S3:E9 "Block Box part 3: A conversation with Stuart Grant, Steve Coppens & Gary Schwartz"

Welcome back to Jeopardy. I'm Alex Trebek. For $1,000, this podcast was recorded inside a glass box at the ASRA spring meeting in Orlando where two anesthesiologists risked observer effect and mild dehydration to chat with three experts on nerve blocks and pain medicine. Natalie. What is painful conversations? 

Sorry. That's incorrect. Daryl. Oh, what is, between the needles? Close, but no. 

Samantha. Oh, wait. I know this is block it like it's hot. Yes. And as a treat for our contestants, here's an entire episode of block it like it's hot. 

Welcome back, friends. Just when you thought you'd heard all the interviews possible from the BlockBox at ASRA, boom. We hit you with some more. This time, we start by having a wee chat with our good buddy, Stuart Grant from UNC. And let me tell you, what he had to say left us both, well, have a listen for yourself. 

I only found out yesterday that this guy is going to be a future Azra president, which is incredible. Yes. Who who have we got on the table? None other than, doctor Stuart Grant, professor. Hey. 

Hey. Professor of anesthesiology. It's the university of some place called North Carolina. The top university in North Carolina. That's amazing. 

What is near and dear to my heart. I am really, really privileged that you've come to join us here. But first of I've just got to say, I've gotta apologize because I'm feeling a pony this morning. You're feeling a pony? A little hoarse. 

Oh, come on. That was sorry. Sorry. That was my you're leading? That was actually gonna be my joke. 

I caught the man after anesthesia. Was that really gonna be a joke? Well, I'd I'd say if I if I'd the man feel like Chetland Pony, he was a little horse. Oh, wow. That's actually gonna be it. 

Because, actually, I am feeling a little bit hoarse. Oh, I'm so sorry. Ripped ripped untimely ripped. Blown it. That is oh, how to ruin the first interview of them all. 

Way to go on it. That wasn't what I had in sorry. Have you got another joke for us? I just thought that's clean. Oh, it's practically Can we a much does a how much does a pirate pay for corn? 

Oh, it's o r A buccaneer. Oh. A buccaneer. That's good. That's good. 

I love that. Okay. Jokes. And that was kind of that was high level. That's a great start to to our little segment here, Stuart. 

Somebody tells me that as well as having responsibilities amongst the the Azure board, you're also the recipient of a prize at this Oh, yeah. Best in show. Best in show. This sounds like this this sounds like something abstract. Best yeah. 

Exactly. Best out. Yeah. Uh-huh. So your gums are looking very I have. 

I've been I've been blow dried and crimped. Good tail. Yeah. Uh-huh. Yeah. 

Uh-huh. Good tail posture. Yeah. Tell us about the best in show. So submitted an abstract for a new a new pain device. 

So we are still using opium poppy Yes. Yes. And cocaine derivatives. Yes. So and and with that, I was thinking, what would the ideal pain killer be? 

You used to do the the chapter in the textbook. What's the ideal volatile anesthetic? Yeah. So shouldn't be shouldn't be explosive. That's a good thing. 

Yeah. Should be fallible. Should wear on quickly. Should wear off quickly. Could be liquid. 

Easy to store. Right. So if you say, right, what's the ideal pain killer? Yeah. You want something that generally reduces pain. 

Uh-huh. It's non addictive, doesn't stop your breathing, doesn't have a motor block Yeah. And would last a long time. And so I started with, like Sounds like the holy grail. Yeah. 

Exactly. And so I started looking like, oh, can we add additives to to blocks to make them last? Well, what about catheters? I've even done research with nerve stimulation, but not found anything that's what's simple to to use, leaving an electrical stimulating cables and wires. It's got real kind of factor, as you'd say, in Scotland. 

So so this company I've started working with years ago, and when you challenge engineers, the amazing thing is to go and find a solution. Sometimes those solutions are okay and not things you want, but god, these guys came back with a device that you put under ultrasound guidance so that the skills that you guys have, you get ultrasound of the nerve, you put the needle in, you deliver the electrical energy and pull the needle out three minutes later, and you get a top call analgesia with no motor block, and it lasts twenty days. Hold on a minute. I'm gonna have to wind wind this back here. So you're talking about percutaneous percutaneous procedure, we put the needle next to the nerve. 

Mhmm. Electricals proximity. And then you do the stimulation? Yes. It's called radio frequency stimulation. 

This sounds like something our pain medicine colleagues are doing. Is that some is it the same kind of device? So they use radio frequency devices to to ablate nerves, but they get the temperature very high. Yeah. Yeah. 

Yeah. This is just stimulation. This is also delivered in a different way in terms of the frequency, the sine wave. There's actually two needles. So you put a needle as you would if you put your needle under a femoral nerve. 

You also put a short needle. It just goes in the in the subcutaneous fat. So it's a high impedance between the two, high resistance, a high voltage field between these. So you create this little field with which the nerve is within. Uh-huh. 

And it's been used in brachial plexus. It's been used in femorals. It's been used in popliteal sciatic through experimental work. Before that, there's a lot of work done in animal model and then human volunteers to show that you get small fibers, a delta c fibers get blocked, but it doesn't block your reflexes, your touch, your power. So just the a delta and c fibers. 

Just the a delta, small, unmyelinated fibers. And you're saying it's a three minute intervention and then everything comes out? And then So you're not leaving anything at all? There's no cable, no wire, no pumps. It's Do you have to direct the orientation of the field with the two needles, like the one underneath the nerve and one on top so it's going through the nerve kind of thing? 

Yeah. That's what we're trying to do is trap in this high voltage field. And I I think that so the mechanism, still not sure. But when you actually look at it, there's there's no damage to the nerve for you doing each and each stain on a and you've done this in animal model, you then you just need to add a more stain, the sciatic nerve. Sciatic nerve looks There's no there's no morphological change in the nerve. 

So so so they then get the question, you know, is it is it magic? How's how's it work? So that's the bit that's still got it there. And I'm sure those changes occur in the nerve itself, but also this ultra high is, like, hundreds of thousands. The frequency of this field is alternating. 

Those changes gonna be in the spinal cord and then the thalamus with the pain pathways. I can't get my head around. It's all it it almost sounds too good to be true. Right? Yeah. 

Twenty days. Twenty days. So so Just an anal like I saw No. A septic block. I've done this in a patient for a the study site went down, met a patient to have a knee replacement. 

So the first thing is, Gaston here is, you know, going to smaller and smaller nerves. That's right. More injections. And, yes, it works a pain control method, but there's there's no way we can do you know, keep doing 10 or 15 injections because we found another You can do it in three minutes. You need to From from ten or another. 

So I I need something that's sustainable. Yeah. And the beauty with this is you go back to the big nerves. You, know, your resin can find the popliteal sciatic nerves. They can find the nerve. 

So it's it's large nerves. You're putting this across this this field across, and it's and it's this makes it easy to see as opposed to, you know, geniculars. We're pretty local around there so we can't see. We're now going back to something we can see. Yeah. 

Yeah. Yeah. I think that makes it easy. The generator unit is reusable. The the two parts along cable and the individual needle is the is the per patient use. 

So you can do a couple of blocks on that, put the needling under ultrasound guidance. You can block the femoral and sciatic, the same patient. Is the effect immediate? Like, could you do it day of surgery? It's, like, three to four hours. 

So by the time your patient's hitting the recovery, there's a spinal's waning off. You have got It takes three to four hours for you to appreciate the full effect. The full effect. Yeah. But can you give me, or give us an idea of the quality or the level of allergies you get from this? 

Is it the same as doing a full sensory block? So how you test that, you you put local anesthetic block in, and they usually use an electrical intensity to to look at the what your your threshold is. So if you block and have the lidocaine, you get a 300% increase in your ability to tolerate pain and discomfort. Eventually, do get some breakthrough. This is higher than you get with local anesthetic. 

So what does a patient perceive when we look to the pain scores and movement after total knee arthroplasty? It's like zero ones or twos. They get a tightness, but the pain is is is gone. Do you get the feeling that we're that we're gonna look back at this conversation I totally do. And think that was the moment that we heard about this thing that has changed everything. 

Completely. It was 1999 that I put peripheral nerve catheters on on cue pump with Steve Klein. We did that and and then blocks and sent them home 2,000, published a big season, you know, using pumps in day surgery. And, yes, I'm such a fan of that, but also realized that's such a a lot to do and manage the pumps and manage the patients. And since then, I've been, like, searching for something that works because I realized that nothing we've got last long as long as patients pay. 

Yeah. Mhmm. And so I've had some VIPs. I've you know, they've gone home, and the pumps run out. They're on cue pump, and then I've gone and put a second one in at home and give them six or eight days. 

Mhmm. And when you get around that duration, you notice a difference. And there's one study done in where they dealt to patients. They they left them in for a, you know, distinct period of time. They actually showed a difference in in in chronic pain outcomes. 

So we've they had to replace the pumps. It's only your medication showed a difference in in chronic pain outcomes. I think this might make a difference in persistent postoperative pain as well as managing the grail. Yeah. But, you know, taking away the pain, have you note have you any of your patients, you put blocks in Uh-huh. 

And I'm good to go? So the old guy sitting at home with no pain in his knee watching the grass grow is out with the lawn mower, mowing the lawn. So I think, you know, the the things don't work out. You know? If you have no pain, pain restricts what you do. 

I don't want people, you know, getting on like Jeff does or Lycra and doing their aerobics, you know, a day or two after this. I want them to be Nobody can see that. You know? So that might be we change the instructions. Maybe we put a knee brace on to stop them doing too much. 

Yeah. These are things that are gonna be all gonna be worked out. But, certainly, from a pain point of view, pain on movement, not at rest, but pain in movement after total arthroplasty scores are zero to two. That's okay. So I I think you're I feel that you're right. 

We're at that phase where this could be a thing. But the thing that actually, actually won you, excuse me, best in show, what was in the paper? This was the case series of the the initial interventions. It's not randomized. So everybody got they got the therapy that it was prospective, you know, investigation of feasibility of this. 

If you put a knee neoplasty patient and we looked at the pain scores, We looked at their functional outcomes. Pain at rest was significant. Pain and movement was significant. Average pain was was significant. And they also showed a improvement in their functional outcomes. 

And what about opioid? And significant through twenty days. So this is just part of the data, getting together all the opioid data now. One of the the things that we didn't do in the first study and we'll do in the future was when you go and see your physical therapist after an arthroplasty, say, when you come to see me, what we want you to do is freely leave the house, just take your oxycodone. Mhmm. 

Because they're used to people not completing physical therapy because they're sore. That's right. So one of the things we need to do in a prospective study is phone the physical therapist and say, look. I know you normally say, you have this person enrolled in the study. Please don't don't do that because people were taken. 

I have to take an opioid because the physio told me to do it. Not because of a sore. Yeah. Yeah. But I am sure it's gonna be reduction in pain, and there was a clear, like, reduction in opioid use. 

Wow. That's incredible. Wow. Because you look at that, you you make you see that infographic of mood after total knee arthroplasty, and it's a really interesting graph. Right? 

You see all the the thing that we're interested about initially in the first four days. But, actually, up to six months, these guys, there's variations for whether they're feeling great or feel terrible or regret having the surgery. So if you can get up to twenty days of significant impact, I'll be interested to see what happens after that because in order to get those changes from a three minute intervention, it makes the mind boggle as to what physiological changes that The interesting thing is once once it's wearing off, the patient's go, you know that sharp pain you've been asking about? I think it's back. But at this stage, in a normal recovery profile or pain recovery profile, the pain scores are are reasonable, they can handle it. 

And then and people don't have the the severe pain and discomfort. So and the 100 patients now, nobody's had your worry good, but also harm. Has anybody had any persistent weakness Mhmm. Or sensory changes? No. 

It wears off. Nope. No. Not even sensory block. Just just No. 

You're you're Yeah. Amazing. And it's neat because we we always I mean, I I think about the pain trajectory and what's the right number of days that you'd want to block after a total knee or something. And, you know, four or five days seems to be kind of the magic spot where after that, it's just going to impair the recovery. But they've gotten through the most of the pain. 

But Yeah. But that's not every patient. And maybe it's not even most patients. Yeah. Maybe twenty days is what we need. 

So I Ten or fifteen. I've had I've had one operation, and I I this is a family show and talk about my hemorrhoid surgery. But There we go. I was waiting. It was all getting too sensible. 

But but I tell you, it took day 11. You know, I was going and crying after I had to, you know, go go to bathroom. Yeah. So it is much more than this. Yeah. 

This is like a three or four days and you're fine. I think we do that because almost all our things are three or four days. Right. And, you know, if you can keep patients comfortable so the the one caveat, you know, people who are born without the ability to feel pain, the folks that walk in the coals, their life expectancy is much less. I didn't know that. 

So if it's a protective mechanism, there's a reason here. You know? You don't wanna, famously, I had somebody talk tell me a story of a patient. They've got a catheter in for a shoulder surgery. They've patient at home with their sling. 

And, of course, when you're sore, you get chicken soup. And it helps healing. I mean, the chicken soup, they dip their their numb hand dip their numb hand in the chicken soup and burn their finger fingertips. So maybe not chicken soup for every operation that we're recovering. But but that that that reflex pain so these are the things I think we need to work out. 

But overall, for the vast majority of patients, if we can be opioid free major surgery Yeah. And then I'm left with questions, how far how close to spinal cord can I go? Yes. Can I ask for PVBs? So doing individual intercostals will be, you know, time consuming. 

But, you know, for peach patients who are maybe anxious, depressed, taking opioids, you spend the time to do this. And then not just what we do. Young kids, adolescents go in with sprained ankles. It's just it's if you don't give people opioids in the ED Mhmm. That is a big deal of of risk factors. 

You're usually done a week or ten days out. Why is that gonna be so terrible while you wait? So the the the option's good. Frozen shoulders manipulations. You know? 

The so the I think this could be That's incredible. Massive. Well, first of all, I'm gonna say massive congratulations of winning the best best post in show. Best show. Best in You do look like a room today. 

It's it's such a great movie. Go back and relook at the jokes come fast and furious and best in show. But, yes, Seffe, one of the best of meeting ever. Think Jeff is right. You have witnessed a monumental thing. 

I think we will look back at this thing. Thank god we've got video footage. We can say we're the first people to interview Stuart about it when he's We'll be old guys Yeah. On the on the chairs looking at your grass growing. Remember? 

Used to do now. I I I I was there. Don't get excited about a lot, but really excited about this. Okay. Well, that is Terrific. 

Amazing. Thank you so much for spending the time. He's got one of the busiest schedules I've seen of anybody at this meeting that we are very fortunate that we managed to get this window of opportunity. I to quote Ron Burgundy, I'm kind of a big deal. Yeah. 

Brilliant. Thank you so much for your time. Great. Great. Thanks, Steve. 

Time, guys. Thank you. Next up, we spoke with Steve Coppins from Belgium who had some not so subtle thoughts on the ESP block and philosophies about teaching trainees. Okay. Amel, we are now joined by none other than Steve Coppins from Leuven, Belgium. 

Steve, welcome. Yeah. Thanks, guys. Thanks for the invite. Yeah. 

Yeah. It's great to see great to see you in person. I I feel like I get to see you maybe once a year, but it's always always always a good time. Oh, thanks. Thanks. 

Yeah. Same. Same. Yeah. Thanks thanks for joining us, Steve. 

I know you I know you've got a busy schedule here. Ezra, so we're great. Ezra, that's a faux pas, isn't it? I know you got a busy a busy See, I'm a say I'm a say globetrotter here. Yeah. 

Yeah. Knows where he is. He just mixes up my yeah. Am I in Tasmania? Am I in Brazil? 

No idea where he is. Yeah. But but tell me, you guys have known each other for a while. Right? So tell us a bit about the history about that. 

We used to date. Yeah. Yeah. That was really hot. I I I could blame either of you. 

I I I could see that. Oh, come on. This is horrible. But no. Actually, we we we met each other due to the the exchange of the Duke fellows. 

I think Okay. Of course, Admir and and and Jeff knew each other, worked together, and they wanted to do an exchange. And then the fellows from Dukes were gonna come over to Louvre. And and, yeah. I mean, Admir, wanted to involve me as well because the the university hospital is close by. 

And so I got involved in that, and usually the fellows come a couple of days to the the university hospital and then move over to Edmir's hospital, which is quite close, 40 kilometers away. So, yeah, it was a great exchange, and we've been having this almost every time except for the the COVID years in between. But Yeah. Yeah. That it's a really amazing thing to be honest. 

Yeah. Let me tell you. It it is a it's an incredible experience for our fellows to be able to go and and see two wildly different practices in a different country. Right? So they get the Yeah. 

Big, big university practice with Steve and his fellows and how they organize their teaching and the cases there. And then they go to see Admir's, you know, private practice magical shop over there. So and they got to, you know, Leuven is like one of the most beautiful cities in Europe. Lots of, you know, french fries and mayonnaise and beer and Yeah. Right. 

Yeah. Right. So we've known for bit so well, one of the things that was very striking, and and Steve has shared his generosity and and seen on social media platforms, was just how many procedures your fellows can get done at your institution, which blows my mind. Every fellowship is is is a little bit different. I I I I'm not always sure that I I mean, I've had a lot of discussions with other fellowship directors, and it's not necessarily that because we give them a lot of, opportunities at block that it's better. 

It's just different, you know, because we have a a complete different setup with with the block rooms, and we give our residents a a little less opportunity. They only do one or two months during their five year residency. Right. So our fellows get a a truckload more. So, I mean, there's no perfect solution. 

Sometimes, some of the our residents do complain. However, I generally make sure that they at least have a 100 to a 150 blocks during their whole residency. I don't necessarily block myself a lot anymore. I see a lot of procedures, but what happens Uh-oh. What happened I took that to me. 

He doesn't block. He doesn't stick a needle in his own body Yeah. Anymore. No. What I knew somebody that's What what happens is I get all the I get all the the difficult cases. 

Right? Right. Or you have private patients. They're they're asking for me. So, actually, I do, like, one or two blocks a day. 

And if there are 20 blocks, the 18 others go to the fellows Yeah. And and then maybe one or two to the residents. So yeah. So what is fascinating that that one of the problems that we're seeing now in our in our teaching institutions is that we've now made regional anesthesia a core part of the curriculum. It was all of our anesthesia trainees or residents are expected to to get a certain standard. 

But if the fellows are getting all of the best opportunities, there is a lot of competition. Yeah. Yeah. Absolutely. That yeah. 

How do we if we've got a limited number of blocks, how do we make sure they're equally distributed? Because we got responsibilities Yeah. To be the generalist, and those are gonna be specialists. Yeah. It's a challenge. 

Yeah. I'm I'm not saying I have a solution, to be honest. I've I've had this discussion with fellows, with residents, with staff members, even with with people from other hospitals in Belgium saying, you know, like, yeah. We we we we have a new consultant, and and he he he he or she can do she did a 100 blocks, but she's not really proficient at it. And you train all those fellows and it's great, and you're on Twitter, and you promote how great you are, but I I don't think you're that great because, you know, you should put more effort in in in in residence. 

And I I kinda understand the idea, but there's no magical solutions. There is none. Well, speaking of magical solutions Uh-oh. Is this a joke? No. 

Okay. I wanna talk about a block that works so well. Everybody's favorite block. The t s drop The ESP. Yeah. 

Yeah. Yeah. Yeah. Yeah. Why do you why do you love it so much? 

I it's it's become a a sort of running gag. Right? By the way, this is the closest I've been to Steve when we've been talking about ESP blocks. Normally, he responds to me via correspondence or on social media. This is the first time he's gonna tell me to my face this close why he hates the block. 

It's become a running gag. Like like, I I mean, truly, they call me doctor no ESP. I I was the bad guy in the RAUK. He was James Bond, of course. Yeah. 

I mean no ESP. Come on, man. It's become sort of a joke. Now, I I mean, the if I have to be honest, I mean, I don't think I'm really anti I ESP. What I'm really anti on is, like, the the hype thing. 

You know? It was like with the the adductor canal Yeah. Sort of it became a magical thing. You know? You had you had the obturator in there. 

You had the the medial cutaneous nerve. You you did you did an adductor canal, and you saved the world. You you you you you cured the patient from from cancer, whatever. And and and it's been always like that. You know? 

It it was the tab block, and then then it's the ESP. And when I see publications pushing the ESP for crazy shit like Alex Falkis or whatever That's our first beep. Is our first beep of look, I think. I mean, I I really get annoyed on that. Yeah. 

Another aspect is, of course, I'm as a I I'm mainly a clinician, but I do try to do some research. And as a researcher, if I set up an RCT and I try to investigate the ESP, I come up with zero zilch. Each time we did two RCTs, properly blinded, randomized controlled on cardiac surgery, and it came up tilt. That's that's pretty information. We did one on VATS, which is now currently under minor revision in anesthesiology, where we compared I I know I'm I'm gonna be public number enemy number one now, but, you know, it was surgical infiltration of intercostal blocks versus ESP for VAT surgery. 

And what what showed up was that the intercostal block of the surgery was better in morphine consumption. But Wow. What's even worse is I I it was properly blinded. We sent up plasma samples to Groningen in in The Netherlands Yep. To show us the ropivacaine levels. 

Because our idea was ESP is is also mainly, like all facial plane blocks, partly or even mainly an an intravenous by proxy block. And what came back is that the local anesthetic ropivacaine level was double the amount in the ESP than in the intercostal. I know you don't believe me. Anesthesiology didn't believe So which was the highest? The highest was in the ESP. 

Double the amount. Fascinating because, you know, we always memorize that list Yeah. As a resident, like, what's the highest absorption In in our cost list. Yeah. So when that came back, I checked it a 100 times. 

I sent it up to Danny Hochma who helped me. I sent it up to our study nurse, to the statistician to check if if I hadn't switched the keys. What I'm hearing is not only is ESP not efficacious, it's unsafe. Yeah. I think it's efficacious for, like, posterior rib fractures and for spine surgery, but I I really in doubt the anterior component. 

I'm really in doubt of that. And I think it has an intravenous by proxy effect as well. Interesting. Were you using epinephrine in any of your solutions? No. 

We were not. And that started with fats because I knew it was gonna be criticized. We did a double blinded randomized control trial, but we did the multicenter trial. So I asked Jalil Hassanin, who's a good friend of mine, who had his training by the NICE ORAN, who's pretty pro, Bloxy had a couple of very good publications in RAPM on efficacy a effect of the the anterior serratus block. So this was a guy who believed in ESPN. 

And so I asked him to do the second arm, because it was multicenter. So he came up with the same results. There was no difference in Wow. In so yeah. Interesting. 

That's that's fascinating. Wow. So hopefully, it will be published in a couple That's of great, man. Looking forward to that. I wonder if some of the magical thinking about ESP is just because it's so It's easy. 

It's easy. It's easy. And and and it's there's an attractive concept, like, oh, I can do cervical, thoracic Yeah. Lumbar, sacral That's why. And get it you get the whole body. 

Yeah. Yeah. Coccygeal. Yeah. I don't know if there's anything with coccygeal Yeah. 

ESPs. Yeah. Yeah. There's everything. There's even a publication on, PDPH with ESP working really well. 

Is that right? Yeah. I haven't heard of that. It's a case report. Okay. 

So listen. I I I think So I'm taking two things from this. One of the things I'm definitely taking, is that, you're not a fan of a block being hyped and promoted without an evidence base. Yeah. And I think I think that's That's the main thing. 

Right? Sounds pretty reasonable. Yeah. But more importantly, you're a big proponent of thoracic imagery analgesia. Right? 

Yeah. Yeah. So so I I remember asking Jeff this question in the past about does he ever see there being a time where we're gonna be performing less and less thoracic epidurals? It's already happening. Already seen that in The UK. 

Yeah. That's one of the challenges that we're having is we're not performing enough thoracic epidural. Yeah. So the training opportunities are not there. Yeah. 

Exactly. But you're happening to work in an institution where you do enough of these so you're able to keep your skills up. It's And that's and we're not in that position. It's it it's it's all about oh, come on, Bublik. He's writing ESP on there. 

Right? Forever. Thanks, Ian Bublich. Nice. That's a shout out to Ian Bublich there. 

Yeah. It it is about perspectives, I think. And my perspective in that is that Tureshi Kipenduro is, I think, in selective cases, still phenomenal. Yeah. So Goldstein. 

If you lose that due to training diminished, then you lose it forever. So our idea is, like, let's still perform thoracic epidural in the cases where it might not be super essential anymore, but it's definitely not contraindicated. Like Yeah. So we won't do it for fats, but we will do it for fats when the surgeon calls us up and say, there's a high chance of conversion rate. In my opinion, you can do it to rashicaputral. 

So it's seizing the opportunities to have enough cases, and we should do that as well. The surgeons are there are multiple publications on surgeons saying, you you know, you need to do, like, 50 esophageal resections to be proficient at it. Yes. And we never I I don't see any publications on anesthesiologists. You need to do at least so many blocks to be proficient at it. 

We should do that as well. I mean, I still think you can, in selective cases, make a huge difference. And if you lose that, come on. Yeah. It's it's like it it would be a damn shame. 

Yeah. Oh, curse word again. That's okay. That's okay. That's This is the spicy part of the podcast. 

So so So for a midline laparotomy, are you doing a thoracic epidural or are you doing rectal sheath blocks? I I do a I do a thoracic epidural. Yeah. If, of course, it's a a laparoscopic procedure and it ends up in a in a midline incision, I will do a rectal sheath block. At the end of surgery, after closing up surgery, just put in a recto sheet block. 

It works really well as well. And then go with multimodals. So listen. You said something, which my ears my Mickey ears freaked up at. Yeah. 

Because we've put in the Go ahead. Epidural there. Yeah. The epidural Yeah. Asleep. 

Yeah. Asleep. Why not? What? Why not? 

Asleep. Oh, why not? We have epidural? We have, like, a Middle, spine, patient awake, can't say, ah. It's like a harpoon. 

No? Come on. There's there's actually a Ezra pediatric guidelines saying that the rash keep This is If it's good for pediatrics, it's good for for for adults. Right? I I did my training. 

I did liver transplant fellowship, liver transplant anesthesia fellowship, and they only ever did a sleep thoracic epidural. So I learned Yeah. Doing a sleep thoracic epidurals, but they knew they had the insight to know that actually not everyone's gonna be cool. Yes. I I I usually only do that with one or two other people. 

But it makes me feel scared, guys. That I you you think I'm not scared when I do stuff like that? I I I mean, you should be scared. If you're not scared, then you're a cowboy. So you you should be scared. 

Another bumper sticker. If you're not scared, then you're a cowboy. We're getting great bumpers. I loving that. I quote you the common Power partner. 

Yeah. Yeah. Steve, this has been amazing. I wanna hear a dad joke from you. I want the joke. 

Oh my god. Okay. So, yeah, we're we're in Florida. There there are a lot of seagulls here. Yeah. 

Seagulls? Yeah. Why a seagull is called a seagull? Because it flies over the sea. Right? 

Right. If it were to fly over the bay, it would be bagel and would be eaten by breakfast. Right? Okay. Okay. 

That's fine. That met the criteria. That was good. That was Amazing. I'm gonna get a selfie with us Of course. 

So that we can memorialize this. Nice. Guys. Thank you so much. No problem. 

Steve, thanks, man. That was really awesome. Really thought to see you, buddy. And then we rounded things out with our boy Gary Schwartz from Brooklyn, anesthesiologist, pain doc, and tension pneumo survivor. Gary had some very cool things to say about cryo and told us why he thinks anesthesiologists are the best periope leaders. 

Pull out a little bit closer to Yeah. Is that better? That should be good. Yeah. Now you look like yeah. 

The Britney Spears look. That's what people are Oh, baby. Do I get the python to carry around? I can put on a skirt Yeah. If you want me Why not? 

Okay. We're good to go. Jeff. Yeah. Go ahead. 

Jeff, I am delighted that we are joined in the GE block box. Deli nay. Thrilled. I've used delighted twice. I need to be thrilled. 

I'm thrilled. I'm thrilled. Overwhelmed Yeah. That we're joined by none other than doctor Gary Schwartz. Gary, thank you so much for joining us, man. 

Thanks, buddy. For the invitation. This might be the highlight of career my career. This is my favorite podcast. Well well, thank you very much. 

My favorite podcast. That's amazing. I like it. Podcast is listed. He listens to one. 

So yeah. You guys are number one on my playlist. Yeah. Exactly. Gary, you are interesting for us because as time is going on in on block like it's all, we're opening out from people who just did regional anesthesia. 

You have a a a practice that is kind of broad based. Tell us a little bit about yourself. But before you do that, so I want you to start off with a joke because we kinda got straight into the conversation with a few people. So you know the deal. We need to know a joke before we get into that. 

I love the jokes, and, yours are a lot funny. I hope I deliver them. I have a few I was thinking about. Okay. Know we're in I know we're in the Disney area. 

I'm not a Star Wars fan, but I know you like movies. Oh, yeah. And I know you like music. Yep. Yep. 

So what was Indiana Jones' favorite band? Not Bob Dylan, a great documentary the other day, but it's a little bit of a hint. The Rolling Stones? Not so funny. Not as good. 

That was good. That was good. He's warming up. Okay. I'm warming up. 

Yeah. What is the most reliable part of the human body? Reliable. Reliable. Since we're talking about blocks, not back. 

We treat a lot of them in the pain office. The most reliable part of the human body. I didn't know you tell us. Your fingers. You could always count on them. 

Okay. And I'll leave you with the decent we're warming up. I was gonna say Ahmed's mouth is his most reliable part because he just can't shut him up. Yeah. Exactly. 

But you know what? I'm I'm loving hearing the accent as he's delivering the jokes because we haven't had an accent like yours on the podcast. This is I'm loving this. So, like, I know you guys like some rap music and stuff like that. Uh-huh. 

Colder than the other side of the pillow. Who is the coldest doctor or physician in the hospital? Okay. I think I'm gonna like this. Who is the coldest physician in Oslo? 

I don't know. An ICU doctor. Okay. Okay. He left the is that is that the last one? 

That's the last one. I got the decent like, medical jokes too. I tried to get medicine in there to kinda keep with the theme. Not bad. That was amazing. 

Good job, man. I bring the white New Balances and the jorts here for the talk, but maybe next time. Well, you you built us up really nicely to that. So now tell us a little bit about, who you are, what you do, and what your passions are. So I'm, Gary Schwartz. 

I like to sit on the beach all day when I'm when I'm not working, but I have an interesting practice. I do, regional anesthesia, run the acute pain service at our group, AABP. We're a private group in Brooklyn, New York. We have integrative pain and wellness where we do all sorts of interventional pain management. So I do regional pain and then some academic stuff because we have a residency and then some admin. 

So my life is pretty busy. Fairly busy. Yeah. Like a portfolio career. You got you got me. 

Like a dysfunctional Swiss Swiss army knife. So within so tell us about your wellness work because that sounds really interesting. Wanna So we're looking at wellness in our practice. So people come a lot of times with chronic pain. Yeah. 

So I know you guys are very good, a lot of people in the meeting, they have a knee arthroplasty, and you figure they get better. But about ten percent don't. Okay. So they come to the office after. So what could we do to improve their functional quality of life or even prevent surgery? 

So we do a lot of regenerative treatments now, stem cells, PRPs, that we're giving if people are not ready for surgery. Are you doing PRP? We do PRP. So for the listeners, I'm sure most people are familiar with. A lot of people heard of it from Kobe Bryant years ago. 

He had to go to Germany for the treatment at that time. Now you come to Gary. Yeah. Come to Gary. You know? 

Gary's PRP shack. That's what we could do. We could sell oysters there. We can get PRP. Maybe a cannabis shop in there. 

We could have a lot of fun. Sounds like total wellness. Yeah. Use your own body to heal. Yeah. 

Yeah. So we have a lot of that. We're bringing nutritionists to our practice, some acupuncture. I wanna understand. So you're taking their blood. 

You take the blood out of whatever vein you want. You're spinning it down. Spinning around. You get the high platelet concentration, and you inject it back. Where where Or where does it hurt? 

Not just into the air. So if they have, like, a knee osteoarthritis or a tendon injury in the shoulder, you could inject that tendon or ligament to hopefully heal over time. The biggest risk from it is you have to not take NSAIDs or decrease your NSAIDs used for a week or two after. And then as the cartilage, tendon, ligaments heal, you could send them back to physical therapy, rehab, a physician directed exercise program, maybe yoga with Jeff and Amit or something in the future. And it helps them to, number one, motivate themselves to work on themselves. 

Yeah. And two, hopefully have non addictive substances that they can get better. Wow. Sometimes it hurts during to have the procedure because you get an inflammatory response that could be Mhmm. Pretty painful, and they're not taking NSAIDs. 

So sometimes we cryo people or give a nerve block before we do the treatment to help decrease their pain. So they allow the PRP to work, but we decrease their pain in the meantime. Yeah. Yeah. Oh, that's great. 

Wow. Is there good evidence behind PRP? Is it There's decent evidence. A lot of them are small studies. The biggest problem with it is they don't count necessarily the exact platelet count. 

There's different products that people use, and a lot of them are small case reports. But there's more and more data coming out. There was a study a couple months ago that showed it was just as effective as hyaluronic acid or like gel injections for knee osteoarthritis. So I think we'll see more research in the future as people are using it. Data aside, your feeling is it works. 

I think it works. Look, there's a large placebo effect also in all pain procedures and anything we do in medicine type of thing, and people have to pay cash for it. So it's a motivating factor to They have to. Make lifestyle change. So if you're gonna pay a thousand dollars, $1,500 for a procedure, you're probably gonna stop smoking. 

Right. You're probably gonna actually go to I'm saying you're probably gonna go to physical therapy after if you're doing all this work to get better. It's an extra motivating factor Yeah. To do everything you need to do in addition. Yeah. 

Just like our surgeons. They could do the greatest knee arthroplasty in the world. You could do your I pack geniculars, adductor. I could cryo it beforehand. But if they sit in bed all day, they're not going to have a good outcome. 

Yeah. Yeah. Hey, tell us more about the cryo. Where are you seeing cryo really make a difference for patients? In the And we're talking about cryo neurolysis here, right? 

Cryo neurolysis. So we could form an ice ball, application of an ice ball freezing cold to a nerve. So what it does is it kind of stuns the nerve, and you have a lesion. So kind of a prolonged nerve block because we're very good at giving nerve blocks, but they wear out. But we but we're doing something materially to the structure of the nerve when you're using You're giving a grade two lesion, but it grows back. 

We've been doing stuff to nerves forever. Number one, local anesthetics are toxic to nerves. Yeah. We inject them freely. We give all sorts of additives to our nerve blocks and just see if they work. 

Yeah. I've been r f ing nerves in the lumbar spine, the cervical spine, some peripheral nerves for over a decade. Right. And there we're taking eighty degrees of centigrade, but it kind of injures the nerve. Yeah. 

They grow back, but we don't know what's gonna do. That. You say r f u nerve. Exactly. Yeah. 

I really get angry. You could do PNS, which might be Jeff's new favorite technology in the future. But So Peripheral nerve stimulator. Just so I wanna make sure our listeners are over here. I see Jeff with a big smile on his face, so I don't wanna get in trouble or banned from the podcast. 

So But the the degree the thermal threshold or thermal injury, it it the degree of injury and the type of tissue that it it affects depends on the temperature. Right. The temperature. If you go, like, less than a 140 degrees, that's what our IR doctors use. That's for cancer pain where you're just destroying the nerve. 

It's not coming back. So it's nondestructive. What you're doing is nondestructive. It causes wallerian degeneration. It does. 

A grade two lesion, if you remember from medical school. So the nerve gets kind of stunned. You get the wallerian degeneration. It grows back about a half a millimeter to two millimeters a day depending what study you look like. Like if you had long hair and then you cut it short, it hopefully will grow back. 

Long hair. I used to have hair down to here. That was your boy band aid? Yeah. Yeah. 

Yeah. Completely. It was I I I can picture it. Yeah. It must have been fabulous. 

But I also had an undercut, so I had it shaved up to here. So long hair. So had to pull it. But, anyway, sorry. I don't You put it in ponytail? 

Yeah. Yeah. I'm picturing a slow mo run down the beach with the Yeah. Hair. That's how he got his wife probably. 

Well, yeah, that that's another story. But, yeah, maybe. So the nerve gets destroyed, but then it grows back. So you get an immediate relief of pain, and it lasts for three months or longer. So the patients could recover from whatever surgical procedure they're having. 

Or I use it a lot for prehab, like pre knee arthroplasty, because our nerve blocks are good. And we could add whatever mix of the day using femoral trio, ductor, eye pack, genicolas, whatever you wanna do, but they wear off. Yeah. But the pain persists. After day three of the surgery, day four, it's, like, pretty bad between, like, two to four weeks, depending on the patient when you ask about. 

So it helps them recover from that. I use a lot of knee arthroplasties in my practice. And what I've been utilizing recently is for rib fractures. Yeah. Okay. 

So these are two topics that we talk about a lot in the podcast. So can I back up? Right. Knee arthroplasty. You mentioned prehabilitation. 

Tell me how that works. What's the concept behind that? So most people that are having knee arthroplasty, at least in our area, are not physically fit. It's not someone who just wore out their knee. They're normally obese. 

They have diabetes. They don't walk around that much. You have a big mush of a leg where not much muscle mass. So now we're telling someone who hasn't really walked for months, maybe years, we're gonna cut open your knee. We're gonna destroy the bone. 

We're going to repair everything. And now we're gonna have a large amount of inflammatory process, swelling, and we're gonna expect you to get up and walk. Yeah. Okay. Yeah. 

Like that day and go home. Right. So some people are not ready for that. So we could do it like a month before surgery, send them to physical therapy so they could strengthen their quads and their hamstrings. At least, again, in our practice, we don't have a lot of people that just don't have a unilateral knee OA. 

They have lumbar spine, osteoarthritis, hip osteoarthritis, the opposite leg that they're operating on so they can get stronger so we could they can actually get up and move out of bed and go home. But are you using cryoneurolysis as part of that? Because a lot of people who've got preoperative pain, they struggle to exercise in one because it may be physical fitness, but their pain is a lot. So I I've heard of this being used pre So we do it. So some people are not ready for surgery. 

Let's say they come to me. They might be a smoker. They might be overweight. Maybe they started one of the GLP one agonists, and you wanna let them marinate a little bit, drop 15 pounds for surgery, stop smoking Yeah. Etcetera. 

The other reason we do this is some people might have gotten a steroid injection into the joint Uh-huh. From, like, one of these urgent cares or doc in a box, and now they see the orthopedic surgeon, and their literature shows they can't have their joint replacement for three to six months. But I could still cry with before, let the steroids wear off, lose some weight, stop smoking, strengthen their quads and their hamstrings and everything else, and then have the surgery at the appropriate time. So what are you using? Nerves are you blocking? 

So depending on the area, a lot of times I'm blocking the anterior femur cutaneous nerves. Believe Doctor. Gadsden, Jeff over here named them cuties online, which we love. The cuties. Yeah. 

They're adorable. It makes it seem like a more fun procedure. So you cry the cuties? And they and I also get the infrapatellar branch of the saphenous. I block it kind of in the suprapatellar area right over here, and they get immediate numbness. 

So they get numb anterior thigh down to the fascial plane in the top of the knee and wrapping around where their infrapatellar branch of the saphenous does past the medial component, and that's a lot of their pain. And the benefit is I don't know if you guys have ever experienced radiofrequency ablation or at least heard of it. It could take weeks to kick in. This is immediate, almost like our nerve block. So when they leave my office, they get up, I'm like, they're numb. 

And and and let me I'll I'll share a story here that that corroborates with Gary's show. The first time I ever saw cryo being used for this, I flew to Nebraska to an orthopedic surgeon named Josh Urban, and he was because he was doing this. He was doing it under ultrasound. Himself. Himself. 

Great. Had good ultrasound skills and he was doing it himself in his clinic. And patient walks in and sort of hobbles in. He's got eight out of 10 pain. I'm like, okay. 

He does the cuties and the infracatellar branch of the saphenous. She gets up, flexes her leg, and says, oh, pain's like a two now. I'm like, come on, man. You paid that you paid that woman to say that for in front of me. Like, there's no way. 

Because I'm also thinking those are cutaneous nerves. Yeah. How on earth Yeah. She has osteoarthritis, cartilage, bone, and then it happened two more times that day. Like and I was like, okay. 

I'm maybe the what am I missing here? And what I what I didn't understand, and our trainees don't understand this either, is that the fascia lata that encircles the entire lower limb is richly innervated by the cuties. Wow. And and that has a lot of role in force transmission around the knee. And so that if you can calm that down using local anesthetic or cryo, that explains why that that so called cutaneous block worked for those patients. 

And it's incredible. I've I've had people come in and, like, they'll bring in, like, a cane, and they'll walk out. They're feeling better. They still have an awkward walk sometimes because they have a mechanical issue. But I've had patients leave the office. 

As they walk back the cane. Yeah. They they're holding the cane in their hand. And, like, a couple of people said, do I still need surgery? I said, yes. 

I was like, I'm telling my referral base. Yes. Are there a a proportion of patients who are like, hey. My pain's gone. I don't need an operation now. 

Well, I tell them it's still it doesn't fix the mechanical issue. This is there for the help you recover or prehab, and you could have it repeated and delay the surgery. But, like, if your knee looks like this, the viewers can't see this because thank god we're on radio. Well, they can. Well, here, they can see us. 

But when they're listening to the podcast, they say they have a face for radio. If they still have the mechanical issue over here where their bone is touching bone, that's not gonna get fixed from the cryo. It just decreases their pain. Yeah. Yeah. 

Yeah. It's make a big difference. I'm curious to see what's, like, the next step. Could you get a lesion big enough to maybe help post amputation pain? Yeah. 

Because, like, these cuties are small, so an ice ball could envelop them. The sciatic nerve is big. You'd need, like, five or six ice balls. Use cryo to these big nerves? You could. 

I haven't done it personally because I don't have a set number of how much lesions you would need to actually freeze the nerve. And when you say lesions, you you'd have to do the procedure at multiple points along the path of the nerve? Yeah. So at least the company and the device that I use, the the it's a couple of millimeter ice ball. There's some other companies where you could control the size of the ice ball, but from my knowledge, there's nothing big enough now that you would be able to knock out, let's say, the femoral and the sciatic with one lesion. 

And we don't wanna have, like, a denervation injury where you partially freeze a nerve. That could be something that's painful. So I think that's the next step if we could calculate that. Like, imagine if you have, like, a knee arthroplasty or, god forbid, like osteosarcoma, like an amputation, and you could say, we're gonna freeze this, and you're not gonna have pain for three, six, nine months. As you recover, you can get fitted for your prosthesis, go for your chemoradiation, get the psychiatric help that you need to deal with such a life altering event. 

I think that's the next step. Yeah. Yeah. Amazing. And so so that's the knee arthroplasty. 

So you're doing some of this pre procedurally, but there's a a large proportion where you do it post procedure. Post procedurally, and I sometimes block the deep geniculars. Like, we've all seen this in our practice. If you look at the data, it's what? Ten percent of people have chronic pain after knee arthroplasty. 

You send them back to the surgeon. You could look at these X rays. The knees look fabulous. Yeah. Of course, the surgeon's gonna say they're fabulous. 

They say maybe it's from the laxity of the knee, how they put them in. It's not a native knee, and they have pain. So now I shut these fibers off after these nerves off so they can continue rehab. They could function and move around their weight loss journey, whatever they're doing after the surgery to decrease it. It's made a large difference in our practice, and it's lovely helping patients. 

Tell us about rib fractures because that's the other thing that's interesting. So where are you blocking? So I'm blocking the intercostal nerves a little bit more proximal to where their fracture is. I've had two patients over the past two weeks. One was a patient that fell on a banana boat. 

And on vacation and got kicked by one of the other people, like, you know, straight karate kick. Yeah. Yeah. Yeah. Right? 

Cracked, like, five ribs. So we did our normal we didn't want that a dancing incident or something or, You know those banana boats where people are, like, on The Caribbean and they they sit on the back of the boat and they drag you and they try to fly you off? Dangerous. Yeah. I don't go on them. 

People like me are not good for these situations. So I guess one of them flew off. They multiple flew off. As they were full bodies were flying, they got, like, a kid leg right to the ribs, broken ribs. So they had to get come to the hospital after they flew back. 

They didn't have a pneumothorax like myself, which is always good. And then they didn't want an epidural. So we did an ESP because they wanted to go home, but then the block wears off. Yeah. So she came to the office, and I cryoed the five ribs, intercostal nerves, and it took away her pain. 

I had a patient the other day had a syncopal episode. And thank god his cardiac issue no cardiac just got vasovagal Uh-huh. Fell, cracked his ribs on a toilet. Thank God he didn't hit his head because he was fully anticoagulated. Oh my goodness. 

He has a big bruise. You can't put an epidural in the hospital for the anticoagulation. I don't like to do paravertebral when they're fully anticoagulated, but he wanted to fly back. He didn't have a pneumo. He wanted to fly back from where he was from. 

So, like, cryo those ribs and took away, like, 90% of his pain because rib fractures, even more so than knee arthroplasties, don't heal. It could take eight to twelve weeks to get better, to fully heal, at least six weeks, especially on anticoagulated patients. Now they have probably a large hemothorax or at least a deep bruise to the muscles. I don't know if you ever cracked any ribs, either of you two. I've not had that experience. 

No. I did that once and it hurt. Oh, you got was only one. Not often. Just one time. 

It's a I try things once and that's about it. It's when I have these injuries, I don't wanna have them again. Well, hold on a second here. This reminds me that you told me a story once about someone trying to help you, and it didn't quite go as planned. Yes. 

So Jeff still thinks it's BS, and the the listeners of the podcast could not see, but I'm I'm not a svelte person over here. So is. Let's go six pack. I had a Up there. Maybe one day. 

I I I moved the patient on a call one night, and I had a spasm in, like, my neck back area. So one of my former residents used to be a pain PA. So I'm like, oh, could you give me a trigger point? I think I'll get better. He's like, I've done thousands of them. 

And I'm really not a small person. So we had local anesthetic with a one and a half inch needle. Okay. And he gives me the injection. He's like, you feel better? 

I'm like, yeah. A little bit better. And I walked outside to get, like, a cup of coffee or a seltzer or something like that. I'm like, I don't feel good. I look at my Apple Watch, and my heart rate goes to one seventy. 

What? So I'm I'm on call. I go I'm, like, meet me in the OR. I look at my sat. It's 99%. 

And this is during COVID times. I'm gonna say, I don't know what's going on, but I have to finish my call. I, like, put some oxygen on me just in case. But I'm like, there's no way I got a pneumothorax. Well, I'm like, this is cool ever. 

Yeah. It's it's a really bad call. Had a couple of C sections. I'm coughing a little bit, but I'm like, maybe I'm just not feeling good. I get home the next morning, and my wife's like, I'm, like, coughing up a storm. 

And my wife's like, are you sick? You you have you can't go in the house. Bring COVID home to our family. I'm like, maybe I'll go for a jog or something. So I'm like, I'm bending down the toe. 

That's slightly opposite of what I think about the. Because I'm like, I don't there's no way I got a pneumothorax. Just small tension pneumo. Yeah. I think for a job. 

So, like, I bend down to put on, like, my shoes, and I'm like, I feel weird. It feels like my heart's moving. Like, it I can't describe it. So I'm like, my wife said, gotta go to urgent care. So go to urgent care, and the guy's looking at me. 

He's like, oh, you look crazy. I'm like, something is wrong. I don't complain. Did you percuss out the No. So this so he gives me he's like, you're probably just nervous or something. 

I'm like, yeah. You know, I'm a Jew from Long Island. I understand all this. He comes back in the room, and it was like an elderly like, some of the guys in the urgent care, a little bit older, semiretired. He looks like white as a ghost. 

I had a forty percent collapse of my left lung. Oh. Wow. My goodness. So this resident felt bad. 

I got to give his I I healed. I didn't need a chest tube. Thank god. It healed. Did it? 

No. So I went to the ER with my disc from the urgent care. Now they let me drive to the emergency room, and I'm waiting to bring heart rolling around in your chest. It happened all So the ER doctor has a chest tube. He's like, what happened? 

He's like, do you do? I'm like an anesthesiologist. He's like, oh, we'll call in the we'll call in the pulmonary doctor. He was ready to put if I said I'm a mechanic, he was sticking that chest tube in me with a little bit of local anesthetic. So then the pulmonary guy comes in and he's like, you look okay. 

Just get serial serial chest X rays. So I sat in the ICU over day. It's the only date I missed of work as an attending, like, a nonvacation. My PA texted me the next day. She's like, why aren't you in the office? 

So I sent her a picture of me hat backward, oxygen mask, and a gown. I'm like, I'll be in tomorrow. But it got better, so that was my lesson learned. The Wow. The the carefulness being And and you think that the the cause was a 100% this this I don't know what else they got. 

Wow. I had a I see a CT chest surgeon. I got a CT. They thought it was straight from that. And I spoke to the ER doctor. 

He said it happens. But I'm like, one and a half inch needle And a 25 gauge. It really gave me some it's and I make the residents always give, make show me the needle when they have a good view. So I got to announce him at graduation after because he was going to he was my mentee. So his his family's all there. 

He's in his nice suit and, you know, make a nice speech about it. And I'm like, his parents everyone's so excited to see him. That's how I started my speech. I'm like, I introduced his parents. I'm so I'm sure you guys are so proud of your son, and you're probably so happy that he's here today. 

But I'm like, no one's happier to see him today than me because he nearly killed me five months ago. And I'm like, if he used a little bit bigger needle or or I didn't catch it, I would have been dead. So I'm the happiest to see him graduate today. And I hope to never see you again out the door. Oh, man. 

Wow. What a story. I kinda get the vibe that we're hearing things that some of them are brand new and some of them are technologies that have been out there, but you give us such a convincing story about the potential benefits of these technologies. So do you get the feeling that we're just on the cusp of what cryo neurolysis can do? Is that gonna is that something that we should all be doing? 

I think more people should get involved or at least research it for their practice because we're it's like a prolonged nerve block that you could advance the patients. I think the two big technologies coming out are the cryo, how we expand that, or peripheral nervous stimulation. I won't use the PNS too much to scare the viewers, but I think how could we make our blocks and recovery last longer? So before, it was just like, okay. How can we numb the nerve for surgery? 

Yeah. Then it's how could we maybe get them home not staying in the hospital? Now it's how could we be like the perioperative pain physician or transitional pain service? How could we help them through their recovery? Like, as anesthesiologists, as acute and chronic pain specialists, how could we get them through? 

Because the surgery, yes, two hours in the Operating Room, but how do we get them through the recovery period? Yeah. Or help them rehabilitate from their injuries to function back in society. And that, think, will be the value of pain practitioners, both acute and chronic going forward is what we could offer to these insurance companies, our governments, like Yeah. In The UK and even, CMS for The United States. 

Like, how could we help these people through the process so we show our value? That's, I believe, the next step. But I'm You know what's interesting? So we, over time, as as doctors in general and you pick your specialty, we all kind of came down to a small niche, became areas. But what I'm hearing more and more is that we need to step back and become these physicians again or at least have services that talk to each other because you're in a unique position in that you're a regional anesthetist, but you're also a transitional pain physician because you're doing stuff pre procedure. 

You're taking care of the anesthesia. You're doing some some stuff afterwards. And then if you add in the whole hocus journey, we're then suddenly becoming like the super doc to the hospital. Gary is the utility infielder of The bench warmer who gets called in occasionally. I wanna be an anesthetist, not an anesthesiologist. 

That's why I wanna get the next level. Yeah. Yeah. But I gotta say it was the accent though. It's anesthetist. 

Exactly. That's he hasn't done his British accent at all in this podcast. More Australian. Yeah. Yeah. 

Yeah. Everyone says the same thing that they know his English accent isn't on it's okay. But but is there a danger that we're taking on too much? I mean, you you you add all this stuff. I don't know. 

Who better to leave than us? Yeah. You wanna be the quarterback of the operating room or the maybe the hospital at that point. It's probably anesthesia and pain are one of the few specialties that touch every other specialty. Orthopedics, general surgery, trauma, acute chronic pain, maybe we should be the leaders of this the next era because it's one of the few specialties that touch every part of the hospital, and you have an in-depth knowledge of it. 

So who better to lead is the question I propose to you. I love this. I love that. I kinda feel that this is like a mission statement. This is the future. 

We're getting a lot of big calls, big statements on this podcast. Gary, I'm inspired. I think I could I could do a whole episode. In fact, we probably have got a whole episode of content here. I could do a whole episode just talking to you. 

Very insightful individual, and you've got me excited again I love that. We can do. This is since we're at the fiftieth AZRA meeting, this is fifty years of AZRA. The first time I met you guys was at an AZRA meeting. That's right. 

I think we were so excited to get to the lecture. We woke up extra early in the morning. I think I it was in Las Vegas. I believe we got up so early. I think we were there before the meeting started, like, at four or five in the morning, and we couldn't find the event hall. 

So we had to find another space to hang out at that time until the meeting opened up. That was, like, a couple years ago. That's how I became friends with you guys, the the excitement that it brings. That's right. There's very few people I could hang out with at four or five in the morning other than you two. 

In preparation for the for the meeting. Oh, the the excitement just overtook us, I believe. Gary, thank you so much, man. Amit, Jeff, this is an honor and a privilege. Truly the highlight of my career so far. 

I appreciate it. So much cool info and mediocre jokes. And there's a lot more where that came from, so keep tuning in. Oh, and in the meantime, our producers have asked us to ask you to please remember to block it like it's hot.