S3:E7 "Block Box Part 2: A conversation with Ed Mariano, Eleni Moka and Michael Bullock"

Todd, this meeting is so cool. I'm learning so much. Yeah. Totally. It's my first time at ASRA. 

I'm loving it. Wait. Hold on. What's that commotion over there? People seem to be crowded around some kind of glass box. 

Oh, wait. I think I know what that is, Todd. It's it's it's Block it like it's hot. Hey. Welcome back. 

We're glad you're sticking around for more convos in the glass black box live from AZRA 25. First up is a chat with longtime friend Ed Mariano from Stanford who shares his tips on social media strategies and the origin and future of the plan a blocks concept. Okay. So, Jeff, I am delighted to welcome Delighted? Delighted. 

He's not often delighted. I yeah. But I'm delighted to welcome professor Ed Mariano into our GE Healthcare Blockbox. Ed, how are doing, man? Great. 

Good see you. You know, thank you. Might as well. Yeah. Yeah. 

Yeah. I mean, we've been longtime friends, but I've never been a guest of the podcast. Well, this There's a first time for everything. Yeah. Here we are. 

We knew we had to make some big differences coming to this conference. I'm so happy that we managed to get you here. How are you? Are you having a great time? I've been great. 

I mean, it's been it's been really an incredible meeting already. I mean, it's we've never been to this this venue, so this is a first. But I really like the space because I've had a chance to catch up with a lot of people. I sometimes come to Ezra, and I just feel like I'm the I'm like the official Ezra greeter. I basically stand at the registration desk, and then people sort of come by and say hi. 

We catch up. I I never make it into the session that I'm supposed to attend. And You can't but that's one of the beauties about Azra. It's such a friendly meeting. We were talking yesterday to to Sandy Sandy Kop and Nadia Hernandez, and we're just saying one of the things I love about the meeting is it's so social. 

You should have seen Jeff when he arrived at the at the hotel yesterday. He walked in, and he wasn't able to walk five meters without somebody else saying, hey. How are you doing, man? So what have been the standout I mean, know we normally start with the with the joke, but I've gotta ask you because you've been here. You've attended some talks. 

Have there been anything that stood out to you and you're thinking how? I love that. I love that topic. I love that conversation. I love that that talk. 

Has anything stood out so far? Well, I I haven't actually made it inside too many of the sessions. So but I I can tell you I can tell you something that was fairly memorable. But just from yesterday, I was, I was teaching a problem based learning discussion. And, you know, in the historically, when we have these PBLD sessions, they're usually at lunchtime. 

Yeah. And so it's twelve to one, and then everyone grabs their box lunch. There are no slides. You just sit around a round table. Right. 

So with a sixty minute session, you basically spend about twenty, thirty minutes just eating, and then you chat for about thirty minutes, and you're done. Yeah. So the PBLDs at this meeting are two hours long. Oh my gosh. Before or after lunch, so there's actually no food. 

So No distractions. No distractions. Of Yeah. Like, in a round table kind of talking. Exactly. 

So here I am. Yeah. I walk into the room. There's, like, four four round tables. My session is ten to twelve. 

Wow. And I just think, people are signed up just to sit with me for two hours. I'm like, what are we going to do? No slides? No slides. 

It just What was the topic? I was talking about social media for academic careers and development and Well, you could I mean I mean, there's no one who can do that. Point, right, of of how you've you were number one, your academic career has has done that, but you've used social media to your advantage. So it's kind of what you talk about all the time. And I'm a little bit of a talker. 

So Really? But, nevertheless, with people that you maybe haven't interacted with before for two hours, that's I mean, that's a big thing, and and it went well. I think so. I mean, at least and no one ran away. Okay. 

And the What a Yeah. What a cool session. Like, what a gift to be able to sit and tap Ed's mind on social media stuff for academic careers for two hours. Hold them hostage. That was basically how I thought, oh, what am I gonna do for two hours? 

So then, of course, you know, we start, you know, we we stray into other topics just as things are sort of connected. Like, I had, we had one of our attendees asked a little bit about just, just networking. I mean, he's a early career faculty member at a university and was just wondering because you come to these meetings. And, I mean, we remember when it was like this little tiny thing, and you could just see everyone that you know and talk to the people that write the books and articles. And, and it's not so so big, but I I'd say it's probably at least two or three times what it used to be. 

So Right. It does feel overwhelming for people. And, I mean, his his question was was very valid, so I gave him some of my practical tips of just how do you network because sometimes it's tough. I mean, we're, you know, we're all anesthesiologists. Anesthesiologists, I think, are majority introverts. 

Yeah. So, yeah, how do you get out of your shell and meet people? It's hard. That's an interesting observation. And I was I was telling Amit a while back that I always I never thought of myself as an introvert, but I am. 

I I I identify Is it isn't it amazing? You're getting all the the deep secrets. Yeah. Yeah. I know, man. 

It doesn't mean that you hide in the closet all the time. Right? Just have to I like my alone time. I like I like yeah. But hey. 

So I have a question for you, and not to not to, you know, go back to that issue that you spent two long hours having to discuss about. But Those poor attendees. I I feel compulsion to to have a presence on social media. And I feel like I do an okay job of it with X or Twitter, but there's so much more. Like, do I need to be and do you have a strategy for how to have a presence not only on one platform, but also on TikTok and Instagram Right. 

LinkedIn. Great question. The all the stuff. Do you just Yeah. Do you just take the same thing you post on one thing and then just shotgut it across everything? 

Or do you is there certain types of content that are better suited for certain things? You know, I think because we we didn't grow up as social media. So I think that, you know, our it's interesting. I was thinking about this yesterday. Like, of course, all of this is inside my head as I was sitting around, you know, with, with these these participants, you know, for two hours, you know, talking about social media. 

But because I mean, you know, we grew up where phones were connected to the wall, and we didn't have Internet. So because you remember those days. So a long curly cord. Exactly. And you and on a on a long phone call, I'd like you to play with the cord, curl it around your finger. 

Or I'd have a pen. I'll be wrapping it around the pen. But Or you'd stretch it so far into the next room that your sister would come in, like, clothesline herself as she's running through the kitchen. Yeah. So so those days. 

Those days we grew up. So those old days. So the so I'd and my perspective on social media is built entirely on this period of my life when I've been a physician. I've been a professional, which I think is very different than, you know, many of our, colleagues who are in their early career or still in training. And I think that the probably the best advice that I've received and also I tried to give people is that you just you just have to do what you're most comfortable with. 

Yeah. And there are just certain types of platforms that I I definitely feel like I can handle a bit more, and there are certain types of platforms that I know that I won't be able to handle a bit more. One of them. So I'm not made for video. So, I feel very strongly about this. 

But I disagree about that because number one, this is one of one of the the members of Ezra Ezra faculty who always is the sharpest dressing. Yes. And I I I've never been disappointed when Ed shows up, and I'm I'm really happy if I ever coordinate with him. I'm like, yes. I'm on point. 

I'm on style. I I feel like a slob next to YouTube. Oh, come on. You guys are But but, you know, but you're saying so you don't feel comfortable with the video format. That's right. 

So so certain types of formats, I think, yeah, are just not I don't think that they're my forte. So, so I think in in terms of the like, if you were an early career anesthesiologist, physician, professional, then I think that there are a couple of potential platforms that definitely have more appeal. I think right now, if you were if you're just looking at it purely from an academic perspective, and that's this is really the, the angle that I took with our attendees yesterday, then, I said, well, it's very helpful to at least have, like, a LinkedIn presence because, you know, while you used we used to think about it only for business people. Correct. But I think that it's actually start it it's really spread to all professions, and, it's also generally a a positive platform in the sense that you can put you can put your your CV, yeah, on LinkedIn, and then it becomes, essentially becomes your your public facing profile, which is good because then that helps you develop reputation on things you do that. 

So now if you're gonna have a meeting or interaction with another professional, almost the first thing they do is look you up on LinkedIn. Right? And, actually, it's really it's so it's like a living CV. Right? So you can update things, but I didn't realize how many people would use it as a default. 

So it's important to keep things like that current and to so people know what you're up to in the same way that some academic institutions will look at x or other platforms to see what you're doing. But LinkedIn, I've only just started to connect with recently because I didn't feel it it it didn't sing out to me. It seemed like the place I mean, I think maybe it was in the beginning, the place you went to find a job. Right? Like, you you'd look for employees or you would try to put yourself out there with your CV, but I'm seeing a lots more video content and just sort of more, don't know, traditional social media type stuff on LinkedIn. 

So it seems like a place people go to for to learn. And it still has that, yeah, that environment of job hunting or job seeking too. So Yeah. I know, search firms use LinkedIn to look, especially if they're trying to fill specific positions, especially in leadership. But one of the things I I've, come to appreciate is that besides besides thinking of LinkedIn as basically your on sign online CV, it's also a very positive culture. 

So on LinkedIn, I mean, it's it's very common to see some of your colleagues, you know, already in person, some who you know only virtually, you know, who'll post well when they start a new job or Yeah. That's right. Receive an award or they and it's very positive. You get a lot of, like, you know Great job. Well done. 

You've done fantastic. Congratulations. And so I I always find that, that the you know, life is about balance. So whenever I feel like, you know, we've done something, like our group has produced something new, we've been innovative Uh-huh. Published a paper, then I always feel like I should share that on LinkedIn and just, you know, get get a little bit of the reaction. 

Most of it's, you know, reliably positive. And then when I post it on on X, I feel like then you sort of get a little bit of a criticism. Like, oh, yeah. That study's garbage. Yeah. 

You know, that that's where you really get, like, the balance between Well, I'm not even sure now if I'd say x is balanced. I think the it it depends. But I haven't come across trolls on LinkedIn. I haven't I have not either. I have had Anesthesia trolls. 

No. There are people that that seem to post the same content, and there are there's definitely some content I get thrown at me again, but it's not a negative thing. People have generally have their own agenda. They wanna push it. But so I so to Jeff's point, do you ever tailor your content? 

So you said now celebratory stuff or positive academic stuff you put out there, but would you put the same post that you put on one, platform such as X, for example? Would you then put that on on LinkedIn as well? Or Yeah. I do. You curate carefully? 

I do. I mean, I think that one of the common questions I get with the use of social media, especially as busy professionals, is how do you have time to do that? Yeah. And so I I tend to have is sometimes, like, similar posts that I'll share in different formats, because, you know, with depending on the platform, sometimes you have to tailor the length. So for example, on on X or formerly Twitter, then there's a character limit. 

Although, you know, one attractive feature of of the platform is that, it does allow you to have live links. It also allows you to include an image or photo or video, and then you can tag up to 10 accounts. So I find that in terms of dissemination, X is still very powerful. Yeah. And, and even though, you know, the the culture overall in the platform has changed and the algorithm has changed, and sometimes it makes it you're not always seeing things on your home feed that you necessarily want to see. 

In terms of community, especially for our group for regional anesthesia, I think that one of the, there's still very reliable, yeah, functions of x, at least in my professional life, is that it I'm still connected with all these other anesthesiologists around the world who who are interested in similar things to me. That's why I think some of the other platforms are not gonna match what we've got on x. So I lot of us have spent time curating an audience and and a following, on this one platform. As I said, the regional community is generally quite positive. If I think about one of the closest runners up, so Blue Sky has come out, you can't tag people in your posts and images, and it's limited, and they've got the whole new set of of hashtags. 

I don't know who's gonna come in and take over. Do you think there's hope for something like blue sky? Is that got the potential? I mean, I think that they we've we've seen a few different versions. I mean, recently, this and we've had the the MedMastodon. 

We've had threads here from Metadata. Right? And then and then, you know, with the the this use of Blue Sky. And I think they all have features that are somewhat similar to x, but they don't match the features of x. And and it's really interesting to when you when we observe practice, at least what we see, especially at conferences, even though in our off time between conferences where there's been a lot of interest in trying to transition away from x, All of a sudden, here we are at azure spring twenty five, hashtag azure spring twenty five, and then, you know, the use of x just explodes again That's right. 

Especially amongst the attendees. And also some of the You published on this. Right? The use of social media at meetings and how useful it can be for dissemination of information. But, d, the it'll be fascinating for me to see whether the engagement is the same because I feel that, generally, the amount of people that are on the platform overall has dropped. 

But it'd be really fascinating after this meeting to see if there is that big spike. I kinda almost get the feeling like there was an initial rejection of that platform for Yeah. Reasons that had to do with the the what was coming across your feed and that sort of thing. And people sort of embrace Blue Sky, but then maybe it's shifting back because you can't do as much on Blue Sky. And so and people, you know, Tanya Selak, when we interviewed her, made the comment that, oh, just block people. 

Like, people are jerks. I'm just gonna block them. And for the most part, our community is a very supportive, you know, community that's gonna give you good vibes. Yeah. Absolutely. 

And I also think that there's, there's a bit of a there's a there's a balance, and there's there's definitely some, two way or directionality, I think, when it comes to using social media. And I think the from from an academic perspective or from a journal perspective, we tend to often think about using social media for dissemination. I, you know, I I did this thing or I published this paper, and I was gonna push it out. But I think that if you if you further if you really look, I think, almost at the scientific method. So, yeah, one of the papers that we wrote, a year or two ago was about how social media can be part of the scientific method. 

And so while dissemination is a is one aspect, like, when you publish your results, that's one aspect of the scientific method. The scientific method actually starts with observation. And one of the things that I know I've learned in in using X and, and other social media platforms is is similar to listening to conversations in the break room or sitting in a lecture hall, listening to ideas, or or reading an article and and reading that end part where they say, well, future directions for research. You're seeing what topics are of interest to people. Yeah. 

People like you. Yeah. You're seeing what people engage in, what they debate about. And I think that that, in many ways, it it informs how which topics, which questions we pursue, and that's part of the scientific method. Think that that's a really important part. 

We published a paper on knee blocks of some sort of thing. And then someone had asked the question, yeah, but do you get motor block with the when you block the nerve to vastus medialis? That's right. Yeah. Was like, well, I don't we don't don't see it. 

We're not aware of that, but we should probably test that in a rigorous way. And and so now we're doing it. Now the IRB is in. So clever. That is a perfect example. 

Yeah. Our plan a blocks was actually another example of just a conversation we were having internationally on on X. But this is this is a perfect segue because I wanted to talk about this. So so so tell us about how the whole concept developed. So, so this started as a conversation. 

And while when X was Twitter, and we were there were a number of different people, like, you know, who you know, a lot of our friends, you know, were having, just asynchronous conversations about how many blocks does the general anesthesiologist even need to know. Yeah. And, you know, the our coauthors our lead author was Lloyd Turbot in Belfast and then, Kareem Elbuck Dudley, you know, your colleague at Eisen St. Thomas' Trust in Cleveland Clinic London. And, we were we were going back and forth, and I had given the example of, well, you know, when when we were residents here in The US Yeah. 

The the requirements for a resident in The US, you know, for peripheral nerve blockade, it often gets interpreted as a minimum of 40 blocks. But I would see. Well, and it's actually even less because I always like to point out to, you know, many of our trainees who, who use that as a standard. They say, well, you know, the minimum you have to learn is 40 blocks, yeah, by the end of your residency. And I said, actually, if you read the requirements for residency, it says that you have to have a minimum of 40 patient care experiences with patients who've received a peripheral nerve block. 

So that doesn't necessarily mean that she somebody. It could be zero. So so I say, but even if you interpreted it as 40 blocks, say, well, you know, forty forty block procedures. Back in the day before ultrasound, I mean, you could argue argue that there were, like, there was a handful of core blocks that maybe you could do. And and if you did four of them 10 times each the same way with a nerve stimulator, for example, You knew how to do an inner scaling block. 

You could do an axillary block. You could do a femoral block and a popliteal sciatic block. That was pretty good. Right? Especially if you're going to general practice. 

I still can't do those. Still working. You know, it's lifelong learning. But nowadays, I mean, with ultrasound, I mean, know, we like to joke around and say there's there's no fascial plane that doesn't deserve to have local anesthetic in it. So, I mean, you could you could say, well, there's you could do 40 different blocks one time each. 

Yes. And then you would finish residency with not knowing how to do anything. Or what's even worse is now we have, you know, 10,000 blocks. And so, you know, do you actually have to know them all? So this is this is basically how this conversation started. 

And I think Lloyd was actually the one who I think made the comment on on Twitter that, well, you know, it would be better to do, you know, like, one block a 100 times than a 100 different blocks one time each. And so I thought, you know, this would be an interesting paper. Wait. So before you get into the story, I'll say Lloyd Turbot, you cheeky man. I'll tell you why he's cheeky. 

Mhmm. Because he was doing a procon debate against me at REUK twenty nineteen, and the the title of the the debate is we're making regional anesthesia too complicated or something. And I was arguing against the motion, and he was pro the motion. So he must have had his cogs thinking the whole time, and he was just putting some stuff out on x to get people talking. And then he did, as he does anyway, this very eloquent, presentation. 

And about a month later, your paper came out. This guy was It was perfect timing. He knew what he was doing. So tell me, there's lots of things we could talk about about the paper, but geez, I mean, I would say the whole plan a concept has completely changed the way we think about modern regional anesthesia. How does it feel today to be part of that crew that kind of changed our thinking? 

Well, I mean, it's interesting because I I'm I'm I'm a little bit, cynical about my own career and influence only because, yeah, there was this article in Smithsonian Magazine, you know, when that came out one year that that said that well, I wish. But it said that half of all scientific papers are only read by the authors and the reviewers. Oh, yeah. Yeah. Yeah. 

Well I think I think there's some truth to that, and it's a little bit sad. But, but we all know it's true. So, but I think that but so I think so here so here's a here's a paper that we wrote. I mean, editorial. So it's not wasn't even a, rigorous, randomized clinical trial. 

And, you you know, like, we've we've all done randomized clinical trials and how much work goes into that. And, I would like to think that, yeah, some of those have changed practice, but we also know that there are so many different steps to translating evidence into changes in clinical practice. And, you know, we estimate that the time course from, you know, new evidence to to change in care is probably seventeen years or never. Right? Yeah. 

Yeah. So so the idea that, this concept from an editorial, yeah, resonated with enough people in our community that it very rapidly changed the way that people viewed the the learning and the teaching and learning of regional anesthesia is pretty crazy. I mean, I it's it's it's hard to believe. I mean, the REUK adopted it very quickly. REUK, I mean, it helped that that Lloyd is part of REUK as a faculty member, but very quickly thought, this is what we need to do to change the way we educate with regional anesthesia. 

Why are we trying to make everyone do everything? So did that did that actually happen at a curricular level? So now the Royal College of Unisys have we have a new curriculum, of which regional anesthesia is a core component. And whilst they haven't adopted the terminology or plan a blocks, it's much more streamlined in but the disadvantage is that now, because we put it down on paper, that people have to do x, y, and zed blocks, the pressure is on to make sure that every anesthetist can do these techniques. So we kind of we've committed to it now, but we've made people more aware of it. 

So it's given us the power to say, alright. Let's make sure everyone could do just these few. Whereas it wasn't said quite so explicitly before Yeah. That you could get your certificate of completion of training in anesthesia and kind of done a bit of regional anesthesia, but it wasn't so prescriptive as to what you should have been able to achieve. It was now that piece of paper, if you get a piece of paper, it's expected that you should be able to do block x, y, zed. 

Yeah. In The US and Ed, you may have different feelings on this. I think we're still kind of wild west. There's still few curricular imperatives to say, everyone should do a femoral block. Everyone should do a Papatille, like that sort of thing. 

So depending on where you train, you have a different vastly different experience. Fellowship, a lot less so. And and Ed was instrumental in helping to shape what the fellowship would look like in in regional anesthesia and acute pain medicine. So, so I think that's a much more predictable experience Yeah. With that training. 

Yeah. I've heard from, various residency programs that have elected to adopt a plan a blocks methodology for their, resident rotation in in regional anesthesia. Stanford is one. And part of I mean, it was one of our suggestions because we thought, well, you know, how do you how do you structure a core regional anesthesia rotation for residents, that gives them some progression over the course of four weeks? And especially with with very large residency programs in The US, you're you have all of these mandatory rotations. 

And so the timing of your rotation is not always to your preference. So you can imagine you could be in your, in the middle of your residency, do your one regional anesthesia rotation, and then you may not see regional anesthesia again until you graduate. So so really trying to focus on, these these these core blocks that every anesthesiologist should know, it becomes a priority, I think, in those types of programs. Yeah. It's a it's a concept. 

Right? You're not prescriptive. The whole idea is not to say you must do block x, y, and zed for upper limb. Mhmm. It's it's to say, pick whatever it is that you think you need to do and and make that the standard. 

So because this is where the ESP well, I'm not we're not gonna have time to talk about this, but this you guys put your money and on ESP, but I'm getting the impression that wasn't universally accepted amongst the authorship. I think well, that was actually one that we did accept. Oh, it's And it was. So we did not You guys heard it here first. Ed loves the ESP block. 

Well, I do love it for some things, and I think the the idea when I mean, that troll obviously is an opinion piece. Yes. So it's just three people just putting their opinions out there. But one of the things that we wrote about, even though I think that the the table of the plan a and then the BCD, I think, probably gets the most attention Yeah. What we had described in the text was that you know, one of the one of the basic tenets, I think, of plan a blocks is not to say that these this is an explicit list, like you said, and where you these are the blocks that you have to learn. 

It's that you should focus on different parts of the body and then teach what you do best at your site, for your trainees so that way they learn something that they can take away from the training program. And the other very important tenet of of this concept of plan a blocks is that you wanna teach transferable skills. So the transferable skills allow what your colleagues, your trainees, and when they become consultants to then grow. So you because our trainees, they're they don't know what type of job they're going to have when they graduate, They may be in a practice where they will be doing a lot of regional anesthesia, and and they're going to have to grow that practice. So what should they learn so that way they can build on the foundation? 

So this idea that you should learn the ESP block because I know as you've talked about before too, if you if you if you find yourself in a job where you do work with breast surgeons and your patients are eligible for having blocks, well, if you've done a lot of ESP blocks, then, you know, it's not that difficult to make us make some progression. Yeah. It's not that difficult to start doing a bit more, providing a better block It's a gateway. Your practice. It really is. 

Yeah. Now I got two two questions before we before we let Ed go on to his next thing. Yeah. Is there have you is there any plans to revise or tweak the recommended column a blocks? That's question number one. 

And question number two, getting back to the social media stuff, how many duck face selfies should I be posting per day? I'll take the second question first, and there is no limit for your duck face selfies. I what you wanted to hear. I think this this is what this is what the Internet is asking for. There is demand for this. 

That means I need to work on my lip fillers. You cannot disappoint your audience. So that's the second part first. Okay. To your first question, it's, it that is very good timing. 

And, yeah, and you you could hear it first that Oh. We have been asked have a whole set of CSS. Been asked. We've been asked by the editor in chief of Anesthesia, Matt Wiles Yes. To provide an update for Wow. 

Okay. So I So they're floating away. Will be coming. This will be coming. It has been in the works. 

Teasers. I will I will only say that this has been in the works for some time, and so I will I will have to pin down my coauthors. Yeah. Lloyd and Karim are gonna be hearing from me. Okay. 

We're gonna we'll we'll put our heads together, and and we'll come up with something that hopefully will gonna come I didn't. Of interest. But but I've wondered about it because it's 2021 was when it first came out. Yeah. '20. 

Actually, I think it was, it was Yeah. Yeah. Early online first and then eventually published. Yeah. Fantastic. 

Alright. Something to look forward to. I'm so excited, guys. So you've heard that that plan a blocks revised version is coming out soon. Ed, what a pleasure. 

What a pleasure. For having me. Thank you for being here. It's a pleasure. It's my first first time. 

Yeah. First time. Very memorable. Not the last. Yeah. 

Definitely not the last. Well, pleasure. Thank you so much, professor Ed Mariano. Thanks, Ed. Appreciate it. 

Next up, we spoke with Ezra president, Eleni Mocha, who inspired us with her work on bringing regional anesthesia education to the whole world. Well, hey, Ahmed. We are privileged to have doctor Eleni Mocha here today with us to, to join our podcast. Welcome. Thank you so much, Ellenie, for joining us. 

Thank you. The privilege and pleasure is all mine to be with you too. Uh-huh. But you are so famous with this blockage like it's hot. Well, I don't know about the famous, but I'm sure I'm sure everybody knows that we are sitting in the company of the president of the European Society of Regional Anesthesia. 

And for us, that is a big, big win to have somebody Yeah. Of your stature, your experience come and join us. So thank you very much. Oh, now I feel so left out. They're speaking Greek. 

We're gonna do the rest of this, conversation in Greek. Okay. Yes. Maybe it would be a good idea. Yeah. 

So so listen. You've flown all the way over here to be at this meeting to be a faculty member. What have you enjoyed? What what have you seen so far? What are you talking about? 

So tell us. Tell us. Well, first of all, it was a great, pleasure and honor for me to be invited and be here both as a person representing ESTRA, but as a physician also. What I liked in this congress is, this ambiance they have, which is quite vibrant, inspiring with very nice talks, good interactivity between the speakers and the audience, between the the presenters in each panel from what I attended. And a new thing that I have noticed in this congress is, the expansion of, the scientific program to faculty outside, The US continent and the American North American continent. 

You see, they have speakers from Asia, from Europe, like myself, like others, and there is a good exchange of opinions on the same topics that we are all worried about. But we all see them maybe through different perspectives. Mhmm. Yeah. So, I mean, you you really do feel that the societies of various international societies of regional anesthesia have got this sisterhood, this brotherhood, whatever you wanna call it, you feel there's some kind of connection there that maybe there wasn't originally or maybe in the past or something has changed. 

Something has Yes. And yesterday, we had the sister society session, with a very nice title and inspiring title, together we can stunt. So each one of us, from each sister society, from Ezra, Hazra, LASRA, AFSRA, also a pain medicine could, of course, say a few things on the status of regional anesthesia in our continent, in each continent from where we come from, and then speak about the more scientific topics. And it was very nice because there was a way to make me think of, items that maybe I considered granted and in other continents could not be the case. Is that's that's interesting. 

And do you think there are are things that Ezra and Azra are doing that were we didn't recognize before that we can learn from each other and and, you know, get better as a society to to bring better value to our members. Definitely. Yeah. We have the same vision Yeah. The same values Yeah. 

Same principles in our practice. However, we have not managed up to now, maybe a couple of years ago, I don't know exactly until when, to exchange ideas and opinions on the common goals. And these meetings, except of learning from each other on the scientific, level, let's say, on topics of interest, is a very good are very good opportunities to understand how we can partner together. Because, as I said in World Day, for example, alone, we can go fast. Together, we can go far. 

And this is something I said yesterday. I like that a lot. Yeah. That's cool. And, Lenny, I wanna ask you something. 

Under your presidency at Ezra, there's been a lot of change. Mhmm. Things have changed. You've rebranded Ezra. You have a mission statement. 

They published collaboratively as a society involved in these international projects, these Delphi consensus projects. What have you been most proud of in your term as president that you've achieved? What is it you think you know what? Now that I've done that, I feel I that's gonna be my legacy. Okay. 

First of all, it's not because of me that the changes happened. It's because of the team. And I was privileged enough to take over after the presidency period of. I think he did the first reform and of Thomas Volk, of course, who stabilized what Allen had done. Mhmm. 

And then for me, it was a a great team that was already set in place to start working further. For me, the most striking thing, if I may say that I feel proud, is the World Day of Regional Anesthesia. Okay. It was an event that, started in 2024 with a very modest, expectations. It went very well last, last year in January. 

We repeated it this year, and the enthusiasm was so high. We had 60,000 participants Wow. Across all continents. 60,000 across transfer we managed to transfer the message that we are here, that we do the same things. We don't know what others do in other cities or in other countries. 

But through this activity, we managed to exchange opinions, to sit on scientific, level on a table to discuss, and why not improve everywhere the care we offer to our patients? Yeah. That's amazing. So you I know that it grew from 2024 to 2025. Do you see the World Day growing even further? 

Yes. It will. Definitely. There are new ideas on the table for next January. Initially, all the sister societies didn't understand exactly what this can be, what this could be. 

The first year, they were more reluctant, I would say, or scared. The second time, more liberal to participate. And now before we have sent the invitations, they have already started asking. Can we do this? Exactly. 

What is what is your expectation for this day? Is it that people should all be providing education on that day or in that week, or should people all be talking about the same topics at the same time? What what's your wish? What what do you think should happen? This idea that came to my mind before being launched was the based on the fact that there are a lot of disparities, in education all over the world. 

You come from a country where few things or a lot of things of for education are taken for granted, and the same happens in my country. We have resources. Uh-huh. We have ultrasound machines. We have mentors. 

We have mentorship programs, teachers, and so on and so on, training opportunities. By traveling as president, I quickly realized that these resources and these opportunities are not available everywhere. Right. So I thought, how can we help these people in a relatively low cost model? Because they cannot afford the financial burden to travel to Astra. 

Everybody cannot. So what could we do to help them improve their knowledge status? So we created a common program as a guidance Ah. Which was not mandatory a 100% to be followed. However, based on this skeleton, people could build their own programs based on their own faculty and experts locally and the necessities, of course, of their areas. 

And it worked very well. Next year, we will have lines live streamings offered by Esraf with live demonstrations, baby streamings for cat from Godever workshops. I cannot tell you everything. Okay. But Because it's not fully planned yet. 

But the idea is on that day, all across the world, there is education going on in the name of the World Day and Regional Anesthesia. It's a great concept. Right? I wanna ask you about something else you you said, which was we all practice in resource well resourced areas and hospitals, but much of the world doesn't. And how do we apart from the World Day, how do we get the message and the skills and the education to those parts? 

We can't just mail an ultrasound machine to some of these places, but are there different ways that we could do it that don't require that? Yes. Of course. In my opinion, what we're doing next, I will tell you and what I had thought or we had thought as a group. First of all, through offering educational periods for the trainees, we should focus in the on the young generations, not, on the old people, of course. 

As an old person, I understand. Yeah. Fresh blood. Not fresh blood. We are offering them educational opportunities Yeah. 

Giving them grants. We are very proud that since last March, as you know, in NESRA, we had approved training centers of excellence in Europe. I don't remember exactly the number. It's thirty thirty two, something like that. And we understood that we had people from Asia, from other continents that could not afford to come, I don't know, from, Indonesia to Belgium because of the cost and all this. 

So for the first time, we have already approved one training center of excellence outside Europe in India. Ah, okay. Oh, I just saw this on social media. This is just recent. Palaventka, the echo impatore. 

So by this way, we somehow, decrease the distances. Because if somebody for from India wants to be trained, I cannot understand why this cannot take place in the hospital, which is a good one and, with a high level of, knowledge and expertise and everything and should come to my hospital or to your hospital traveling Yeah. Two times. You know? So in order to get recognized, what what does that institute committee. 

There is education committee, NESA, that is, led by Alan McFarland, since last September. There are some rules, some guidelines, some prerequisites. The center can make an application. The committee receives the applications, reviews them, shortlist, and so on and so on. It's not just like that. 

And, of course, to, guarantee the the quality of the training that is offered, The committee regularly would do site visits to check not the you know, in a strict way, but in a productive way to improve the training that is offered. Right. So you've you've essentially approved a minimum standard of training. You think, actually, this is not just minimum. This is excellent. 

So if you go to this institution, the education and the exposure you'll get will be something that we approve of. And then you fund people to do that, or or you just or you just spotlight it or highlight it? No. We fund. We offer educational grants. 

It's around 12, grants per year to people that, want to go to one of those approved training centers. Wow. Yeah. That's amazing. I mean, so you're you're doing a pra very practical thing there that's going to have results because those young people, as you said, are gonna get that excellent training and then start to spread the word, and then gonna catch on. 

But it's almost like a badge of honor. If you get approved as a as a as a place of excellence, then you're like, that's great. So, actually, we'll encourage people who've got the skills to put on a to put on a great program, to get approval, to get more people trained up. And the more people you train, they take the information, they disseminate. We saw a very good example yesterday. 

One of Jeff's previous, fellows, James Kim, came on here, and he's taken Jeff's knowledge and skills and applied it to where he's gone. And so, actually, we wanna propagate that knowledge. Exactly. Other ideas that have crossed my mind, and I don't know if I will suck if we will succeed as a group is why not to go to the hospitals at the second step. Imagine that the fellow does a fellowship somewhere, Lasix. 

Yeah. He goes back to his hospital, but to her hospital, but this person does not feel a 100% sure to apply the methods. Why couldn't an expert go through an organizational pathway together with a fellow for a couple of weeks or one month to to kick to to to help the person start from the beginning? We will be those people. Yeah. 

Yeah. You wanna go anywhere. Yeah. Yeah. We'll to Indonesia. 

Oh, dear. Oh my goodness. That's amazing. What is I mean, this I love you know what I love about this is you can tell the passion that you have for securing the future of our subspecialty. That's what comes across from you. 

It is inspirational. But I what I I like about what you've done is peep there's a lot of talk. Right? People like to talk about making a change and talk about, oh, we should do something. You've done it. 

Yeah. And you're doing it. I mean and that's those are real things. I mean, that those are real people, 12 granted fellows a year that are gonna get these opportunities. So you're changing the lives of these individuals, but also all of the patients that they're gonna they're gonna treat. 

The patient is a target at the end. That we have not only patient centered care. I would take it a step further. Human centered care. Oh my god. 

This is like I'm getting chills. I'm it's what I believe. But that's what I mean oh, we and that comes across. This is what we do in our practice. Speaking of humans, I wanna know more about the human side of Elenimocha. 

What do you do for fun in Crete when you're not traveling? Like very much reading. I like very much going to the sea. It's my favorite week. And Oh, really? 

I'm really missing it this period because the weather in my country this time is so nice. And I fully like to organize gatherings with all my friends, family members, not only for Christmas or for Easter or whatever. Uh-huh. So you are the party planner. Yeah. 

Yes. Always. This is how the world day I offer the home of myself. The home. And I say, guys, come all together, and let's organize what we want to organize. 

This is something I like a lot. Listen, Jeff. I could speak to doctor Mocha for hours. You have inspired me. You put a smile on my face because of how much how passionate she is about it. 

Said thank you for taking the time out of your busy schedule. Us on the show. Thank you. The pleasure was all mine. Then we chatted with Mike Bullock from Duke University who shared some startling new data on cervical ESPs and some fab work he's done on preventing tourniquet hypertension. 

We're joined by none other than W. Michael Bullock. Wow. MD, PhD. Oh my goodness. 

He's I have the doctor. I have doctor. Doctor. Doctor. I'm not sure. 

I have the privilege of working with Mike Uh-huh. On a daily basis, and he is So he's one of your colleagues from Duke? One of my colleagues from Duke University. Just an absolute star. Okay. 

Everything he touches turns to gold. So you may be aware that over the course of the podcast you know, I've told you stories about me being blocked. I have ESP blocks. I've had Dorsal dorsal of the penis. Sorry. 

We no. Sorry. Sorry. Okay. That was a was just for fun. 

Okay. We don't have needles that small. I'm so sorry. Okay. So yeah. 

Yeah. So let's start again because everyone's gone. Okay. So, yeah, so you're telling me that on the podcast, you talked about you having blocks on yourself. That's right. 

And and, you know, there's been times that I've done my own, like my tibial nerve that night when I was in extreme pain. Yeah. We've planted fasciitis. Yeah. Somebody else is doing that block. 

And most of the time, that guy is this guy right here, Mike Bullock, because I trust his hands. Okay. Okay. That's that's that's really interesting to know. Yeah. 

Mike, I don't know if you remember walking through the glass block box. There was a sign on the door that says something about jokes. I have I have plenty. Oh, woah. I was expecting to say that you didn't have any jokes. 

I I do. Off, why does a duck have tail feathers? I know this one. I don't wanna take the butt slime for you. Their butt quack. 

Yeah. That's very good. That's very good. Did you you had that one? I used that. 

You used that one. We had Andy Andy Andy Roos from Australia. Oh, that's right. His daughter told us a quack joke. Yeah. 

I was like, the butt quack joke has gone around the globe. Okay. I love that. All the way around. So I think you need to give us another one. 

I do. What do you call a cow with three legs? Hold on. Wait. Wait. 

Wait. Wait. Okay. I love how he has, you know, like, a box of silver too. So, you know, I can't remember the joke. 

No. I've got want to. Cow with three legs. Okay. Hold on. 

Not milkshake. K. What do call a cow with three legs? Lean beef. Oh, leaning over to one second. 

Yeah. Do you love the way that Jeff has to explain the joke secret ones? I love that. Even better? I just I I'm getting the joke Okay. 

Several seconds after you are getting it. Sharing. Yeah. Yeah. Yeah. 

Okay. That's allowed. Yeah. So even better, what is a cat with no legs? I don't know. 

Ground beef. Oh my. Jeff, this guy is to be. This guy is amazing. I said, I think joke tick tick tick. 

That's retakes for the jokes because what I'm most impressed about was just how freely they came out. So No. They they would, like, lock I mean, he's got two young boys. I have a I have a 10 year old. I have to stay on my game. 

But that's really impressive. Okay. So so I'm really interested to know this is a regional season podcast. It's not all about fun, but we'd like to do education in a fun way. What are the things that most drive you in regional anesthesia? 

What are you passionate about? Yeah. You know, we had a couple of presentations today with our fellows Yeah. Looking at posterior cervical ESPs for posterior cervical fusions and such. He said ESP. 

That is the first mention of the ESP block that we had. So we need to have an ESP block, like a Tali count. Counter. Yeah. That's ESP block that we mentioned for the first Can you go into a little more detail about those outcomes? 

Because I I know the answer to this, but tell Amit how I wanna know. Right. Yeah. And and so we we started doing this because we saw the success with our lumbar ESPs. Okay. 

And we saw the success with our thoracic ESPs. For what surgeries? For spine surgery. Spice surgery. Specifically, the lumbar ESPs for posterior fusions. 

Okay. Single shot? Single shot. Many times using liposomal bupivacaine K. Because with our lumbar surgeries, that was kind of the tradition. 

And with that tradition, we've seen that there was a great outcome post forty eight hours. We can do that. Talk about the outcomes, I've got to ask you a question here. And Jeff always gets annoyed at me when I when I derail him when he's going in the direction. But ESP blocks, pre procedure Mhmm. 

Do you ever see the medication leaking anywhere near where the surgeons are working? No. And the reason I asked this question, this is not a completely this is because I've had some colleagues not with, liposomal bupivacaine, which stays where you put it, But with regular local anesthetic pre procedure ESP blocks, I've had some colleagues say that the surgeons have complained that pre procedurally, it changes the anatomy or the medication. There's some edema. They can see the medication. 

So so what are your thoughts on that before I before you answer the outcome thing? Is it is it something that can happen? Is it something we should be worried about? I think it's something that can happen. I think anything can happen. 

But along the same lines, I don't think that it's something that's common. I've been on spine advisory panels where folks have performed ESPs with both liposomal and non liposomal, and their surgeons have not had any sort of issue with Okay. Tissue distortion or infiltration into their field. So that's really reassuring to me because when this was fed back to me, I said, I've never heard of this before. It's not something I've encountered. 

And, like, and, like, how about the monitoring? So we we often do these spine cases with, you know Nerve monitoring. Nerve monitoring does do these blocks have you ever seen these blocks interfere with nerve monitoring? No. And and they don't at all. 

Actually, that's been proven through and through many times. I don't think that the data is out there. I don't think that's been published as much as it should be, but, it's definitely not interfering with any sort of, monitoring. Now back to your point about, infiltration into the field, there are surgeons in particular institutions that do their own, ESP blocks under direct visualization, and they don't get extravasation into their field. And pre but presumably, they're doing that just prior to wound closure, are they? 

Correct. Yeah. Okay. But still nothing is They don't see anything leaking. Correct. 

And and they've they've made that dissection by then. Right? So if it's gonna leak, you're the kind of expensive wood do. Exactly. So I that's I hope the person that you know who you are who asked the question. 

I hope I hope that's answered your question that these guys who are doing regular lumbar thoracic and cervical ESP or cervical as they pronounce it, in The States are not getting issues. So so don't give up. So it might give up. When we do a cervical ESP There's accent. English accent number one. 

Tick. When we do a cervical ESP Okay. This is highly Australian. I can't help it. Okay. 

Should I go more like more more like Liverpool? Oh, if you could do Liverpool, I will be on the floor. I'm just gonna stick with my Okay. Tell us about the results. How what kind of things are you seeing? 

Cervical or cervical? Cervical. Cervical. Cervical. What we're seeing is a decrease in pain scores. 

We're seeing a decrease in opiate consumption. We're seeing a 50% decrease in opiate consumption over the course of seventy two hours. That's a big deal. It's a big deal. Percent? 

I think the most striking thing, we're seeing a two and a half day decrease in hospital length of stay. Is the cervical ESB Two and a half day. So so Two and a half days. Hold on. Hold on. 

Cervical. Cervical. Two and a half days. This is a really big So this is A really big deal. So can you tell me exactly what the surgery is? 

Because we got a lot of ACDF surgery going on. We wouldn't do it. It's like a So what is the surgery you're doing? So it's for posterior surgery for posterior fusion. So posterior cervical fusion. 

For posterior. And you're doing single shot cervical or cervical ESP blocks with liposomal bupivacaine, you're cutting your stay by two and a half days. Two and a half days. That is mind blown. Right? 

In conjunction with multimodal analgesia. In conjunction with multimodal. Both groups received multimodal. Both groups received the same sort of multimodal preoperative acetaminophen. They received their ketamine, their intrapnarcotic usually What was your other arm? 

Just control as a historical control group. Okay. So That was that was pair matched. But skin infiltration with local anesthetic? Or They did skin infiltration with local anesthetic. 

With regular local anesthetic with regular bupivacaine. And what what I think we're hearing from the surgeons is that it's the spasm that the is the big factor there. So if you imagine posterior cervical musculature being sort of, you know, hacked apart by a surgeon, after that surgery, they have incredible spasm and pain from that. So did you used to do these with regular local anesthetic? And if so, what was the duration of benefit? 

That was an n of two with regular local anesthetic. The duration of benefit was about what you'd expect to expensive. Eighteen, twenty hours. So so no surprises there. No surprises. 

But this was a game changer. Two and a half days. Two and a half days. Yep. Opioid reduction was to what degree? 

You'd be told that We went from a sixty five mill morphine milliequivalents to 32. Important how important is opioid reduction to you guys in The States? You know, is is it a big deal? I know I know what the answer is gonna be, but I've gotta ask them. Well, my answer is no. 

Personally personally, my answer is no. I think, where we see a lot of our benefit is in the functional outcomes. We can see a lot of opiate reduction, and we can see that across the board. That's great. But if patients aren't doing what they need to be doing, then we're not doing the right thing. 

And how are you assessing that? Are you doing formalized patient recorded outcome measures, or what what is your assessment of success here? With this study, unfortunately, we didn't have anything set in place. This is more of a retrospective study. Looking forward, we will look at some of those outcomes. 

This is more based on, their physical therapy, availability Okay. Their time to discharge, their readiness for discharge. Okay. So many of those metrics that that go along with it. We're looking at the the the whole patient, how they're gonna function getting out of the hospital. 

If we can control their pain, at that point, if their opiates are the same or not, who cares? As long as we're getting them out of the hospital because we're keeping them out of pain so that they can do the things that they need to do, that's really where we wanna be. For me, it's difficult to argue against this intervention. You'll not be surprised to know that the ESP block gets a lot of grief from a lot of people. There's a lot of people that don't share the love of the ESP. 

I guess the counter quest the counterargument to this, or maybe not an argument, the alternative is, would you get the same benefit if the surgeon did post procedure skin infiltration with liposome bupivacaine. So I can chime in here and say that we did a cadaver study with a renowned pediatric scoliosis surgeon named Peter Newton from San Diego. Uh-huh. And we said, Alright, Peter, you infiltrate on one side the way you would normally do so prior to closing your incision in the cadaver. We opened it up, and then we would do an ESP on the other side, and we'll we'll see where the dye goes. 

Uh-huh. And we we did that, opened it up, and the dye was in in our in the ESP example, was submuscular, expending up to some t 12 down to l five or s one. On the surgical infiltration side, it was scattered all over the place. So Because he's doing like, a random point and shoot aspirate withdrawal all all all this kind of stuff. And and and the the kicker the, I mean, the clincher for me in that scenario was he looked at that and went, oh, I Really? 

Yeah. I guess I guess we should be doing ESPs for this because because it's an image guided procedure that puts you in the correct plane. Okay. And, you know, Mike mentioned surgeon perform Yeah. ESP. 

That was actually Peter that did those. Was that right? Yeah. That's interesting. As you had difficulty in doing it without image guidance is and you'll probably both have the same experience. 

Sometimes you're you think, oh, I'm in the my needle tip is in the right spot. Yeah. You give the first injection. You're like, oh, no. I'm not. 

I'm too shallow. I'm too deep. And it takes a bit of finagling to get your needle tip in the right place. What is that phrase you just used? Fenegling. 

Fenegling. Are you familiar with that? It's an it's an Irish flaze. I fenegling quite a bit. It's Fenegling. 

Fenegling. Amanda, have you ever she can't hear me. No. She can't hear me. No. 

I I I Fenegling. Okay. My friend's finagling. There's all the fenegling. Okay. 

That is obviously Scottish accent. Scottish. Not Irish. Okay. I can't do Irish. 

The only accents I can do are Scottish and Australian. And he thinks he can do those. Anyway, so listen. Mike, I need to ask you something else. So, Jeff told me that one of your other publications was something that's quite interesting. 

There's something about an injection around the femoral artery to do something with tourniquet pain. Yeah. It's one of my favorites. Hold on a minute. So for for the benefit of our listeners, I wanna hear about this because I read this paper, and I was like, is this really a thing? 

So can you can you tell us about this? Because this is fascinating to me. 100%. And I have to tell you that this came the the study came about with a lot of discussion with Stuart Grant and Jeff. Because he was on the publication. 

Was on the publication as well. And it There's our Scottish accent. That's absolutely a terrible Scottish accent. Doctor. Garthston. 

Oh, let me tell you now. That was absolutely terrible. So maybe criticizing my Scottish accent. Okay? Okay. 

Oh, okay. Anyway So That's the world's first. Thank you, sir. It was great. Okay. 

It was great. Says the doctor doctor. Yeah. As a as a fellow, we spent many of time in the, foot and ankle room. Okay. 

And we saw tourniquet hypertension daily. So these are patients who are getting a general anesthetic plus a regional block or just a regional block alone? A general anesthetic without airway control. We can call that a heavy mac. Gawah. 

GWAC. Gawah. No like Gawah. No like Gawah. Okay. 

Okay. So so so, like so monitored anesthesia care? Monitored anesthesia care with a with a heavy dose of propofol. Okay. But, of course, really dense nerve blocks in the the popliteal and saphenous. 

And we saw that patients consistently achieved tourniquet hypertension, and they would achieve about forty five minutes to an hour and a half. Mid thigh tourniquet? Mid thigh tourniquet. No femoral block? No femoral block. 

And what we found was that they were getting a lot of systemic opioids. They were getting fentanyl from our CRNAs that continued to just give them fentanyl. So once the tourniquet came down, surprisingly, their blood pressures came way down as well. Uh-huh. They had postoperative issues sometimes with, sedation from the amount of fentanyl that they got from the tourniquet as some of our surgeons maintain tourniquet times of two and a half hours. 

Okay. That's a So observe observing this as a fellow, you know, kind of made me question why. We would go see the same patients postoperatively. We would test their blocks. They were completely numb, but yet sometimes they were still having some pains. 

We would go and find that their cast posteriorly would kind of curl up into their, calf Yeah. And cause a little bit of ischemic pain there. Okay. So the two thought processes were we see this tourniquet going on. We see that they're numb, and now we have this heme through the block. 

What's going on? So we started looking at anatomy and looking at some of the data that's out there, and there wasn't really anything great. And we've found that looking back at anatomical structures that we could see that c fibers run up the artery, and the c fibers are gonna be responsible for this, tourniquet pain, this this crampiness that's that's going on inside the leg once that tourniquet is up. So if we were to put local anesthetic around the femoral artery prior to going back to the Operating Room, could we stop that signaling from the lower extremities saying, hey. I need blood. 

Give me something. Oh, is that that that's amazing to when you understand what the I mean, so you It's a great theory. Uh-huh. So it's a great premise. But but but the step to you doing a periarterial infiltration was all about c fibers. 

It's about c fibers along the artery that are conferring that ischemic pain that are sending the afferents to the brain. Is that brilliant? It is brilliant. But but, what if I remember correctly, you you were using lidocaine. Mepivacaine. 

Mepivacaine. It's a short acting local anesthetic. Correct. Get your facts. Three, Sunny. 

For two reasons. One, we don't need it to last longer than the surgery. By the way, that is the worst. I I apologize It is to our one spotted Scottish listener for that. Stuart, I'm sorry. 

Okay. So so so tell us. You you wanted to use short acting local assay specifically because you didn't want them to get For two reasons. Ah. If there was any chance of a motor block, if there was any chance, we want it to be very limited. 

Yeah. There was no motor block that we saw. You never saw? Never saw. The fascia liacus separates the artery from the nerve. 

No motor block. Secondly, we don't need it to last longer than the surgery lasts. No. So we want it to be three, four, five hours, and which is a perfect timing. So we we're no strangers to cheeky femorals with with Lardy Caneso. 

I love a cheeky femor. But but are you so we so were you coming were you coming out of plane? No. In plane. In plane. 

Extremely shallow. Coming from lateral to medial Lateral to medial. Over the nerve. Mhmm. Wow. 

Okay. So, typically, I aim for 11:00 or 01:00 on the artery, and I let the the needle kind of carry itself. Even sometimes maybe use that whiteboard. But I but I think that that description of time was of clock face is perfect. And what volume were you using? 

10 mls. And I wanna see that that artery kinda pushed down. Is it like a winking do you get, like, a winking sign? I want the winking sign. King sign. 

Come on. You must be familiar with the the winking sign when you do a sub sartorial injection. You you didn't see a winking sign? I I winked at you then. We I've always called up the Gadsden sign. 

No. That's that's the power winking sign. Really? Yeah. Yeah. 

Yeah. Yeah. And I I I always tell my trainees, that's the Gadsden sign. No. No. 

That's associated with 100% success. So that is a power winking sign. I'll do it to camera. Uh-huh. We so we so so you aim for stop. 

You're turning me on. Okay. So so that That's the goal. That's the waving side. So is that something you will do routinely now when you do, Mac cases? 

It's a routine it's a part of your practice. It's it's instrument. It's changed practice in that we can actually run a normal MAC anesthetic as opposed to a GWAC. There's nothing normal about MAC anesthetic, by the way. Okay. 

Let let's just let's just put that out there. But as normal as you can get one. We we've deep researched it. I'm joking. You're right. 

I'm teasing for a UK audit. I'm teasing for actually, The US audience is just, like, kind of edged up over the last few months. Actually, The US guys are gonna love this. Just saying. For The UK guys, it's MAC is not something we do all the time, but but it's been a game changer for you guys. 

It's been a game changer for us. Okay. 90% reduction in esmol. Yes. But you guys were using esmol to treat the sympathetic effects? 

For for the study, we were. Generally, in clinical practice, it was fentanyl beforehand. And that and that's the problem. Right? That's the problem. 

People are using opioids to treat tourniquet pain, which is gonna go away as soon as the tourniquet's released. Correct. But then the side effects of the of the opioids are, you know, present. So if you can obviate that, if I may use if I may use the word obviate. Obviate. 

Obviate. That's pretty good there. Obviate. Oh, yeah. Back when I was in Inverness. 

Inverness. I was obviating left and right. There was no stopping me from obviating. It's totally gone. I'm pissed here. 

Closing closing question because it have have you actually made your point? No. I don't I I don't believe a heart. If I if you can obviate the the opioid requirements Okay. There there we go. 

Then That's really great. Great. Right? Yeah. Uh-huh. 

Okay. That that's a great point. I'm so happy we waited for that because now I feel complete. As I realized, I remembered from watching Jeremy McGuire recently, you know, that completed me. That sentence completed me. 

Complete me. And and and this block showed me the money. Oh, 2 Jerry Maguire coins in one bit. Okay. Doctor doctor Bullock, what can I say? 

What an absolute pleasure to meet you. It's my pleasure. Thank you so much for being buddy. Never been worse. You know, some podcast guests get flown into places. 

They get they get, like, stipends. You get a sticker. I get a sticker. I love it. I I will rock at this exit. 

Listen. Thank you so much. Thank you. Appreciate it. Thanks, buddy. 

The BlockBox has been so much fun, but guess what? It ain't over yet, baby. Stay tuned for more insightful interviews and cringey jokes coming your way soon. Until then, as always, we implore you to block it like it's hot.