Overglorification of nerve blocks

[Sonny Crocket]

My residency was strong in regional. When I joined my practice, I quickly became the regional guy. Don't get me wrong, love doing blocks. However I feel they are over glorified. You put local around a nerve. We should all be able to do this.

There are some new staff at our practice who are supposed regional 'gurus' but I just don't get. It's a block. Don't make it a big deal. Do the block. Be safe and good at it. Be efficient and move on.

They take too long to do the block. Talk way too much about it. Kiss up too much to the orthopods.

Any thoughts on this?

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[Planktonmd]

Agree with you!
This started since the introduction of ultrasound, the block that used to take 3 minutes to do from start to end now requires 30 minutes and way too much drama.
We used to be able to do regional anesthesia in the background without being noticed, and without affecting turnover times, that's not possible anymore.
I love ultrasound and I have switched to exclusive ultrasound blocks but I do miss the time when blocks were not such a big deal.
Also that whole thing about being a "regional guru" is very silly... it's a core component of our practice and does not require gurus or wizards... a well trained chimp can do it.

 

[deleted126335]

Any thoughts on this?[/quote]

My residency was strong in regional. When I joined my practice, I quickly became the regional guy. Don't get me wrong, love doing blocks. However I feel they are over glorified. You put local around a nerve. We should all be able to do this.

There are some new staff at our practice who are supposed regional 'gurus' but I just don't get. It's a block. Don't make it a big deal. Do the block. Be safe and good at it. Be efficient and move on.

They take too long to do the block. Talk way too much about it. Kiss up too much to the orthopods.

Any thoughts on this?

-For most practitioners, ultrasound makes blocks more successful and less dangerous.
-There are plenty of folks in practice who are not proficient in blocks. For those that are, calling attention and adding drama to the block is a way of "distinguishing" yourself for some, particularly in departments where only a few folks have the skills.
-Patients and surgeons generally like blocks, so it is a feather in the cap of those that can do them since it is still not quite widespread. Blocks are the flavor of the month. When they become widespread and routine, they won't be. Enjoy it while you can. Leverage it while you can.

 

[urge]

Agree with you!
This started since the introduction of ultrasound, the block that used to take 3 minutes to do from start to end now requires 30 minutes and way too much drama.
We used to be able to do regional anesthesia in the background without being noticed, and without affecting turnover times, that's not possible anymore.
I love ultrasound and I have switched to exclusive ultrasound blocks but I do miss the time when blocks were not such a big deal.
Also that whole thing about being a "regional guru" is very silly... it's a core component of our practice and does not require gurus or wizards... a well trained chimp can do it.

I disagree. Regional was a big deal before the ultrasound. Many people wouldn't even attempt it because of the high failure rate. It was a rare skill to have. That's why crocket is the "regional guy" and the one after him are "regional gurus". The old guys don't know much about blocks. Back then a regional fellowship would set you apart.

Nowadays with ultrasound peripheral blocks are a basic skill. That's why I think doing a regional fellowship in it is silly. It's like doing a fellowship in general endotracheal anesthesia.

Not sure why it takes 30 min to do a block at your place.

I have seen people do blocks with a lot of fanfare. The ultrasound has nothing to do with it.

 

[Impromptu]

My new group has been pretty impressed with my regional blocks. I think the fanfare is that to make the flow work it takes a lot of coordination to get that patient ready, especially with the hospital requirements. The biggest holdup is that the surgeon has to be there to see and mark the site prior performing the block. It is basically the same problem with getting the surgeon to the hospital on time, but now multiplied because he/she has to be there an extra 20 minutes earlier.

 

[somedumbDO]

My new group has been pretty impressed with my regional blocks. I think the fanfare is that to make the flow work it takes a lot of coordination to get that patient ready, especially with the hospital requirements. The biggest holdup is that the surgeon has to be there to see and mark the site prior performing the block. It is basically the same problem with getting the surgeon to the hospital on time, but now multiplied because he/she has to be there an extra 20 minutes earlier.

It's like everything in life... People want to be special so they make it a big deal. Every residency should teach you how to do regional. Fellowships in regional is academic hokum. Most blocks shud take 5 min tops granted jabba the hut could be behind the curtain and tack on a few min. 3/4 of my private group are "gurus" surgeon finishes previous case while pt waking up, signs the next pt, pt to pacu, the room is being turned over I say hi to the new one: midaz/marcaine/room/prop/gas and repeat. Boom!

 

[Maverikk]

The regional experience is one that is very variable between programs which is a shame because it's one of the core requirements. At my med school different orthopods didn't want them due to slowing down the case because we only had 1-2 people who could do it fast and efficiently while teaching the residents and most other people made a big deal, like 30-60 minutes to do one block. The residents were lucky to get 10 blocks in one month. The place I'm at now the orthopods and anesthesia respect each other's proficiency and timeliness, the last person on their block month did over 200. Needless to say we do have a very large orthopedic program. Just meeting the requirements is good for ACGME but being able to know what you're doing and how to troubleshoot and get a minor procedure done fast helps the whole process go smooth and fast making everyone happy and appreciate the benefits, this comes with repeatably doing it until you're comfortable. The fellowship is academic hokum but it does make for a cheap attending for one year

 

[ssmallz]

It's the sad state of affairs in PP. The truth is that most of the older docs can't do regional and don't want to learn b/c they have little incentive to do so. The ortho guys don't care, they want room turnovers ASAP. At most hospitals there's no help from preop and no push from administration so it falls on each anesthesiologist to push for blocks. Given that it's a lot of extra work for 3-4 units with a ton of downside if it doesn't go smoothly every time a lot of guys just don't do em. Call it the dumbification of anesthesia. Surgeons want sleeping patients, admins want happy surgeons, no one who matters cares about anesthesia or post op pain control.

 

[psychbender]

That's pretty much the situation at my place. Small group, the older folk don't know how to use USD well, don't care about doing blocks (government hospital, no incentive to do anything more than GA), but are willing to supervise CRNAs/SRNAs taking forever to stumble through an ISB or pop sciatic. Combine this with surgeons who have trained and worked almost exclusively at this same hospital/OR environment, and I'm fighting a perpetual uphill battle to get the surgeons to let me block anything other than a shoulder or rare ankle.

 

[BLADEMDA]

It's the sad state of affairs in PP. The truth is that most of the older docs can't do regional and don't want to learn b/c they have little incentive to do so. The ortho guys don't care, they want room turnovers ASAP. At most hospitals there's no help from preop and no push from administration so it falls on each anesthesiologist to push for blocks. Given that it's a lot of extra work for 3-4 units with a ton of downside if it doesn't go smoothly every time a lot of guys just don't do em. Call it the dumbification of anesthesia. Surgeons want sleeping patients, admins want happy surgeons, no one who matters cares about anesthesia or post op pain control.

I've taught my entire Group U/S guided Regional Anesthesia. Now everyone is competent at doing basic blocks. Older Anesthesiologists can and do learn new techniques if you are patient and proctor them with hands on training at the bedside. I myself am no spring chicken and made the transition from NS only blocks to U/S only blocks over a 14 month period. Because I was an expert with NS guided blocks prior to my transition to U/S it made the process much easier. I now perform 95% of my blocks utilizing U/S.

 

[deleted126335]

I've taught my entire Group U/S guided Regional Anesthesia. Now everyone is competent at doing basic blocks. Older Anesthesiologists can and do learn new techniques if you are patient and proctor them with hands on training at the bedside. I myself am no spring chicken and made the transition from NS only blocks to U/S only blocks over a 14 month period. Because I was an expert with NS guided blocks prior to my transition to U/S it made the process much easier. I now perform 95% of my blocks utilizing U/S.

Or if they are highly motivated. Motivators can be positive or negative.

 

[Sonny Crocket]

I've taught my entire Group U/S guided Regional Anesthesia. Now everyone is competent at doing basic blocks. Older Anesthesiologists can and do learn new techniques if you are patient and proctor them with hands on training at the bedside. I myself am no spring chicken and made the transition from NS only blocks to U/S only blocks over a 14 month period. Because I was an expert with NS guided blocks prior to my transition to U/S it made the process much easier. I now perform 95% of my blocks utilizing U/S.

How did u teach them the blocks? Did you show them with real patients or have courses where you show how to find nerves? I ask because our new 'guru' wants to have a course where he just shows how to find nerves. To me this is impractical because the whole trick to this is localizing the needle under the probe. You need real patients, time, and practice. Nothing that can be learned in a two day course.

I teach the residents as I learned with real patients and I think that these courses are almost useless.

 

[urge]

The ortho guys don't care, they want room turnovers ASAP. At most hospitals there's no help from preop and no push from administration so it falls on each anesthesiologist to push for blocks. Given that it's a lot of extra work for 3-4 units with a ton of downside if it doesn't go smoothly every time a lot of guys just don't do em.

It doesn't help that now you need the surgeon to have marked the side, and a block "timeout" with a nurse. We owe it to a long line of "gurus" who kept blocking the wrong extremity.

 

[Oggg]

How did u teach them the blocks? Did you show them with real patients or have courses where you show how to find nerves? I ask because our new 'guru' wants to have a course where he just shows how to find nerves. To me this is impractical because the whole trick to this is localizing the needle under the probe. You need real patients, time, and practice. Nothing that can be learned in a two day course.

I teach the residents as I learned with real patients and I think that these courses are almost useless.

Scanning is the biggest hurdle. You need to be able to find the nerve in all sorts of patients, and you have to be able to do it fast, and you have to be able to relocate the image quickly. A course can be useful, but I think it's an expensive approach. The best way is to scan asleep patients and your own body.

 

[HollATme]

Scanning is the biggest hurdle. You need to be able to find the nerve in all sorts of patients, and you have to be able to do it fast, and you have to be able to relocate the image quickly. A course can be useful, but I think it's an expensive approach. The best way is to scan asleep patients and your own body.

I agree. If you can quickly locate the location you need to block (using a vessel as a landmark or in general the nerves to be blocked), then it doesnt take much longer to figure out the angle of the probe needed to visualize the needle.

 

[deleted126335]

How did u teach them the blocks? Did you show them with real patients or have courses where you show how to find nerves? I ask because our new 'guru' wants to have a course where he just shows how to find nerves. To me this is impractical because the whole trick to this is localizing the needle under the probe. You need real patients, time, and practice. Nothing that can be learned in a two day course.

I teach the residents as I learned with real patients and I think that these courses are almost useless.

What I did:
-Going to courses and workshops with didactics and scanning live models.
-Self study, Hadzic's book, Neuraxiom, Actually dug out anatomy text form med school-ugh, Online videos- youtube, Blockjocks.
-Following a guy in a high volume practice for two days watching how he actually prepared his kits, manipulated the probe, needles, catheters, order sets, post op rounds., etc. was the final step that crystallized it. This last step was set up by one of the companies that makes regional anesthesia products. Then being watched by the guy in my practice who was most skilled and watching him. There are plenty of older docs who just haven't put in the time. It's not that hard if you are motivated.

 

[cognitus]

What's .

 

[ssmallz]

I've taught my entire Group U/S guided Regional Anesthesia. Now everyone is competent at doing basic blocks. Older Anesthesiologists can and do learn new techniques if you are patient and proctor them with hands on training at the bedside. I myself am no spring chicken and made the transition from NS only blocks to U/S only blocks over a 14 month period. Because I was an expert with NS guided blocks prior to my transition to U/S it made the process much easier. I now perform 95% of my blocks utilizing U/S.

USG makes it so easy anyone can learn how to do a safe and effective nerve block but getting older anesthesiologists to buy into regional is a tough sell b/c there is no motivation from the people who matter (surgeons, admins, chief, or $$). I have taught a few of the older guys how to do em but most them were like you, liked doing NS blocks and wanted to do USG. My old head of the group would actually discourage people from doing nerve blocks if they delayed the room or had any sort of complaints. In that environment people just aren't going to be willing to try new things, especially when the reward is only $100, a happy patient, and a missed lunch. Pain will go away and it's not their problem to deal with once the pt is out of the PACU so the anti regional guys just don't care.

It doesn't help that now you need the surgeon to have marked the side, and a block "timeout" with a nurse. We owe it to a long line of "gurus" who kept blocking the wrong extremity.

Exactly. If you wanna start a block program, you need administration to buy in and give a nurse to set up the patient, have everything ready to go, assist with the time out and block so that all you have to do is walk in, do the preop, get your gloves on and go. When you're the lone guy pushing for the block you're gathering materials, setting stuff up, and looking for a nurse who isn't busy with preops, room turnover, or lunch to help you out.

 

[HollATme]

What's the difference in PAY between the guys that DO regional blocks and the guys that don't? I'm most interested in getting PAID and if being the regional guy gets me PAID, then I am there.

That's the right mindset. lol

 

[deleted126335]

What's the difference in PAY between the guys that DO regional blocks and the guys that don't? I'm most interested in getting PAID and if being the regional guy gets me PAID, then I am there.

How about pride in staying current and providing top level care as opposed to mediocre care? If you want something more tangible, being the go to guy for top shelf care will make it more likely that you will have a nicer chair if and when the music stops in your corner of the world.

 

[jeffblue]

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How about pride in staying current and providing top level care as opposed to mediocre care? If you want something more tangible, being the go to guy for top shelf care will make it more likely that you will have a nicer chair if and when the music stops in your corner of the world.

It's hard for me to buy that doing fewer blocks is mediocre care. That is a stretch. And the real reason blocks have taken off in the past few yeas is $$$$$$

 

[HollATme]

How about pride in staying current and providing top level care as opposed to mediocre care? If you want something more tangible, being the go to guy for top shelf care will make it more likely that you will have a nicer chair if and when the music stops in your corner of the world.

I'm guessing you went to the blockjock 2 day preceptorship. Apparently they offer a fellowship, is this worthwhile to pursue?

 

[urge]

I was wondering, how does a solo anesthesiologist do an ultrasound block? Who injects?

 

[deleted126335]

I'm guessing you went to the blockjock 2 day preceptorship. Apparently they offer a fellowship, is this worthwhile to pursue?

Something similar. Looks just like their program. Found it worthwhile.

 

[cognitus]

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[deleted162650]

I was wondering, how does a solo anesthesiologist do an ultrasound block? Who injects?

Either the cilcuator/pre-op nurse injects or one of my colleagues who wants to learn USG injects. For those asking about money, USG blocks can be quite lucrative. For instance a TKA goes from 7 unit base to 21 unit base w/ an USG fem cath.

 

[HollATme]

Either the cilcuator/pre-op nurse injects or one of my colleagues who wants to learn USG injects. For those asking about money, USG blocks can be quite lucrative. For instance a TKA goes from 7 unit base to 21 unit base w/ an USG fem cath.

Why can't one inject him/herself after locating the nerve and needle tip via US?

 

[HollATme]

Something similar. Looks just like their program. Found it worthwhile.

I'm currently a resident and it's time to look into fellowships. Right now I'm torn between pain and regional. A close third being peds (but, I will probably not go this route). I know most consider regional fellowships to be a waste of a year; however, do you think doing a regional year there is worthwhile or a waste? Thanks

 

[deleted162650]

Why can't one inject him/herself after locating the nerve and needle tip via US?

While you could attatch the syringe directly to the needle and inject yourself, most find this a little awkward especially if using a 20cc syringe and tuohy. Its easier to put some extension tubing between needle and syringe and have someone else inject. I don't like to let go of the needle while injecting + I like to move the needle optimize local spread while injecting. For some blocks like a fem where you have the needle burried through a lot of tissue you probably could just let go of the needle though and be OK. This has been discussed on here in the past.

 

[ssmallz]

It's hard for me to buy that doing fewer blocks is mediocre care. That is a stretch. And the real reason blocks have taken off in the past few yeas is $$$$$$

I'm guessing your at a program that doesn't do many blocks. Have ever spoken to patients about their experience? I've had many that had a TKA on one knee w/out a block, then I do a single shot fem and pop for the other and they tell me it's night and day. How bout shoulders and ACLs? I can't even count the number of grateful pts I see when I throw in a rescue block post op and their pain goes from 10/10 to 0/10 in a matter of minutes.

You can say that blocks aren't worth your time b/c the reimbursement is only 3-4 units for the increased risk and that's fine but understand that you are by definition providing mediocre anesthesia.....just look at the literature. Just about any case can be done w/prop, roc, tube, and gas but what separates a good anesthesiologist from a mediocre one is the ability to figure out how best to provide an anesthetic for an operation taking into account the patients disease, type of surgery, and post op plan. Sometimes that involves a block, sometimes an LMA, and sometimes an A-line or RSI.

 

[Southpaw]

Either the cilcuator/pre-op nurse injects or one of my colleagues who wants to learn USG injects. For those asking about money, USG blocks can be quite lucrative. For instance a TKA goes from 7 unit base to 21 unit base w/ an USG fem cath.

Just for perspective, my group gets nowhere near that for blocks and/or catheters. We get a flat fee, which works out to about 1 unit. From a monetary perspective, it's certainly not worth it, but from a patient care perspective it's exceedingly rare for a patient to not absolutely love their block.

 

[cognitus]

Just for perspective, my group gets nowhere near that for blocks and/or catheters. We get a flat fee, which works out to about 1 unit. From a monetary perspective, it's certainly not worth it, but from a patient care perspective it's exceedingly rare for a patient to not absolutely love their block.

So basically, if you're doing a TKA, then you would get reimbursed X units for the TKA + 1 unit if you add a regional block?

 

[cognitus]

Either the cilcuator/pre-op nurse injects or one of my colleagues who wants to learn USG injects. For those asking about money, USG blocks can be quite lucrative. For instance a TKA goes from 7 unit base to 21 unit base w/ an USG fem cath.

What region of the US do you practice?

 

[guitarguy]

I definitely consider myself a regional-inclined anesthesiologist. I have seen many patients experience profound analgesia and great satisfaction from peripheral and neuraxial blockade. I'm often amazed, however, how effective a multi-modal approach can be in patients who did not want or could not have blocks. It's also humbling to look through the literature and see how when you examine large populations, it's very hard to show meaningful benefits to blocks. Yes, there are plenty of studies that show benefit A and B...but there are also plenty of studies that fail to show any benefits. I don't think it's fair to argue that the failure to provide blocks is necessarily 'mediocre anesthesia' -- and I'd much rather have mediocre anesthesia than experience a nerve injury from a top-notch anesthesiologist when the only real benefit to that block was 12 hours of pain relief, but my arm remains numb or weak for days-to-weeks...

 

[deleted162650]

What region of the US do you practice?

West Coast in an area notorious for low unit values. That extra 14 units includes 2 units for USG (need a pic) and then 3 days of f/u documented by prog notes.

 

[cognitus]

West Coast in an area notorious for low unit values. That extra 14 units includes 2 units for USG (need a pic) and then 3 days of f/u documented by prog notes.

How

 

[urge]

and I'd much rather have mediocre anesthesia than experience a nerve injury from a top-notch anesthesiologist when the only real benefit to that block was 12 hours of pain relief, but my arm remains numb or weak for days-to-weeks...

My residency did a lot of blocks back in the day, over 20 a day. My program director used to say we had a few nerve injuries every month. Granted, it was before the ultrasound. If you do enough blocks it will happen.

 

[BLADEMDA]

In Florida medicare pays about $100 for an U/S guided nerve block. Most of our private payers reimburse double that amount per nerve block.

 

[ssmallz]

I definitely consider myself a regional-inclined anesthesiologist. I have seen many patients experience profound analgesia and great satisfaction from peripheral and neuraxial blockade. I'm often amazed, however, how effective a multi-modal approach can be in patients who did not want or could not have blocks. It's also humbling to look through the literature and see how when you examine large populations, it's very hard to show meaningful benefits to blocks. Yes, there are plenty of studies that show benefit A and B...but there are also plenty of studies that fail to show any benefits. I don't think it's fair to argue that the failure to provide blocks is necessarily 'mediocre anesthesia' -- and I'd much rather have mediocre anesthesia than experience a nerve injury from a top-notch anesthesiologist when the only real benefit to that block was 12 hours of pain relief, but my arm remains numb or weak for days-to-weeks...

If you're facile with blocks and know the literature and still feel regional isn't appropriate then I believe that's superior anesthesia from a true physician. The majority of people who don't do regional haven't reviewed the literature, don't want to learn how, and just want to churn through the cases. Those people are mediocre anesthesiologists at best but unfortunately there's little incentive for those people to learn b/c as long as the cases get done, most of the higher ups don't care how.

 

[deleted126335]

Anybody who has been doing regional and rounding on these patients would want to their mother to have a TKA or or major shoulder procedure without a block?
Unless you can answer that question affirmatively, those saying that it is not mediocre care are less than honest.

 

[guitarguy]

To be honest, I'd want done to my family whatever is the norm for their surgeon and anesthesiologist. Some of the orthopedic surgeons I work with want blocks or catheters, some do not. Most of the patients without blocks do well - the surgeons tend to instill a lot of intra-articular local, we give drugs like tylenol and toradol, and the patients do quite well without needing a ton of narcotics. Sure, they need more narcotics POD#0 than patients with blocks, but by POD#1-2 you can''t tell who got what. Someone with severe OSA: I'll push for a block hands-down. If I was in labor, I'd certainly want an epidural: but satisfaction scores between laboring women with epidurals and remifentanil PCA's are very similar. Blocks are great but they are not everything.

 

[deleted126335]

To be honest, I'd want done to my family whatever is the norm for their surgeon and anesthesiologist. Some of the orthopedic surgeons I work with want blocks or catheters, some do not. Most of the patients without blocks do well - the surgeons tend to instill a lot of intra-articular local, we give drugs like tylenol and toradol, and the patients do quite well without needing a ton of narcotics. Sure, they need more narcotics POD#0 than patients with blocks, but by POD#1-2 you can''t tell who got what. Someone with severe OSA: I'll push for a block hands-down. If I was in labor, I'd certainly want an epidural: but satisfaction scores between laboring women with epidurals and remifentanil PCA's are very similar. Blocks are great but they are not everything.

I never said that they were. But major ortho surgery that is routinely done without them being an option is second best care. Not everyone gets them or should, but being unable to do them or unwilling to offer them is mediocre plain and simple. Not the same thing as substandard.

 

[urge]

Anybody who has been doing regional and rounding on these patients would want to their mother to have a TKA or or major shoulder procedure without a block?
Unless you can answer that question affirmatively, those saying that it is not mediocre care are less than honest.

I would not get a block or neuroaxial on myself. I have had orthopedic surgery in the past with GA only and it was fine.

 

[Oggg]

When you look at your career as a business endeavor, you can't just look at the pittance that Medicare pays you for doing a block. You have to include the hard-to-quantify value of nerve blocks: you have more anesthetic options, you can do anything a pt or surgeon requests, patient satisfaction, surgeon satisfaction, improving your own reputation, differentiation from CRNAs, negotiating for a hospital stipend, making it harder for anesthesia management companies to replace you, improved pain scores that help the hospital collect more money from Medicare, faster wakeups, less vomiting, surgeon gets less phone calls,etc. Basically. if nerve blocks keep you employed longer, that's a lot of cash...

 

[Pooh & Annie]

Whether short or long term outcomes are any different is one aspect. So is the word of mouth when the 60-something retiree tells her 60-something buddies that her TKA was smooth and nearly pain free. People get a lot of advice from each other. At this point in time good service can potentially mean good business.

 

[jeffblue]

When you look at your career as a business endeavor, differentiation from CRNAs,, that's a lot of cash...

If nerve blocks differentiate crnas from DOCTORS, then this specialty is definitely in serious trouble if that is what you think.

Having said that. I had a surgeon complain to me about a colleagues nerve block and wanted to refer the patient back to us for follow up care. Basically the patient came back to him complaining of altered sensation and some weakness in the lower extremity I believe it was after a total knee or arthroscopy I cant remember. At any rate, I dug up the anesthesia record and come to find out there was NO BLOCK done...

 

[BLADEMDA]

I've had a few blocks on myself (postop pain). I would want another one and recommend them for all friends and family members. I've performed dozens on hospital staff, administration, surgeons, athletes, etc. I am an advocate for a pain free surgical experience if possible.

 

[Sonny Crocket]

I love doing blocks. Even considered a regional fellowship but glad I didn't bother. I was already slick enough after residency. I agree that it is a good thing for the patient. What I don't agree with is people telling me and everyone else how great they are at blocks and are regional gurus. Then they go and block everything under the sun and slow down the OR. What a crock of $&!$. You put local around a nerve. Do it safely and be efficient and don't make it a big deal.

 

[Ronin2258]

I think it's definitely worth it. I have taken a 6'6" football player after an ACL repair from near tears to joking and flirting with the nurses by well placed single shot fascia lata and femoral blocks. Definite improvement in patient satisfaction.

I am going to be pushing 200+ out of the 40 blocks required to graduate, if not more. Just finishing a rotation in the local joint replacement center and I have been placing adductor canal blocks and catheters, very selective tibial nerve blocks, among other things. with the adductor catheter, most of the TKAs *walk* with PT by mid- to late afternoon. The guys here also do circumferential knee field blocks for neuropathic patients and interspace between the popliteal artery and capsule of the knee (IPACK) blocks, also for neuropathic patients, avoiding the named nerves completely.

I know general surgeons that insist on TAP blocks for their hernia patients. I did bilateral rescue upper abdomen TAPs for something that went open from 'scope, and the patient had no pain for at least a day. The post op check they are not taking opioids at all in PACU. Feedback from the surgeons from their post-op visits stated patients didn't have to take anything for pain for 48-72 hours.

About the only thing I haven't been able to do with my training is paravertebrals. I would like to learn more as I can.

Looking at ASRA's guides for fellowship training, about the only things I haven't done in their basic is the Beir and the intercostalbrachial. I have done all the intermediates save genitofemoral, and the advanced continuous blocks and the paravertebrals.

I love doing the blocks. Give me an ultrasound and/or a good marker, stimulator, needles, and someone to push drugs for me, and I could be doing these all day.

 

[Yangkower]

With basic US skills, regional should be a piece of cake for anesthesiologist.

For upper extremity all you need to know is supraclavicular and Interscalene. We do all our shoulders with one shot IS. The key is getting the surgeon to schedule short cases prior to the shoulder and blocking the shoulder prior to the short case so it has time to set up. Everything else can be done with a SC or field block by surgeon.

Lower extremity. Neuraxial with IT morphine and surgeon injects long acting local in wound. Our TKAs are walking the same day and 75% home POD #2.