So Cool. Nice. 

So do do you buy these cars? And then Oh, yeah. So I buy them really cheap, like, you know, absolutely in a state, and then just spend ages taking them apart. And then I bring the parts into the kitchen to show my wife. She must love that. 

And then she knows that it what she has to notice them and go, oh, yes. Very nice. And then I take them away. You're like a cat with a mouse. Yes. 

Exactly. Good job. Well done. Yeah. Go away. 

Yeah. Yeah. And then and then I I put it all back together again. So, yeah, it's fun. Yeah. 

Yeah. I love it. Oh, it's amazing. Practical hands on. Yeah. 

Yeah. Think that it's really important to have a hobby where you use your hands. Yeah. Yeah. You know? 

Yeah. Yeah. Yeah. Whether it's music or whether it's You're a great musician, aren't you? So yeah. 

That's great. Never kind of be a great musician at all, but I hack around a bit. But Well, you know what? I did I did a call with with Jeff the other day, and in the middle of the phone call, he just picked up the guitar and started playing it to me. I was I I got a little bit emotional. 

That was like, it was a it was a love song. No one's ever done that to me before. It was really lovely. Oh, love song. Oh, that's so so sweet. 

You guys, you're just like pro bands. It's great. Yeah. I I I but it but it was the fact that I wish I could I, you know, I I used to play the saxophone. I played the piano, but no. 

Guitar is cool. I play I I I play French horn. Oh, nice. Yeah. Which is Yeah. 

Very lovely. It's a kind of crossover instrument between woodwind, the brass. It's nice. Yeah. Play a lot of beautiful stuff. 

Yeah. All the bond all the bond movies have a great French horn part. That's right. Yeah. Yeah. 

They do. Yeah. Yeah. Soaring soaring French horns. Yeah. 

Yeah. Brilliant. Okay. So we're getting a little bit of an idea of the of the passion behind the man and what keeps you grounded and what keeps you entertained and what gives you drive and focus, which is fascinating. I could talk about all the nonmedical stuff all day, but I do feel we have a little bit of an obligation to talk to you about another slightly controversial, but I don't know why, topic, which is paramedian spinals. 

Why do you love them? Why aren't they taught more? And should we be using them as first line? Wow. Do we have a sound effect? 

Oh, that'll be good. There we go. There we go. That's my whiskey glass. Yeah. 

Yeah. I was taught thoracic epidural back in the nineteen nineties in Derby by this lovely chap, George MacLeod, and with a hanging drop. And it's the most elegant, beautiful thing you could imagine. And then I learned to lumber soon afterwards. And then I looked up this amazing approach described by a guy called John Taylor, the Taylor's approach, which is the L 5 S 1, which Kijin always talks about too. 

I tell you, Kijin's come to my place for a bit of walking before our UK. Oh, nice. He's the loveliest man in the world, isn't he? Yeah. Anyway, so I I thought l five s one is the most beautiful space. 

Nobody ever goes there, and it's a lovely approach. I thought and it's it's done paramedian. So I thought that's good. So I started trying out different things. I thought, well, if I could do thoracic paramedians, why not do lumbar paramedians? 

So I started doing them a lot, and I just got into it. And every time somebody asks me to help them with a spinal, which is yeah. It happens a lot. I think the best the usually, what the best thing I do is take everything off, start all over again, you know, clean sheet, cuddle the patient, give them a little bit of love, you know, a bit of a dazzle lamp Yeah. And then pop a paramedian in. 

And, hell, it always goes in. Sometimes you have to make it look a bit difficult. Well, sometimes it is difficult, but, I freely admit. But, you know, it always works. So I suddenly thought, well, if it always works, why don't they just do it all the time? 

Now it's no surprise that the ultrasound view, the parasagittal oblique view, is exactly what you do when you do a paramedial spinal. There we are. Evidence. It's a massive space. Once you've worked out your where your midline is and the angulation, and Keyjin and Katherine Poots, who I have to mention, who's awesome. 

She's from Northern Ireland. They wrote this beautiful article in PGA Education February, which is a must read for anybody who does spine medicine. We can link that in the episode, mate. So they Please do. It's just one of the best articles I've seen for years, but I would do, wouldn't I? 

So it's not taught because do you know, anesthetists, we're weird. You know? We're very fixed in our ways. Uh-huh. And what I try and do with my trainees, especially the senior ones, is, look. 

I say to them, look. You're not here today. I was talking to Trina. I I reg today, and I said, look. Look. 

You're not here for me to watch what you do every day. Yeah. You're here to do it differently. So I teach them all how to do it, and they love it. And it's a great way of teaching thoracic epidurals because the angulation, the muscle memory is just the same. 

Yeah. And so why wouldn't you do it? I think you just need to be adaptable. You need to be able to achieve. So I think they're not taught well because they require a little bit of thought. 

But once you've worked it out, they're brilliant. Yeah. Yeah. Do you do them, guys? Do do them? 

Yes. I love a paramedian. And I I so my my standard anesthetic for a hip fracture is Yeah. They come they arrive supine. We've already blocked them in the emergency room the day before they arrive. 

So they've got a ping block sort of keeping them kinda comfortable. Ten of propofol, ten of ketamine. Oh. Let their eyes glaze a little bit. Turn them on their side. 

Okay. Yeah. Yeah. Yeah. Okay. 

Making funny faces at you, Jeff. I like the little bit of a glaze and then turn them on the side so there's, you know, the residual pain won't hurt. And then and then it's a prep Good. My man. My man. 

Paramedian spinal l four five ish. Absolutely. Beautiful. Yeah. Absolutely. 

So so so I so I've I've got a confession. So, Robbie, and you'll know because I've may have mentioned it a few times, I only use them when either my resident has struggled or when I struggled. And then when it goes in, you're like, why didn't I do that the first time? And so so I've I've I haven't made that jump yet to say I'm gonna do it first time every time because my practice of god knows how many years has not been to do that. Do it. 

Do it. It's so such a joy, and it's great to teach, and it's it's just works A treat. No. And I think Kijin says is good, so follow Kijin. That's right. 

That's fair. I keep a little anatomical model of the lumbar spine close to the block area. So I can pull it out and say, okay. Here. Because the understanding of the geometry can be a little bit nuanced, right, and tricky. 

So if you haven't thought about, okay, here's how the lamina is shaped and here's why you're gonna sort of hit the lamina and then just walk straight up. And they always want to tell me if this is your experience too, Robbie. Everybody always wants to overangulate back to media. And I'm like, it's it's it's it's straighter than you think to get into this. Totally agree. 

I totally so today, Trino, he he's really good at them, and he was he'd done his it was his fourth today. And he was going in. I said, yeah. You're you're 15 degrees, not 10 degrees. And you're given where you started, that's a bit too far across the midline. 

He kept banging into into transverse pros into into spinous process. And I said, right. I didn't I didn't touch him. I didn't do anything. I just said, right. 

Five degrees less, and you'll be fine. It went straight in. Yeah. Wow. Absolutely agree with you. 

And this is exactly what Kijin. It's a kind of paraspinous Yes. Or or sort of as opposed to paramedian. Paramedian. Yeah. 

And it's it's subtle, but, you know, you just gotta it's a bit of a mind mind's eye thing. But, yeah, once you start doing it, you just why would you do anything else? Mhmm. But, know, so I've started getting up virtual anatomy apps on my phone while people are doing spinals and just with the three d model and just putting it next to the patient back and go, look. This is what I think you're doing. 

Yeah. And this is what I think you need to do. And it's amazing how when you put those things together, how people it helps. You've gotta have that model in your head. Right? 

Yeah. Model in your head. Absolutely fine. Yeah. No. 

I just think they're they're just yeah. Fantastic. And I have little tricks as well. I you know, I'm a great fan of the lateral decubitus for patients like Jeff said. You know, it gets you out of trouble sometimes. 

You know how you get a really obese patient, curl them up, and suddenly the spines just pop out a bit more. And, also, the necrophying patients always do them lying on the good side. I do it similar to you, Jeff, but I I use alfentanil for my analgesia for them. I do a block and then alfentanil internal inside, but otherwise, pretty well the same. The other thing is oh, this is controversial. 

Oh. I do like a bit of controversy. There's an accent again. You're making fun of me. How about how about how about putting a spinal in thoracically? 

We talked about this in our controversies episode. Now I'm not talking about a thoracic spinal for abdominal surgery. I'm talking about using the lower thoracic spine to get your spinal in in a really difficult patient for a knee surgery, say. So I had a guy the other day who had a huge scar down his back with a curve at the bottom. He'd had, metalwork from sacral right up to t 12. 

Big obese guy. He having knee replacement, and he wanted a spinal. I said, well, I'll have a look. And I always say to patients, I will not mess about. If I can do it, I will. 

So I use a 27 gauge paramedian approach, winkle it in, put a hanging drop when I get to the ligamentum. So I take the trocar out, put a hanging drop in, and just gently like, Gordon Lancelot does this, I think. You gently just advance your needle in, and this you can see that meniscus just reverses. So you know your epidural space, and you just know that it's just a gentle and you're in. And you get CSF back. 

Yeah. Pop it in. Works a treat. Now you may say, well, oh, it's dangerous putting thoracic epidurals in spinals. But, I mean, we stick sixteen gauge epidural needles right near the spine, and we think that's just fine. 

So I think a controlled use of an appropriate level of small needle is, for some situations, done by somebody who does it a lot, entirely appropriate. Not like you're doing it without thought. So you're going low thoracic but for lumbar dermatomes and myotomes and and and it works. And what are you and what are you injecting? That would be three and a half mils of Pralocaine for a knee surgery. 

It's fine. Yeah. Works beautifully. And, do you know, sometimes it's better to do that than mess around multiple times trying to do it where you can't do it. Interesting. 

So yeah. Love it. You got you got us thinking, Robbie. I love it. What I like about your description of that technique is that hanging drop element of it so that you are Yep. 

You know the millimeter Yep. That you're in Yeah. That that you're that you're not gonna go too too far. So you first you and it's okay. There's epidural space, and then it's just another couple of millimeters until you get until the meniscus reverses again, I guess, and it comes back out at you. 

Now are you using a a what kind of needle is this? You said 27 gauge, but, like, what kind of Oh, good question. I knew you'd ask me this. Yeah. Great question. 

I'm using a 27, but I'm using a a sprot, actually. Sprot's for everybody. I know Gordon uses he goes for the Quinkies because he says you get a Yeah. Like, a more rapid feedback. But, frankly, I'm fine with the sprott. 

It works beautifully. So Listen. I've got to ask you a question. Yeah. Yeah. 

So so why was I, when I was a trainee, where people call them sprotters? Uh-huh. So is what's the what's the correct pronunciation? Great question. I say Sprat. 

I say Sprat. But I imagine that doctor doctor Spratte is I'm assuming I think it's Spratte. I but I I don't know how much. Okay. I know we've got a lot of German listeners. 

We need someone to tell us. Hand me the Spratte needle, please. And that's what I was The Spratte needle. I think we ought to ask William Harrop Griffiths because he will have an opinion on this. It's gonna be sprott, isn't it? 

Because I'm obviously overthinking it, but I think it would be sprotter. I don't know. Please chime in, listeners, onto the social media channels. Is it sprotter or sprott? Zekwinka or Zekwinki. 

Yeah. Yeah. Yeah. Oh, there. Sorry. 

Look. There's I'm creating trouble already. Did you finish your sentence? Are we we we would we were no. Oh, I ramble on. 

Listen. I, what about a 22 gauge needle for difficult spinals? That's just my go to. That's Keith Jim's as well. Absolute game changer. 

So if you're in trouble, you got a big patient, difficult patient, just whip out your 22. That's another slogan. Yeah. Yeah. That's that's the next T shirt, which is to whip out your 22. 

Oh, okay. Whip out your This is your 27. This is Get a sprott. Sprott up. Sprott up. 

And do a hanging drop. Oh my god. It's a good one. Wow. Oh, it's it's fun. 

It's fun. It's really good. But, no, great way of of directional stability, great flow, great feel, great approach. Much better than trying to do the needle through needle technique some people use, which is horrible, horrible. I agree. 

We recently submitted a paper looking at the incidence of TNS in lidocaine spinals. Yeah. And so look for this is a shameless plug for our team, but look look for that to be to come out soon. I will. But in it, we had disclosed that a good proportion of our spinals were done with 22 gauge Quinkies. 

And and there and and one of the reviewers said, I just can't believe you're using a Quinkie and and 22 gauge. And you but it's like you said, Robbie, there are patients that Yeah. It it the 25 or 27 is just way too flimsy. And you'll you'll just you'll spend half an hour trying to get that in. Sure. 

I mean, listen listen. I use $20.20 sevens for everybody. But if I have I just automatically have a difficult patient, a large patient, I'll just, you know, straight for a 22. Yeah. And and, of course, you can use the full length of the needle. 

You don't need to introduce her, so you can use more of the needle than you get away with. So so, again, it's a it's a it's it's just a a game changer. One of Robbie's top tricks. I love that. Hey, Robbie. 

Speaking of speaking of difficult and challenging spinals, what are your thoughts on ultrasound for neuraxial anesthesia? Oh, that's a great great question. Do know it may interest you to know that old though I am, I have done it. Now do I do it routinely? Well, no. 

I don't. Sorry. I should say I should because That's also my answer too. Yeah. Don't say sorry. 

We ask we want your honest answer. So Robbie's principle of these things is like art lines or or whatever or paramedians. Do them all the time, and then and then when you have a difficult one, it's not a problem. Yeah? Yeah. 

Would you say ultrasound for that and stuff? But do you know? I just don't need to do it, so I don't do it. I don't mean to sound big about this, but do you know what I mean? No. 

No. No. No. It didn't it didn't come out that way. Like, ultrasound for for regional is fantastic because you can achieve things you never achieved before so much better with less dose. 

But spinals, I just just put it in, so it's fine. I have found it a couple of times handy for finding the midline. Yes. Yeah. Yeah. 

Because because once you know where the midline is, a paramedian is a doddle, particularly in larger patients. So I think that's when I would use it. I'm not sure about the the need to find the depth of space, which can vary depending on the pressure you put on. And and do you do it you can't really do it in real time. I what do you feel, guys? 

I think you just push that needle in as far as you can, and eventually, you're gonna hit something. Well, see and since since so that that statement itself makes me feel sick because and I'm literally I'm actually had to hold a bit of vomit down. Sorry. I just said that because because I've watched an individual whom I thought, you know, they they know what they're doing, do stuff, and and and the the needle's in. It looks like it's in a fair long way, and then the the hitting bone, and I'm like Strong right arm. 

Yeah. That doesn't seem right. And, I've taken over, and I've found the space, like, four centimeters more superficial. And so Oh my god. So that makes me nervous. 

But but I know Jeff was joking. Yeah. I know. I know. I listen. 

I I I don't use it a lot. I totally get it, and I think it's a great thing do. So you know? And But I think yours is the most sensible take on it. You're a guy who's got years of experience with landmark guided intrathecal anesthesia, spinal anesthesia. 

You moved to paramedian. You don't fail that often, but Yeah. You'd say, well, look, there is a potential role, and midline ed identification seems totally fair. I think there is a a a new generation of us who are coming through who are feeling guilty for not using it all the time, but I don't think it's practical. So so, Jeff, sorry. 

I I cut you off in your mid thought. What were you gonna say? No. No. I I agree with both of you. 

I think I I might and that's my actual practice too is I pull it out when I'm having trouble. I don't start every spinal with it. No. Sorry. I'm trying not to be like Stop it, Jeff. 

Stop it. When you edit this, you'll realize why I pull their face. I know. I know. I can see your face, though. 

It's kinda anyway, you could see his face. Right. Well, listen. As the so so so you're what you're saying is, Robbie, it potentially has a role, but you're not gonna use it all the time, and I think that's fair. So listen. 

Robbie, as the youngest member on this podcast Wait. What? Is that true? I think it probably is. But, you know, you can say what you like, but it's fine. 

I'd like to ask a question because I think it's relevant because I can see this is gonna start happening to me now. How easy or difficult has it been for you to constantly modify your technique from landmark to paresthesia to nerve stimulator to ultrasound? And still, from my point of view, you are on the top of the game. So how do you keep on the top of your game whilst having to you you having to reinvent yourself and learn new things? Because as we get older, a little bit more challenging to take on these new things. 

How do you do it? Yeah. That's a great question. I mean, I'm kind of somebody who I just relish, trying to get it better all the time. I think if you do that, then it's not a problem at all. 

I mean, I haven't ever used parentheses. You keep going on about how old I am, and I no. You don't really. But I I've never really used parentheses. But no. 

But I have. Weirdly, I was looking at an old lecture the other day that I did back in '97 of Nigel Bedford I was in Borden. Yeah. In Nottingham and on the regional course. And, actually, Will Griffiths was giving the first talk, and I kind of summed up my whole philosophy, Will. 

He's such a great guy. His talk is entitled why regional anesthesia. And, actually, he crossed out the RA and put GA. And that just sums me up. Yeah. 

So it feels that's your starting position. So it's always been my way. So but my talk, weirdly, was on peripheral nerve stimulation, physics, practical use. Isn't that amazing? And here we are, full circle. 

We're still using it. I mean, Jeff, uncle Jeff, uses it, and I use it. And, you know, ultrasound's fantastic, but your proof your nerve stimulator can be really, really beautifully to you beautiful to use. So I'm a big fan. So and I just like moving on all the time. 

I listen to you guys. I listen. I read the stuff. I read the science. I look at the evidence. 

I go and see my patients after the operations, and I see what I do. Key. Right? It's you know, my old boss, John Stephenson, when I was training, he said, Robbie, one thing. Always go and see your patients. 

Look at what you do to people. And I Yeah. And and I did acute pain for years, and I learned. And you learn every day. I I before I came home today, I nipped to see my two patients from the morning, and you see what you do to them. 

And, yeah, that's really, really fundamental. And that drives me, and that changes what I do all the time. Yeah. Constantly looking for better. Love it. 

That that perfectly answered my question. Thank you so much. That's so important in regional too. I mean, it's like you said, GA is not that hard, and they're all gonna have a fairly similar post op course. I do you know what really gets me sometimes? 

I'm a bit of a bee in my bonnet is this mad thing about GA versus RA. What is that about? You know, you'll see this with Necafims all the time. Yeah. Getting a bit you know, I get a bit oh, I'm about the only thing I get grumpy about. 

Stop trying to show a difference between generals and spinals. You're never gonna do it. Yeah. Let's just embrace the whole the holistic approach. Just don't make regional special. 

Don't make generals special. Just involve them together and create what you need for the patient in front of you. That's what works. And try and get as good as you can do for each technique, and I think that's what we should be doing. Right. 

And just acknowledge that spinal's better. But the Oh, absolutely. Yes. Of course. But but yeah. 

I'll now get blocked again. I can't say that. I love you guys. So I asked the first question. I'm also gonna ask the last question here. 

So how I read someone had some note on Twitter recently about how regional anesthesia has an image problem, and it took me by surprise because I thought that's if anything, we have an amazing culture and vibe and and image and what we're doing for patients Oh, yeah. Is is incredible. But do you have any thoughts on that? And and how do we continue to inspire? I mean, I I I hear you talk, and I I wish I could be a trainee at Derby. 

I would I would give up my job to go back and be your resident. Oh. Oh, I agree. But how so, yeah, I don't think you have a problem with this, but how do we as a as a group continue to inspire the the new generation? Yeah. 

I think, Thanks for that. I mean, I I it's a lovely thought. I mean, I I wish I was a trainee again now. It's so exciting. They've got so much opportunity now I never had, and it's such fun. 

So you just gotta enthuse them. I think, I think I think the first thing is to make regional anesthesia smart. You know? It's gotta be achievable. It's gotta be deliverable. 

It's gotta be, manageable for people to take on. If you make it too clever and too smart and and sorry. Too too complicated, They, you know, describing this, that, or, you know, you get people who keep inventing new blocks for things, and they'll do this block and that. But you've just gotta keep it simple and introduce it in that way. And it's like your approach to knee surgery, isn't it? 

You know? I often say, I had a I was teaching up in the Saint Andrews course with James Bonas, and he's such a lovely guy. And Yeah. He you know? And it's just and there was a trainee there. 

She said no. She was a new consultant. She said, I'm starting to do knees, but I'm a bit anxious about doing the blocks, and I'm not sure. I said, okay. Okay. 

Don't worry. Just find and I think Jeff says this. Find a space. Pop your block in. Just if you can do anything, do a femoral triangle block. 

Just do that. Do it quietly out the way in the reception area or something or somewhere or block room or whatever. You know? Toilift. Yeah. 

In the lift. Yeah. Or in the block room, whatever. Quietly pop it in, and then get bring your patient around, do a spinal, and let them infiltrate some local. That's your baseline. 

That's that's your you know, we talked about it. It's your bronze level, and that's fine. And and then your surgeon will say, oh, my patients are really good. It's looking good. You know? 

Encourage them, and then and then you start to learn. And then so learn in a relaxed environment. Learn the simple stuff. Yeah. Learn the straightforward stuff. 

Don't make it complicated, and look at the trajectory of the patient that we talked about. Just look at what you're trying not just I can do a block, but learn, you know, how what what what the patient in front of you needs today and how they're gonna manage afterwards. So and infuse them, encourage them to listen to you guys. I mean, you guys make it cool. You know? 

And the education you provided with just this podcast is just it's just awesome. Acceptable. It makes it you talk about when you get things wrong. And Jeff's video is great because he talks about when he gets he goes, puts it in the muscle. Oh, it's in the muscle. 

But, no. Let's do this. Do know that's real? We've got to make it you gotta make it, like, for every man. Yeah. 

That's the that's the way to That's a really wise answer. I like that. I hope so. Yeah. So I think and stop trying to pick regional and general against each other. 

Just make it inclusive. Yeah. Yeah. Yeah. So that's my that's my approach. 

Always try to be better and go and see your patients. That's that's a great that's fascinating. It's I think it's a great way to kind of summarize it, and, you know, we're trying to do our bit, but, we want to make regional anesthesia as inclusive and as accessible as possible. That's the key. That's what we wanna do. 

Yeah. We don't want people to be scared, and I think your approach makes perfect sense. So, thank you so much, Robbie. Yes. Thank you so much, Robbie, for being here today. 

This has been, such a pleasure. Oh, it's been immense. I just it's been such fun. I'm sort of like chatting to to friends, and that's what it's all about, really. And I think we are. 

And that's great. Exactly. And to everybody out there as well, just enjoy it and have fun and and just try and try and keep keep getting it better every day. Yeah. Absolutely. 

Well, that's another T shirt slogan that we're gonna aim to put out there, keep getting better every day. Robbie, it's been so wonderful, that we've got a chance to know a little bit more about the man behind the paramedian spinals and a man behind ambulatory spinals. I feel that we've we've learned so much, but we would like to give you the ability to start our outro. Would you be happy to do that for us? It's it's not an honor, but it's a it's the ability. 

Oh, man. I think it's a prize. Oh, it's great. It's great. So you want me to close, dear? 

Yes, please. So I here we here we go. Okay. Okay. So, folks, as you say over there, please like and subscribe to our podcast from your usual podcast provider, and please give us a rating and leave us a comment too. 

And, Jeff, where can they follow us? We have Twitter or x at block it underscore hot underscore pod. There is now bluesky@bilih.bsky.social. YouTube at block it like it's hot. And we also have, yes, you know my favorite one, Instagram at block underscore it underscore like underscore its underscore hot, no apostrophe. 

And don't forget our hashtag hashtag b I l I h or the full block it like it's hot. Get involved in conversations online until the next episode. We hope you all block it like it's hot.