S3:E5 "Somebody call 911! Nerve blocks in the ER Part II 🚑"

Previously on block it like it's hot. Unfortunately, people thought we were insane, and people thought we were completely I remember giving talks and various people leaving. Come upstairs and do some intubations. We call it a tube and lube rotation. So in the morning, they intubate. 

In the afternoon, they they, do ultrasound. Tube and lube. Oh my god. Is that what Why what have I done wrong? What do you call it? 

The raptor? I I Raptor block? Raptor. Raptor. Hey, man. 

Let's do us some let's do us some raptors today. Oh, no. God. Then why is is that another word? I think this is the hook. 

Right? This that is the I've taken away so much already. Yeah. But that is the that's the phrase. Right? 

That's the phrase of the pawn. That's a bumper sticker. Stay tuned for the exciting conclusion to our two part episode, blocks in the ER. I'm Amit Power. And I'm Jeff Gadsden. 

And this is Block it like it's hot. Arun and Andrew, on our pod over the last few years, we've talked a lot about elective surgical indications for regional anesthesia, but we're interested on getting your experience on certain techniques that some of our listeners have brought up in the past by writing into us. Yeah. We I mean, we've had some really interesting stories shared with us and some questions posed from EDs around the world, and we'd like to get your take as experts on them. So the first one we touched on already, let's start with this big topic of hip fracture. 

And hip fracture, of course, was, you know, responsible for the majority of the box in your paper. We've got choices of femoral, of fascia iliac compartment blocks. So traditionally, the infra inguinal fascia iliaca, supra inguinal fascia iliaca, or pain block. So in your case, guys, what is the go to block for hip fracture that everybody should be doing? I'm picturing this like Family Feud style. 

Top four answers on the board. What is our best hip fracture block? I I I personally like the infrainguinal fascia oliaca block if I'm gonna admit the patient and they have, you know, intratrochanteric fracture. If they have specifically Ramey fractures and maybe my orthodontist wants to send them home, then I'll then I'll try to do the pain. I like the infrainguinal fascia iliac because it teaches my new learners how to target the nerves, open fascia planes, hydro dissect. 

So I think it's a great block for them to get comfortable with basic anatomy, which is nerve artery vein. So I personally like that for my basic fractures. So the fascia iliaca compartment block or infrainguinal. Okay. Okay. 

Now Andrew's smiling. So I don't know whether he's smiling because he agrees or because he doesn't agree. No. I agree. I I thought Arun may say peng block just because of the unique block that it provides to the ED, but I am a big fascia iliaca block fan for educational teaching and teaching our faculty. 

It's a safer block. It avoids all major structures. It's much easier to educate them on, and there's great evidence behind it for emergency physicians. Uh-huh. I'm starting to come in love with the peng block more and more given its lack of motor effects, but I think there's just something about that fasciaelyaka that just makes it so ideal for emergency physicians. 

That's interesting. And when you do your infrauminal fasciaelyaka, how much volume are you typically using? I do about 30 to 40 ccs. Okay. Yeah. 

So I I we we do 10 for the hydrodissection of normal saline just to open the space up so I know that my learner's in the right space and it's tracking medial. Once you're in that space, then I'll probably put in, like, 15 of the anesthetic. Obviously, basing it and looking at all their all their, age, etcetera, and then I close it within their ten cc's normal saline, so probably put like thirty in there. Yeah. Thirty, thirty five of volume. 

Yeah. Yeah. That's good. It's interesting. I I do agree that having the pain block is great, but it's not the whole picture and a lot of the pain burden comes from quad spasm and and that sort of thing. 

So, Amit and I talked about in the past about doing a cheeky femoral block. Yeah. After a ping. So especially if someone's if I'm doing a hip fracture block in the ED at 4PM, they're not walking. They're they're not doing laps of the of the board that evening. 

Right? So I'll do the ping and then a little cheeky femoral just to to quiet things down. So I've got two things to say. The first, again, is I'd like to kind of push to see where I can find pressure points and see if I can get people to curve under pressure. So this is the question I'm gonna ask you. 

Why do you need to do an infraregional fascia iliac block when you could just do a femoral nerve block? I mean, why don't you just do a femoral nerve block? Why are you calling that? Because I think, and this is where people may be upset with me, I think an infraregional fascia iliac block is just a not very well executed femoral nerve block. Or let me rephrase that because that sounds insulting, and that's not what I mean. 

A femoral nerve block done from further away using hydrodissection to get towards the nerve. That's what it actually meant. Not not not, you know, not not well executed one. So why not just do a proper femoral nerve block? Boom. 

Because do you really believe that you're getting the obturator? And do you really believe you're getting the latch contains nerve of thigh, which may not be relevant for analgesia? Okay. End of controversy point number one. I I I I 100% agree with you. 

I think this is I always used to call it the femoral nerve block. It's it's the infra inguinal fascia iliaca, just a higher volume block. The reason I do like it is it gives my really new learners a chance to keep the needle far away. So they're coming through, like, the sartorius. They come and they pop through the fascia They push, and they see that fluid track medially, and that gives them a little bit so, essentially, it is a femoral nerve block in the lateral aspect. 

So I think you're a 100% right. We changed our nomenclature from femoral nerve to infrainguinal fascia iliaca Right. To comply with everybody so everybody's on the same page, but I think you're a 100 right. It's interesting. I I agree with that. 

Okay. Okay. So listen. What I applaud about that, yeah, potato patata, the name is kind of not there, but I understand what you're saying. But what I love about what you're doing is you're saying, well, listen. 

I I want them to do it from a nerve block, but I want all comers to be able to do this. And I want a novice practitioner who's doing it for the first time. I wanna be comfortable they're not gonna stick a needle and go straight in something. So actually, I get it. I love it. 

But the next question I wanna ask you is why don't you migrate to the supra inguinal fasciae Aker block? Is it because you don't think that the extra analgesic benefit you get in an ED is worth the increased complication rate and technical difficulty? I think it I think the the second point is the key. I think the hard part with at least in our patients, right, we get the 85 year old woman who comes in with a hip fracture. When we rotate to a suprainguinal and get that, quote, unquote, bow tie, I have a lot of novice learners or even learners who've done ten, fifteen get very lost with anatomy, and they call me over. 

And they're like, hey, Arun. I'm confused. Where do I go? Where do I go? And they're and and and the problem is that the they're not doing blocks like you guys every day. 

I recognize they're doing blocks once a week or once every other week, so that skill doesn't come back. The beauty of the femoral nerve or the infrainguinal fascia iliac block is everybody knows naval, nerve, artery, vein. Like, that is in Yeah. In their brain because they palpate the pulse there. They do chest compressions. 

They palpate the pulse. Yeah. They got it. Yeah. And so I know that I can upscale these guys in that. 

It's it's so scalable. Yep. We had the same problem because we we have an agreement with our emergency medicine department that we'll we'll go down for the hip fractures, and and and they do a lot of other blocks that we don't care to get involved with. But we used to do femorals, and then we switched to doing some fascia iliacas, but the problem was it was inconsistent. And we we could it's not me on call every night of the year. 

It's a a lot of my nonregional faculty friends, and and so they're relying on the resident to have some expertise in doing a super inguinal fascia. Those planes are mushy, man, sometimes. And you look at them, you're like, I have no idea. What is that is that the fascia, or is it good to see a bunch of soft tissue? Yeah. 

The only only time the planes are perfect is when it's on a on somebody's Twitter account or on a podcast. Every time other else YouTube video. Yeah. Yeah. Yeah. 

It's I do the same thing. We all do it. How dare you? How dare you? If you put it in perspective, especially, Akka, hip fractures are our largest block. 

In order for us who are developing our programs, we need the highest level of success with the lowest level of complications, and fascia iliaca gives us that block. It's just like the plan a block. You know? Like, you everyone should be able to do this safely. You know, look for the thing that's gonna have the easiest easiest to perform with the lowest complication rate Yeah. 

Easiest anatomy, easy to reproduce. I love it. I I will tell you one thing. Like, by the time our our fellows finish their year, they're always like, Arun does boring blocks. He's not teaching us more advanced blocks. 

Because in their mind, right, they've they're like, this is easy. I can do it. And what I what they don't realize is that I'm gonna have to be here year after year and train novice providers. And as as somebody who's an expert, yeah, of course, I want them to to learn the I will teach them that. But but they've it's that that same thing. 

It's you have to realize that the novice learner is your key to scale. Yeah. And if you can get that person to scale, then you've actually won the game rather than teaching Mhmm. The person who's been out five years to do something esoteric. Yep. 

Exactly. Alright. Next controversy, rib fracture blocks. ESP, serratus plane block, paravertebral. What do you choose, hotshot? 

What do you choose? I only I go between ESPs and serratus. And to me, it's about and this is the part emergency medicine is kind of more unique. It's about where is the pain and how is their mobility. Oh. 

Can I get them sitting up? Can I get them laying, on their side to be able to do an ESP, which I think is actually more efficacious? If I can't and they're on their back, then I'm gonna go with serratus just before patient comfort. Mhmm. It really Yeah. 

There's multifaceted reasons of why to do either. Yeah. I agree. I think the patient tells me what I can do, and so I'm not gonna cause you pain to sit you up to reduce your pain to lay you back. So I think if I can if they're able to be mobile, I'm happy to do an erector. 

I don't do perivatubals. We published a case series on this years and years ago, and the problem with it is it's too close to structures that I don't like other people or even myself being next to. So I think the thoracic cage worries me because it's hypervascular, both venous and arterial. Mhmm. So I always am concerned about people going so close to vasculature. 

Does fracture location ever have a impact in in the block that you choose? Because, you know, for example, would you do an ESP block when you knew there were very obvious anterolateral fractures, or would you do a straight as playing when you knew they're very likely posterior fractures? I guess I guess, as you said already, it's a multifaceted how you made the decision, but how important is knowing block location for you guys when you're teaching your your residents? It it's very important because isolated posterior fractures, serratus is is not really gonna touch at all. And so knowing that pretty much makes the decision for us, and that's the patient I'll actually try to get up and sit up even if there is pain. 

Right. But it's I it like I said, it's it's all a game of where these fractures are and what the patient allows us to do. Yeah. I'm I'm gonna I'm gonna lie on this not lie, but BS on this one. But if I have a patient that can't move because they have a leg they have a pelvic injury and a thoracic injury and they can't roll and they got posterior rib fractures, I'll I'll try ten cc serratus with some with some volume and maybe because what because, again, I think it's a multimodal. 

And and if if people are right and if there's some smart people who think this is a venous absorption process, then maybe it'll help them. Mhmm. So I I have done it numerous times in the past. I don't know what applications this is, and I think it's a good great question for research. A related question, and we've had this question from one of our EM listeners in Australia, Kylie Baker. 

What are you doing for chest tube analgesia? Are you doing a block or are you just infiltrating? Like, when I used to do this as an intern, I used to just go down, hit the rib periosteum, put a bunch of local there and just hope it went to the right place. But do you guys have a more sophisticated way of approaching that for chest tubes? We work really well with the trauma team. 

So they if the patient's stable, obviously, obviously, if it's an emergent chest tube, we're we're just doing it. But for a stable chest tube, commonly, my go to is again, this is my go to. We'll do a low dose ketamine, point three mgs per kg over in a 50 cc normal saline bag, run over fifteen, twenty minutes. While that's infusing, I'll do a serratus. I'll put in ten to 15. 

So it's a nice multimodal. They wait for about twenty, thirty minutes. By the time trauma gets all set up and they, you know, they get into their seven gowns and and hats, by the time they're pretty numb, and then they go in and their patients are comfortable both during the procedure and then postoperatively. It's actually a nice field block for them. That's great. 

I've done the same. I've taken it from Arun's playbook here with ketamine infusion. But I will say I will only do a serratus for more large bore where there's gonna be an incision rather than a pigtail where it's a little bit less invasive. How magic is ketamine? Right? 

Like, when we have when I Yeah. When we get those hip fracture patients out to the OR and they need a spinal, my typical formula is tenketamine, twenty propofol, push that in, wait till their eyes glaze over, and then turn them on their side. And you might get just a hint of a moan as they turn on their side and then a perfect. And then by the time you don't even need skin local. Like, you just do your spinal. 

And by the time your spinal's done, put them back, and they're kinda recovering from that keto fall. But Yeah. So I I I do that for most of my blocks nowadays. So if if a patient is tolerating it, I will I will do low dose ketamine with a block as a multimodal utility just because it allows them to chill. And I I I put I we had a issue with pushing it because people get a little bit they get a little nauseous, and they get a little bit of the the psychoactive effects of ketamine. 

So we generally put it in a 50 cc normal saline bag. By the time the nurse strips it in, I'm doing my block, and then it just it works like magic. Okay. Shoulder dislocation. If you gotta reduce the shoulder, what do you like? 

I I go back and forth. So I've done both. I I use intra articular lidocaine and see if it works. And then if it doesn't, I go to interscaling blocks. Okay. 

Yeah. That's right. I think it also depends on the patient. So for me, the 75 year old woman who has COPD and has a dislocation, I'm gonna be much more cautious of going below the clavicle. So we're thinking about, can you do axillary blocks without doing a suprascapular? 

I mean, you've talked about this on on your educational videos. So we're we're thinking about, can we just do a solo axillary at the deltoid? Maybe. So really, really low dose inner scalene. So I'll do five and just try to get c five, c six because that's really all you really need. 

So I try to get it just right between the middle scalene and right in that low area, pushing you know, open the space up, put five in, and then see if that works with a little ketamine. Yeah. Because the last thing I wanna do is is, in my COPD patient, have some frank neural paralysis. I I have a good example. I did, intra articular lidocaine on probably a woman that was a 100 pounds wet. 

Uh-huh. But she fought me the entire time of trying to reduce it. And I was in this minor bay, which is probably the size of my office desk maybe of how to do this. But I could get a monitor in there. Uh-huh. 

And so then I then I I I went to the interscaling. It was able to basically take the motor function, everything away, low dose interscaling, and then it popped right back in. It was just a matter of loosening the muscle. Do do you ever see that happen where you do the interscaling block and then you just wait a few minutes, the musculature kinda relaxes and it almost reduces itself? That's exactly what happened. 

I I externally rotated the shoulder and I was like, why was this so easy? Yeah. Yeah. 100%. 100%. 

That's great. Well, listen. Just flipping flipping joints again, it's so funny. On the January 7 this year, in anesthesia reports, there was a case report of a patient who had a pain block who they presented to the ED with a dislocation of a prosthetic hip. And for analgesia, they performed a pain block. 

And, actually, the hip popped back in by itself without any intervention. So, and, you know, we've always been told that pain blocks are supposed to be motor sparing, but but something must have happened there Yeah. Yeah. That caused that to kind of relax. So he's I'm I'm fascinated to hear that sometimes you do endoscalines and the shoulder sort of almost goes back in by itself. 

It's really cool. I I did a pain block, and I tried this. It didn't work for it. Okay. But the pain relief was awesome for their dislocated hip. 

And as you probably know, the ED is having nursing shortages. The ability to get enough staff to do procedural sedation in the ED has become a lot harder. And so these alternative methods, like trying the pen block, actually can try at least to make a difference. But for me, it didn't work. I'll try it again if this really actually worked for someone. 

Alright. Cool. We'll check it out. We'll we'll put the link maybe in the podcast notes. Sorry. 

I was maybe it's that volitional pain, like, with the with the or the volitional muscle contraction with the pain. It just they won't let you reduce it. And then if the pain's relieved, then it's less of a motor block, which is Yeah. That's it's more comfortable to move. Yeah. 

And we we we saw this with shoulder dislocations in the past. It was always about relaxation, not really about the pain. Yeah. Yeah. Yeah. 

Interesting. We'll be right back after this word from our sponsor. Hey, Jeff. I have to share some news with you. Oh, this sounds serious. 

Okay. You have my attention. Well, I was trying to do an interscaling block the other day, and I couldn't quite make out the brachial plexus. So I pointed to a structure on the screen, and then my resident alerted me to the fact that I was actually pointing to the power button. That's when I realized I need to start wearing reading glasses. 

Well, in addition to getting some readers, did you know that the Venue family of machines from GE Healthcare have a tool that just might give you the reassurance you're looking for? This sounds interesting. Don't tell me that with the push of a button, there's a way that the nerves can be highlighted. Hey. Are you reading my script? 

That's exactly what I'm gonna tell you. There's a feature called c nerve on the Venue family of ultrasound machines that when activated within the correct machine preset can aid with nerve identification prior to the performance of a block. Hey. That sounds handy. So in addition to brachial plexus, what else can it help identify? 

Well, the c nerve can also be used for the popliteal sciatic nerve and for the femoral nerve. Well, this is great to know. So it sounds like in addition to me getting my eyes checked, I need to head to www.gehealthcare.com and click on Venue Family to find out more. Yep. And I also have some news for you, Amit. 

Okay. So now I'm nervous and you've got my full attention. So our friends at GE Healthcare have decided they would like to collaborate with us here at Block It Like It's Hot. Tell me, what's the one exciting way you could see this happening? I don't know. 

How about bringing us together at the American Society of Regional Anesthesia and Pain Medicine Golden Jubilee meeting in Orlando, Florida on May 2025 so that we can record a live in person podcast. That's exactly what's gonna happen. Come and see us at the Glass Block Box in the Exhibition Hall at ASRA spring twenty five this May. It's gonna be so much fun. We'll be taking questions, recording live content, and interviewing faculty and delegates. 

I can't wait. I'll see you there. And now back to our show. Okay. Next question. 

Favorite brachial plexus approach, and why is it the raptor? Oh, not the raptor. Not the raptor. Okay. This this so I think it's I think it's the best block that we have if we're gonna do it, for a pure, you know, quote, unquote, anesthesia of the arm. 

The problem again is in the hands of you, great. Do it. But the problem is I'm gonna have to train a second year resident or a first year resident through this, and what I want them to do is safety first. And, they can learn this block by listening to some great podcasts you guys put down, websites. But I try not to walk walk junior faculty members or junior residents through this block until they're very skilled at needle localization and be comfortable not seeing the needle for two centimeters. 

Yeah. The leap of faith. So so so, Aaron, so if you were to summarize, what is your number one go to brachial plexus block? Not what you think is the best. What is your go to for for for all covers? 

I I like the supraclavicular brachial plexus just because it allows my learners to have a backstop. They see the grapes really clearly lateral to vasculature. There's some level of comfort, and they can generally go below. Again, we we don't sandwich our blocks. We kind of just go below because what they're gonna do is add other analgesia on top. 

So I'm okay with them not getting a perfect block and really just getting analgesia on board. Mhmm. And, Angie? That same supraclavicular block. I even say it sometimes they get a little bit higher too. 

It's like this in between interscalene and supraclavicular and low dose, and it seems to work great. So this is this is interesting for us. Go go on, Jeff. You're smiling. I want you I want you to give you a comment on that and then before I say No. 

No. I'm still laughing at I'm still laughing at not the raptor. No. It it is interesting because we we have spent a lot of time, Amit and I, talking about infra versus supra, and and it is a fairly academic discussion. I mean, they all will serve the same purpose. 

So a lot of it's more about comfort, your comfort, clinician comfort in doing it and safety profile and that sort of thing. And I like your point Arun about, you know, we're not trying to get surgical anesthesia here. We just need at least good pain control, some muscle relaxation possibly, but not a perfect I can do surgery on your arm block. That's right. That's right. 

Because, yeah, so this is where I think it's really fascinating to look at, you know, the same technique, but in different locations for different indications. It's so because if I had to teach a novice practitioner for surgical anesthesia, actually my go to block for teaching the novice would be the auxiliary. But in an ED, you kind of want a one and done, not something that's gonna involve lots of poking around even though it might be safer. Want something that someone can get set up, get in position, bosh, do it safely, and it's just good enough. Whereas, actually, I don't think infraclavicular is necessarily the go to in all of those either because although I I do love it, it's now my favorite block. 

Not all patients fit into that criteria where the majority of patients you can stick a probe in the supraclavicular fossa. But the way I do it for surgical analyses, Jeff and I disagree with this, you know, we have a big disagreement. I I think you have to be a little bit intra sheath, intra plexus to get a really dense block. And for that reason, I don't practice it because I don't think it's safe to do that. And I think doing what you're doing, which is just good enough analgesia wouldn't suffice my patients' needs for surgical anesthesia. 

So actually, it was the first brachial plexus block I learned. I did the most of it, and I remember putting a video out on one of the Elsora videos. And Ed Ed Mariana contacted me and said, great video, but, woah, that's very aggressive needling. We wouldn't do that. And so, actually, I don't do that block anymore. 

Yeah. And I think for our patients, if I have a distal I mean, upper extremity injury, I can't roll them up to get a nice view of the axillary arteries Yeah. And and the nerves, so it's really hard to move them. So I'm kind of stuck with somebody in usually a sling in that position, so that's why it's very hard to get to that position. And Yeah. 

Yeah. That that, again, for me, it's regional analgesia rather than anesthesia. I think you guys do anesthesia, which is great. Yeah. We're just adding on multimodal analgesia. 

Yeah. Yeah. Hey. I I'm reading a few case reports of people using genicular blocks for acute knee pain, and which is really fascinating because we use it for for surgical pain. But, have you had experience with this, and have you have you doing this? 

Yeah. So I think, it's this is interesting. This is, obviously, I'm gonna go back to a dad joke. Right? You come to an you're like, I have arthritis, and the doctor's like, yep. 

You have arthritis, and they send you home. So that's it's like right. I think that we all know like, the patient comes like, I have arthritis, doctor. You're like, yes. You have arthritis. 

Go home now. Here's here's a medication that was invented in 1842. It's called Tylenol, and you can take it again. Right? It's so I I think that the genicular block is is really nice because it allows pain control and analgesia. 

And I saw my mom get it when she was having, knee pain and eventually went to surgical repair. We have this conversation with orthopods. They love it. And so now instead of having them referred back to PMD, referred to orthopedics who then refers them to pain, who then does a genicular buck, We just have stepped in and have done it. And one of actually, Andrew's residents that came over to Highland really was the one who championed it in our department. 

We I've done a few, but he's really pushing it to to really get it as a standard tool in our tool belt for patients with known osteoarthritic pain. I'm loving that. It's great. Right? You know, it's such an interesting thing, teaching. 

His name is Joe Stegman. He's over at Highland now. But he mentored me on how to do this block, and now I've started doing it, which is such a interesting thing when the learner becomes the teacher. It's amazing how fast that that happens. Right? 

Like, I I joke all the time about all things I learned from YouTube. Like, I'm a amateur plumber, amateur electrician. But you and and also, like, you can I can learn how to do all these medical procedures on YouTube and feel like a quasi expert? Yeah. So so and then we talked a bit about your you alluded earlier about four arm blocks, and I think these are perfect for for your needs. 

Like, low risk, really can't hurt anything, super useful for all kinds of lacerations and whatever else you're doing for the for the hand and wrist. You use a lot use a lot, I I imagine. Yes. Yeah. It's it's become it's become really the de facto block in our we have a little urgent care outside. 

So it's our fast track or a low acuity area. And our nurse practitioners are and our physician assistants are APPs. Our residents, our attendings all do them out there. It's very common if you come with a hand injury at Highland, you're getting blocked and irrigated and then repaired. So it's very, very common. 

Wow. It works much better than local. Yeah. And are you doing them at the, the, like, the mid forearm level? Not not not so much the wrist. 

Correct. Right? Okay. Yeah. Correct. 

At the at the mid at the mid forearm. And it's nice because then then, you know, then then one of our techs irrigates the patient, cleans them up, gets them ready, and then the repair can happen. Patient's comfortable. They go home on oral medications. Yeah. 

And so it's kind of a win win for everybody. That's awesome. So cool. Anything else we're missing that that you use a lot that we're not thinking about? Well, do you know I wanted to ask them whether they do what are the fascia plane blocks you did? 

So, guys, you know, abdominal wall blocks or interpectral pector serratus or what we, you know, used to call PEX blocks. Are you guys doing those? And and and what's the indication for it? Okay. So tell me about some examples. 

So I I I use the you know, PEX one, PEX two, which now is a new name. Yeah. Yeah. But I do that for, again, breast abscesses. Women come in with breast abscesses for us. 

It's lateral. And and, again, hi. I have a breast abscess. Yes. You have a breast abscess. 

Here's some Tylenol. Go home. So, commonly, our surgical residents will come down, or we if it's small, we just aspirate those. But the patient's really there for pain. They know they have an abscess. 

So we'll use these blocks to really give good local anesthesia to those areas along with whatever medications you wanna use and either aspirate or get our surgical colleagues involved to come down if they're large and breast comes downstairs to do it to give them pain control. Because we've all seen people scream when people just get local for Big Art abscesses. So we do that, I think, commonly now. It's become kind of our go to for breast abscesses. That's great. 

We did a bunch for appies. We did a bunch of taps for appies just to see how efficacious they were. And I think it depends on the types of appies. If the appies touching the abdominal wall, I think it helps. I don't know how efficacious they are for early appies. 

I I don't I don't know. But we did that a few. I don't know how useful that is or how scalable that is to everybody else because most people are usually young and okay. And those are the two that I can think of off top of my head. I've done a lot of clavicular pectoral fascia blocks lately, mainly for people riding their bike with nasty clavicular fractures or skiing out in the rural areas where there are neuroorthopods for ones that actually need to be repaired rather urgently. 

And that way, it gives them some significant pain control as I send them to the tertiary care center that actually has an orthopod. Wow. Yeah. And that's a great one too because it's so so, again, risk free. You're just you're just basically putting local on the bone kind of thing. 

Yeah. Yeah. Works great. Super easy block. Oh, that's great. 

I wanted to ask you guys what are for our listeners as well, and I hope I hope that we have a lot of EM listeners as part of our audience for this particular episode, but what are your favorite online resources that we can link to in the show notes to give people more information? Oh, yeah. What are your go to teaching tools? My favorite tools for all ultrasound things in general as well as Neuroblocks is five minutes. No. 

Quick, easy hits of quick videos that give learners an initial kinda inertia. I I love that site. That's, Jalen Avila. Right? Like, I I have Yes. 

Learned so much from her over the years. Poke like, a lot of POCA stuff, but I there's a lot of nerve blocks stuff on there as well. So, yeah, I agree. That's a great one. POCAs Atlas would probably be another one that has some great images, especially for me to try and get the images really quickly for a talk maybe even. 

Arun has quite a few. Highland ultrasound is probably the best NerdBlock one on the web right now for EM. And, Nareun, do you have anything else that you wanted to add? Yeah. I I use, Jeff's website, our YouTube channel, all the time. 

It's something that we use for our residents. We we use it when we do we have a you you guys have Blocktober. We have a month where we do blocks for for journal club. And so we we make everybody watch all the videos. It's it's standard, standard operating procedure in our department for all of our residents to watch all that stuff. 

And it's really just come back, ask questions. How does he do it? How do you do it? You know, what does he do this for? Why do you care about this? 

This is it allows us to to increase the space, increase the thought process, and it's done so well. I think the education is phenomenal. Yeah. 100 I I echo that. I mean, I you know, every time I need to do something, the first thing I do is go on Jeff's YouTube and say, let me just make sure I'm doing it right. 

Thank you. Thanks, guys. Appreciate that. That's great. I'm glad it's a I'm glad it's a good resource. 

We'll put we'll put links to all these in the show notes, guys. So if you wanna check out all these different resources, they'll be there for you. So, guys, is there anything that you think that we haven't covered in this podcast episode that's important for you to get across from an ED perspective? Yeah. I think that I think the the the beauty of blocks is multimodal pain control and really reducing that initial insult of pain, which when you break your hip or you have a humeral fracture or you're going home after back pain. 

And I think that the key when we do these blocks is to really give good instructions to the patient. And that means because your pain is zero, does it mean you need analgesia still to prevent it from coming back? Because I've seen this. I've seen the discharge, and the patient is pain free, and then they they come back with a severe, severe pain, which sometimes is even worse than the initial insult. And so I I tell them that that pain management for the first twenty four hours post block is should be almost like antibiotics. 

You're just taking it before the pain comes on, and it's really to reduce that rebound pain. And it's something that people forget about in the ED. He said rebound pain, Jeff. He said rebound pain. That's a trigger alert. 

Okay. Sorry. Sorry. So, Irene Irene, carry on. Yeah. 

Yeah. So I think I think just as as ED docs, we have to be very cognizant of the fact that I know we're taking care of their pain, but we have to give them instructions on when it comes back, how to deal with it. And I think it it's not a one and done high five your friends and walk out of the room. It has to it has to be a little bit more nuanced than that. I I think we were all doing it as EM docs already when it comes to kidney stones, especially saying, take your Tylenol, take your ibuprofen around the clock no matter what if you're having your colicky pain because that will help reduce what may happen in the future. 

We have just applied the same thing to blocks, so that three days from now, they're not coming back with severe pain. Yeah. Well, you know what? This is fascinating because we assume that all of our listeners will do this because in anesthesia, one of the things we talk about is you have surgical, anesthesia from the block or or or an analgesic block, and and then they go to the the ward or they get discharged home and we know that block's gonna wear off. So it's kind of ingrained in our in our in everything we do as as people are controlling pain to do that. 

But actually, it's a step that many people miss out from all specialties And especially when you've got, a new enthusiastic community, emergency physicians that wanna learn blocks, you don't want them to come undone or fail at the first hurdle because they have a whole host of patients coming back. So thank you for reminding us to talk about that. I think that's super important. Yep. Great instructions. 

Well, good. Well, this has been a great conversation. I have loved talking to you guys because it it's just a different perspective. Right, Amit? Like Oh, a 100%. 

You know, we one of the dangers of the two of us just, talking to each other is that we, you we're both, you know, either agreeing or arguing with each other, and we don't get perspectives outside. It's a regional anesthesia nerd echo chamber. Yeah. Absolutely. But and we've taken some amazing things. 

So what was that what was that phrase we're gonna use? I get controlled motor what was what was it? Controlled motor deficit. Yeah. Oh, love that. 

Yeah. That would happened if it wasn't from this. I mean and it's and it's really fascinating to to hear how you apply different principles, the same techniques that we can all perform, but and I love that whole kind of, I want everybody to be able to do this technique so I could do this, but actually what's important? And this is you know, I want all we want everybody to get access to regional anesthesia, so I'm gonna teach this technique. Awesome. 

Well, this has been amazing and so much fun, guys. Thanks so much for joining us. Thank you so much. Thank you for having us. Thank you. 

Yeah. Thank you, guys. We've learned so, so much. So, folks, please do like and subscribe to our podcast from your usual podcast provider. Please give us a rating. 

I'm hoping after this episode, we're gonna get a full five stars from all of you. Let us know what you wanna talk about next. Jeff, where can they follow us? Well, they can follow us a bunch of places, but first, I wanna make sure we have the well, I wanna know how to get to Blockheads. How do we Oh, yeah. 

Yeah. What is the website for block is it Blockheads? It's blockheads-em.com. Okay. To check out that website, go to blockheads-em.com. 

We'll put a link in the show notes. And and we are having a course in Miami in April, so please join us if you wanna learn some specifics on EM blocks. Perfect. It's in Miami, guys. Miami. 

I'm booking one ticket now. Is it at a brewery? Yes. It is. It is. 

Oh my god. Okay. We're you know, I I need to change how I live my life. Be be more like be more like a Blockheads. I it does it is there Blockheads merch? 

Can I get a Blockheads T shirt? Yes. Yes. We will we will we will send both of you Blockheads merch. We promise. 

You guys are getting Blockheads merch. Fantastic. Oh my goodness me. Sorry, guys. We're stopping the ending of this podcast because we're trying to hook ourselves up with some Blockheads merch. 

I apologize, but this is all it's all about us at the end of the day. So you can follow us at Twitter on Twitter, Rex at block underscore hot underscore pod, bluesky@bilih.bsky.social. There's YouTube at block it like it's hot. And why do I always save the worst one for myself? You can also follow us at Insta at block underscore it underscore like underscore it's underscore hot. 

Please don't forget our hashtag hashtag block it like it's all or our new abbreviated hashtag hashtag b I l I h. Get involved with the conversational line, and please tell us what you wanna hear next. Ask us some questions, and I want you to get engaged with this this ED episode. Until the next side, guys. The next episode, we hope you all block it like it's hot.