anesthesia enthusiasts and welcome to this month's
episode of style points i'm your host john crow
today we're talking to my friend and colleague
dr brad buddy who directs the regional anesthesia
and acute pain fellowship here at the university
of cincinnati we'll talk about his perspective
on pain management and the philosophy behind
it we don't have an rsi for you this month so
let's jump right in so what was your radio experience
like in college it was um It was interesting
because I had, it was like a full studio. So
I had no idea what any of the stuff was doing,
but our one buddy did. And so we were just talking
sports and we had the Sunday evening time slot,
which rivaled Sopranos. So, so we, so we, we
got to, we got, I think we got up to 41 listeners
at one point. 41. That's the highest number of
listeners for any show on Miami student radio,
which is saying something about who we were broadcasting
to. Miami Student Radio. Yeah. What was the call
sign? I don't remember. Oh, come on. The name
of our show is Crunch Time. I remember that.
But other than that, I don't remember much about
it. Well, loyal listeners, welcome back to Crunch
Time with Proud Buddy. we would do trivia and
like, we'd all be like three, four of us would
be really into it. And people in the air, like
our buddies are Texas, like stop, like don't
care. It's about this. Like, but, but we're having
fun. Like that's all that matters. Well, people
text me all the time that they don't care about
what I'm doing. So yeah, it's, I mean, you have
kids, they never care what you're doing unless
you're doing exactly what you tell, they tell
you to do, but that's great. Brad, thank you
so much for joining us. Thanks for having me.
So. We have a lot to talk about in the world
of regional anesthesia, but before we do that,
I wonder if you could tell us a little bit about
yourself, what your interests are, and what we're
here to talk about. My name is Brad Buddy. I'm
an associate professor here at the University
of Cincinnati in anesthesia. My main interests
right now lie with my family. I'm married and
have two young boys, five and three years old.
So they keep me pretty busy. I've always had
an interest and passion for sports. So I like
watching sports, playing sports, mostly golf
these days. And then I have my career, which
has been mostly dedicated to regional anesthesia
and acute pain medicine. So much so that I've
started my own fellowship and run my own division
and really enjoy doing it. So why regional anesthesia?
What's so interesting about that? So it's a little
bit of a longer story, but it goes back to my
interest in sports. So when I was young, I really
liked playing sports with my friends. And I was
actually over at a friend's house, and his dad
actually happened to be an orthopedic surgeon,
a sports surgeon. So we were in their basement.
They had all this sports stuff. And my young
brain said, wow, if I'm an orthopedic surgeon,
I can have all this sports stuff in my house.
I'm like, I really want that. Found out later
that he actually played on a national championship
team for University of Louisville basketball,
which is why he had that stuff. But it still
piqued the interest. So I was so interested in
sports that I finished college and I didn't go
right into medical school. I went and got a master's
in sports studies at Miami University, thinking
about going into potentially coaching or athletic
administration. And there's still something about
that draw to orthopedic surgery and medicine
and kind of a sports surgeon. that I really couldn't
let go. So I applied and got into the medical
school, and I came in so tunnel vision, all I
cared about was orthopedics until match day came,
and I didn't match into orthopedics. Oh, wow.
Then I had to kind of go, huh, this whole drive
and passion is kind of a lot harder than I was
anticipating. It actually was my April of my
fourth year of medical school where I did my
anesthesia rotation. And at the time, even though
I didn't match, I told everyone, I'm doing orthopedics.
I'm going to do it. And so the anesthesiologist
that I was fortunate enough to rotate with here
at University of Cincinnati, as well as some
of our community hospitals, took my passion for
orthopedics and said, look what we can do to
help the orthopedic surgeons and showed me nerve
blocks, regional anesthesia. And I had no idea.
I'm like, this is really cool. And that really
kind of spiked the interest there. Then when
I was doing my preliminary intern year at Penn
State, I got to see and experience a little bit
more of anesthesia and regional anesthesia. So
then I said, this is kind of more of my passion
and interest. I want to go into this and be in
anesthesia. And then once I got to Rush, where
I did my residency. Our regional anesthesia director
there, her and I really connected and I learned
a lot from her and kind of really just drove
that passion forward about how I can use this
interest in sports, but to also help kind of
that patient population, but then expand it out
to, wow, I can actually help a bigger group of
people than just athletes with this. And so that's
what kind of led me to where I am now. It's so
interesting. that this podcast makes it much
easier for me to have these conversations with
people because I find all this really interesting
to find out about you for the first time because
I never knew any of that. But I don't know that
I would have ever asked you just in casual conversation.
Yet we've known each other for eight years now.
And this is, yeah, like you don't ever tell people
about the whole story of how you got here. Right.
And, you know, it's kind of interesting. Like,
why are you interested in what you're interested
in? It's usually more of a. I just liked it.
There's something else to it, usually. Yeah,
it's been really rewarding for me to find out
people's origin stories just at random and find
out more about them. Yeah, finding out the why
for people, I think, really helps you understand
why they are doing what they do, how they take
a little bit more and kind of makes you appreciative
of what they're doing and why they're doing it.
Especially if it's something that you don't really
see it the same way. It's like, well, at least
I understand. why they see it that way and that's
a little bit more of a uh collegial and collaborative
effort i think yeah i agree with you well let
me back up and ask you the famous dinner question
that i ask everybody uh i'm going to go out on
a limb here and guess you're going to pick somebody
sports related if you could go out to dinner
with anybody in the world could be somebody from
the past or from fiction who would you pick and
why I have been asked this question before, and
it is not sports -related. It's family -related.
Wow, there you go. So I would pick my maternal
grandfather. I'm a pretty family -oriented person.
I grew up in a good family. I now have kids,
and I want to instill that into them. And I was
very fortunate that my dad's parents I was able
to connect with, they had a really super interesting
story of living in Germany, growing up in Germany.
living through the war. My grandpa was forced
to fight in the war for Germany and, like, beyond
his will, right after the war, they moved over
here and had my dad. So it was cool to kind of
get to connect with them. And on my mom's side,
I got to know my grandma, but my grandpa was
fought in the war on the American side. So my
grandparents actually, my grandpas actually fought
each other in World War II. Wow. Which is kind
of cool. Not directly, but... Well, not that
you know her. That's true. That's true. But apparently
he passed away when I was really young. I guess
he got exposed to some things during the war
that he could never really recover from. And
so I talked to my mom. She didn't know him that
great either just because he was in the war and
then he was kind of sickly after that. But apparently,
according to my grandma, he was a fighter pilot
for the Air Force. Apparently he was a pretty
well -renowned guy. And my mom has found some
interesting kind of articles and things, letters
from... you know, the Air Force stuff about him.
So I just would really like to sit down and kind
of know more about his trajectory, his path,
what got him into Air Force and flying and all
that kind of stuff. It's just kind of a piece
of my personal family history that I would really
like to know a little bit more about. That is
so interesting. Do you feel like you act as a
fighter pilot at work sometimes? Well, I mean,
there's the obvious correlation between the airline
industry and anesthesia. But not knowing anything
really about the airline industry, I have no
idea. I'm guessing yes, but maybe. Something
about checklists, I assume. Yeah, right. Yeah,
so maybe there's some of that in me from my grandpa
that I never really knew. So you have spent a
tremendous amount of time, and I know from my
experience with you that you have a lot of opinions
about pain management. and how to handle pain
in the perioperative setting. When you're thinking
about pain as a clinical problem generally, what
do you think most anesthesiologists don't get
right about it? I don't know how to put this
without being insulting, but there's a lack of
understanding of pain. And I think that's healthcare
-wide. I think it's culture -wide, society -wide.
Pain is very complex and it's very gray. And
I explained this to a lot of our trainees that
a lot of times in medicine, we like objective
numbers. We like diagnoses. We like numbers to
point and say, this is why this is happening.
You can't do that with pain. What about the pain
scale? Isn't that an objective number? That was
the attempt to put an objective number on pain
that has failed miserably, but yet still maintains
today. So that's to me is pain is very complex
and it's very subjective. There's a lot of feelings
from the patient side that go into it. And obviously
there's a lot of bias from the provider side
that goes into it. And I think specifically anesthesia,
I think we deal with a little bit of a unique
situation that we don't have patients telling
us about their pain. Which I present this to
our fellows and some of our senior residents.
And I say, you know, can the patient under general
anesthesia experience pain? And if you look at
the definition of pain, they can't because it's
subjective. So they can't tell you about it.
They're not having it. And then most people are
like, nah, it doesn't make any sense. And it's
like, I get it. It's more of a philosophical
discussion. But I think. anesthesiologists or
anesthesia providers in general put a lot of
their own biases into what pain is and looking
over the drapes saying that hurt I'm gonna give
something for that versus really understanding
the complex complexity of the things that are
going into what's causing the pain and then on
the other side is you know there's a lot of historical
reasons why pain is treated the way it's treated
in the perioperative setting and I personally
think it's backwards. I think we use opioids
as a mainstay therapy. It's not as strong as
it was when you and I were training 10 years
ago or even 20 years ago. But I still think that's
the crutch that everyone leans on. And I think
that we have better alternatives now that can
help. And opioids have their role. It's just
not as expansive as it is currently being deployed
in anesthesia. So you wouldn't say that pain
is the fifth vital sign? I would not, and I would
hope that everyone understands what a massive
mistake that was when we went down that path.
Why don't you back up a little bit for our audience
and tell that story a little bit? So you can
tell this story in a number of different ways,
but I think it was back in the late 90s, early
2000s, there was this push that pain was being
undertreated and that we weren't. as a healthcare
community, we weren't taking care of pain with
enough compassion and doing enough for it. Now,
I believe and most people think that that push
was coming from the pharmaceutical industry that
had created these great medications called opioids
and that we have this medication that can fill
this void that you guys have created in healthcare.
I would argue there wasn't avoidant health care
with that, but it became this forefront of we
were not treating pain and we're not treating
patients' subjective feelings of pain well with
what we were doing. And so that's what kind of
pushed opioids to the front line. And that's
what generated the pain scale, you know, the
one, the zero to 10 scale that everyone knows.
It didn't take a full comprehensive look at it.
And again, I think it goes back to the underlying
of. why it kind of spiraled the way it did is
because not a lot of people in healthcare felt
comfortable with pain. They didn't understand
it well. They didn't really know about it. And
here came this new shiny thing of they're having
pain. You don't know what to do. Give them this.
And it's an opioid and that's Oxycontin. This
was the original one. And it, it, it works. Opioids
work for pain. And so I was like, wow, we did
it. We did it. Mission accomplished. Mission
accomplished. We can put our stamp on it. The
fifth vital sign is here to stay, and we know
how to treat it, and we're going to do it well.
So then what happened? Then, you know, despite
the pharmaceutical companies explaining to everyone
that, you know, as long as patients are having
pain, there are no side effects. We then found
out pretty harshly that there are side effects
and one of the main one being addiction. And
that's kind of what spiraled into the opioid
crisis that we saw. Going into like the 2007
to 8 is when it really kind of exploded and when
still everyone is very familiar with the opioid
crisis. Now I think they teach it a lot of medical
schools about what it is and what's going on.
And, you know, I. I still think that there is
a little bit, going back to the, what do the
anesthesiologists do wrong with pain, is assuming
that they aren't part of the opioid crisis problem.
If you are pushing or giving an opioid, you're
potentially part of the problem. And I don't
think people want to admit that or think that.
And the steps to get from giving someone a pain
medication when they're in pain to them developing
an addiction is a far step and a lot of steps
along the way to get there. the possibility exists
and there are many many famous examples from
athletes to actors that have been injured started
opioids get addicted most recent one in the news
is tiger woods he's he's i just saw today that
he's back from his six weeks rehab in switzerland
for his opioid addiction that he's got so um
started with back injuries and back surgeries
and you know kind of derailed him a little bit.
So even the most powerful and the most mighty
and the most famous can, can succumb to this.
And we just don't know who it's going to be.
And I think that's kind of the tenant I take
is that I look at every patient as a potential
future addict that I don't want to be the one
that starts them down that path. How well do
you think that residency does training people
to think about pain and anesthesia residency
specifically? I think anesthesia does a far better
job than the other residencies that at least
I've seen and been familiar with. I think pain
is a central component to the ACGMA structure.
You have to learn about acute pain, chronic pain,
regional anesthesia. So I think that there is
a good infrastructure curriculum there. I think
kind of one of my gripes with anesthesia training.
And where I think we're missing the ball on it
is the PACU recovery side. I think back in my
training, I remember our preoperative kind of
training was kind of limited. We did a little
bit of it. We had a clinic that we kind of went
to every once in a while. It's nowhere near as
robust as it is here at University of Cincinnati
or at other places I've seen now. So I think
our preoperative optimization has gotten better.
Interoperative training has always been spot
on. I think everywhere you go, everyone focuses
on it, does it, and does it well. I've seen people
from tons of universities that do interoperative
management well. What we don't do is we don't
follow these patients. We drop them off in PACU,
and that's about the extent of our knowledge
of how they've done. And everyone in anesthesia,
no matter who you are, lacks the follow through
to after they leave the PACU. Like we as faculty
get a little bit more experience in the PACU
because we get the phone calls or we make sure
the patients are safe when we get out of the
PACU. But even after that, we don't really follow
them that much afterwards to see how they do
unless we have a particular interest in a particular
patient. So I think that is the piece to the
pain puzzle that is missing. I think if people
could know fully how each of their patients have
done and look back at what they did for those
patients pre -op and intra -op and how it set
them up from a pain perspective, I think it would
really help lock in some of the stuff that we
try to teach and train when it comes to pain
management in the period of setting. And that's
what I really like about my position and what
we do as far as a pain service here at University
of Cincinnati and other pain services around
the country is. we follow these patients through.
Not all of them, but we get to follow these patients
and see how they're doing and how these things
affect them. And it's kind of a, it allows us
to get onto that side better because, you know,
when I was training, I always thought, if I can
get this patient who's either healthy, unhealthy,
whatever, get through this surgery, big, small,
and get them through to the PACU safely, like,
I did a great job. And then I started, when I
got into fellowship, what I really started to
learn and think about is like, can I do more
though? Can I make other decisions during those
time period to keep them safe through it, but
also set them up for success in the recovery,
which I think is a piece that's missing in general,
but I think is something that we try to incorporate
here, at least from our pain side. I really liked
how you mentioned that pain is gray. And I think
from my experience as well, there's a whole bunch
of different components and there's certainly
a lot of. what we do as far as relieving pain
that has to do with expectations and the patient's
psychological frame. I wonder what your take
is on the non -drug variables for how pain is
managed. I think that's a very undervalued part
of this because, as I mentioned, pain is subjective.
And so in order to In order to best treat their
pain, you've got to understand what they're experiencing
and how they are kind of experiencing it. And
it's a very challenging thing to do. And it's
a very uncomfortable thing for people to do too.
Because you've got to get into let them be vulnerable
with you and allow them to explain to you what
they're going through. And one of the things
I try and do a lot when we're rounding on patients,
seeing consults, is just listen. Listen to them.
And anyone that's been in academic medicine.
These patients have hundreds of people coming
in other rooms every day, and they all have a
particular agenda, right? And a lot of times
pain is one of the most important things on the
patient's mind, but not on all those 99 other
people that come in and out of their room. You're
there to talk about their pain, or even if you're
not there to talk about their pain, let them
talk about it. And there have been numerous times
where I've had our residents come to me and say,
we didn't do anything for that patient, but they
said their pain was better after they talked
to us. Just because you listen to them. And they
said, someone listens. I don't want anything
different. I don't want anything different. I
just want you to know what I'm experiencing.
And I think it's a huge, hugely undervalued part
of pain. And you don't always have to reach for
an opioid because their fifth vital sign tells
you that their pain score is a nine. And what
else goes into it? Like, why is it a nine? Like,
what makes you say nine versus eight versus 10
versus 20? Like, we've seen it all. all these
scales and all these scores, but like, what is
it really that is bothering you? And sometimes
it's like, I just want a glass of water. I just,
I want to watch my news at night and I can't
figure out how to get the TV on. Like it can
be simple things that think about when you're
at home and what makes you a little uncomfortable
with this. You just adjust and do things, not
stuff you can't do in the hospital that well.
Sometimes you just need a blanket. Sometimes
you need a backstretch. Somebody needs something
simple. And all of a sudden it's like, eh, it's
okay. It's better. There are some pains that
you can't just talk away or you can't do little
nuanced things. You can't do a Sudoku puzzle
and feel better about it and distract you from
it. And that's where the pharmaceuticals come
in. But there's a lot that we can do if we just
honestly just took the time to listen to people.
So often when you're doing nerve blocks or starting
IVs, you're doing something that causes some
degree of pain that you need to give them before
they can be relieved from. a larger pain. What's
your framework for approaching that with patients?
Are there any phrases that you recommend or that
you say to them? Do you think that this is going
to be a big pinch or a little pinch? Do any of
those phrases matter or what do you think? So
that depends on the patient. So some patients
don't want to hear anything. They know it's going
to hurt or you've already explained it. I think
a lot of it comes in explaining what you're going
to do before you do it. And you lean on them
to tell you, like, do you want to know when we're
starting? Some patients like to know, like, exaggerate
a little bit. Like, this is going to really hurt.
Or some people are like, don't tell me it's really
bad. Then that's where it's like, oh, small little
pinch versus, oh, this might hurt a little bit.
Like, oh, yeah, this might suck. But for nerve
blocks, it's pretty easy. Like, this is a very
minimal amount of time for discomfort to have
a much easier recovery, much better path going
forward. And that stuff can all be handled during
the kind of when you're talking to them pre -op
and, you know, it's part of the thing that we
learn as anesthesiologists. You got to build
a rapport and get to know that patient and what
they're looking for in a short period of time.
And I think we all come from varying walks of
life and backgrounds and we all tend to figure
out how to do that fairly well. And so I think
that's, I don't have any particular go -to phrases.
I like to try to be as positive I can with patients
when I can be and talk about a lot of the positives.
I don't try to dwell on the pain that might go
into getting to the positive side of stuff. That
makes sense. Focusing on the positive does tend
to make a big difference. And I think that I
guess reflecting, I think I do a lot of that
too. I think a lot of anesthesia providers do
it without really even noticing it, right? Right.
It's because it's our way of kind of making the
patient feel a little more comfortable because
we know what kind of the best path is for them,
what's going to create kind of the better outcomes
for them. And so it's an easier way to kind of
get them comfortable with the idea. versus if
you explain every little detail of pros, cons,
negatives, like this could go really, really
bad because we know that everything could go
bad in healthcare, but do they need to know about
all that? Or can we just talk about like, there's
some risks to this, but the benefits are huge
and we do this a lot. And so try to focus on
the positives, set them, get them more comfortable.
And a lot of people coming to surgery are more
worried about anesthesia than they are surgery,
which is wild to me. I agree. That sort of rhymes
with, talk that I often give to the residents
about how to pre -op a patient and how to talk
to the patient about risk. I frequently, and
not necessarily downplaying it, but I like to
compare it to something that the patients already
know and are comfortable with and familiar with,
which is why I tell patients that anesthesia
is safer than your car ride over here. It kind
of puts them in a frame of mind that's a little
easier for them. Yeah, it's interesting. I've
kind of used some of those things before, and
it's fascinating to me. I don't know your experience,
but some people are like, I don't care. I ride
in a car all the time. This is not my normal
Tuesday morning where I get anesthesia. So it's
interesting how sometimes those messaging can
make sense, but how it's going to be received
isn't as well. Well, you have to be careful.
You can't tell patients who have just gotten
in a car wreck. That's very true. What brings
you here, Carmack? Well, yeah, this is safer
than that. Probably. Okay. I want to talk about
something that I have heard in every single resident
presentation about a pain plan that I've ever
gotten, which is that they plan to do multimodal
anesthesia. That is the buzzword. What does that
mean? Can you explain to me what the residents
are talking about? I wish I could. I agree. It's
a little bit of a, every time I hear that, I'm
like, what does that mean? I always ask it. What
does that mean? So multimodal in and of itself
just means, you know, two or more of ways to
attack something. So you can do multimodal anesthesia,
multimodal analgesia. You know, it's interesting.
Just last week, I was, we're starting a. an orthopedic
surgery case. And I was talking to the provider
in the room with me. And we were talking about
how we're going to help, you know, tackle the
patient's pain. And, and the orthopedic surgery
resident goes, you guys can use multimodal. And
I'm like, what does that mean? He goes, isn't
that two types of opioids? And I'm like, Maybe
that could be a way to do it. Um, so, so yes,
it's a buzzword. People know how to talk about
it. They know what to say. Do they know what
it means? Probably not. Now I'll give our residents
credit. They know more than, than that orthopedic
surgery resident, which, you know, is what it
is. Wow. Um, but. But, you know, I think the
interesting thing about multimodal is that while
it's great on the surface, like, you know, we're
not as opioid -centric for our analgesic plans
as we used to be in anesthesia. I think the problem
with multimodal is a lot of people have either
jumped – they're swung the pendulum all the way
to the other side. Like, I'm not going to give
any opioids. So, therefore, I'm going to give
you every possible pain medication I have in
this drawer. There's no real thinking behind
it. Like, what's the goal? What are we trying
to do? And it kind of goes back to, you know,
what I think we fail on anesthesia a lot is we
just assume there's going to be pain. Like, we
have to be doing something for pain during surgery.
Now, everyone knows that surgery is pain. It's
going to be painful. That's why we exist in anesthesia,
because patients can't tolerate the level of
pain without us being there. It takes me one
of my, my, my favorite teachments when I'm working
with residents of the OR. And I asked like, okay,
take away all nerve blocks, everything else you've
done in pre -op in the OR. What's the best thing
you can do for this patient's pain? And they
start rolling off these things. And I'm like,
have you ever thought about not giving them something
might be the best thing for them? Like not exposing
them to opioids in the OR if you can avoid it.
And so that kind of my philosophy in anesthesia
is like, if you. Though everyone likes to get
the train tracks anesthesia. You want to have
the easy, even vital signs. You want to have
boring anesthesia. I'm assuming everyone likes
that. I like that. Maybe like Dr. France here
may not like that. He likes a little bit more
of the chaotic, crazy stuff. But I'm like, that's
finding the right depth of anesthesia for that
patient where you don't have to chase vital sign
changes or anything like that. That means that
they're not experiencing a lot of pain, a lot
of stimulus and things like that. So sometimes
you get to those perfect depths of anesthesia.
You don't need to give them anything for pain.
Just let the anesthesia do the job for you. And
so that's where I think multimodal anesthesia
can be helpful when you add a couple of different
elements to increase the depth of your anesthetic
without causing a bunch of hemodynamic variation.
Opioids can fit into that. We do that with neurosurgery,
spine surgeries, but you can also do it without
it. So I think the multimodal is a great concept,
but it's kind of pretty ill -conceived in what
it actually means and how to execute it. There
are so many things beyond opioids. Ketamine,
lidocaine infusions. Presidex has certainly come
into vogue in the past few years. Gabapentin,
Celebrex. What's overrated? What's underrated?
What do you think? I think now I speak kind of
more of our practice here. And what I see here,
I think ketamine is a little overused for what
it's worth. I don't complain about it because
if someone's going to grab for a little bit of
ketamine over a little bit of fentanyl, I prefer
that for a patient. I think that's better. When
you're thinking about long -term kind of recovery,
kind of getting through the PACU and kind of
better set them up for there. I think in the
current landscape, I think, I think the gabapentinoid
class of medications actually has a role. I know
that there was an article that came a couple
of years ago that said it shouldn't ever be used
for acute pain. And a lot of people have grabbed
that, but it goes to the lack of understanding.
What is that drug doing? What are we doing with
these medications? And I think it goes to people
have jumped on the multimodal and you're right.
There's a ton of options available for people
now. Like you don't have to just grab for an
open. I think that's great that people are doing
this is why I love working in an academic environment
to teach the residents about this, but. If you're
going to grab the ketamine, what are you trying
to do with that medication? You're grabbing Robaxin.
You're grabbing Celebrex. You're grabbing Gabapentin.
You're doing these things. What are you trying
to accomplish? What do you really want to come
from that? And what are you actually treating?
So pain, there actually is pathophysiology to
pain. So what is causing this person's pain?
Is it nerve -related pain? Is it inflammation?
Are they, do they take a bunch of opioids? Are
they opioid tolerant? And so therefore you need
to work on, you know, maybe a little bit of a
different mechanism. So there's a lot of different
options out there, but knowing what you're going
to target instead of just shotgunning it all
and blanking it all, which is some people tend
to do, I think it's best to tailor your approach
to each individual patient. And that allows you
to get a little bit more sophisticated with your
medications. But also when you're, when you're
treating the actual things that are going on,
you have less risk of the bad side effects coming
when you just kind of shotgun and give everything.
So let's say you've got an opioid -tolerant patient
coming in for surgery, and it's somebody who
is chronically taking massive amounts at home.
We've seen this plenty of times, each of us.
What framework would you want one of our residents
to approach that patient with? I think everyone
needs to come from an understanding of what does
that mean? What is that patient's body? How is
it going to react to pain? to a painful stimulus,
to any pain medication we give them, and which
of our options are best suited for those patients.
So, you know, when patients are opioid tolerant,
taking a lot of opioids, they need way bigger
doses than most people are in healthcare comfortable
giving them. We get a lot of consults on our
pain service saying, hey, we need help controlling
this person's pain. We don't feel comfortable
going up higher in doses. I'm like, you're giving
them a tenth of what they get at home. So, of
course, they're going to hurt like their body's
used to it. And so we see the anesthesia. And
what I find fascinating from my standpoint is
I have someone in that situation. You can give
them opioids, but it's not going to have the
effect you're going to have it. So you're going
to have to lean on your multimodals. You're going
to have to lean on your other medications. And
I think that freaks some people out sometimes
because I want to be able to give them my fentanyl
and Dilaudid and have the patient be comfortable,
and it's not going to happen. And so knowing,
again, all the different medications and options
you have, how do they interplay with each other?
That's one where I've seen those patients and
ketamine is not part of their analgesia plan.
I'm like, that doesn't make any sense to me because
that's the best medication you could give for
that patient. You know, then no one really thinks
about methadone in those patients. Like that's
a great option. Like there are so many options
like available. I don't know, like maybe it's
just my training or where I was, but when I was
a resident, I feel like we didn't have all the
options. Presidys was too expensive. Ketamine
was not really available. Gabapentin wasn't given,
Celebrex wasn't given. I don't know if it was
cost or whatever. Like I remember IV Tylenol
was like the Vogue thing, but it was too expensive.
So we're not supposed to give that. So it's like,
we're giving Tylenol and opiate is all we really
had. And now, you know, you think about all the
options we had, like you have a lot of things
you can do. And those patients that are opioid
tolerant or are on any kind of opioid use disorder
medications, that's where more of a shotgun approach
might be beneficial. You got to try to attack
every different receptor. pain pathway you can
find try to help them because you you're our
main our main gun that we have for analgesia
is opioids and they just aren't going to be as
useful as they are for opiate naive patients
so a lot of times you find yourself advocating
for doing more nerve blocks that makes sense
you're the director of regional anesthesia i
hope i am and i think you do a great job at it
but sort of what i want to know is What are these
conversations that you're having with surgeons
to advocate for those nerve blocks? So that's
a, it depends on the surgeon. So I treat my relationships
and communication with surgeons kind of like
with patients. Like I need to understand where
they're coming from. And I kind of had an aha
moment about two years into being faculty. I
was actually teaching. uh cadaver ultrasound
course at Walter Reed um University of Maryland
and um they had a guest speaker a surgical oncologist
and he was uh going over how he appreciates help
with pain and anesthesia and all these different
things and um and then he got to the Q &A part
and uh my old fellowship director at the time
was an older kind of a little bit more aggressive
individual he uh he tried to pin him down and
say why don't you like NSAIDs they're great Why
don't you like epidurals? Like they're great.
And the surgeon just admitted it and said, pain's
not number one on my list for this patient. It's
not my number one priority. It's not my number
one concern. He goes, it's maybe not even my
top 10. I'm worried about, can I get them through
surgery without blood loss? Can I get them without
infection? Can I get, can I not have their anastomosis?
So to me, that was my thing. So I'm coming at
it as, like, all I care about is pain. I want
to do everything from a pain side, from the regional
side, like, block side. What can I do to help
this patient? I'm like, I have the best block
for this case. I'm going to do it. And I go to
the surgeon, like, I don't want that. I'm like,
what's wrong with this person? Do you not care
about this pain? Do you not care about this?
Do you not care about, you know, them getting
opioids and all those things that I care about?
And that's down on their list. They would like
to have that happen, but they got to think, can
this patient walk after surgery? Can they do
this? Can they do that? Me really trying to talk
and understand what are their priorities and
then how can we fit our regional anesthetic into
that to not interfere with how they are trying
to get their patient to recover the best they
can for their surgery. And so that's where I
needed to have that aha moment to get rid of
this. Like I need to be, get away from this,
be a pain purist. Like I'm going to do everything
exactly perfect for everyone's pain. but fit
into the actual healthcare system? And how does
this help everyone and everything get the patient
to recover the best and have the most chance
for success after surgery? I had an experience
with a surgeon who will remain nameless that
I thought was really illuminating for me when
they were injecting local at the end of the procedure,
which I really appreciated by their surgical
site. They asked for local, and it got drawn
up for them, and the nurse in the room asked
them, do you want it with or without epi? And
the surgeon said, without. And I was confused
because what I know of epi is that it tends to
dents in the block and make it work better and
last longer. And I thought about it for a second.
I was a young attending, like second or third
year. And so finally I just asked the surgeon,
I was like, can you help me understand why you
didn't want epi as part of what you're injecting
there? And what he said really stuck with me
was, I don't know, what's the difference? I was
hoping that was going to go a different way.
So sometimes it's not necessarily that they have
a master plan in mind or that they, sort of have
thought that hard about it and they have a specific
preference. It's just that they are given two
options and they pick one. Yeah, that's the other
side of the relationship coin is I need to be
able to explain what we're trying to accomplish.
What's my goal for this patient? Why am I doing
this? And there are some surgeons that are very
interested in learning and understanding why
we're doing what we're doing. Like some would
answer that question and go, what's the difference?
And you would explain the difference and be like,
oh, okay. And maybe make a different decision.
And I did. Yeah. And did they make a different
decision? They did. There you go. And then there
would be others that would say, why are you asking
me that question? This is my decision. Right.
And so, you know, it's kind of interesting in
anesthesia where we are a consultant in every
aspect of it. We don't bring these patients to
the OR. We don't do any of this. So we need this
relationship with the surgeon. And some are a
lot more collaborative, a lot more willing to
have discussions and have a shared common goal.
And others are more of these are my goals. You
fit around them or you make them work. The nice
thing about regional anesthesia is that we have
a lot of options available to us where we can
fit in, and sometimes I don't like it. I don't
think it's the best bet for some patients to
be doing some of these things, but it does allow
them to get something, like you were saying,
injecting local anesthesia, better than nothing.
So if we can get a little bit of extra analgesia
from these things, then I'll fit within the system
and we'll try to do the best we can and work
with the surgeons on what their goals are as
well. I don't think about the post -surgical
outcomes that they're thinking about. So if we
can mesh it all together, I think we give all
these patients the best chance going forward.
I don't do as much regional anesthesia as I did
in residency, of course. I did lots of blocks
back then. I got pretty fast on. I still feel
comfortable doing basically all of the main blocks.
But I wonder if you can comment on some of the...
newer types of blocks that have uh come into
vogue what do you think's uh overutilized what
do you think's underutilized what's what's the
landscape look like in terms of the new nerve
blocks so the the newer thing in regional anesthesia
is fascia plane blocks um the it's again trying
to fit regional anesthesia into the surgical
outcomes that that surgeons are desiring and
Honestly, trying to catch up with surgical advancements.
A lot of the minimally invasive robotic laparoscopic
surgeries, you know, these patients aren't in
the hospital for a week or two like they were
before where you put an epidural in and manage
it for a couple days, manage their pain for a
couple days. They want these patients out in
the hospital in two or three days. So how do
we fit into it? And so a lot of it has been fascial
plane block related. And the reason why it's
fascial plane block related is because you minimize
your side effects. I think epidurals are great.
I think they're one of the more underutilized
things, especially here at University of Cincinnati,
but I know other systems have moved away from
them because you have to worry about side effects.
You have to worry about bleeding in and around
the spine. You have to worry about blood pressure
issues with the sympathectomy of it. I think
paravertebrals are great, but you still have
some of those issues and a little bit more of
a challenging block. So people have gone to some
of the newer blocks are erector spinae plane
blocks. um pex blocks serratus interior blocks
um there's always been tap blocks been around
for a long time i think tap blocks are by far
the most overutilized block that doesn't do a
lot of anything i think that's what has spurred
some of these newer blocks of fascia plane because
if tap blocks are doing really well we wouldn't
be looking for replacements of the of it so um
we don't do a lot of those here because i just
don't believe they're adding to any benefit to
the patient Now, some of these newer blocks,
the interesting thing with the regional anesthesia
is that someone comes up with a new block, and
they put out paper basically saying, here, look
what we did. The patients looked like they were
better, and people just start doing it. The most
recent example is something called a PENG block,
which was designed for hip replacement surgery.
I think I've seen something about EMG. Yeah,
pericapsular nerve group. It doesn't really fit
or make sense, but the guy who developed it was
Dr. PENG, so he had to make that work. So it
was just like, hey, they don't want us to do
ephemeral nerve blocks. They don't want these
patients weak. They don't want us to do a fasciolacca
block anymore because they might get weak because
you're going to hit the femoral nerve. So why
don't we just go deeper and just put local all
right by the hip joint itself? And he described
it and everyone started doing it. And now three,
four years later, studies are starting to come
out. Let's do randomized control trials of this
and, you know, placebo, whatever. It's not really.
not really faring too well against saline or
placebo. So, you know, I made that mistake early
in my career when erector spinae blocks came
out. We started implementing them for a couple
of our surgeons because they didn't want to do
epidurals for various reasons. And we didn't
see very good clinical success for them. And
we slowly weaned them out. And then a couple
of years later, when studies really started to
come out with them, they started to bear out
like maybe this isn't it. And so there's still,
there's still some trials out about some of these
about maybe refining the technique, but there's
a, there's a big push to do these fascial plane
blocks, get something new, get it out there,
let everyone start doing it. And then we'll figure
out, is it useful or not? And. kind of a frustrating
area to be because as the regional anesthesia
director, I get asked a lot from various leadership
people and trainees, like, why aren't we doing
this new thing? It's like, I don't know if it
works. And I don't want to be the one experimenting
on patients without it being an actual study.
Like, so we can set up an actual research study
and do it then. Yeah, that makes sense. But it
is interesting seeing how all these things come
out and then how they're implemented. And then
we wait for the evidence to show. whether it's
going to work or not. I couldn't let you get
away from here without getting your best hot
take on everyone's favorite drug to argue about,
which is Expirel. Can you talk about first maybe
explaining what Expirel is for maybe some of
our medical student listeners, and then give
us your take and maybe what the broader takes
on it have been? So Expirel is... Technically,
liposomal bupivacaine. So they take bupivacaine,
which is a very old local anesthetic that is
still used commonly today, and they put in these
little liposomes, and they are supposed to kind
of dissolve over time and release the medication
at a kind of a consistent rate over the course
of 72 hours. And so it was billed as a long -acting
local anesthetic. So now most of our single injection
nerve blocks last anywhere from 12, 18 to 24
hours. enough for some surgeries, but not enough
for other more painful surgeries. And so a lot
of people in the pain world think if you can
get three days of pain control with a nerve block
or renal, that's the reason why we place catheters
for some of these patients. That'd be the holy
grail of regional anesthesia. You would never
have to put a catheter anymore. You can never
do that. So when it came out, they did some small
studies to show, again, Does, can this be used?
And like, yeah, it can be used. And it has numbing
medicine, so it can numb things. And, and so
it just, they, the company that, that runs Expirel
is a brilliant company. They marketed it well.
They knew where to hit the trigger points. They
knew how to get surgeons mostly on board because
they go to the surgeon and say, you don't want
to deal with pain. You don't deal with opioids.
You don't want to deal with these pain catheters
or these pain people hanging around your patients.
You just inject this. There'll be three days
pain -free and then you don't have to worry about
it. and people sunk their teeth into it, and
it became a very, very popular medication. It's
been used. It's very expensive still. To get
a vial of plain bupivacaine is about $0 .30,
and a vial of Expril is about, I think, $350.
So it's a pretty big difference. Over the last
two to three years, maybe it's been a little
bit longer than that, some studies have started
to come out that were not funded by the company
that makes XBRL, comparing XBRL to plain bupivacaine.
And the results have not been good for XBRL.
At best, it's been equivalent, but some have
said it's worse than actual plain bupivacaine.
And whenever I've been around their representatives,
they don't like it because I just explain the
math to them. And it doesn't make sense to me.
To explain it to people in the simplest terms
is we inject around 150 milligrams of plain bupivacaine
in a typical nerve block. There's 266 milligrams
of bupivacaine in Expro. And so if you do the
math of 266 milligrams of bupivacaine over 72
hours, and if it's released continuously at a
slow rate like they say it is, you're getting
not enough local anesthetic to the nerves to
make a difference. And when you look at the math,
it'd be like us putting a catheter in and running
it at less than one CC an hour, whichever one,
if you think, if you look at it, it's like that
doesn't spread around on the nerve as well. So
that's why it doesn't work. It's a cool concept
and it would, it does work the way it's supposed
to, but problems when they're, when they're doing
their initial studies, they tried to put more
bupivacaine in the liposomes, but they had issues
with the. the subject animal subjects not making
it because of local anesthetic toxicity because
if it doesn't release in a consistent fashion
you release too much you're going to get toxicity
and so that's 266 the most they could get in
there safely and it's just not enough to achieve
the goal you're going to make it really hard
for me to get sponsored by xrel for this podcast
i think they'd still sponsor it they're looking
to sponsor anything they can get their hands
on so Well, so far I haven't run any specific
ads on the podcast, but advertisers, if you're
listening, if you would like to give me money.
We're interested. Please feel free. In general,
the opioid pendulum has definitely swung away
from opioids. People have realized that there's
the opioid crisis. And our residents, and I think
residents sort of. across the nation are starting
to understand that opioids aren't the way forward
and are coming around to your point of view maybe
a little bit more slowly than we would like.
However, do you think that it might be swinging
a little bit too far? Do you feel like maybe
we're not treating acute pain appropriately in
some of these populations? I think possibly,
yes. I think i don't like to have anyone have
the concept of if you're not giving an opioid
you're not treating pain well that's not true
um i personally think the pendulum in anesthesia
specifically has not swung far enough uh away
from opioids as opioid centric i don't know the
exact percentage but i would say probably 20
20 percent of cases should get opioids the other
70 75 should not I think that there's a lot of,
because we have so many options nowadays. And
now this is just pre -op and intra -op. I think
we can get them through. And if we deploy all
of our options that we think make the most sense
for that patient, that surgery, and they wake
up and they're in recovery and they're having
pain, then you can use a small amount of opioids.
And that usually works really, really well. And
you don't have to use a ton. And it usually helps
get rid of their pain very well. So I think that
the, I don't, I think there are some, particular
individuals that i become you know the term is
opioid phobic where they don't they're not gonna
give anyone an opioid no matter what and i think
that's where you can get yourself into problems
so as long as you don't have that you understand
that opioids are one of the weapons you have
to combat pain it's just not the main one and
i like to view like from my position i use local
anesthetics nerve blocks as my main weapon that's
how i'm trying to attack pain But if you ask
me, if you took away one other option, I'm fine.
And that's where I was like, if I tell certain
anesthesia people like providers, like you can't
use opioids, they don't know what to do. And
that's a problem. Like to me, that's an issue.
I had an attending and residency that would,
every time I worked with them would just say,
you can't use this medication today. How are
you gonna get around it? And most of the time
it was like, it was fine, but then. like took
away propofol. I'm like, Oh, you know, it's like,
that's a big one. Um, but you know, it's like,
you can imagine like, okay, you can't use a paralytic
today. How are you going to get through these
cases? You know, in some cases you can, some
like that's going to be harder, but it's just,
I like to think of that in the pain sense. Like
if, if I can, and that happens, right. You get
an elderly patient, you get, you know, certain,
certain patients, you know, on an opioid, you
know, diversion therapy or something, you can't
give up. You're going to take classes of analgesics
away from you. And sometimes surgeons and surgical
techniques, like I can't do a nerve block for
it. How else, what else am I going to use? And
so as long as you're always thinking about their
pain and trying to do something for them, you're
not going to undertreat them. But I think there
are some people that have gone too far to the
too scared of opioids, but don't know enough
about all the other alternatives that they will
be undertreating some people's acute pain, which
is the number one thing you can't do because
that will lead to potential chronic pain. Let's
talk about your fellowship a little bit. Who's
it for? Who's it not for? So the main reason
why I would recommend anyone do a fellowship
in regional anesthesia acute pain is you love
it. You want it to be a part of your life. Regional
anesthesia, everyone does it. Every anesthesiologist
can do it, should do it. I'm a firm believer
in regional anesthesia. As long as you can do
it safely, do it. The more nerve blocks and injections
we can do, the best. There is a whole nother
layer of regional anesthesia and Q pain management
that the fellowship gets you to. So we, we've
had plenty of really brilliant CA threes that
have like killed it through their whole career
as residents here for regional anesthesia, Q
pain. And there's still layers I can get them
to. And so if you have that passion desire, I
want this to be a key central point of my career.
I want any practice I go to, I'm going to be
the go -to person for blocks, the go -to person
for pain. I want to set up an acute pain service.
I want to run a surgery center. I want to have
leadership opportunities. That's who should be
doing a fellowship in regional anesthesia acute
pain. There's no more money involved with it
typically, which some of the fellowships can
kind of hang their head on. There's no like preferential
scheduling you get from it, which some other
specialties can get. So those are the people
that I'm looking for for the fellowship. People
that are genuinely just interested in learning
that deeper level of why do we do what we do
and how do you do it. And honestly, if you think
about your career and if you think like, oh,
I can go take a job where if I do blocks rate,
if I don't, I don't care. Probably don't need
to do a fellowship. If you're thinking like,
I can't have a job where I don't do this, then
fellowship is probably the best spot for you.
So how do you take that strong CA3 and take them
through that year of fellowship and turn them
into that person you're talking about? So understanding
everything that there is to know about regional
anesthesia and acute pain sets that individual
up to have those conversations with the surgeons
that we talked about earlier. It allows you to
better explain. what you do, how you do it, and
how you fit into their system and how you make
it work. So I had a conversation with one of
our colleagues a couple months ago. We have a
new orthopedic surgeon. He wants to take a little
bit of a different approach to some nerve box
just because he's in his earlier career. And
the question I got from our colleague was, why
can't he just do the standard of care that we
do here? I'm like, because we don't do standard
of care here. I've used my position and my fellowship
training, my knowledge base to fill in these
surgeons' ideas of where we should fit into their
life as orthopedic trauma surgeons. And so we
do way more blocks and regionals here than anywhere
else. And it's because I've been able to use
that. So that's how I was able to set up and
build our pain service basically through that.
So the fellowship starts with building that knowledge
and building that confidence in that you know
this better than anyone else. And then you have
to actually be able to do it, right? So we have
our residents here graduate with hundreds of
blocks, right, over the course of three years.
Really good experience. They get exposure early
and late. They get exposure throughout. But I
still think it's not enough if you want to be
the person. If we're going to plop someone into...
orthopedic surgery center that's going to have
eight rooms and you need to do all the blocks,
spinals, everything, keep it efficient, keep
it effective, keep it flowing because you can't
have them pack you slowdowns. You got to have
the reps and you got to have the familiarity
with how to do that. And so we get the knowledge
and we get the skill down for the fellows and
that sets them up to be able to produce, but
also to be able to set up and communicate to
the surgeons how they fit into that mold. From
my side, which I very much underappreciated that
I got from my fellowship, is how do you also
deal with administration? And how do you explain
how you fit in and why are we here? Like, what
are we doing? What value do we provide to the
health system? And because a lot of them don't
have the medical background to understand everything
that's going on, but you can use your knowledge
and understand a little bit more where they're
lacking their knowledge and fill those gaps to
then have them say, you are providing a very
valuable service. That's great. How can we help
you? And how can you get involved and stuff?
And so it also, you know, having that fellowship
training also gets you into positions where you
can be on these committees and working with administration
and leadership to try to figure out how to best,
of course, the health system, but also to the
benefit of you and what you're trying to do and
how you're trying to help your trainees and patients.
This has all been a really great conversation.
I appreciate it. But I want to wrap up with my
final style points question. are your personal
style points or points of personal preference
that have helped you build a pain service, that
have helped you succeed? I'd love to hear them.
So the number one thing that comes from my mind
that took me a while to learn through my career
is communication. You can never, ever over -communicate.
And having toddlers, I've learned a lot from
them. You have young kids. They may not know
how to communicate, but when they want something,
they make sure you understand that they want
something, right? When they want to get a point
across, they do it, but they communicate it.
And if you're not understanding their first form
of communication, they try a different one, and
they try a different one. A louder one. A louder
one, typically, right? That doesn't always work
in the professional healthcare setting, as I've
tried, but communication is so, so important.
And I use it in my personal life. You know, I
use it in my wife, my kids, my family, with my
friends. It's trying to – communication is a
two -way street, right? It's like I need to be
expressing to my views and what I'm trying to
get across, what my goals are. But I also need
to be hearing whoever I'm working with what their
goals are and how it fits. And, you know, doing
that in a rational, calm, patient manner. really
helps build build relationships so communication
is the key point that starts then you build relationships
and you know this if you have a relationship
with a colleague in anesthesia or a surgical
colleague or whoever it is it makes life so much
easier right like hey hey buddy like you know
like i i remember the story i was with i went
golfing with one of the orthopedic surgeons right
had a great time it was cool got to see him outside
the hospital literally like two weeks later we're
doing a case together we're finishing the case
He happens to be walking through patient. All
of a sudden we're waking up, not doing well.
Patient happened to get a spontaneous pneumo
randomly, but I just had, I just be able to look
at him. Hey, we've got a problem here. He instinctively
just got on the phone and called our ACS trauma
backup and said, Hey, I need you to come to this
OR like, and by the time he got there, like,
Hey, we've got a new more than they, it was five
minutes from when I told him we have a problem
here. We got an x -ray. They did. They, they
put the chest suit. It was in the patient was
fine. And it was just like, it was easy. Cause
I just, I had no problem to say, Hey man, like
this, this is what I need. I need some help.
And he, he knew kind of, you know, it's just,
it makes life so much easier to ask for help,
to understand where you're going, have communication.
So starting with that communication, building
relationships, it just, it just, it makes every,
it makes life so much more enjoyable, so much
better and so much easier for everyone. So really,
I suppose. Everyone can learn from you is to
be more of a buddy. Buddy with an E, yes. Brad,
thank you so much for joining us. Thanks for
having me on. This was fun. Well, that's it for
this month's episode of Style Points. My thanks
to Dr. Buddy for coming on and giving us his
perspective. If this episode didn't teach you
everything you wanted to know about acute pain,
well, you'll just have to apply for his fellowship.
If you got something out of this episode, the
single best thing you can do to help other people
find the show is to leave a rating or a written
review. It really does work, even if I pretend
that I don't look at them. As always, you can
reach me at stylepointspodcast at gmail .com,
and I'm still happy to mail you a free StylePoints
sticker for your water bottle. Take a deep breath.
Open your eyes. We're all done.