S3:E6 "Live from the GE Healthcare Block Box Part I 🎤: A conversation with James Kim, Sandy Kopp and Nadia Hernandez"

Ladies and gentlemen, welcome to Orlando International Airport. The local time is 2PM, and the temperature is a lovely 82 degrees. Please stay seated while we taxi to the gate, and remember to collect all your microphones and hoodies. We know you have a choice when it comes to podcasts, and we appreciate you being a loyal listener of Block it like it's hot. Welcome to Azra Spring twenty five brought to you by GE Healthcare. 

We find Amit and Jeff beginning their in person catch up on Thursday evening at the reception in the Exhibition Hall in something called the black box. Oh, and in our excitement, the microphones get a bit hot. What can we say? We're excitable. The audio settles down after a few minutes, so bear with. 

Partner. How are you doing? Howdy. Howdy, partner. What are we in the Wild West now? 

Yes. We are. I'm doing well, man. How are you? Well, I'm doing very good. 

But, Wait. Hold on a second. Something just feels different about this. I I feel like today's podcast is just a little bit well, I can't put my finger on it. What's what's going on? 

Well, I was kind of wondering how long it was gonna take for you to say the most obvious thing. This we're we're actually in the same country, in the same place, at the same time recording the podcast. That's it. But we you know, what on earth is going on? How are we doing this? 

We've never we've never done this before. Come here and give me a hug, man. We haven't done this before. Man. That's There we go. 

Good to see you. You have a day softy. So where are we in the world, and how did this come to be? Well, we are extremely grateful to our friends here, GE Healthcare. They are collaborating with us. 

They brought us together for the first time to record this podcast in person. So this is a joint venture. Now why are you rubbing at so we suddenly interrupted. Now in case people hadn't realized, something else is a bit different here. Right? 

So That's right. Yeah. So we're in this glass black box, recording the podcast for GE Healthcare. This is crazy. Right? 

Exactly. A big thank you to GE Healthcare for putting us together and believing in our podcast. And now for the folks who are listening without the benefit of the video feed, we I think we should give a little more context here. We're inside this box, this triangular box. And Is it a triangle? 

It's roughly triangle. Trapezoid? I don't know. Yeah. I didn't pass shapes when I was a in an exhibition hall at Azra Spring twenty five or Azra fifty. 

This is the golden jubilee meeting for Azra, which is crazy. Right? In Orlando. In Orlando, Florida. It's in more specifically speaking, we're at the Rose and Shingle Creek Resort in Orlando, Florida. 

Orlando is one of my favorite places in the whole world. You don't say. But we're not here for the dude with the big ears and the talking dog who's got a pet. Right? You Pluto? 

Pluto. Yeah. No. Pluto is the dog. Okay. 

Pluto is dog, but but the Goofy's you know, Goofy's also a dog, but he's like a human dog, but yeah. Confusing and somewhat creepy. Yeah. Now as much as we love that theme park that starts with a d that you're referring to, we are here for the fiftieth annual regional anesthesia and acute pain medicine meeting. This is the golden jubilee. 

Yes. Fifty years. It's running May. This is going to be a really fun meeting, man. It's going be amazing. 

We're going to catch up with some, some colleagues Yeah. While doing our podcast right here in the middle of it all. Absolutely. I mean, you know, the thing that I'm most looking forward to is the meeting is really, is really exciting. They're talking about safety, efficacy, innovations, in regional anesthesia. 

So I'm I'm interested to hear what people have hear about the meeting and also what they've learned. But the thing I'm looking forward to the most is meeting some of our friends and our colleagues and bringing them in here. We're bring them right into the BlockBox with us and interview them and and find out what's what's happening in their lives. But we've always talked about how we wanted to get guests on the podcast, and this is, like, amped up to the next level. So we're getting, like, all of the guests. 

It's a little different having actually sitting beside you doing this. I'm still not quite used to seeing you. You're looking at a screen and seeing your face. I know. Lovely face. 

But now I'm Well, thank you very much. Yeah. It feels like you know, I almost feel like this is not real. I should be looking at a small screen with your face, but it's great. But, actually, now we can see what our listeners are looking. 

In fact in fact, if you look, you can see that this is a live exhibition booth. That's me looking at the camera over there, and I was seeing my face over there, and this is, like, blowing my mind, but this is crazy. At some point, I might have to take these ears off. I'm not sure if are they working for me? Oh, no. 

My ears have folded forward, but that's that's the ears are left. Yeah. But but what's lovely is you can see this is an active booth. There are people doing stuff in the background. So, if you got sharp eyes, you might be able to see what's happening. 

And if you wanna join us, you can come with feature in the background as well. But I'm Wow. There's like there's like a ripped dude behind us getting getting scammed. Oh, that's me. That was a picture of me from that's you. 

Yeah. Listen. We I think we've done enough chitchat. Should we should we get into the let's get into the the nuts and bolts. Yeah. 

Let's before we do that Yeah. I've got I've got a joke for you. Okay. I'm gonna put my glasses on because I need to hear this properly. Okay. 

So Okay. I can't put them on I can't put them on with my ears. Alright. Oh my there are oh my goodness. There are, some Oh my goodness. 

Flamingos. Hi. Wow. How are you guys? There's some flamingos over there. 

Stilted flamingos. Wow. Hello. How can I get an effort like that? We'll trade. 

Yeah. Do some tradesies. Okay. I'm sorry. It's so you do have a joke? 

No. I do have a joke, but I have to share something. I've been hacked. Like computer hacked? Like, yeah. 

My my password was hacked and, like, people had my account and stuff. So I wanted to tell you and our listeners that if you Oh my god. This Okay. So, like, the camera is like, oh, that's better than go. You can see the flamingo. 

They're getting right in on the action. This is what we've been missing by not having a video podcast. Right? So How do you how are you doing that? Like, that that takes some serious quad strength. 

Very long tibias. Yeah. Look at that. Oh my okay. This is gonna have to go out after 9PM. 

Hashtag Flamingo Squats. Flamingo Squats. Okay. Sorry. So so go back. 

So you've been hacked? Hacked. Okay. It I just want to let I took listen. It happened. 

But I wanna let our listeners know that if you get an email from me saying about canned meat About canned meat. Don't respond. It's spam. Oh, gosh. Why didn't I see that coming? 

Listen. Thank you very much. That is absolutely terrible. No. Wait. 

I have a I have a different joke now. Oh, okay. Okay. So It's bad. Okay. 

Sorry. I may I'm just getting over it. I was I was playing with the kids. Uh-huh. We were making paper airplanes. 

Yeah. Took a piece of paper, folded it up Yeah. Threw it as you do. And instead of going across the room, it just sort of stayed there hovering. A hovering paper airplane? 

Yeah. Did it move. Okay. And that's when I realized it was stationary. Oh my goodness. 

That is the worst. I don't know if you guys can hear that, Jay. That was the worst joke I've heard. Okay. Are you done now? 

Have you got any more? Yeah. No. That's okay. Okay. 

Listen. Before before I tell you my joke, I gotta tell you something really cool. So I arrived at Orlando Airport, and you know they've got carp. They've got a koi carp exhibition there. Did you know that? 

Koi carp are those fish. Yep. Those goldfish. Yeah. They're goldfish. 

The airport. They've got well, they're not goldfish. These koi carp are massive, and they got, like, a wildlife guy. Eat them? I don't think so. 

They're expensive. And there was a wildlife guy that was there, and he was giving me some information about the koi carp. And he said, you know what? Koi fish always travel in groups of three with one phony. So I guess there's groups of four, but three koi fish and one phony. 

So if attacked, koi a, b, and c will scatter, leaving behind the decoy. No? Okay. Okay. That was terrible. 

Okay. So my I'm okay. That was really bad. Oh my gosh. What is the difference? 

Okay. I'm gonna go into the real jokes now. Okay? What's the difference between a camera and a sock? What is the difference between a camera and a sock? 

Sock. Don't know. A camera is for photos, and a sock is for five toes. Photos. Five toes. 

That's good. Come on. Come on. That's pretty good. Okay. 

Yeah. Yeah. Okay. One more. One more. 

Okay. Okay. A man walks into a bar Right. With a big grizzly bear, And the barman says, what's the story? And after a short pause pause after a short pause, the guy says, bear with me. 

Bear with Okay. That's that's literally terrible. Well, that's a good way to start. Yeah. Yeah. 

I like that. It's just set set the tone. Right? So I feel like I need to retell the COI comp. Did it come across No. 

A COI b. Deco yeah. Deco. I was gonna go with COI d, but it didn't No. Didn't make sense. 

No. Yeah. Okay. Our first guest in the block box was James Kim from the University of Texas Southwestern in Dallas who had some great thoughts about catheters and more. I cannot believe I'm here. 

You are the first live guest we've ever had on Blocket Like It's Hot. We're making history here. Well, you really are. You are. My goodness. 

I feel a a great affinity for James because this is second time we've met in person. Right? The first time we met was at an ASRA meeting two years ago. Fort Lauderdale. Y'all saw Florida. 

Was that was that was that Fort well, I thought it was Miami. Hollywood, Miami. They're kinda close. Okay. Well well, that was great. 

Since the first I met, James, but for everybody who's watching the podcast, tell us a bit about who you are, where you work, and why you love regional anesthesia. So my name is James Kim. He's like, oh god. I didn't know. Currently live in Dallas, Texas. 

I'm on faculty at UT Southwestern. Okay. I You should stop drinking. Sorry. I've had that no. 

No. Said no one ever. Okay. I've had the the distinct pleasure of training under Jeff at Duke in 02/2016, and he has been a huge inspiration to me to to really pursue a career in regional anesthesia and then also stay on in academics. Oh, fantastic. 

Yeah. Now I'll I'll gonna just do a little bragging here. Okay? So James, one of the best fellows we ever had. If I said he was the best fellow we had, I'd be offending some Right? 

Like, Malika's right there saying, like, oh my what? How about me? What the so Malika. One of. One of. 

One of. Okay. We're winking here in the background. But so James came I I I don't even know what we did for James. He came to us, like Already good. 

Right? With hands of gold. Every now and then you get a fellow who you're like, what can I teach this person? They're already great. Yeah. 

So did you say he he taught you the jokes. Right? Did he teach you any jokes? Because that's obviously gonna be I don't know. It was all We might have we might have fell short of him. 

Just kidding. It's all business. Yeah. Well, that's all gonna change because you read the sign on the door. Right? 

Dad joke required for entry. Ah. Okay. I do have one. Okay. 

Well, hold on. Hold on. But but, Jeff, which is bigging you up. Sorry. Interrupted the Yeah. 

I go like, continue the the the bragga the bragga show bragathon. Bragathon. Bragathon. So James then went on to he he graduated with, like, this incredible skill set, went on to take a job at UVA. And just for those non, US people, UVA is University of Of virtual anatomy. 

Vir virtual anesthesiology. Oh, that's like when you do anesthesia from home. I'm doing my worst American accent ever. It and the block gets in. Yeah. 

It's like when you get a degree great career. When you get a degree online. Yeah. Yeah. Like, go on. 

What is it? Victorian Albert? University of guess. Virginia. Virginia. 

And what's the name? Of it. Also Virginia. Virginia. Ah. 

Yes. Okay. University of Virginia. Virginia. Yeah. 

Okay. Yeah. K. So we Lovely place. James crushes it there, excels, like and then he decides to go to Philadelphia, Penn, UPenn. 

I'm a lizard. So that's what okay. Alright. Okay. So I knew that you were there. 

Oh, because I used to see you on X or Twitter as it was then talking about all the Penn stuff. Okay. Yes. Yes. Yep. 

And then he was He's now moved twice. Yep. Twice. And then recruited heavily to become the division chief at UT Southwestern. So, basically, like a big cheese? 

He's a big cheese. A slice. Okay. He's like I'm a slice. Gouda. 

Okay. He's Gouda. Gouda. Gouda. He's Gouda. 

That's a Gouda. That's a Netherlands joke. Okay. So, anyway, so now he is the chief of regional anesthesia at UT Southwestern and the program director for the fellowship. Wow. 

Okay. Yep. So he's he and he's just doing amazing. How many times have you won teacher of the year since you graduated from Duke? Oh, one at one at one at every institution. 

One at every institution? Oh, wow. How about that? That's pretty impressive. Is it? 

That's pretty impressive. Isn't it? Yes. Like, to win teacher of the year once is pretty impressive. So, you know, I I was sharing this with Jeff. 

I attribute a lot of that not just to the fellowship, but to all the nice work shops where he has graciously invited me to teach. Yeah. And the amount that I learned from him outside of my fellowship during those sessions, just his teaching style, his PowerPoints, and Yeah. Yeah. Just Do you use PowerPoint? 

Oh my god. I'm not gonna talk to you. I thought you're a Keynote guy. Are you using PowerPoints? It's Keynote. 

It's Keynote. Keynote. I mean, Keynote. Okay. Just picking up his teaching style. 

Feel like Meg Rosenblatt. Just saying hi to Meg Rosenblatt. She's out there. Okay. Amongst the flamingo. 

Meg, come come come right behind us. You'll feature in the background of the podcast. Oh my gosh. This is Nadia Hernandez, one of our net. Don't interfere with James' moment, Nadia. 

Okay. Sorry. So we since he was talking. Yeah. But Yeah. 

Yeah. So, basically, you're saying Jeff uses Keynote Do know? Power power point. Yeah. Yes. 

And and he was great. So listen. I've learned a lot from him virtually from watching his videos on yeah. I gotta say, I I actually sent him a screenshot, you know, when you get your your residency evaluations and they write comments. One of them not one, several said, it's like I'm getting a personalized NYSORA And it's all it's it really is. 

That's pretty amazing. Yeah. Yeah. Yeah. And so it's it's really nice to as as an educator yourself, it's you know, you're you're really making an impact on all your trainees, and we're just proliferating that that teaching style Well, it's to the that's one of the beauties about having a fellowship is that you you train the whole host of regional leaders for the future. 

And if you've got that type of magnetic style or that or there's something charismatic about your teaching style, you infuse the people that you're teaching, and they carry that on. I think it's a wonderful thing. Listen, Jeff. We gotta get James to tell us a joke. Okay. 

Because I think, you know, we're this has been the big up Jeff show. I need to know the joke. I I have a I have a joke. Now I know dad jokes are usually just like a one liner and then an answer of one liner. Can I can I do a thirty second joke? 

Oh, yeah. He does this all the time. I'm like, what is he telling me? Is this a story? Or how might you never admit this? 

This is in light of all the the the the travel affairs I had yesterday, the difficulties I had getting here. We heard. Alright. So here's my dad joke. Okay. 

There's a plane full of professors of aeronautical engineers sitting on an airplane ready to take off for their national meeting. Okay. And then they learned that their very students designed that plane in which they were sitting. Oh, right. That leads to pandemonium, and everyone, you know, gets up and runs to the door to try to avoid this death trap. 

All but one professor who just sits there quietly and calmly. The passenger's sitting next to him goes, why are you so calm? Are you sure you taught them well? To which he responds, no. But I am sure we're we're safe because this plan will never take off. 

Okay. So, hopefully, we don't have that attitude toward any of our trainees. That's fair. When we train them, we can, you know, send them off very confidently and say our regional plane will take off with with our, trainings and those we educate. That's good. 

I like how you tie that in too. Have you got a specific question for James? Because if not, I'm I wanna ask one of those questions as up there on the screen. Why don't you no. Let's go go ahead. 

I wanna answer these questions too. So I I appreciate that I'm kind of asking the question probably to the wrong person. But the first question we got there and when I say the wrong person is because you're already a big fan of these. So the first question we've got there is what are the main barriers for using peripheral nerve catheters? So do you see any barriers to this? 

Or I guess if you flip the question on the side, why do you use peripheral nerve catheters in your practice? The biggest barriers, that I can see are just the the time and the man woman power it takes compared to a single shot and and sending them off. If you don't have that infrastructure of the follow-up of of an actual acute pain service, We can follow-up with them. That seems to be a big barrier. So tell me, in an ideal world, what is the infrastructure you require to run a safe and effective proof on the service? 

I I can from personal experience, I can only speak from Yeah. An academic institution level. But, typically, someone, whether it's, you know, a a a trainee, resident, fellow, where you don't necessarily have to be in house. Like, it's pager call. Yeah. 

And then a a faculty who's also on pager call who can address any of the issues with any of the peripheral nerve blocks or the epidural catheters as well as actually staffing and placing them in an efficient manner. So that's the that's the key. Right? By the way, if if you are people who are watching a video can see professor Peter Hebbott has jumped in at the back. He's coming all the way from Australia. 

Peter. How are going? How amazing. This is so this is I love that photobomb. That is a photobomb that's worth keeping. 

We should frame that. So what I'm trying to work out is what proportion of your faculty can cite single shot peripheral nerve blocks versus continuous regional anesthesia or continuous blocks? Is there a difference, or do is or all of your blocks only cited by by the regional anesthesia faculty? The the the latter. Okay. 

And and I understand that that's a luxury that we have. I know a lot of practices don't have that luxury. Right. I can speak for just the feedback that I've received from graduated fellows and residents who have gone on to to private practice. They just the the the whole workflow of placing catheters and managing them, it's far and few in between at this point, and they haven't done them in such a long time. 

So in a year or two, when they go back to try to do it, they'll they'll call me or text me and say, hey. Can you just remind me again? Yeah. How do we do this? Do we place it. 

Yeah. So time. Tell me about time. Single shot block. You need duration of action. 

No. Time to insert. Yes. Oh. So the average block The the average block, if originalists were to place it, I don't think would be a problem. 

Right. Right. Because, you know, we work in efficient service. You get it done without issues. How long does it take to put a catheter in? 

And don't you answer it? I want, you know, I want your your part of one to answer that. My myself or Yourself and then one of your less experienced faculty members? Double catheter, so sciatic plus adductor. Yeah. 

So when all the kits are already open and ready to go, five minutes for both. I mean, that is No. Okay. Okay. You okay? 

Right? Okay. I'm gonna ask you people out there. Does it take five minutes for the average person to put nerve catheter in? If the answer is yes, you need to come and take my job. 

Ask the average person. No. No. I can sit here. I know that. 

So he's not But let now let me follow. Now when I have a trainee and I need to walk them Yeah. Yeah. Twenty to thirty minutes depending on the trainee. So that adds a lot of stress. 

If you got to run an efficient service. They have everything in their hands from start to So they do it all. Yeah. And you're just talking through I'm just talking them through it. Yeah. 

Okay. Catheters. Yeah. Take some time. But it's investment into the patient's experience. 

And if you have someone who's got, say, an amputation, that's a horribly Okay. So that right. So I can okay. Hold on. Amputation. 

No. No. Amputation. When you do an amputation, if you're doing an above knee amputation Uh-huh. The surgeon sees the nerve. 

So why can't they just thread a catheter in there? I'm not trying to say I'm not against catheters. Right? But I'm just trying to look at think outside the box. So if they're gonna cut the the leg and they see the nerve, why can't you get the surgeon to put a catheter in at that point? 

That's certainly an option. But what we find a lot of times with the amputations is they're coming in with a threatened limb with ischemic pain. And so we'll block them a day ahead of time. So that I get that. And I think that's a difference. 

So I guess I guess the the reason why this question resonates with me Right. Is I'm working in the National Health Service in The UK. So we're we don't have block rooms as a regular part of what we do. We're time limited. We've got to get, we don't if we don't haven't got a block room, and we have got a small room before theater, the operating room, the patient comes into this room. 

We'll do our magic and get the patient into theater and keep the turnover going. Right? So we could put these blocks in, but not everybody in our service is capable of doing catheters. So what about the fact that you put this catheter in under guidance, and you hope you know where it is, But sometimes catheters migrate, and they end up going to places where you really don't want them to go. So we all have heard about the intrathecal interscaling catheter that was topped up on the water afterwards. 

That's some you know, that's the thing that's happened before in the past. Doesn't We have we have heard of that. What? Have you not heard about this? Wait. 

No. When did that happen? Okay, guys. Let me tell you about this. You heard it? 

Pull up a chair. Sit down. Relax. So It's papa. Yeah. 

Papa Papa Power is gonna say this story. So so there was a Don't put a catheter in camera so you can hear this. So so there was a nerve simulator guided, interscaling catheter that was cited as part of general anesthetic. This is by you? Not by me. 

Okay. Alright. God. But the people who did this published it, which is what I think is great. Amazing. 

So they did a nerve simulator guided into skinning catheter. They lost their twitches at point three milliamps. They gave a bonus to the catheter. The patient had a general anesthetic, then they were sent off to the ward afterwards. Well, they got to the ward. 

A few hours later, they started complaining of some pain, given a bolus. The next time the patient was reviewed, five hours later, rest in peace. Right. And when they did a post mortem CC scan, the cath had migrated. So I guess what I'm saying to you is, I hear all of this, but there is a potential for some crazy stuff to happen with these catheters. 

Does that ever worry you? I when's the last time you placed a stem only guided catheter? Back in the nineteen hundreds? Right. Okay. 

So what you what you're telling me is yeah. What you're telling me is that your that your, root for putting catheters in is all ultrasound guidance. I I'm being controversial because, listen, of course, I love that's a surprise. Right? Shocker. 

Yeah. I I I do I do like catheters. I don't do them regularly, and we managed to get away with a decent service without doing it. What I'm just trying to work out is there are some things that sometimes Why are you being a hater, man? I'm not being a hater. 

Yeah. Because sometimes catheters move, and they end up in places where you don't want them. Elective arthroplasty cases. How many times do you guys put catheters in for those those cases? Tons. 

Loads. What percentage? Percentage of my arthroplasty cases? We did it for several years to do See how he's changing his story now? I was there for the catheters. 

Yeah. Yeah. So for a long time, I did a ductal canal catheters. And Are are you still doing those now, routinely? Are not. 

Oh. Oh. Did you see oh, yeah. Okay. Okay. 

Led me down the garden path. Are we. Yeah. Okay. Yeah. 

Well Okay. So why are you not doing catheters for those cases? So part of the issue is is the migration. And we and we actually I've won this. Yeah. 

Okay. Is well, sorry. Was this a pro con debate? Was I supposed to prepare a pro con debate for this? I'm just It's a preview. 

I have a I'm a catheter fan, but there are places, and the adductor canal is one of those places where when the patient gets up and starts doing their physical therapy Moves. You see this? See what I'm doing here? Absolutely. Yeah. 

Yeah. That catheter gets displaced. And we actually show Are you saying the catheter is dislocated? Yes. Of course. 

And we did a we did a study we presented at at ASRA seven, eight years ago showing that if you put them in pre op, by the time you get to PACU, eleven percent of those catheters were no longer in the duct canal. From pre op to PACU? Yeah. Yeah. So think about it. 

Tourniquet, the surgeons moving the knee. So that's a barrier. That's a barrier. I we do so that changed our practice to doing post op catheters. Okay. 

But But then even then, by the next day, it's just it's one of those areas. Okay. So cathodic dislocation is one barrier. Yes. The the dislodgement the the premature dislodgement for sure. 

Okay. I'm gonna flip it around because I want I want it all be about positivity. Yeah. Tell me what is the one indication or two indications we think you couldn't manage without catheters. I think that's a useful take home message for this. 

So do you have them? Amputation seems like a fair. Yeah. The amputation for sure. I mean, we're I know you you mentioned seven days. 

We're we're leaving them in for even longer as Nice. Yeah. And are you tunneling them? We don't tunnel them. No. 

It's a we we Dermabond, wrap wrap, Steri Strips. And then once in a while, we'll have More than seven days. And then once in a while, we'll have to redress it. But yeah. Wow. 

Okay. Yeah. There's actually a paper by Kumar et al Okay. In the anesthesia journal, the orange one. Al one? 

Yeah. Yeah. Yeah. Uh-huh. Yeah. 

Great. Great publication. And talking we we tested different catheter securement types. Oh, I've seen this. Yes. 

Yeah. What what was the winner? Chicken dinner. And there was there was there was it was a specific type of So the glue helped. But then Do you remember the, the Dermot Monk glue? 

Was my fellow poster. That's right. Yeah. Yeah. Right at the juncture between the alligator cliff. 

Tell us more about that. Yeah. So we're we're looking at the the premature dislodgement rate Happens to a lot of guys. Among all the catheters. Okay. 

Sorry. The dislodgement from the catheter and the clamp? From the actual junction. Yeah. Between the catheter and the Thurry Borst or the alligator clip. 

Okay. Thurry Borst. Holy. Yeah. Fist bump for using the phrase too many bores. 

That's right. What we wanted to do is just see what is a net zero cost way Yes. To secure this a little bit better. Okay. And we were using Dermabond for all of the insertion sites. 

Okay. Always had some left. Yeah. Yeah. We just started put placing some of that Dermabond right at the junction to see if that would actually minimize the dislodgement. 

And that stopped the catheter from coming out? Dropped. I don't Well, not stopped. I I have to look at the I have to go back and look at the numbers in terms of the drop in the incidence of dislodgement, but it went down. From what I remember, it was about thirteen percent to about five percent. 

But I've also seen people putting the Steri Strips. Yes. Okay. Did you guys do that? And you ah, that's it. 

Okay. Yeah. So what always the weakest part of the whole system. Yeah. Yeah. 

Yeah. So the what I found to help a lot is if you Can you guys see this on the camera? Yeah. Okay. Let's we need to At least we gotta have that actual We need a white background. 

Yeah. Okay. Yeah. So if you have the actual oh my gosh. There's so many people there. 

People. If you stand in the background, guys, you'll get on camera. I Oh, gee. Look at this demonstration. Yeah. 

This is impressive. Yeah. Yeah. Have your Can you do this without seeing again? I wish okay. 

Oh my So let's say this is the Can I just narrow it to this is why he is three time teacher of the year? Yeah. Because he can you look it's like he's just he's like MacGyver. Is that MacGyver? Do remember MacGyver? 

So dude, I grew up in the nineteen hundreds. Sorry. Yeah. Yeah. Okay. 

So pretend this isn't here. This is the tip of the catheter. Okay. Or the the clip. Okay. 

Yeah. Oh, yeah. The Right. This is the clip. So if you double down like this Yeah. 

And then place a catheter from here on out. A serous strip, you mean? No. No. No. 

I'm sorry. A, TEGADOM. TEGADOM. TEGADOM. TEGADOM from here on out. 

And you clamp the the catheter to this part of the the catheter as well as here. Yeah. Ain't no way that's coming out. Try to, yeah, you try to yank as hard as you can. It when when tegaderm So the tegaderm was on ice. 

It's complete yeah. When when it's in full contact here, it is nearly impossible to rip out. That really changed my practice. Okay. That's cool. 

Yeah. That's yeah. That's a good tip. And you get a free mint as well. Yeah. 

Oh, thank you. Appreciate that. Yeah. Maybe after the beer. Well, James, thank you so much for being part of our podcast. 

Yeah. You are the inaugural guest, man. Oh, man. You always have honor. You always have that. 

I was gonna say honor, but is honor really mean, might not be on the bit. It's a it's we are honored to have you. Moving on. Next up was Double Trouble. Sandy Kopp and Nadia Hernandez come by to talk about guidelines and pocus. 

Okay. Jeff, this has got to be, like, the best day of my life. We are in the GE Healthcare glass black box Yeah. We are. With with these two. 

Right. Like, how exciting is this? This is, like, amazing. Okay. So do wanna start off? 

So we could get into asking them to to the questions, so we tell us a bit about who you are. There's a camera over there. Tell us a bit about who you are, and why you're here, and then Nadia do the same, and then we're gonna go straight with the jokes. Right? Oh my god. 

Jokes first? Yeah. Yeah. Oh, wait. Oh, no. 

Okay. I'm Sandy Kopf. I I work at Mayo Clinic in Rochester, Minnesota as well as the Mayo Clinic Health System. I have been involved with ASRA for twenty four years. Wow. 

I'm not even 24 years old. Haven't missed haven't missed a spring meeting in twenty four years. Oh, wow. So you started coming when you were 10. Yes. 

I was. Maybe 11. Maybe 11. Alright. And I'm currently the treasurer. 

And at the end of this meeting, I'll be the president-elect. Wow. How cool is that? That's amazing. Okay. 

So, basically, a really big deal. Yeah. Yep. The other thing we're gonna get into in a short while is that Sandy is basically the guidelines queen for AZRA. She's been involved with anticoagulation guidelines for a while. 

She's now the big boss of the anticoagulation guidelines, and she was also involved in infection control guidelines. So some of the questions we're gonna ask her a bit later are gonna be about that. Do you like the do you prefer the term queen? Or I heard big boss was also in there. Oh, I think that's a better one. 

You said big boss. I said or or or is Doyen. I've also heard Doyen. She is a Doyen. There's no doubt she's a Doyen. 

So we is good. I like queen. Queen? Yeah. Yeah. 

I was gonna go big boss. Yeah. Okay. I big boss, and I cannot love to go big. Sorry. 

That was so I mean, I set myself up for that. Yeah. Well, did you set me up? Maybe you did. Okay. 

Okay. Doctor Hernandez, tell us a little bit about yourself. Well, I'm Nadia Hernandez. Thanks for having me on the show. I I was in academic medicine. 

I was at the University of Texas for ten years, where I was the chief of regional there. I really dove deep into the academic world, lectured all over the world now, I guess, in every state in The US. And I do a lot of educational events, I would say, and that's probably where most people know me from. I'm a fifteen year as a member. Wow. 

Yeah. Nice. Yeah. I don't think I've missed a meeting either. Next year, unfortunately, I can't come, but I don't think I've ever missed a meeting either. 

And that's probably why I know you guys so well. How does What is it about the Azra spring meeting that makes it so special? It's family. I think Yeah. Oh, we can't hear you, Jeff. 

But Jeff asked, what is it about the AZRA spring meeting that makes it so special? And, I'm gonna say what I wanna say, which is what I why I always recruit people into regional is that there's a next level of camaraderie, amongst our group. I think in some situations, there's a lot of competition, and we are just the complete opposite. We propel each other. We support each other through the good, through the bad. 

We never bad mouth each other. We know that we can all be shiny stars together in the sky. Oh, wow. Anyway I love that. That's another bumper sticker. 

We seem to be generating bumper stickers. I wanna be a shiny star in the sky. Yeah. There you go. Well, at Alzra, you can be. 

Yeah. Yeah. There you go. Agree with you. It's always it's supportive is the It is. 

Is the word that comes to mind. Like, you you feel like look. We all have our insecurities and our demons and our impostor syndrome times, and we come to something like this, I think, and people are there to validate you. And Well, the nice thing is you you look around here, certainly a network meeting like this, you have a chance to walk around the floor. You can walk the floor. 

You can speak to people. You can interact with people that you've seen up on stage. So I found it's a very level playing field. I don't I wasn't scared. So I had my first meeting, that I ever attended. 

It was actually the first meeting I spoke at was in 2018, and I was doing a precon debate with who? Meg Rosenblatt. I had never met her before. In that. I'm Jude. 

I bet so. There's no way you're winning that debate. I beat I beat her. Yeah. No worries. 

Where's Meg? Yeah. She's around somewhere. Yeah. But I was really I didn't realize who I was taking on. 

So I communicated with her via email, and then she sent me her slides ahead of the meeting. And she was making fun of me. She said she criticized the papers I've written. I was like, my god. This is really scary. 

I met her in real life. She was so lovely to me. And that was also the same meeting that I met Nadia. I'm not gonna tell this story on camera, but let's just say Nadia scared me. The very first time I met her was at twenty eighteen, and I I sat in her chair. 

What happened? And I was a scary pregnant woman. Basically, I I stole her chair. But I'm not gonna I'm not gonna I'm not I'm not gonna spoil the story, but let's just say that's where I say I yelled at him to get of my chair because I was pregnant, and my food was there. How dare you? 

That was but that's dear you But that's I wouldn't say our friendship began then because I was too scared to speak to her after that. But You should be. But a year after a year when when when when you had the baby, a year after we engaged My hormones regulated. We engaged via social media. Yeah. 

And then we suddenly we we realized who each other were. We became friends. But ASRA brings people together, and it's a it's a it's a fun meeting. It's a friendly meeting. So you get to learn, and and you get fun at the same time. 

But I've we've kind of gone off piece now. I need some jokes. Okay. I got a good one. No. 

Don't. Okay. You're Sandy Kopf. Okay. So I got this from Becky Johnson Okay. 

In full disclosure. So a grasshopper walks into a bar Okay. And the bartender says, hey. You know, we have a drink named after you. He's like, that's super cool. 

You have a drink named Stan? Okay. I love that. That was good. That was really good. 

Eight plus. Yeah. Short. Simple. That is Yeah. 

Right? Perfect. Thank you, Becky Johnson. Wow. What a great joke. 

Okay. Nadia, not there's any pressure. Oh, am so bad at jokes. I'm gonna preface with that. But She's reading this. 

I know. I I saved it because I know last time I told a joke, I, like, told the punchline before I ended the joke. So I have to read it verbatim, but it is a corny, corny dad joke. So singing in the shower is fun until you get soap in your mouth, and then it's a soap opera. Sorry. 

Sorry. That's like, what are Jeff jokes? Yeah. Sorry. What does that mean? 

I love it. Really good. I'm thinking Very good. That was good. I had to choose from a lot of the, things that AI suggested to me. 

Okay. That's good. That's what he does. Yeah. That's it. 

Sometimes I use my jokes. Yeah. Why why did the chicken cross the playground? Why did the chicken cross the playground, Tell me. To get to the other slide. 

Oh, that's a great That's a good, like, five year old kid. Right. Five love year old that. Yeah. So we asked them some questions. 

People wanna know the the education content. Yeah. Okay. Sure. Fine. 

So we'll start with Sandy. Sandy, you work at the may the world famous Mayo Clinic. Can you can you take us through how the invention of mayonnaise happened there, and why is it so healthy for people? I didn't see that one. I love it when it I didn't see that coming. 

Curveballs. I I didn't see that coming, and I I have no comeback, which is so pathetic. Do wanna know something do wanna know something funny? Like, I when I hear the phrase Mayo Clinic Yeah. I get hungry. 

Like, it just it it just so listen. I'm gonna be serious because all you guys are, joking around. There's, like, people, like, making funny faces. I say, if you wanna be in the podcast, get in the camera, guys. Yeah. 

You got a you got a fangirl back here. Okay. So the question I wanna know is how hard or how exciting or or how what do you think about working on these guidelines involved getting lots of people together, looking through the evidence? Because anticoagulation back in the day, that would have been, you know, a few drugs. There's like a lot of drugs now. 

So how on earth do you coordinate a project like this? Tell me how you how you succeed. How do you how do you corral all these people together to come up with some guidelines that people can use? Yeah. That's a good question. 

So I think I think it, you know, it all started back in 1998 when Terry Horlock or Denise Waddell, Rick Rosenquist, you know, all of the people kinda wrote the first one. Right? Like, they did they did the hard work. We've just been updating it ever since. You know, think the hardest thing about the anticoagulation guidelines is there's really not a lot well, there's really no randomized controlled trial. 

Probably never will be. Right? So a lot of it is just really about trying to to come up with kind of what's what is the safest way? And that's what I tell people is, like, you don't have to follow it. But the guidelines were intended to prevent neuraxial hematoma. 

Right? So, of course, they're gonna be the most conservative. It doesn't mean that you can't make a different decision if you think that the risk benefit rate you know, the the risk benefit is is is in your favor. You should you should do that. But but if we made guidelines that weren't the safest, that would be silly. 

Right? Yeah. Yeah. Yeah. I I think that I mean, the the outcome for anorexia of hematoma is Terrible. 

Horrible. Right? So it's natural and I think it's appropriate to be very conservative. And I think, you know, too, what I didn't realize until I started working in our health system, which so I work in Rochester, which is, you know, obviously tertiary care. Every resource known to man times 10. 

The Mayo's. The Mayos. Yes. Exactly. And I work in our health system where I might work in a hospital that has three o r's and no MRI machine. 

Uh-huh. Right? So I might do something different in Rochester than I would in Austin because in Rochester, it would be, like, three minutes, and I could have an MRI and a neurosurgeon. In Austin, by the time I got notified that there was a problem, I would have to transfer the patient from Austin at least thirty minutes Oh, gosh. To another hospital with an MRI scanner. 

And then I might have to transfer them again to get to a hospital that had a neurosurgeon. Uh-huh. So I might on the more conservative side in Austin than I will in Rochester. Right? Yeah. 

Because I can fix a problem in Rochester that I can't fix in Austin. That's a really interesting perspective. Like, you trash your your risk assessment and make different decisions depending on what your backup is and your backup plan. Yeah. Yeah. 

And, you know, the the part of the problem though is that in some of these sites, they're so small that you don't have a whole lot of extra hands. And so a spinal is oftentimes the best option. Yeah. Yeah. Because, you know, if you you don't wanna get into a difficult intubation situation, you're the only one there. 

So there there's a real push pull on what the right thing is to do. But, yeah, I think I I I use the guidelines differently depending on where I work. That's really nice to hear that, actually. Hey. Here's a question for you. 

So what would you say to someone who sees the guidelines that come out in the last couple of months and think, well, they're probably not that much different than the previous edition. What's a what's a quick take home thing to say, hey, you should read this because this is different. So there there a lot is the same, I would I would argue. I think what's different what's what's different is that we've incorporated the the concept of testing, you know, of of doing anti ten a levels because they're more available now. And so maybe in the patient that you they don't quite meet the guidelines, but you really wanna do this and you can get the lab. 

Yep. That that testing and and what the recommendations are there. Thanks a lot. I think we've changed we've changed a little bit This one of the antiplatelets changed a little bit. And I think, honestly, what I think is the best part about this is that people used to they used to hate the range. 

Right? So, like, clopidogrel. Five. Five to seven days. People are like, is it five or is it seven? 

You know? It's a big deal. Yeah. And I told I always told Terry, I'm like, I hate this. I'm like, it's so dumb. 

Is it five or seven? And so I told her when when I got to be the lead author, I'm like, I'm changing this. And she's like, watch what you wish for. And when I looked into it, I was like, oh, you know, maybe we just need to explain it better. So we've we've kind of explained it that, you know, for most people, five days is fine. 

It's the people that are really at high risk that you might wanna push it out to seven. Whereas if we had to pick a day, we would probably have to pick seven. Yeah. Right? Yeah. 

Yeah. But by saying five to seven, the healthy patient can probably go up to nine that patient. That's exactly. Right. So now I appreciate the range more. 

That's interesting. I've got a question for you. Yeah. This is a fairly sizable piece of information. It's a big article. 

Right? Yeah. How can people get the highlights? Is there a usable way they can extract the information from the channel? Because this is a valuable piece of of work. 

A lot of people spend a lot of time going through the literature. You've had, you big consensus discussions. How can we extract meaningful information from this article in a handheld manner when you need to at that point of care? So, maybe I have to have a disclosure that says I'm an Azure board member and and the CoAGS app is an Azure product. Are you talking about the Azure CoAGS app? 

CoAGS app. Okay. Azure CoAGS app is is up to date with the current with the current guidelines. It's a new app. I if you're an Azure member, the app is free. 

Is that right? So there is, you know, definitely a member benefit. And, yeah, I I use the COEX. I I who write As a as a lead. I who write the guidelines and have for the last three editions still use the COAGS app because You can't remember. 

I can't remember at all. I mean Brains are for having ideas Right. Not for remembering. Yes. And and it's too important to remember all the details. 

So so, yeah, I use the Coex app. Okay. Okay. So in case you're wondering why Nadia is just randomly laughing, there are there are some things happening on the other side of the camera. I'm just grateful that you're able to see this. 

And whilst okay. I think this block box idea has given people liberty. Yeah. Or the freedom to take liberties with gestures. I think you've been just got moved. 

Yeah. Yeah. Yeah. That's what we're talking about. So listen. 

Whilst we you're sitting next to the pocus innovator chief educator, Nadia Hernandez, I know you'd lined up some questions for her. So You did? Yeah. We we we had some questions on it for you. I'm gonna come back to you on on on the infection guidelines. 

I'm ask some questions. Oh, really? I know what you're gonna ask. But but Controversy. I I wanna you have some questions Fanodi. 

Yeah. So, I I mean, I I think, one of the things that is amazing about POKUS is its translatability across specialties. Right? And I think I'm imagining myself as a medical student in 2025 thinking, oh, POKUS. That means an intensivist is doing this or an ER doc. 

And how would you describe the role of POCUS in perioperative setting? Or how does it play a role in your perioperative setting compared to someone in the intensive care unit? Yeah. So it's funny because, like Sandy mentioned earlier, the setting can be very different. And so when I was at a, you know, tertiary care center, you know, those same ICU patients that are having surgery and the same issues that they may have in the ICU, they when they come down to the OR and they get exsanguinated and they get emboli, whether it's CO two, whether it's fat or whatever, or they've dislodged a clot, we still need to have that same, reliable, repeatable skill that you can use to quickly diagnose something. 

It has really changed, I think, how we practice anesthesia because I feel like in the past, everything was, oh, it maybe was a PE. And now, you know, you can look. Are there signs of a PE? Oh, there are not signs. Okay. 

So keep going down your differential. In the past where you had to call for a chest X-ray, now you could just the same ultrasound that you already have in your hand, you can use that to rule out the pneumothorax, to, you know, do whatever figure out what's going on with the patient. You know, there was I'll give an example. I got called one time to the OR by my own colleague because the patient was hypoxemic after I had just done a block. And it was the most insulting call I had ever gotten. 

I'm like, come on. You're calling me your block. After a subcostal tap because you think I caused a pneumo. And Subcostal? Okay. 

Yeah. Come on. Okay. But but that was the cool. So I put the ultrasound. 

I had the ultrasound with me because I had just done the block. I put the ultrasound on one side, put the ultrasound on the other side. One side has sliding, one side doesn't. Uh-oh. And I said, oh, sweetie. 

You're just main stemmed. And so it just you know, as opposed to coronary main stem occlusions. She's talking about Yeah. Talking about the EZT. The endotracheal tube was in the ribosomes. 

Just for the international audience. Yeah. It just changes. Right? And it took me two seconds versus calling a chest X-ray and error. 

You know? Because sometimes it's hard to tell. You know, patients are coming different sizes and shapes, and it's hard to tell if the tube is the right length or not. So, you know, instead of calling for help, I just use the same thing that I did to do the block with to make the diagnosis in two seconds. Yeah. 

So it really just and the surgeons see it, and everybody all of a sudden, there's this new gained respect for your diagnostic abilities. So so how the question is so I hear all of that, but your colleague went straight to call you to help out. ICU colleague. Sorry. How do we go from I'm a practicing anesthetist. 

I'm a practicing anesthesiologist. I'm very comfortable with my skill set. How do we get people to open up their skill sets, say, you know what? Something is not right. Is there anything I can do to use this tool that I've used to put in a block or that's in the corner for my line insertion? 

How do you get people to change their mindset and say, you know what? I can do this. I can stick a probe on, and I can identify that something could change. Because that's the challenge. For me, I'm very happy to do the block. 

If I have a cardiovascular disturbance happening during my fear, the patient becomes hypersensitive. I'm not at that point yet where my brain switches to, I'm gonna pick up this tool and use it to scan the heart because I'm scared. It's scary. Yes. I I It's scary. 

It's so scary. I agree with you. I think that that switch happens when people finally get it. So how do we get it? Scan a bunch on your own, and then somebody explains it to you, and you're like, yes. 

I think when you finally under it just takes a lot. I mean, you pick it up, start scanning, and it's just like using a stethoscope. You didn't know how it worked at first. You to practice. I know. 

She does make it sound easy. Thing that I have been convinced with I I so I'm scared. But but pneumothorax, I I can kinda get on with that. Yeah. I I think I've got some some and it's but then how do I then move to the next step? 

Because I think it'd be quite nice to know that there was, a pericardial effusion or a tamponade or to look at the left ventricular outflow. But even saying those words, I'm getting palpitations because I I if how do I know when you get I I guess a different way of asking that is, like, if you were to if you're for the total novice, if they were to dip their toe into pocus, what would be the first thing they do, the second thing they do? Okay. That's a nice that's a nice That's a good question. And you have to remember, you're not, you know, taking a cardiologist's place. 

You're you're looking for gross obvious pathology. Right. Heart working. Heart not working. Yeah. 

A giant amount of fluid around the heart, you know, versus, like, you know, when I and even a small pericardial effusion is not gonna cause enough hemodynamic instability that you you know, if you don't see it, you don't see it. It's not there. And if it's there, you can't miss it. Right? So I think I think starting off with the easier exams will give you more confidence to move on to people think cardiac is the hardest. 

And and I I think it's the hardest. It's scary. Think it's the hardest. You know, I think I think I'm afraid I would miss something. Well, I think I I agree with you, and I think that's because the cardiology experience is out there. 

And we're like, well, am I gonna miss a very like, they talk about the e to a ratios and all the Listen. A really hard because hard get focus has got so many acronyms in it that I get lost. No. No. It's focused. 

It's focused. It's like a fully three letter word. Obvious pathology. Sure. If you get into it, you can really go into diastolic and and all these things, but that's not what we're doing. 

I think that's Putting on the probe, we're looking at the image. Does it look normal, or does it look abnormal? I can work with that. Normal, call a cardiologist. If it's abnormal, do something and get a CT scan. 

Do a chest X-ray. So I so I'd like to know. So for example, in the middle of a of a trauma case that they're they're nailing the femur or something and suddenly my patient becomes hypertensive, I want to be able to sit the probe on and come up with an answer. Can is that is that can we is that Absolutely. Yes. 

Can we do that? Yeah. So, actually, that that that does happen often. So every time that a a total joint happens or a Centimeters nail or a femoral nail happens, every time they ream or they nail, emboli are dislodged. And you can see this? 

You can see them on the ultrasound. If you have the ultrasound over the heart, you can see them. Are you doing this proactively? Like, you're saying, hey. Watch this. 

Watch this. Because I like to show the residents. But but does that always give you the answer as always it doesn't always cause hypotension. It doesn't always cause any problems. You can start to see when the pressures on the right side are getting higher because the septum gets shifted over, and you get a d sign. 

And it's obvious. This is McConnell's sign. Well, McConnell's sign is a little different. That's the only d I know Disney. Yeah. 

Disney. It's a Disney side. Yeah. Yeah. It turns it goes from a circle to a d. 

And and so that means that the right sided pressure is That means the septum is getting pushed over to the left side because the right side is overloaded with pressure. So I kinda feel like everybody needs a Nadia in their OR or their Right. Right. So so when you stick the probe on, you get the answer. So this No. 

You would see it. You put the probe on, you're like, oh my god. It looks different. But I'm gonna there's a question over there actually talking about AI. But that's that question is about AI for regional anesthesia. 

Does AI exist for focus, and does it have a role? If somebody said, you know, do you know what to do? And, like, well, this machine can tell you. What do you think about that? Is that a thing? 

Yes. It does. It does. There are several, like, assisted AI exams for point of care ultrasound. For instance, you can put the ultrasound on the stomach. 

It'll give you the volume of gastric content. You can put the ultrasound on the heart and hit auto EF, and it'll But when it's you, what have you gone? Yeah. Well, it's kinda like the the Tesla thing. Right? 

Like, Elon Musk, when asked about autonomous cars, you know, there's still gonna be some crashes, yes, but at a far like, a reduced rate compared to actual humans. So maybe AI isn't perfect, but it's probably better than a 100 humans. It's better than the random sonographer and cardiologist that are just doing the quick stat pre op echo for you. Okay. So I'm gonna go back to Jeff's question. 

So Sandy and I, we're both, you know, in our early thirties. We we we're we're at that point where we're not really up for learning new techniques. So if we were if if you wanted to make us better perioperative positions, so we can do regional anesthesia, we've got that now, we can do invasive procedures like lines and everything on ultrasound. If you want to take on pocus, where do we start? What's the first step we should take on that ladder? 

I would start probably with lung ultrasound because you use the same ultrasound that you do for your blocks. Lung ultrasound. For what indication? Straightforward. To rule out pneumothorax Okay. 

To rule out interstitial syndrome, which just means increased amount of fluid in the lungs. So if you get negative pressure pulmonary edema, for instance, that's interstitial syndrome. Okay. And if you wanna take it a step further and you have a curvilinear probe because you use it for your regional anesthesia, you can then take that curve and look at the diaphragm and see if you have diaphragmatic hemipragitis on bottom. When she's saying that, I'm like It's right there. 

The diaphragm? It's right here. Okay. Yeah. You it's so easy to see. 

Jeff, do you do diaphragm focus? We actually do. Oh my god. Sandy, do you do diaphragm? Okay. 

We need to up our game. I know. Okay. So you do do so is but is it easy to is it easy to learn? It's it's it's incredibly easy to learn because so when I teach a novice diagnostic ultrasound, it is so much harder to teach someone that doesn't know how to use an ultrasound because you have to start from the basics. 

Like, okay. Angle of incidence Yeah. And, you know, gain depth, all the stuff. We're already further along. Already along the way because you know how to use the machine. 

You know how it works and how to optimize your image. All you need to learn is the anatomy. If you know the anatomy and you put the ultrasound on, you will know what you're looking at. Okay. Guaranteed. 

Alright. I'm gonna switch go go Ask the question because I don't wanna switch it up because I wanna get into that controversial question. It seems like It's fairly binary. Right? Like, it's yes. 

They're sliding. No. They're sliding. Yes. Are beelines or no? 

No. They're Rule in rule out. I like that idea of rule in rule out. Right. I can work Heart not moving, heart moving. 

Yes. Maybe that's a bit simple. That's so during compressions, that actually, we do that. But but but pumping well get rougher now. Pumping well. 

I I I kind of I like that. Yeah. Okay. Yeah. And then once you've mastered this, right, you have the curve probe. 

You can learn gastric ease gastric is probably easier than lung. So I would say I'm more confident with gastric mucus than I am with lung now. It's a little bit more comp I think it's a little complicated. It sounds easy. Right? 

But then, because everyone's looking for the halo, but when the stomach is full Yeah. It looks it's distended, the halo is gone. It becomes a little bit more difficult. Is there a gastric pocus YouTube video that you prefer? I like all your YouTube videos. 

Oh, cut that part out. Amazing. After you've mastered those and you and you wanna buy and now you have to get the phased array transducer to do cardiac pocus. After you've mastered lung and you've mastered gastric, you can move on to the phased array. It's just a linear array. 

It's not fancy, and you already know how the ultrasound works. It's just a matter of getting the images. It's it's time to get controversial. Okay. So the ASRA infection control guidelines. 

Yes. But big, big document. They cover a lot of pain procedures as well. Yeah. So, you know, the the things to to do with patients who've got infections, antibiotics, and skin decontamination or wearing gowns. 

Get to the point, Power. Tell me about peripheral nerve blocks and probe covers because I know a lot of people I'm just gonna get ready here because I I don't one of the guys who wrote the the this particular section. I won't say his name. This was this caused a lot of controversy. Right? 

So tell me what the guidelines say about probe covers in as far as you could recall, and what do you think about it? And is it sensible? And and let Rosenblatt come on. Doctor Rosenblatt, come around here. We wanna see you in the big picture. 

Man. Yeah. Yeah. Okay. Okay. 

So so probe covers. So Probe covers. So do you take them, or do you probe cover? Probe cover. She uses a probe cover. 

She practices safe scanning. Okay. Why do you practices safe scanning. Always. I borrowed that from him. 

Always. Yes. Wrap it or regret it. You're right. Do you use a probe cover? 

Absolutely. Okay. So tell me, why why do you use a probe cover? Because what people will tell you is there and I know what you're gonna say, but they will say there is no evidence that using a a probe cover makes it safer. So or or is there? 

Tell me differently. Well, why why not use a probe cover? Because, you know, you could use a Tegaderm. You just plunk it on there. And why use this long well, we didn't say to use long things. 

But yeah. But but but tell me why should you use a probe cover? When because people are talking about sustainable anesthesia. That's the that's the push. Right? 

I get the whole green thing. Right? That that, yes, it is something that gets disposed of. But, honestly, I think I I think it's probably most important in teaching institutions because you've got a whole lot of learners who who knows what they're gonna move the probe into. Right? 

Yeah. And once you've punctured the skin, now anything that that probe touches is and anything on that probe is a vector to infect what you've punctured or to get contaminated with that. And so Go on. But but but what about people that say that a single shot nerve block is not a sterile procedure? Because it is you know, do you put sterile gloves on, when you put an IV in? 

No. Hernandez? No. We do we don't. Right? 

I lick my hands. I don't when I'm usually, lick the skin. No. I don't. I really don't. 

I don't. I I guess I so listen. I am somebody who at the moment so I wouldn't go, as Jeff calls it, bareback. I would not go bareback. I would not use Good. 

I would I would not take a probe and put it directly on the skin and puncture skin because that feels wrong. That I think that's the biggest thing. Right? Now the the whole Tegaderm thing is not necessarily AZRA saying you shouldn't do it. It's the manufacturer says you shouldn't do it. 

Because they're not FDA or MHRA approved to be used for the indication. Right? Exactly. So I don't think that that's necessarily ASR that says don't put a Tegaderm on. ASR is saying the probe the the manufacturers and whatnot say that that is not okay on the probe. 

And, also, it it's a bit messy. You take this Tegaderm on, you know, whether you're using sterile gloves or not, you put it on and then it's not really clean. And then it kinda bunches up, then some gel squirts out the side, and then it slides off. I think it makes the whole pros and I am speaking, hands up. I use Tegaderm, but I'm not gonna anymore. 

Because, because these we've got some guidelines that that sort of say, look. Actually, this is what you should do. Right. And, actually, what Jeff told me about that, I wasn't aware of was you can get short probe covers You can. Yeah. 

As opposed to getting these long things that are already you call them shorties. Right? Yeah. Yeah. Which is kind of on brand for us. 

Right? But Which is probably all you need for a single injection. Yeah. Right? I mean because because what we find with the and I and listen. 

I use for years. Yeah. But, like, especially at a training institution, like, if you're doing a block or you're doing a block, no problem. Different. Right? 

Do whatever you want. Exactly. But they're as Sandy said, they're moving the probe all over. Yeah. There there are multiple punctures in the skin. 

There's blood now on the probe handle. So gross. Right? And I'm like, come on. And then How often have you looked at the probe before you've used it to see? 

And you'll it's amazing how many you know, if it's not been cleaned by yourself or by a tech beforehand, there could be debris on that. Right? Yeah. It can be gross. I mean, yeah, don't do a block on me without a probe cover. 

Okay. So now I'm gonna ask you Oh. Mister Landis, do you use probe covers for single shot block? So I so I'm getting from from you, Sandy. You'll use a probe cover. 

Right? Do you use probe covers for single shot blocked? This is being recorded. So I'm gonna tell you that Please. That that's that's really mean. 

When I was at the trauma center and the patients rolled in there with grass in their wounds Yeah. And I and Okay. Listen. And we you know, you put it in an IV. The IV, you get an alcohol swab, regular gloves. 

You put the IV into the vein Yeah. Into the circulatory system Yeah. And it's not sterile. And so when I was at the trauma center, I was like, come on. We're not even going that deep. 

We're not even going into the vascular it's like Patient still have deep growth. Ain't dying of nerve blocking. You know, it's an I'm thing. Like, so we didn't use them at the trauma center. We never did for single shot blocks. 

We use them for catheters because the catheter is a, you know, foreign object that's gonna be in dwelling for, you know, four or five days, seven days. And we never used them. But now that I'm in private practice and we're doing total joint replacements and we've had a couple of infections that are really, really bad outcomes. Like, if your joint gets infected, that joint comes out. Right? 

If your joint gets infected, you might end up with an amputation. Exactly. The the last thing the surgeon wants to see is me raw dogging it, okay, around their their knee where they're about to put, you know, a prosthesis into. So now in private practice, we prep, we drape, and we use sterile probe covers for single shot blocks. Oh, wow. 

Shot. So you're blocking it like it's hot. Oh my god. Oh, wow. Plus, we've also crossed a threshold here. 

This is the first time in the podcast history Correct. That we've used the phrase raw dog. Yeah. Sorry. Oops. 

No. So so so listen. I think We we tell we tell what I it is I think this is fascinating because what that demonstrates to me is you move from a trauma setting where it's all go, go, go, big trauma. And you when you you're talking about someone who's coming in with grass and gravel in the wound, and now you're talking about a purely elective private practice. So it's putting a clean joint and a clean knee. 

So it's about optics, but it's also about safe practice. But I and I think it's also about just like we were talking about before with the anticoagulation, it's a risk assessment. That's exactly right. Risk changes. Right? 

Like, she's not causing an infection doing under a block without a probe cover and someone who's already got grasp on the Yeah. But in that elective case near the hardware, the the risk balance I can't that I contribute to that Right. Bad outcome. If if there was a bad outcome and and you hadn't been you hadn't been taking all those precautions, it's difficult to say it wasn't me. Right? 

Yeah. And, you know, in this situation, like, we're putting Meg has stolen my man. In this situation, we're putting needles right where they're operating. Yeah. Right before they operate. 

Yeah. And we're going through the skin, and we're hitting. And I and I just it's just different versus someone having an blames anesthesia. Fair. Exactly. 

I mean Yes. Come on. You put a needle there, you know it's gonna be your fault even if it isn't. Yeah. So that's I I'm fascinated by the fact aren't you? 

You thought I was gonna say something else. Done by the way, listener, she's done a complete about turn because Uh-huh. Because she was opposite. Right? I I mean, we never had infectious comp complications with our single shot blocks at the trauma center. 

There was no, like, more infection more wound infections in the patients who got blocks versus the ones who didn't. We never had issues. But you're in a different place now. Right now? Yeah. 

Different space. Different. Yeah. And I and It it hits different. It does. 

It it And my kids' feet. Yeah. Yeah. That's another bump we're getting a lot of bumper stickers. I don't know. 

It hits different. What was the star thing that you came up with before? Oh, it we're all Bright bright shiny stars. Yeah. Right? 

Yeah. Yeah. Something like that, wasn't it? I don't remember. I'll I'll come back. 

Like, you kinda have people or something. Yeah. Okay. The moment's gone. Okay. 

Well, so listen. I I'm watching the flamingos holding that probe over there. I don't know. Now they put it down. But Okay. 

I wanna know where the flamingos are are are scanning. Yeah. I don't know. Jeff, this has been the highlight of my conference so far to have these two queens, Doyen, whatever whatever adjective you wanna use. A princess. 

She's a queen. I'm the princess. You're the queen 100%. I dreamt just because I'm a baby. No. 

No. No. Oh my god. You are goals, honey. Gold is goals. 

Yeah. Yeah. You are goals. Thank you so much for joining us. This was fun. 

Thanks for loving us. We're gonna do wait. Wait. Before we go, we're gonna do a little selfie. Yeah. 

Because come in come in here. Come in here, queen. Yes, queen. Yes, queen. I love it. 

Beautiful. And you each get a block of black Oh, I can't wait. For your laptop or water bottle. Realize there was a we we we we made the rap video, and and we promised that so we, yeah, so we made the rap video when we hit 50,000. Wait wait till a 100,000. 

Jeff said vocals? We can be background singers. Oh, jeez. Yes. We need vocals. 

Little bit of wine. We can do it. I'd I'd need a little bit more wine. So if we hit a guys, if we hit a 100,000 downloads, we're gonna do we're gonna do another video, another wrap. Right? 

Yeah. Well, we'll see. Well well, I don't know what we're video vixens. Oh. I just think I'm too old for that. 

No. No. No. No. Guys, thank you very much for listening. 

This is gonna be wrapped up into some kind of beautiful package, and and we will put it out there. So thank you very much. Guys, you're amazing. Thank you. Thank you. 

And that's it for this episode. Now that's just the tip of the iceberg or maybe at Disney, you say, miceberg. I hate that I made that joke. In any case, stay tuned next time when we'll bring you more guest interviews from the GE Healthcare BlockBox at Azra Spring twenty five. And in the meantime, we hope you all Block it like it's hot.