Ok. So share why you made those changes. Ongoing learning is a core competency
Okay I will - but please note - I didn't before because these ideas are easily criticized and toppled with a few swift reasonable statements...and I am thin skinned and hate criticism. I am not a Millennial, but have taken on their persona and am easily triggered and need a safe space frequently.
So - I do more TFESI than ILESI for two reasons. #1 - I kept hearing fellows nearing the end of fellowship say they didn't have much experience with TFESI, so I started always doing them to get them more experience. #2. I had an anesthesia staff once tell me "Every time I watch a resident do an epidural (he was referring to the labor deck), a part of me dies." I thought that was so funny, and very true. I think it happens for me watching a psych fellow (for example) with little experience doing an ILESI. I know they aren't dangerous, and wet tap is only an inconvenience, but nonetheless, watching them is a little anxiety provoking. It is interesting, that as I get older, I get less patient with these learners. I thought it should have worked the other way with time and experience, but it hasn't. I have no idea why.
Regarding local anesthetic - When I came out of fellowship, I was the smartest guy on the block. I made a lot of noise about all my colleagues who put local in their cadaul/ILESI. I would say "No one that trained in the last 30 years, or who isn't in the military puts local in their Caudal/ILESI" and think I was so important and smart.
I suspect the reason that this is partly true is because of liability issues. But I don't have the same liability issues that those who are in private practice. I have to practice smart and safe, but I can make good decisions without that hanging over my head at least.
Anyway, a much wiser, and brilliant pain physician would smile at my retorts. One day, he told me..."let me tell you why I do local. I want the patient getting up off the bed feeling 100% better immediately. I want them to walk out of the clinic thinking they are cured and life is going to be that much better." I have thought about that idea a lot. Considering the complexity of chronic pain and the toll on the psyche, I have come to believe how important that might be in a person's experience. I put very little local (maybe 1ml or less of 1% lidocaine in my 10ml solution for caudal, less for ILESI).
If I were in private practice - I would never do caudal unless clinical picture highly dictated that. That is because they can be very uncomfortable. Patient's are going to go to the guy next door if their last epidural from them didn't hurt, and my caudal was very uncomfortable. However, I have a "trapped" patient population. They can't go anywhere else. And see above (TFESI vs ILESI) about why my first choice is usually caudal (super safe, fast, easy). Plus, I get a huge kick out of the contrast pattern on a caudal each time. It's fun and cool watching the contrast spread in the anterior epidural space.