WEBVTT

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anesthesia enthusiasts and welcome to this month's

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episode of style points i'm your host john crow

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today we're talking to my friend and colleague

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dr brad buddy who directs the regional anesthesia

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and acute pain fellowship here at the university

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of cincinnati we'll talk about his perspective

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on pain management and the philosophy behind

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it we don't have an rsi for you this month so

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let's jump right in so what was your radio experience

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like in college it was um It was interesting

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because I had, it was like a full studio. So

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I had no idea what any of the stuff was doing,

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but our one buddy did. And so we were just talking

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sports and we had the Sunday evening time slot,

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which rivaled Sopranos. So, so we, so we, we

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got to, we got, I think we got up to 41 listeners

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at one point. 41. That's the highest number of

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listeners for any show on Miami student radio,

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which is saying something about who we were broadcasting

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to. Miami Student Radio. Yeah. What was the call

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sign? I don't remember. Oh, come on. The name

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of our show is Crunch Time. I remember that.

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But other than that, I don't remember much about

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it. Well, loyal listeners, welcome back to Crunch

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Time with Proud Buddy. we would do trivia and

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like, we'd all be like three, four of us would

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be really into it. And people in the air, like

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our buddies are Texas, like stop, like don't

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care. It's about this. Like, but, but we're having

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fun. Like that's all that matters. Well, people

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text me all the time that they don't care about

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what I'm doing. So yeah, it's, I mean, you have

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kids, they never care what you're doing unless

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you're doing exactly what you tell, they tell

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you to do, but that's great. Brad, thank you

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so much for joining us. Thanks for having me.

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So. We have a lot to talk about in the world

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of regional anesthesia, but before we do that,

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I wonder if you could tell us a little bit about

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yourself, what your interests are, and what we're

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here to talk about. My name is Brad Buddy. I'm

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an associate professor here at the University

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of Cincinnati in anesthesia. My main interests

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right now lie with my family. I'm married and

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have two young boys, five and three years old.

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So they keep me pretty busy. I've always had

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an interest and passion for sports. So I like

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watching sports, playing sports, mostly golf

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these days. And then I have my career, which

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has been mostly dedicated to regional anesthesia

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and acute pain medicine. So much so that I've

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started my own fellowship and run my own division

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and really enjoy doing it. So why regional anesthesia?

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What's so interesting about that? So it's a little

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bit of a longer story, but it goes back to my

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interest in sports. So when I was young, I really

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liked playing sports with my friends. And I was

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actually over at a friend's house, and his dad

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actually happened to be an orthopedic surgeon,

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a sports surgeon. So we were in their basement.

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They had all this sports stuff. And my young

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brain said, wow, if I'm an orthopedic surgeon,

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I can have all this sports stuff in my house.

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I'm like, I really want that. Found out later

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that he actually played on a national championship

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team for University of Louisville basketball,

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which is why he had that stuff. But it still

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piqued the interest. So I was so interested in

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sports that I finished college and I didn't go

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right into medical school. I went and got a master's

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in sports studies at Miami University, thinking

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about going into potentially coaching or athletic

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administration. And there's still something about

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that draw to orthopedic surgery and medicine

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and kind of a sports surgeon. that I really couldn't

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let go. So I applied and got into the medical

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school, and I came in so tunnel vision, all I

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cared about was orthopedics until match day came,

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and I didn't match into orthopedics. Oh, wow.

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Then I had to kind of go, huh, this whole drive

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and passion is kind of a lot harder than I was

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anticipating. It actually was my April of my

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fourth year of medical school where I did my

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anesthesia rotation. And at the time, even though

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I didn't match, I told everyone, I'm doing orthopedics.

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I'm going to do it. And so the anesthesiologist

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that I was fortunate enough to rotate with here

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at University of Cincinnati, as well as some

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of our community hospitals, took my passion for

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orthopedics and said, look what we can do to

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help the orthopedic surgeons and showed me nerve

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blocks, regional anesthesia. And I had no idea.

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I'm like, this is really cool. And that really

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kind of spiked the interest there. Then when

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I was doing my preliminary intern year at Penn

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State, I got to see and experience a little bit

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more of anesthesia and regional anesthesia. So

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then I said, this is kind of more of my passion

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and interest. I want to go into this and be in

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anesthesia. And then once I got to Rush, where

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I did my residency. Our regional anesthesia director

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there, her and I really connected and I learned

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a lot from her and kind of really just drove

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that passion forward about how I can use this

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interest in sports, but to also help kind of

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that patient population, but then expand it out

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to, wow, I can actually help a bigger group of

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people than just athletes with this. And so that's

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what kind of led me to where I am now. It's so

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interesting. that this podcast makes it much

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easier for me to have these conversations with

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people because I find all this really interesting

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to find out about you for the first time because

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I never knew any of that. But I don't know that

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I would have ever asked you just in casual conversation.

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Yet we've known each other for eight years now.

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And this is, yeah, like you don't ever tell people

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about the whole story of how you got here. Right.

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And, you know, it's kind of interesting. Like,

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why are you interested in what you're interested

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in? It's usually more of a. I just liked it.

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There's something else to it, usually. Yeah,

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it's been really rewarding for me to find out

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people's origin stories just at random and find

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out more about them. Yeah, finding out the why

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for people, I think, really helps you understand

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why they are doing what they do, how they take

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a little bit more and kind of makes you appreciative

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of what they're doing and why they're doing it.

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Especially if it's something that you don't really

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see it the same way. It's like, well, at least

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I understand. why they see it that way and that's

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a little bit more of a uh collegial and collaborative

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effort i think yeah i agree with you well let

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me back up and ask you the famous dinner question

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that i ask everybody uh i'm going to go out on

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a limb here and guess you're going to pick somebody

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sports related if you could go out to dinner

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with anybody in the world could be somebody from

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the past or from fiction who would you pick and

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why I have been asked this question before, and

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it is not sports -related. It's family -related.

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Wow, there you go. So I would pick my maternal

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grandfather. I'm a pretty family -oriented person.

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I grew up in a good family. I now have kids,

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and I want to instill that into them. And I was

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very fortunate that my dad's parents I was able

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to connect with, they had a really super interesting

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story of living in Germany, growing up in Germany.

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living through the war. My grandpa was forced

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to fight in the war for Germany and, like, beyond

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his will, right after the war, they moved over

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here and had my dad. So it was cool to kind of

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get to connect with them. And on my mom's side,

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I got to know my grandma, but my grandpa was

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fought in the war on the American side. So my

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grandparents actually, my grandpas actually fought

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each other in World War II. Wow. Which is kind

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of cool. Not directly, but... Well, not that

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you know her. That's true. That's true. But apparently

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he passed away when I was really young. I guess

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he got exposed to some things during the war

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that he could never really recover from. And

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so I talked to my mom. She didn't know him that

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great either just because he was in the war and

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then he was kind of sickly after that. But apparently,

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according to my grandma, he was a fighter pilot

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for the Air Force. Apparently he was a pretty

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well -renowned guy. And my mom has found some

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interesting kind of articles and things, letters

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from... you know, the Air Force stuff about him.

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So I just would really like to sit down and kind

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of know more about his trajectory, his path,

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what got him into Air Force and flying and all

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that kind of stuff. It's just kind of a piece

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of my personal family history that I would really

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like to know a little bit more about. That is

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so interesting. Do you feel like you act as a

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fighter pilot at work sometimes? Well, I mean,

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there's the obvious correlation between the airline

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industry and anesthesia. But not knowing anything

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really about the airline industry, I have no

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idea. I'm guessing yes, but maybe. Something

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about checklists, I assume. Yeah, right. Yeah,

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so maybe there's some of that in me from my grandpa

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that I never really knew. So you have spent a

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tremendous amount of time, and I know from my

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experience with you that you have a lot of opinions

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about pain management. and how to handle pain

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in the perioperative setting. When you're thinking

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about pain as a clinical problem generally, what

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do you think most anesthesiologists don't get

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right about it? I don't know how to put this

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without being insulting, but there's a lack of

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understanding of pain. And I think that's healthcare

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-wide. I think it's culture -wide, society -wide.

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Pain is very complex and it's very gray. And

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I explained this to a lot of our trainees that

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a lot of times in medicine, we like objective

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numbers. We like diagnoses. We like numbers to

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point and say, this is why this is happening.

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You can't do that with pain. What about the pain

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scale? Isn't that an objective number? That was

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the attempt to put an objective number on pain

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that has failed miserably, but yet still maintains

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today. So that's to me is pain is very complex

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and it's very subjective. There's a lot of feelings

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from the patient side that go into it. And obviously

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there's a lot of bias from the provider side

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that goes into it. And I think specifically anesthesia,

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I think we deal with a little bit of a unique

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situation that we don't have patients telling

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us about their pain. Which I present this to

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our fellows and some of our senior residents.

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And I say, you know, can the patient under general

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anesthesia experience pain? And if you look at

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the definition of pain, they can't because it's

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subjective. So they can't tell you about it.

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They're not having it. And then most people are

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like, nah, it doesn't make any sense. And it's

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like, I get it. It's more of a philosophical

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discussion. But I think. anesthesiologists or

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anesthesia providers in general put a lot of

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their own biases into what pain is and looking

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over the drapes saying that hurt I'm gonna give

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something for that versus really understanding

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the complex complexity of the things that are

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going into what's causing the pain and then on

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the other side is you know there's a lot of historical

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reasons why pain is treated the way it's treated

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in the perioperative setting and I personally

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think it's backwards. I think we use opioids

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as a mainstay therapy. It's not as strong as

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it was when you and I were training 10 years

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ago or even 20 years ago. But I still think that's

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the crutch that everyone leans on. And I think

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that we have better alternatives now that can

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help. And opioids have their role. It's just

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not as expansive as it is currently being deployed

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in anesthesia. So you wouldn't say that pain

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is the fifth vital sign? I would not, and I would

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hope that everyone understands what a massive

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mistake that was when we went down that path.

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Why don't you back up a little bit for our audience

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and tell that story a little bit? So you can

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tell this story in a number of different ways,

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but I think it was back in the late 90s, early

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2000s, there was this push that pain was being

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undertreated and that we weren't. as a healthcare

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community, we weren't taking care of pain with

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enough compassion and doing enough for it. Now,

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I believe and most people think that that push

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was coming from the pharmaceutical industry that

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had created these great medications called opioids

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and that we have this medication that can fill

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this void that you guys have created in healthcare.

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I would argue there wasn't avoidant health care

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with that, but it became this forefront of we

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were not treating pain and we're not treating

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patients' subjective feelings of pain well with

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what we were doing. And so that's what kind of

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pushed opioids to the front line. And that's

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what generated the pain scale, you know, the

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one, the zero to 10 scale that everyone knows.

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It didn't take a full comprehensive look at it.

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And again, I think it goes back to the underlying

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of. why it kind of spiraled the way it did is

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because not a lot of people in healthcare felt

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comfortable with pain. They didn't understand

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it well. They didn't really know about it. And

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here came this new shiny thing of they're having

00:12:45.299 --> 00:12:47.019
pain. You don't know what to do. Give them this.

00:12:47.080 --> 00:12:49.399
And it's an opioid and that's Oxycontin. This

00:12:49.399 --> 00:12:54.419
was the original one. And it, it, it works. Opioids

00:12:54.419 --> 00:12:56.940
work for pain. And so I was like, wow, we did

00:12:56.940 --> 00:12:59.970
it. We did it. Mission accomplished. Mission

00:12:59.970 --> 00:13:02.309
accomplished. We can put our stamp on it. The

00:13:02.309 --> 00:13:04.549
fifth vital sign is here to stay, and we know

00:13:04.549 --> 00:13:06.330
how to treat it, and we're going to do it well.

00:13:07.669 --> 00:13:13.509
So then what happened? Then, you know, despite

00:13:13.509 --> 00:13:15.830
the pharmaceutical companies explaining to everyone

00:13:15.830 --> 00:13:16.990
that, you know, as long as patients are having

00:13:16.990 --> 00:13:19.250
pain, there are no side effects. We then found

00:13:19.250 --> 00:13:21.210
out pretty harshly that there are side effects

00:13:21.210 --> 00:13:23.789
and one of the main one being addiction. And

00:13:23.789 --> 00:13:26.490
that's kind of what spiraled into the opioid

00:13:26.490 --> 00:13:30.669
crisis that we saw. Going into like the 2007

00:13:30.669 --> 00:13:32.950
to 8 is when it really kind of exploded and when

00:13:32.950 --> 00:13:34.690
still everyone is very familiar with the opioid

00:13:34.690 --> 00:13:36.149
crisis. Now I think they teach it a lot of medical

00:13:36.149 --> 00:13:38.190
schools about what it is and what's going on.

00:13:38.289 --> 00:13:41.639
And, you know, I. I still think that there is

00:13:41.639 --> 00:13:43.779
a little bit, going back to the, what do the

00:13:43.779 --> 00:13:46.820
anesthesiologists do wrong with pain, is assuming

00:13:46.820 --> 00:13:49.000
that they aren't part of the opioid crisis problem.

00:13:49.220 --> 00:13:51.559
If you are pushing or giving an opioid, you're

00:13:51.559 --> 00:13:53.620
potentially part of the problem. And I don't

00:13:53.620 --> 00:13:56.159
think people want to admit that or think that.

00:13:56.580 --> 00:14:00.700
And the steps to get from giving someone a pain

00:14:00.700 --> 00:14:03.039
medication when they're in pain to them developing

00:14:03.039 --> 00:14:07.159
an addiction is a far step and a lot of steps

00:14:07.159 --> 00:14:10.340
along the way to get there. the possibility exists

00:14:10.340 --> 00:14:12.480
and there are many many famous examples from

00:14:12.480 --> 00:14:15.720
athletes to actors that have been injured started

00:14:15.720 --> 00:14:19.480
opioids get addicted most recent one in the news

00:14:19.480 --> 00:14:23.220
is tiger woods he's he's i just saw today that

00:14:23.220 --> 00:14:25.440
he's back from his six weeks rehab in switzerland

00:14:25.440 --> 00:14:28.940
for his opioid addiction that he's got so um

00:14:28.940 --> 00:14:30.919
started with back injuries and back surgeries

00:14:30.919 --> 00:14:33.480
and you know kind of derailed him a little bit.

00:14:33.519 --> 00:14:35.500
So even the most powerful and the most mighty

00:14:35.500 --> 00:14:37.919
and the most famous can, can succumb to this.

00:14:37.960 --> 00:14:39.500
And we just don't know who it's going to be.

00:14:39.940 --> 00:14:41.700
And I think that's kind of the tenant I take

00:14:41.700 --> 00:14:43.759
is that I look at every patient as a potential

00:14:43.759 --> 00:14:47.120
future addict that I don't want to be the one

00:14:47.120 --> 00:14:50.320
that starts them down that path. How well do

00:14:50.320 --> 00:14:52.879
you think that residency does training people

00:14:52.879 --> 00:14:55.720
to think about pain and anesthesia residency

00:14:55.720 --> 00:15:00.139
specifically? I think anesthesia does a far better

00:15:00.139 --> 00:15:02.279
job than the other residencies that at least

00:15:02.279 --> 00:15:05.940
I've seen and been familiar with. I think pain

00:15:05.940 --> 00:15:08.519
is a central component to the ACGMA structure.

00:15:08.759 --> 00:15:10.860
You have to learn about acute pain, chronic pain,

00:15:11.000 --> 00:15:14.019
regional anesthesia. So I think that there is

00:15:14.019 --> 00:15:19.240
a good infrastructure curriculum there. I think

00:15:19.240 --> 00:15:22.299
kind of one of my gripes with anesthesia training.

00:15:23.070 --> 00:15:25.950
And where I think we're missing the ball on it

00:15:25.950 --> 00:15:31.750
is the PACU recovery side. I think back in my

00:15:31.750 --> 00:15:34.370
training, I remember our preoperative kind of

00:15:34.370 --> 00:15:36.330
training was kind of limited. We did a little

00:15:36.330 --> 00:15:39.600
bit of it. We had a clinic that we kind of went

00:15:39.600 --> 00:15:41.019
to every once in a while. It's nowhere near as

00:15:41.019 --> 00:15:43.019
robust as it is here at University of Cincinnati

00:15:43.019 --> 00:15:45.600
or at other places I've seen now. So I think

00:15:45.600 --> 00:15:48.340
our preoperative optimization has gotten better.

00:15:48.720 --> 00:15:50.059
Interoperative training has always been spot

00:15:50.059 --> 00:15:52.019
on. I think everywhere you go, everyone focuses

00:15:52.019 --> 00:15:54.940
on it, does it, and does it well. I've seen people

00:15:54.940 --> 00:15:57.059
from tons of universities that do interoperative

00:15:57.059 --> 00:16:00.779
management well. What we don't do is we don't

00:16:00.779 --> 00:16:03.500
follow these patients. We drop them off in PACU,

00:16:03.600 --> 00:16:05.600
and that's about the extent of our knowledge

00:16:05.600 --> 00:16:08.590
of how they've done. And everyone in anesthesia,

00:16:08.669 --> 00:16:11.850
no matter who you are, lacks the follow through

00:16:11.850 --> 00:16:15.129
to after they leave the PACU. Like we as faculty

00:16:15.129 --> 00:16:16.830
get a little bit more experience in the PACU

00:16:16.830 --> 00:16:18.870
because we get the phone calls or we make sure

00:16:18.870 --> 00:16:20.149
the patients are safe when we get out of the

00:16:20.149 --> 00:16:22.389
PACU. But even after that, we don't really follow

00:16:22.389 --> 00:16:24.110
them that much afterwards to see how they do

00:16:24.110 --> 00:16:26.289
unless we have a particular interest in a particular

00:16:26.289 --> 00:16:30.870
patient. So I think that is the piece to the

00:16:30.870 --> 00:16:34.759
pain puzzle that is missing. I think if people

00:16:34.759 --> 00:16:37.519
could know fully how each of their patients have

00:16:37.519 --> 00:16:40.179
done and look back at what they did for those

00:16:40.179 --> 00:16:41.940
patients pre -op and intra -op and how it set

00:16:41.940 --> 00:16:44.659
them up from a pain perspective, I think it would

00:16:44.659 --> 00:16:46.879
really help lock in some of the stuff that we

00:16:46.879 --> 00:16:50.659
try to teach and train when it comes to pain

00:16:50.659 --> 00:16:53.039
management in the period of setting. And that's

00:16:53.039 --> 00:16:55.440
what I really like about my position and what

00:16:55.440 --> 00:16:57.860
we do as far as a pain service here at University

00:16:57.860 --> 00:16:59.259
of Cincinnati and other pain services around

00:16:59.259 --> 00:17:01.610
the country is. we follow these patients through.

00:17:01.710 --> 00:17:04.009
Not all of them, but we get to follow these patients

00:17:04.009 --> 00:17:05.549
and see how they're doing and how these things

00:17:05.549 --> 00:17:09.809
affect them. And it's kind of a, it allows us

00:17:09.809 --> 00:17:11.970
to get onto that side better because, you know,

00:17:11.970 --> 00:17:14.170
when I was training, I always thought, if I can

00:17:14.170 --> 00:17:15.890
get this patient who's either healthy, unhealthy,

00:17:16.130 --> 00:17:17.809
whatever, get through this surgery, big, small,

00:17:17.910 --> 00:17:20.210
and get them through to the PACU safely, like,

00:17:20.250 --> 00:17:23.170
I did a great job. And then I started, when I

00:17:23.170 --> 00:17:24.730
got into fellowship, what I really started to

00:17:24.730 --> 00:17:26.710
learn and think about is like, can I do more

00:17:26.710 --> 00:17:29.339
though? Can I make other decisions during those

00:17:29.339 --> 00:17:30.839
time period to keep them safe through it, but

00:17:30.839 --> 00:17:33.240
also set them up for success in the recovery,

00:17:33.460 --> 00:17:35.839
which I think is a piece that's missing in general,

00:17:35.900 --> 00:17:39.319
but I think is something that we try to incorporate

00:17:39.319 --> 00:17:44.559
here, at least from our pain side. I really liked

00:17:44.559 --> 00:17:47.519
how you mentioned that pain is gray. And I think

00:17:47.519 --> 00:17:51.359
from my experience as well, there's a whole bunch

00:17:51.359 --> 00:17:54.079
of different components and there's certainly

00:17:54.079 --> 00:17:58.750
a lot of. what we do as far as relieving pain

00:17:58.750 --> 00:18:05.150
that has to do with expectations and the patient's

00:18:05.150 --> 00:18:08.849
psychological frame. I wonder what your take

00:18:08.849 --> 00:18:13.230
is on the non -drug variables for how pain is

00:18:13.230 --> 00:18:18.329
managed. I think that's a very undervalued part

00:18:18.329 --> 00:18:21.049
of this because, as I mentioned, pain is subjective.

00:18:21.430 --> 00:18:25.819
And so in order to In order to best treat their

00:18:25.819 --> 00:18:27.599
pain, you've got to understand what they're experiencing

00:18:27.599 --> 00:18:30.299
and how they are kind of experiencing it. And

00:18:30.299 --> 00:18:32.940
it's a very challenging thing to do. And it's

00:18:32.940 --> 00:18:34.460
a very uncomfortable thing for people to do too.

00:18:34.640 --> 00:18:38.019
Because you've got to get into let them be vulnerable

00:18:38.019 --> 00:18:40.519
with you and allow them to explain to you what

00:18:40.519 --> 00:18:44.359
they're going through. And one of the things

00:18:44.359 --> 00:18:46.799
I try and do a lot when we're rounding on patients,

00:18:46.859 --> 00:18:50.440
seeing consults, is just listen. Listen to them.

00:18:50.519 --> 00:18:52.720
And anyone that's been in academic medicine.

00:18:53.230 --> 00:18:54.849
These patients have hundreds of people coming

00:18:54.849 --> 00:18:56.670
in other rooms every day, and they all have a

00:18:56.670 --> 00:18:59.869
particular agenda, right? And a lot of times

00:18:59.869 --> 00:19:01.970
pain is one of the most important things on the

00:19:01.970 --> 00:19:05.390
patient's mind, but not on all those 99 other

00:19:05.390 --> 00:19:07.490
people that come in and out of their room. You're

00:19:07.490 --> 00:19:10.009
there to talk about their pain, or even if you're

00:19:10.009 --> 00:19:11.009
not there to talk about their pain, let them

00:19:11.009 --> 00:19:13.930
talk about it. And there have been numerous times

00:19:13.930 --> 00:19:15.750
where I've had our residents come to me and say,

00:19:15.829 --> 00:19:18.029
we didn't do anything for that patient, but they

00:19:18.029 --> 00:19:19.589
said their pain was better after they talked

00:19:19.589 --> 00:19:22.119
to us. Just because you listen to them. And they

00:19:22.119 --> 00:19:24.119
said, someone listens. I don't want anything

00:19:24.119 --> 00:19:25.400
different. I don't want anything different. I

00:19:25.400 --> 00:19:26.940
just want you to know what I'm experiencing.

00:19:27.500 --> 00:19:30.599
And I think it's a huge, hugely undervalued part

00:19:30.599 --> 00:19:34.640
of pain. And you don't always have to reach for

00:19:34.640 --> 00:19:37.079
an opioid because their fifth vital sign tells

00:19:37.079 --> 00:19:40.160
you that their pain score is a nine. And what

00:19:40.160 --> 00:19:43.460
else goes into it? Like, why is it a nine? Like,

00:19:43.460 --> 00:19:46.119
what makes you say nine versus eight versus 10

00:19:46.119 --> 00:19:50.059
versus 20? Like, we've seen it all. all these

00:19:50.059 --> 00:19:51.519
scales and all these scores, but like, what is

00:19:51.519 --> 00:19:53.640
it really that is bothering you? And sometimes

00:19:53.640 --> 00:19:56.660
it's like, I just want a glass of water. I just,

00:19:56.680 --> 00:19:59.240
I want to watch my news at night and I can't

00:19:59.240 --> 00:20:01.299
figure out how to get the TV on. Like it can

00:20:01.299 --> 00:20:03.759
be simple things that think about when you're

00:20:03.759 --> 00:20:05.519
at home and what makes you a little uncomfortable

00:20:05.519 --> 00:20:07.140
with this. You just adjust and do things, not

00:20:07.140 --> 00:20:08.759
stuff you can't do in the hospital that well.

00:20:08.940 --> 00:20:10.259
Sometimes you just need a blanket. Sometimes

00:20:10.259 --> 00:20:11.799
you need a backstretch. Somebody needs something

00:20:11.799 --> 00:20:13.980
simple. And all of a sudden it's like, eh, it's

00:20:13.980 --> 00:20:16.609
okay. It's better. There are some pains that

00:20:16.609 --> 00:20:19.009
you can't just talk away or you can't do little

00:20:19.009 --> 00:20:20.890
nuanced things. You can't do a Sudoku puzzle

00:20:20.890 --> 00:20:22.650
and feel better about it and distract you from

00:20:22.650 --> 00:20:24.450
it. And that's where the pharmaceuticals come

00:20:24.450 --> 00:20:27.009
in. But there's a lot that we can do if we just

00:20:27.009 --> 00:20:29.329
honestly just took the time to listen to people.

00:20:30.930 --> 00:20:35.150
So often when you're doing nerve blocks or starting

00:20:35.150 --> 00:20:38.430
IVs, you're doing something that causes some

00:20:38.430 --> 00:20:42.349
degree of pain that you need to give them before

00:20:42.349 --> 00:20:46.589
they can be relieved from. a larger pain. What's

00:20:46.589 --> 00:20:49.529
your framework for approaching that with patients?

00:20:49.809 --> 00:20:52.630
Are there any phrases that you recommend or that

00:20:52.630 --> 00:20:56.509
you say to them? Do you think that this is going

00:20:56.509 --> 00:20:58.549
to be a big pinch or a little pinch? Do any of

00:20:58.549 --> 00:21:01.430
those phrases matter or what do you think? So

00:21:01.430 --> 00:21:04.430
that depends on the patient. So some patients

00:21:04.430 --> 00:21:07.769
don't want to hear anything. They know it's going

00:21:07.769 --> 00:21:09.289
to hurt or you've already explained it. I think

00:21:09.289 --> 00:21:11.630
a lot of it comes in explaining what you're going

00:21:11.630 --> 00:21:14.250
to do before you do it. And you lean on them

00:21:14.250 --> 00:21:16.349
to tell you, like, do you want to know when we're

00:21:16.349 --> 00:21:20.670
starting? Some patients like to know, like, exaggerate

00:21:20.670 --> 00:21:22.109
a little bit. Like, this is going to really hurt.

00:21:22.190 --> 00:21:24.029
Or some people are like, don't tell me it's really

00:21:24.029 --> 00:21:25.730
bad. Then that's where it's like, oh, small little

00:21:25.730 --> 00:21:27.349
pinch versus, oh, this might hurt a little bit.

00:21:27.410 --> 00:21:31.309
Like, oh, yeah, this might suck. But for nerve

00:21:31.309 --> 00:21:32.950
blocks, it's pretty easy. Like, this is a very

00:21:32.950 --> 00:21:34.710
minimal amount of time for discomfort to have

00:21:34.710 --> 00:21:37.390
a much easier recovery, much better path going

00:21:37.390 --> 00:21:40.549
forward. And that stuff can all be handled during

00:21:40.549 --> 00:21:42.630
the kind of when you're talking to them pre -op

00:21:42.630 --> 00:21:45.390
and, you know, it's part of the thing that we

00:21:45.390 --> 00:21:47.210
learn as anesthesiologists. You got to build

00:21:47.210 --> 00:21:49.109
a rapport and get to know that patient and what

00:21:49.109 --> 00:21:51.430
they're looking for in a short period of time.

00:21:51.490 --> 00:21:55.049
And I think we all come from varying walks of

00:21:55.049 --> 00:21:57.130
life and backgrounds and we all tend to figure

00:21:57.130 --> 00:21:59.609
out how to do that fairly well. And so I think

00:21:59.609 --> 00:22:02.069
that's, I don't have any particular go -to phrases.

00:22:03.079 --> 00:22:05.940
I like to try to be as positive I can with patients

00:22:05.940 --> 00:22:08.740
when I can be and talk about a lot of the positives.

00:22:08.839 --> 00:22:12.700
I don't try to dwell on the pain that might go

00:22:12.700 --> 00:22:16.380
into getting to the positive side of stuff. That

00:22:16.380 --> 00:22:18.880
makes sense. Focusing on the positive does tend

00:22:18.880 --> 00:22:21.240
to make a big difference. And I think that I

00:22:21.240 --> 00:22:24.539
guess reflecting, I think I do a lot of that

00:22:24.539 --> 00:22:27.619
too. I think a lot of anesthesia providers do

00:22:27.619 --> 00:22:29.819
it without really even noticing it, right? Right.

00:22:30.140 --> 00:22:32.319
It's because it's our way of kind of making the

00:22:32.319 --> 00:22:34.460
patient feel a little more comfortable because

00:22:34.460 --> 00:22:37.980
we know what kind of the best path is for them,

00:22:38.019 --> 00:22:39.740
what's going to create kind of the better outcomes

00:22:39.740 --> 00:22:42.460
for them. And so it's an easier way to kind of

00:22:42.460 --> 00:22:45.690
get them comfortable with the idea. versus if

00:22:45.690 --> 00:22:48.069
you explain every little detail of pros, cons,

00:22:48.170 --> 00:22:50.250
negatives, like this could go really, really

00:22:50.250 --> 00:22:52.049
bad because we know that everything could go

00:22:52.049 --> 00:22:54.529
bad in healthcare, but do they need to know about

00:22:54.529 --> 00:22:57.130
all that? Or can we just talk about like, there's

00:22:57.130 --> 00:23:00.490
some risks to this, but the benefits are huge

00:23:00.490 --> 00:23:03.410
and we do this a lot. And so try to focus on

00:23:03.410 --> 00:23:05.869
the positives, set them, get them more comfortable.

00:23:06.349 --> 00:23:08.369
And a lot of people coming to surgery are more

00:23:08.369 --> 00:23:09.990
worried about anesthesia than they are surgery,

00:23:10.150 --> 00:23:13.670
which is wild to me. I agree. That sort of rhymes

00:23:13.670 --> 00:23:16.890
with, talk that I often give to the residents

00:23:16.890 --> 00:23:22.029
about how to pre -op a patient and how to talk

00:23:22.029 --> 00:23:25.930
to the patient about risk. I frequently, and

00:23:25.930 --> 00:23:28.490
not necessarily downplaying it, but I like to

00:23:28.490 --> 00:23:31.490
compare it to something that the patients already

00:23:31.490 --> 00:23:33.630
know and are comfortable with and familiar with,

00:23:33.750 --> 00:23:36.809
which is why I tell patients that anesthesia

00:23:36.809 --> 00:23:39.529
is safer than your car ride over here. It kind

00:23:39.529 --> 00:23:41.470
of puts them in a frame of mind that's a little

00:23:41.470 --> 00:23:44.410
easier for them. Yeah, it's interesting. I've

00:23:44.410 --> 00:23:45.970
kind of used some of those things before, and

00:23:45.970 --> 00:23:47.950
it's fascinating to me. I don't know your experience,

00:23:48.029 --> 00:23:51.049
but some people are like, I don't care. I ride

00:23:51.049 --> 00:23:53.250
in a car all the time. This is not my normal

00:23:53.250 --> 00:23:56.869
Tuesday morning where I get anesthesia. So it's

00:23:56.869 --> 00:23:59.230
interesting how sometimes those messaging can

00:23:59.230 --> 00:24:02.509
make sense, but how it's going to be received

00:24:02.509 --> 00:24:04.109
isn't as well. Well, you have to be careful.

00:24:04.230 --> 00:24:06.230
You can't tell patients who have just gotten

00:24:06.230 --> 00:24:09.170
in a car wreck. That's very true. What brings

00:24:09.170 --> 00:24:11.490
you here, Carmack? Well, yeah, this is safer

00:24:11.490 --> 00:24:17.950
than that. Probably. Okay. I want to talk about

00:24:17.950 --> 00:24:22.250
something that I have heard in every single resident

00:24:22.250 --> 00:24:26.150
presentation about a pain plan that I've ever

00:24:26.150 --> 00:24:29.269
gotten, which is that they plan to do multimodal

00:24:29.269 --> 00:24:34.430
anesthesia. That is the buzzword. What does that

00:24:34.430 --> 00:24:37.400
mean? Can you explain to me what the residents

00:24:37.400 --> 00:24:42.259
are talking about? I wish I could. I agree. It's

00:24:42.259 --> 00:24:44.579
a little bit of a, every time I hear that, I'm

00:24:44.579 --> 00:24:46.359
like, what does that mean? I always ask it. What

00:24:46.359 --> 00:24:48.720
does that mean? So multimodal in and of itself

00:24:48.720 --> 00:24:52.539
just means, you know, two or more of ways to

00:24:52.539 --> 00:24:55.160
attack something. So you can do multimodal anesthesia,

00:24:55.240 --> 00:24:58.720
multimodal analgesia. You know, it's interesting.

00:24:58.859 --> 00:25:02.819
Just last week, I was, we're starting a. an orthopedic

00:25:02.819 --> 00:25:06.259
surgery case. And I was talking to the provider

00:25:06.259 --> 00:25:07.680
in the room with me. And we were talking about

00:25:07.680 --> 00:25:08.980
how we're going to help, you know, tackle the

00:25:08.980 --> 00:25:11.519
patient's pain. And, and the orthopedic surgery

00:25:11.519 --> 00:25:14.400
resident goes, you guys can use multimodal. And

00:25:14.400 --> 00:25:15.839
I'm like, what does that mean? He goes, isn't

00:25:15.839 --> 00:25:21.839
that two types of opioids? And I'm like, Maybe

00:25:21.839 --> 00:25:26.380
that could be a way to do it. Um, so, so yes,

00:25:26.380 --> 00:25:28.420
it's a buzzword. People know how to talk about

00:25:28.420 --> 00:25:30.259
it. They know what to say. Do they know what

00:25:30.259 --> 00:25:33.299
it means? Probably not. Now I'll give our residents

00:25:33.299 --> 00:25:35.640
credit. They know more than, than that orthopedic

00:25:35.640 --> 00:25:37.839
surgery resident, which, you know, is what it

00:25:37.839 --> 00:25:41.809
is. Wow. Um, but. But, you know, I think the

00:25:41.809 --> 00:25:43.490
interesting thing about multimodal is that while

00:25:43.490 --> 00:25:46.750
it's great on the surface, like, you know, we're

00:25:46.750 --> 00:25:49.789
not as opioid -centric for our analgesic plans

00:25:49.789 --> 00:25:54.109
as we used to be in anesthesia. I think the problem

00:25:54.109 --> 00:25:57.069
with multimodal is a lot of people have either

00:25:57.069 --> 00:26:00.009
jumped – they're swung the pendulum all the way

00:26:00.009 --> 00:26:00.849
to the other side. Like, I'm not going to give

00:26:00.849 --> 00:26:02.910
any opioids. So, therefore, I'm going to give

00:26:02.910 --> 00:26:05.829
you every possible pain medication I have in

00:26:05.829 --> 00:26:10.039
this drawer. There's no real thinking behind

00:26:10.039 --> 00:26:11.940
it. Like, what's the goal? What are we trying

00:26:11.940 --> 00:26:15.660
to do? And it kind of goes back to, you know,

00:26:15.660 --> 00:26:18.480
what I think we fail on anesthesia a lot is we

00:26:18.480 --> 00:26:20.180
just assume there's going to be pain. Like, we

00:26:20.180 --> 00:26:22.099
have to be doing something for pain during surgery.

00:26:22.200 --> 00:26:25.619
Now, everyone knows that surgery is pain. It's

00:26:25.619 --> 00:26:27.720
going to be painful. That's why we exist in anesthesia,

00:26:27.759 --> 00:26:30.160
because patients can't tolerate the level of

00:26:30.160 --> 00:26:34.059
pain without us being there. It takes me one

00:26:34.059 --> 00:26:36.039
of my, my, my favorite teachments when I'm working

00:26:36.039 --> 00:26:37.599
with residents of the OR. And I asked like, okay,

00:26:37.640 --> 00:26:39.299
take away all nerve blocks, everything else you've

00:26:39.299 --> 00:26:41.240
done in pre -op in the OR. What's the best thing

00:26:41.240 --> 00:26:44.279
you can do for this patient's pain? And they

00:26:44.279 --> 00:26:45.799
start rolling off these things. And I'm like,

00:26:45.859 --> 00:26:48.400
have you ever thought about not giving them something

00:26:48.400 --> 00:26:51.140
might be the best thing for them? Like not exposing

00:26:51.140 --> 00:26:52.980
them to opioids in the OR if you can avoid it.

00:26:53.539 --> 00:26:56.259
And so that kind of my philosophy in anesthesia

00:26:56.259 --> 00:26:58.000
is like, if you. Though everyone likes to get

00:26:58.000 --> 00:26:59.740
the train tracks anesthesia. You want to have

00:26:59.740 --> 00:27:02.720
the easy, even vital signs. You want to have

00:27:02.720 --> 00:27:04.880
boring anesthesia. I'm assuming everyone likes

00:27:04.880 --> 00:27:07.619
that. I like that. Maybe like Dr. France here

00:27:07.619 --> 00:27:09.059
may not like that. He likes a little bit more

00:27:09.059 --> 00:27:11.619
of the chaotic, crazy stuff. But I'm like, that's

00:27:11.619 --> 00:27:13.539
finding the right depth of anesthesia for that

00:27:13.539 --> 00:27:16.039
patient where you don't have to chase vital sign

00:27:16.039 --> 00:27:17.559
changes or anything like that. That means that

00:27:17.559 --> 00:27:19.140
they're not experiencing a lot of pain, a lot

00:27:19.140 --> 00:27:21.440
of stimulus and things like that. So sometimes

00:27:21.440 --> 00:27:22.859
you get to those perfect depths of anesthesia.

00:27:22.859 --> 00:27:24.640
You don't need to give them anything for pain.

00:27:25.119 --> 00:27:27.180
Just let the anesthesia do the job for you. And

00:27:27.180 --> 00:27:29.740
so that's where I think multimodal anesthesia

00:27:29.740 --> 00:27:31.359
can be helpful when you add a couple of different

00:27:31.359 --> 00:27:33.279
elements to increase the depth of your anesthetic

00:27:33.279 --> 00:27:35.480
without causing a bunch of hemodynamic variation.

00:27:36.759 --> 00:27:39.140
Opioids can fit into that. We do that with neurosurgery,

00:27:39.200 --> 00:27:41.660
spine surgeries, but you can also do it without

00:27:41.660 --> 00:27:44.980
it. So I think the multimodal is a great concept,

00:27:45.059 --> 00:27:48.000
but it's kind of pretty ill -conceived in what

00:27:48.000 --> 00:27:51.420
it actually means and how to execute it. There

00:27:51.420 --> 00:27:55.470
are so many things beyond opioids. Ketamine,

00:27:55.470 --> 00:27:59.250
lidocaine infusions. Presidex has certainly come

00:27:59.250 --> 00:28:01.849
into vogue in the past few years. Gabapentin,

00:28:01.990 --> 00:28:04.789
Celebrex. What's overrated? What's underrated?

00:28:04.869 --> 00:28:12.210
What do you think? I think now I speak kind of

00:28:12.210 --> 00:28:13.970
more of our practice here. And what I see here,

00:28:14.069 --> 00:28:19.930
I think ketamine is a little overused for what

00:28:19.930 --> 00:28:23.160
it's worth. I don't complain about it because

00:28:23.160 --> 00:28:24.920
if someone's going to grab for a little bit of

00:28:24.920 --> 00:28:27.000
ketamine over a little bit of fentanyl, I prefer

00:28:27.000 --> 00:28:30.140
that for a patient. I think that's better. When

00:28:30.140 --> 00:28:32.680
you're thinking about long -term kind of recovery,

00:28:32.839 --> 00:28:34.440
kind of getting through the PACU and kind of

00:28:34.440 --> 00:28:38.759
better set them up for there. I think in the

00:28:38.759 --> 00:28:41.240
current landscape, I think, I think the gabapentinoid

00:28:41.240 --> 00:28:43.660
class of medications actually has a role. I know

00:28:43.660 --> 00:28:44.799
that there was an article that came a couple

00:28:44.799 --> 00:28:46.420
of years ago that said it shouldn't ever be used

00:28:46.420 --> 00:28:47.880
for acute pain. And a lot of people have grabbed

00:28:47.880 --> 00:28:50.299
that, but it goes to the lack of understanding.

00:28:50.420 --> 00:28:52.319
What is that drug doing? What are we doing with

00:28:52.319 --> 00:28:56.599
these medications? And I think it goes to people

00:28:56.599 --> 00:28:58.460
have jumped on the multimodal and you're right.

00:28:58.519 --> 00:29:00.200
There's a ton of options available for people

00:29:00.200 --> 00:29:02.059
now. Like you don't have to just grab for an

00:29:02.059 --> 00:29:03.500
open. I think that's great that people are doing

00:29:03.500 --> 00:29:05.279
this is why I love working in an academic environment

00:29:05.279 --> 00:29:07.559
to teach the residents about this, but. If you're

00:29:07.559 --> 00:29:08.960
going to grab the ketamine, what are you trying

00:29:08.960 --> 00:29:10.980
to do with that medication? You're grabbing Robaxin.

00:29:10.980 --> 00:29:13.380
You're grabbing Celebrex. You're grabbing Gabapentin.

00:29:13.460 --> 00:29:15.559
You're doing these things. What are you trying

00:29:15.559 --> 00:29:17.180
to accomplish? What do you really want to come

00:29:17.180 --> 00:29:20.380
from that? And what are you actually treating?

00:29:20.519 --> 00:29:23.220
So pain, there actually is pathophysiology to

00:29:23.220 --> 00:29:26.019
pain. So what is causing this person's pain?

00:29:26.460 --> 00:29:28.259
Is it nerve -related pain? Is it inflammation?

00:29:30.829 --> 00:29:32.509
Are they, do they take a bunch of opioids? Are

00:29:32.509 --> 00:29:34.849
they opioid tolerant? And so therefore you need

00:29:34.849 --> 00:29:36.609
to work on, you know, maybe a little bit of a

00:29:36.609 --> 00:29:38.650
different mechanism. So there's a lot of different

00:29:38.650 --> 00:29:40.930
options out there, but knowing what you're going

00:29:40.930 --> 00:29:42.890
to target instead of just shotgunning it all

00:29:42.890 --> 00:29:44.690
and blanking it all, which is some people tend

00:29:44.690 --> 00:29:47.509
to do, I think it's best to tailor your approach

00:29:47.509 --> 00:29:49.809
to each individual patient. And that allows you

00:29:49.809 --> 00:29:52.150
to get a little bit more sophisticated with your

00:29:52.150 --> 00:29:53.769
medications. But also when you're, when you're

00:29:53.769 --> 00:29:55.630
treating the actual things that are going on,

00:29:55.730 --> 00:29:57.930
you have less risk of the bad side effects coming

00:29:57.930 --> 00:29:59.630
when you just kind of shotgun and give everything.

00:30:01.079 --> 00:30:04.099
So let's say you've got an opioid -tolerant patient

00:30:04.099 --> 00:30:07.420
coming in for surgery, and it's somebody who

00:30:07.420 --> 00:30:10.240
is chronically taking massive amounts at home.

00:30:10.339 --> 00:30:12.880
We've seen this plenty of times, each of us.

00:30:13.980 --> 00:30:18.079
What framework would you want one of our residents

00:30:18.079 --> 00:30:23.640
to approach that patient with? I think everyone

00:30:23.640 --> 00:30:25.500
needs to come from an understanding of what does

00:30:25.500 --> 00:30:28.819
that mean? What is that patient's body? How is

00:30:28.819 --> 00:30:31.269
it going to react to pain? to a painful stimulus,

00:30:31.390 --> 00:30:34.789
to any pain medication we give them, and which

00:30:34.789 --> 00:30:37.809
of our options are best suited for those patients.

00:30:37.950 --> 00:30:40.970
So, you know, when patients are opioid tolerant,

00:30:41.069 --> 00:30:45.289
taking a lot of opioids, they need way bigger

00:30:45.289 --> 00:30:47.670
doses than most people are in healthcare comfortable

00:30:47.670 --> 00:30:49.950
giving them. We get a lot of consults on our

00:30:49.950 --> 00:30:51.450
pain service saying, hey, we need help controlling

00:30:51.450 --> 00:30:53.549
this person's pain. We don't feel comfortable

00:30:53.549 --> 00:30:55.650
going up higher in doses. I'm like, you're giving

00:30:55.650 --> 00:30:57.480
them a tenth of what they get at home. So, of

00:30:57.480 --> 00:30:59.059
course, they're going to hurt like their body's

00:30:59.059 --> 00:31:02.019
used to it. And so we see the anesthesia. And

00:31:02.019 --> 00:31:04.880
what I find fascinating from my standpoint is

00:31:04.880 --> 00:31:07.099
I have someone in that situation. You can give

00:31:07.099 --> 00:31:08.259
them opioids, but it's not going to have the

00:31:08.259 --> 00:31:09.359
effect you're going to have it. So you're going

00:31:09.359 --> 00:31:10.859
to have to lean on your multimodals. You're going

00:31:10.859 --> 00:31:13.220
to have to lean on your other medications. And

00:31:13.220 --> 00:31:14.759
I think that freaks some people out sometimes

00:31:14.759 --> 00:31:16.880
because I want to be able to give them my fentanyl

00:31:16.880 --> 00:31:18.759
and Dilaudid and have the patient be comfortable,

00:31:18.880 --> 00:31:21.900
and it's not going to happen. And so knowing,

00:31:22.059 --> 00:31:24.420
again, all the different medications and options

00:31:24.420 --> 00:31:26.200
you have, how do they interplay with each other?

00:31:26.720 --> 00:31:28.400
That's one where I've seen those patients and

00:31:28.400 --> 00:31:31.000
ketamine is not part of their analgesia plan.

00:31:31.079 --> 00:31:33.220
I'm like, that doesn't make any sense to me because

00:31:33.220 --> 00:31:35.039
that's the best medication you could give for

00:31:35.039 --> 00:31:37.880
that patient. You know, then no one really thinks

00:31:37.880 --> 00:31:39.559
about methadone in those patients. Like that's

00:31:39.559 --> 00:31:42.140
a great option. Like there are so many options

00:31:42.140 --> 00:31:43.779
like available. I don't know, like maybe it's

00:31:43.779 --> 00:31:45.759
just my training or where I was, but when I was

00:31:45.759 --> 00:31:47.200
a resident, I feel like we didn't have all the

00:31:47.200 --> 00:31:49.440
options. Presidys was too expensive. Ketamine

00:31:49.440 --> 00:31:53.779
was not really available. Gabapentin wasn't given,

00:31:53.880 --> 00:31:55.660
Celebrex wasn't given. I don't know if it was

00:31:55.660 --> 00:31:57.500
cost or whatever. Like I remember IV Tylenol

00:31:57.500 --> 00:31:59.859
was like the Vogue thing, but it was too expensive.

00:32:00.039 --> 00:32:01.259
So we're not supposed to give that. So it's like,

00:32:01.259 --> 00:32:03.099
we're giving Tylenol and opiate is all we really

00:32:03.099 --> 00:32:05.279
had. And now, you know, you think about all the

00:32:05.279 --> 00:32:07.140
options we had, like you have a lot of things

00:32:07.140 --> 00:32:09.839
you can do. And those patients that are opioid

00:32:09.839 --> 00:32:14.220
tolerant or are on any kind of opioid use disorder

00:32:14.220 --> 00:32:17.539
medications, that's where more of a shotgun approach

00:32:17.539 --> 00:32:19.519
might be beneficial. You got to try to attack

00:32:19.519 --> 00:32:23.339
every different receptor. pain pathway you can

00:32:23.339 --> 00:32:25.680
find try to help them because you you're our

00:32:25.680 --> 00:32:28.240
main our main gun that we have for analgesia

00:32:28.240 --> 00:32:30.039
is opioids and they just aren't going to be as

00:32:30.039 --> 00:32:32.099
useful as they are for opiate naive patients

00:32:32.099 --> 00:32:37.380
so a lot of times you find yourself advocating

00:32:37.380 --> 00:32:40.779
for doing more nerve blocks that makes sense

00:32:40.779 --> 00:32:42.799
you're the director of regional anesthesia i

00:32:42.799 --> 00:32:46.079
hope i am and i think you do a great job at it

00:32:46.079 --> 00:32:51.089
but sort of what i want to know is What are these

00:32:51.089 --> 00:32:53.849
conversations that you're having with surgeons

00:32:53.849 --> 00:32:58.910
to advocate for those nerve blocks? So that's

00:32:58.910 --> 00:33:03.190
a, it depends on the surgeon. So I treat my relationships

00:33:03.190 --> 00:33:04.630
and communication with surgeons kind of like

00:33:04.630 --> 00:33:07.190
with patients. Like I need to understand where

00:33:07.190 --> 00:33:10.589
they're coming from. And I kind of had an aha

00:33:10.589 --> 00:33:13.309
moment about two years into being faculty. I

00:33:13.309 --> 00:33:16.619
was actually teaching. uh cadaver ultrasound

00:33:16.619 --> 00:33:19.660
course at Walter Reed um University of Maryland

00:33:19.660 --> 00:33:23.480
and um they had a guest speaker a surgical oncologist

00:33:23.480 --> 00:33:26.200
and he was uh going over how he appreciates help

00:33:26.200 --> 00:33:27.619
with pain and anesthesia and all these different

00:33:27.619 --> 00:33:31.460
things and um and then he got to the Q &A part

00:33:31.460 --> 00:33:33.579
and uh my old fellowship director at the time

00:33:33.579 --> 00:33:36.180
was an older kind of a little bit more aggressive

00:33:36.180 --> 00:33:39.559
individual he uh he tried to pin him down and

00:33:39.559 --> 00:33:43.789
say why don't you like NSAIDs they're great Why

00:33:43.789 --> 00:33:45.630
don't you like epidurals? Like they're great.

00:33:46.009 --> 00:33:48.950
And the surgeon just admitted it and said, pain's

00:33:48.950 --> 00:33:52.029
not number one on my list for this patient. It's

00:33:52.029 --> 00:33:53.750
not my number one priority. It's not my number

00:33:53.750 --> 00:33:55.430
one concern. He goes, it's maybe not even my

00:33:55.430 --> 00:33:58.630
top 10. I'm worried about, can I get them through

00:33:58.630 --> 00:34:01.430
surgery without blood loss? Can I get them without

00:34:01.430 --> 00:34:04.130
infection? Can I get, can I not have their anastomosis?

00:34:04.230 --> 00:34:08.219
So to me, that was my thing. So I'm coming at

00:34:08.219 --> 00:34:09.800
it as, like, all I care about is pain. I want

00:34:09.800 --> 00:34:11.780
to do everything from a pain side, from the regional

00:34:11.780 --> 00:34:13.960
side, like, block side. What can I do to help

00:34:13.960 --> 00:34:15.639
this patient? I'm like, I have the best block

00:34:15.639 --> 00:34:18.420
for this case. I'm going to do it. And I go to

00:34:18.420 --> 00:34:19.579
the surgeon, like, I don't want that. I'm like,

00:34:19.699 --> 00:34:20.980
what's wrong with this person? Do you not care

00:34:20.980 --> 00:34:22.260
about this pain? Do you not care about this?

00:34:22.440 --> 00:34:23.940
Do you not care about, you know, them getting

00:34:23.940 --> 00:34:25.760
opioids and all those things that I care about?

00:34:26.420 --> 00:34:28.840
And that's down on their list. They would like

00:34:28.840 --> 00:34:30.719
to have that happen, but they got to think, can

00:34:30.719 --> 00:34:32.739
this patient walk after surgery? Can they do

00:34:32.739 --> 00:34:37.639
this? Can they do that? Me really trying to talk

00:34:37.639 --> 00:34:39.659
and understand what are their priorities and

00:34:39.659 --> 00:34:42.559
then how can we fit our regional anesthetic into

00:34:42.559 --> 00:34:44.679
that to not interfere with how they are trying

00:34:44.679 --> 00:34:46.960
to get their patient to recover the best they

00:34:46.960 --> 00:34:50.440
can for their surgery. And so that's where I

00:34:50.440 --> 00:34:52.760
needed to have that aha moment to get rid of

00:34:52.760 --> 00:34:55.019
this. Like I need to be, get away from this,

00:34:55.019 --> 00:34:56.820
be a pain purist. Like I'm going to do everything

00:34:56.820 --> 00:34:59.530
exactly perfect for everyone's pain. but fit

00:34:59.530 --> 00:35:01.610
into the actual healthcare system? And how does

00:35:01.610 --> 00:35:05.210
this help everyone and everything get the patient

00:35:05.210 --> 00:35:07.530
to recover the best and have the most chance

00:35:07.530 --> 00:35:11.769
for success after surgery? I had an experience

00:35:11.769 --> 00:35:14.230
with a surgeon who will remain nameless that

00:35:14.230 --> 00:35:19.070
I thought was really illuminating for me when

00:35:19.070 --> 00:35:22.289
they were injecting local at the end of the procedure,

00:35:22.369 --> 00:35:25.130
which I really appreciated by their surgical

00:35:25.130 --> 00:35:32.349
site. They asked for local, and it got drawn

00:35:32.349 --> 00:35:34.070
up for them, and the nurse in the room asked

00:35:34.070 --> 00:35:37.250
them, do you want it with or without epi? And

00:35:37.250 --> 00:35:41.070
the surgeon said, without. And I was confused

00:35:41.070 --> 00:35:43.630
because what I know of epi is that it tends to

00:35:43.630 --> 00:35:46.110
dents in the block and make it work better and

00:35:46.110 --> 00:35:49.889
last longer. And I thought about it for a second.

00:35:49.949 --> 00:35:51.769
I was a young attending, like second or third

00:35:51.769 --> 00:35:56.230
year. And so finally I just asked the surgeon,

00:35:56.269 --> 00:36:00.409
I was like, can you help me understand why you

00:36:00.409 --> 00:36:04.469
didn't want epi as part of what you're injecting

00:36:04.469 --> 00:36:07.510
there? And what he said really stuck with me

00:36:07.510 --> 00:36:13.869
was, I don't know, what's the difference? I was

00:36:13.869 --> 00:36:15.030
hoping that was going to go a different way.

00:36:16.070 --> 00:36:22.449
So sometimes it's not necessarily that they have

00:36:22.449 --> 00:36:27.469
a master plan in mind or that they, sort of have

00:36:27.469 --> 00:36:29.530
thought that hard about it and they have a specific

00:36:29.530 --> 00:36:31.710
preference. It's just that they are given two

00:36:31.710 --> 00:36:37.369
options and they pick one. Yeah, that's the other

00:36:37.369 --> 00:36:39.809
side of the relationship coin is I need to be

00:36:39.809 --> 00:36:43.050
able to explain what we're trying to accomplish.

00:36:43.250 --> 00:36:45.710
What's my goal for this patient? Why am I doing

00:36:45.710 --> 00:36:50.710
this? And there are some surgeons that are very

00:36:50.710 --> 00:36:53.090
interested in learning and understanding why

00:36:53.090 --> 00:36:55.489
we're doing what we're doing. Like some would

00:36:55.489 --> 00:36:57.170
answer that question and go, what's the difference?

00:36:57.530 --> 00:36:58.949
And you would explain the difference and be like,

00:36:59.030 --> 00:37:02.030
oh, okay. And maybe make a different decision.

00:37:02.429 --> 00:37:04.849
And I did. Yeah. And did they make a different

00:37:04.849 --> 00:37:07.369
decision? They did. There you go. And then there

00:37:07.369 --> 00:37:09.570
would be others that would say, why are you asking

00:37:09.570 --> 00:37:11.909
me that question? This is my decision. Right.

00:37:12.519 --> 00:37:15.480
And so, you know, it's kind of interesting in

00:37:15.480 --> 00:37:18.400
anesthesia where we are a consultant in every

00:37:18.400 --> 00:37:21.400
aspect of it. We don't bring these patients to

00:37:21.400 --> 00:37:23.980
the OR. We don't do any of this. So we need this

00:37:23.980 --> 00:37:26.599
relationship with the surgeon. And some are a

00:37:26.599 --> 00:37:29.239
lot more collaborative, a lot more willing to

00:37:29.239 --> 00:37:31.679
have discussions and have a shared common goal.

00:37:31.739 --> 00:37:34.340
And others are more of these are my goals. You

00:37:34.340 --> 00:37:38.599
fit around them or you make them work. The nice

00:37:38.599 --> 00:37:41.099
thing about regional anesthesia is that we have

00:37:41.099 --> 00:37:43.380
a lot of options available to us where we can

00:37:43.380 --> 00:37:45.960
fit in, and sometimes I don't like it. I don't

00:37:45.960 --> 00:37:47.980
think it's the best bet for some patients to

00:37:47.980 --> 00:37:50.280
be doing some of these things, but it does allow

00:37:50.280 --> 00:37:51.900
them to get something, like you were saying,

00:37:51.980 --> 00:37:53.860
injecting local anesthesia, better than nothing.

00:37:54.139 --> 00:37:57.760
So if we can get a little bit of extra analgesia

00:37:57.760 --> 00:38:00.000
from these things, then I'll fit within the system

00:38:00.000 --> 00:38:02.980
and we'll try to do the best we can and work

00:38:02.980 --> 00:38:04.940
with the surgeons on what their goals are as

00:38:04.940 --> 00:38:08.900
well. I don't think about the post -surgical

00:38:08.900 --> 00:38:10.860
outcomes that they're thinking about. So if we

00:38:10.860 --> 00:38:14.260
can mesh it all together, I think we give all

00:38:14.260 --> 00:38:15.940
these patients the best chance going forward.

00:38:16.960 --> 00:38:19.780
I don't do as much regional anesthesia as I did

00:38:19.780 --> 00:38:23.260
in residency, of course. I did lots of blocks

00:38:23.260 --> 00:38:26.360
back then. I got pretty fast on. I still feel

00:38:26.360 --> 00:38:29.400
comfortable doing basically all of the main blocks.

00:38:29.639 --> 00:38:33.519
But I wonder if you can comment on some of the...

00:38:33.690 --> 00:38:36.409
newer types of blocks that have uh come into

00:38:36.409 --> 00:38:40.469
vogue what do you think's uh overutilized what

00:38:40.469 --> 00:38:42.269
do you think's underutilized what's what's the

00:38:42.269 --> 00:38:44.250
landscape look like in terms of the new nerve

00:38:44.250 --> 00:38:47.829
blocks so the the newer thing in regional anesthesia

00:38:47.829 --> 00:38:52.429
is fascia plane blocks um the it's again trying

00:38:52.429 --> 00:38:55.389
to fit regional anesthesia into the surgical

00:38:55.389 --> 00:38:57.550
outcomes that that surgeons are desiring and

00:38:58.079 --> 00:39:01.199
Honestly, trying to catch up with surgical advancements.

00:39:01.199 --> 00:39:03.519
A lot of the minimally invasive robotic laparoscopic

00:39:03.519 --> 00:39:06.500
surgeries, you know, these patients aren't in

00:39:06.500 --> 00:39:08.639
the hospital for a week or two like they were

00:39:08.639 --> 00:39:10.280
before where you put an epidural in and manage

00:39:10.280 --> 00:39:12.039
it for a couple days, manage their pain for a

00:39:12.039 --> 00:39:13.780
couple days. They want these patients out in

00:39:13.780 --> 00:39:15.960
the hospital in two or three days. So how do

00:39:15.960 --> 00:39:20.599
we fit into it? And so a lot of it has been fascial

00:39:20.599 --> 00:39:22.480
plane block related. And the reason why it's

00:39:22.480 --> 00:39:24.519
fascial plane block related is because you minimize

00:39:24.519 --> 00:39:28.619
your side effects. I think epidurals are great.

00:39:28.699 --> 00:39:30.659
I think they're one of the more underutilized

00:39:30.659 --> 00:39:31.860
things, especially here at University of Cincinnati,

00:39:31.900 --> 00:39:33.480
but I know other systems have moved away from

00:39:33.480 --> 00:39:34.820
them because you have to worry about side effects.

00:39:34.860 --> 00:39:36.400
You have to worry about bleeding in and around

00:39:36.400 --> 00:39:38.099
the spine. You have to worry about blood pressure

00:39:38.099 --> 00:39:41.039
issues with the sympathectomy of it. I think

00:39:41.039 --> 00:39:42.420
paravertebrals are great, but you still have

00:39:42.420 --> 00:39:43.900
some of those issues and a little bit more of

00:39:43.900 --> 00:39:47.059
a challenging block. So people have gone to some

00:39:47.059 --> 00:39:48.760
of the newer blocks are erector spinae plane

00:39:48.760 --> 00:39:53.659
blocks. um pex blocks serratus interior blocks

00:39:53.659 --> 00:39:56.139
um there's always been tap blocks been around

00:39:56.139 --> 00:39:58.440
for a long time i think tap blocks are by far

00:39:58.440 --> 00:40:00.800
the most overutilized block that doesn't do a

00:40:00.800 --> 00:40:02.860
lot of anything i think that's what has spurred

00:40:02.860 --> 00:40:04.699
some of these newer blocks of fascia plane because

00:40:04.699 --> 00:40:06.840
if tap blocks are doing really well we wouldn't

00:40:06.840 --> 00:40:09.659
be looking for replacements of the of it so um

00:40:09.659 --> 00:40:12.760
we don't do a lot of those here because i just

00:40:12.760 --> 00:40:15.380
don't believe they're adding to any benefit to

00:40:15.380 --> 00:40:17.889
the patient Now, some of these newer blocks,

00:40:17.989 --> 00:40:19.530
the interesting thing with the regional anesthesia

00:40:19.530 --> 00:40:22.030
is that someone comes up with a new block, and

00:40:22.030 --> 00:40:24.789
they put out paper basically saying, here, look

00:40:24.789 --> 00:40:27.170
what we did. The patients looked like they were

00:40:27.170 --> 00:40:30.309
better, and people just start doing it. The most

00:40:30.309 --> 00:40:31.869
recent example is something called a PENG block,

00:40:31.969 --> 00:40:35.050
which was designed for hip replacement surgery.

00:40:35.389 --> 00:40:38.050
I think I've seen something about EMG. Yeah,

00:40:38.130 --> 00:40:40.869
pericapsular nerve group. It doesn't really fit

00:40:40.869 --> 00:40:42.789
or make sense, but the guy who developed it was

00:40:42.789 --> 00:40:47.300
Dr. PENG, so he had to make that work. So it

00:40:47.300 --> 00:40:48.820
was just like, hey, they don't want us to do

00:40:48.820 --> 00:40:49.980
ephemeral nerve blocks. They don't want these

00:40:49.980 --> 00:40:51.900
patients weak. They don't want us to do a fasciolacca

00:40:51.900 --> 00:40:54.099
block anymore because they might get weak because

00:40:54.099 --> 00:40:56.119
you're going to hit the femoral nerve. So why

00:40:56.119 --> 00:40:58.019
don't we just go deeper and just put local all

00:40:58.019 --> 00:41:01.139
right by the hip joint itself? And he described

00:41:01.139 --> 00:41:04.880
it and everyone started doing it. And now three,

00:41:05.039 --> 00:41:06.659
four years later, studies are starting to come

00:41:06.659 --> 00:41:09.420
out. Let's do randomized control trials of this

00:41:09.420 --> 00:41:12.539
and, you know, placebo, whatever. It's not really.

00:41:12.829 --> 00:41:15.010
not really faring too well against saline or

00:41:15.010 --> 00:41:17.250
placebo. So, you know, I made that mistake early

00:41:17.250 --> 00:41:19.190
in my career when erector spinae blocks came

00:41:19.190 --> 00:41:20.929
out. We started implementing them for a couple

00:41:20.929 --> 00:41:22.670
of our surgeons because they didn't want to do

00:41:22.670 --> 00:41:25.250
epidurals for various reasons. And we didn't

00:41:25.250 --> 00:41:27.210
see very good clinical success for them. And

00:41:27.210 --> 00:41:30.179
we slowly weaned them out. And then a couple

00:41:30.179 --> 00:41:31.579
of years later, when studies really started to

00:41:31.579 --> 00:41:33.380
come out with them, they started to bear out

00:41:33.380 --> 00:41:36.340
like maybe this isn't it. And so there's still,

00:41:36.380 --> 00:41:38.579
there's still some trials out about some of these

00:41:38.579 --> 00:41:41.099
about maybe refining the technique, but there's

00:41:41.099 --> 00:41:42.940
a, there's a big push to do these fascial plane

00:41:42.940 --> 00:41:44.800
blocks, get something new, get it out there,

00:41:44.860 --> 00:41:46.760
let everyone start doing it. And then we'll figure

00:41:46.760 --> 00:41:49.440
out, is it useful or not? And. kind of a frustrating

00:41:49.440 --> 00:41:52.559
area to be because as the regional anesthesia

00:41:52.559 --> 00:41:54.860
director, I get asked a lot from various leadership

00:41:54.860 --> 00:41:57.500
people and trainees, like, why aren't we doing

00:41:57.500 --> 00:42:00.199
this new thing? It's like, I don't know if it

00:42:00.199 --> 00:42:02.460
works. And I don't want to be the one experimenting

00:42:02.460 --> 00:42:04.940
on patients without it being an actual study.

00:42:05.039 --> 00:42:07.199
Like, so we can set up an actual research study

00:42:07.199 --> 00:42:10.039
and do it then. Yeah, that makes sense. But it

00:42:10.039 --> 00:42:12.980
is interesting seeing how all these things come

00:42:12.980 --> 00:42:15.519
out and then how they're implemented. And then

00:42:15.519 --> 00:42:18.059
we wait for the evidence to show. whether it's

00:42:18.059 --> 00:42:21.679
going to work or not. I couldn't let you get

00:42:21.679 --> 00:42:24.820
away from here without getting your best hot

00:42:24.820 --> 00:42:27.780
take on everyone's favorite drug to argue about,

00:42:27.940 --> 00:42:32.940
which is Expirel. Can you talk about first maybe

00:42:32.940 --> 00:42:36.300
explaining what Expirel is for maybe some of

00:42:36.300 --> 00:42:39.199
our medical student listeners, and then give

00:42:39.199 --> 00:42:41.400
us your take and maybe what the broader takes

00:42:41.400 --> 00:42:46.619
on it have been? So Expirel is... Technically,

00:42:46.619 --> 00:42:48.760
liposomal bupivacaine. So they take bupivacaine,

00:42:48.820 --> 00:42:50.559
which is a very old local anesthetic that is

00:42:50.559 --> 00:42:53.159
still used commonly today, and they put in these

00:42:53.159 --> 00:42:55.599
little liposomes, and they are supposed to kind

00:42:55.599 --> 00:42:57.739
of dissolve over time and release the medication

00:42:57.739 --> 00:43:00.400
at a kind of a consistent rate over the course

00:43:00.400 --> 00:43:03.840
of 72 hours. And so it was billed as a long -acting

00:43:03.840 --> 00:43:06.380
local anesthetic. So now most of our single injection

00:43:06.380 --> 00:43:08.739
nerve blocks last anywhere from 12, 18 to 24

00:43:08.739 --> 00:43:12.320
hours. enough for some surgeries, but not enough

00:43:12.320 --> 00:43:15.079
for other more painful surgeries. And so a lot

00:43:15.079 --> 00:43:16.920
of people in the pain world think if you can

00:43:16.920 --> 00:43:19.059
get three days of pain control with a nerve block

00:43:19.059 --> 00:43:21.079
or renal, that's the reason why we place catheters

00:43:21.079 --> 00:43:25.559
for some of these patients. That'd be the holy

00:43:25.559 --> 00:43:27.000
grail of regional anesthesia. You would never

00:43:27.000 --> 00:43:28.539
have to put a catheter anymore. You can never

00:43:28.539 --> 00:43:33.340
do that. So when it came out, they did some small

00:43:33.340 --> 00:43:36.539
studies to show, again, Does, can this be used?

00:43:36.659 --> 00:43:39.059
And like, yeah, it can be used. And it has numbing

00:43:39.059 --> 00:43:41.800
medicine, so it can numb things. And, and so

00:43:41.800 --> 00:43:45.039
it just, they, the company that, that runs Expirel

00:43:45.039 --> 00:43:47.400
is a brilliant company. They marketed it well.

00:43:47.519 --> 00:43:49.420
They knew where to hit the trigger points. They

00:43:49.420 --> 00:43:52.480
knew how to get surgeons mostly on board because

00:43:52.480 --> 00:43:54.119
they go to the surgeon and say, you don't want

00:43:54.119 --> 00:43:55.579
to deal with pain. You don't deal with opioids.

00:43:55.699 --> 00:43:57.579
You don't want to deal with these pain catheters

00:43:57.579 --> 00:43:59.219
or these pain people hanging around your patients.

00:43:59.659 --> 00:44:02.260
You just inject this. There'll be three days

00:44:02.260 --> 00:44:03.760
pain -free and then you don't have to worry about

00:44:03.760 --> 00:44:07.860
it. and people sunk their teeth into it, and

00:44:07.860 --> 00:44:10.280
it became a very, very popular medication. It's

00:44:10.280 --> 00:44:15.260
been used. It's very expensive still. To get

00:44:15.260 --> 00:44:18.159
a vial of plain bupivacaine is about $0 .30,

00:44:18.380 --> 00:44:22.079
and a vial of Expril is about, I think, $350.

00:44:22.679 --> 00:44:27.880
So it's a pretty big difference. Over the last

00:44:27.880 --> 00:44:29.679
two to three years, maybe it's been a little

00:44:29.679 --> 00:44:31.579
bit longer than that, some studies have started

00:44:31.579 --> 00:44:33.900
to come out that were not funded by the company

00:44:33.900 --> 00:44:37.400
that makes XBRL, comparing XBRL to plain bupivacaine.

00:44:37.900 --> 00:44:39.820
And the results have not been good for XBRL.

00:44:40.039 --> 00:44:42.519
At best, it's been equivalent, but some have

00:44:42.519 --> 00:44:44.440
said it's worse than actual plain bupivacaine.

00:44:44.519 --> 00:44:47.300
And whenever I've been around their representatives,

00:44:47.519 --> 00:44:49.840
they don't like it because I just explain the

00:44:49.840 --> 00:44:52.760
math to them. And it doesn't make sense to me.

00:44:54.199 --> 00:44:57.360
To explain it to people in the simplest terms

00:44:57.360 --> 00:45:02.219
is we inject around 150 milligrams of plain bupivacaine

00:45:02.219 --> 00:45:05.559
in a typical nerve block. There's 266 milligrams

00:45:05.559 --> 00:45:10.360
of bupivacaine in Expro. And so if you do the

00:45:10.360 --> 00:45:14.159
math of 266 milligrams of bupivacaine over 72

00:45:14.159 --> 00:45:17.239
hours, and if it's released continuously at a

00:45:17.239 --> 00:45:19.440
slow rate like they say it is, you're getting

00:45:19.440 --> 00:45:21.679
not enough local anesthetic to the nerves to

00:45:21.679 --> 00:45:24.179
make a difference. And when you look at the math,

00:45:24.280 --> 00:45:25.840
it'd be like us putting a catheter in and running

00:45:25.840 --> 00:45:28.500
it at less than one CC an hour, whichever one,

00:45:28.519 --> 00:45:29.840
if you think, if you look at it, it's like that

00:45:29.840 --> 00:45:31.739
doesn't spread around on the nerve as well. So

00:45:31.739 --> 00:45:34.519
that's why it doesn't work. It's a cool concept

00:45:34.519 --> 00:45:37.179
and it would, it does work the way it's supposed

00:45:37.179 --> 00:45:39.360
to, but problems when they're, when they're doing

00:45:39.360 --> 00:45:41.000
their initial studies, they tried to put more

00:45:41.000 --> 00:45:43.780
bupivacaine in the liposomes, but they had issues

00:45:43.780 --> 00:45:47.469
with the. the subject animal subjects not making

00:45:47.469 --> 00:45:49.409
it because of local anesthetic toxicity because

00:45:49.409 --> 00:45:51.730
if it doesn't release in a consistent fashion

00:45:51.730 --> 00:45:54.110
you release too much you're going to get toxicity

00:45:54.110 --> 00:45:57.449
and so that's 266 the most they could get in

00:45:57.449 --> 00:46:00.150
there safely and it's just not enough to achieve

00:46:00.150 --> 00:46:02.969
the goal you're going to make it really hard

00:46:02.969 --> 00:46:06.070
for me to get sponsored by xrel for this podcast

00:46:06.070 --> 00:46:09.210
i think they'd still sponsor it they're looking

00:46:09.210 --> 00:46:10.590
to sponsor anything they can get their hands

00:46:10.590 --> 00:46:14.840
on so Well, so far I haven't run any specific

00:46:14.840 --> 00:46:17.920
ads on the podcast, but advertisers, if you're

00:46:17.920 --> 00:46:22.320
listening, if you would like to give me money.

00:46:22.559 --> 00:46:28.880
We're interested. Please feel free. In general,

00:46:28.940 --> 00:46:33.460
the opioid pendulum has definitely swung away

00:46:33.460 --> 00:46:35.639
from opioids. People have realized that there's

00:46:35.639 --> 00:46:39.820
the opioid crisis. And our residents, and I think

00:46:39.820 --> 00:46:43.639
residents sort of. across the nation are starting

00:46:43.639 --> 00:46:45.840
to understand that opioids aren't the way forward

00:46:45.840 --> 00:46:48.219
and are coming around to your point of view maybe

00:46:48.219 --> 00:46:50.380
a little bit more slowly than we would like.

00:46:52.460 --> 00:46:54.940
However, do you think that it might be swinging

00:46:54.940 --> 00:46:57.760
a little bit too far? Do you feel like maybe

00:46:57.760 --> 00:47:01.500
we're not treating acute pain appropriately in

00:47:01.500 --> 00:47:06.800
some of these populations? I think possibly,

00:47:06.980 --> 00:47:11.210
yes. I think i don't like to have anyone have

00:47:11.210 --> 00:47:13.110
the concept of if you're not giving an opioid

00:47:13.110 --> 00:47:15.690
you're not treating pain well that's not true

00:47:15.690 --> 00:47:20.210
um i personally think the pendulum in anesthesia

00:47:20.210 --> 00:47:23.250
specifically has not swung far enough uh away

00:47:23.250 --> 00:47:26.829
from opioids as opioid centric i don't know the

00:47:26.829 --> 00:47:29.110
exact percentage but i would say probably 20

00:47:29.110 --> 00:47:31.050
20 percent of cases should get opioids the other

00:47:31.050 --> 00:47:35.010
70 75 should not I think that there's a lot of,

00:47:35.070 --> 00:47:37.949
because we have so many options nowadays. And

00:47:37.949 --> 00:47:39.630
now this is just pre -op and intra -op. I think

00:47:39.630 --> 00:47:42.309
we can get them through. And if we deploy all

00:47:42.309 --> 00:47:43.849
of our options that we think make the most sense

00:47:43.849 --> 00:47:46.650
for that patient, that surgery, and they wake

00:47:46.650 --> 00:47:48.489
up and they're in recovery and they're having

00:47:48.489 --> 00:47:50.730
pain, then you can use a small amount of opioids.

00:47:50.849 --> 00:47:52.570
And that usually works really, really well. And

00:47:52.570 --> 00:47:54.489
you don't have to use a ton. And it usually helps

00:47:54.489 --> 00:47:57.769
get rid of their pain very well. So I think that

00:47:57.769 --> 00:48:01.820
the, I don't, I think there are some, particular

00:48:01.820 --> 00:48:04.539
individuals that i become you know the term is

00:48:04.539 --> 00:48:06.400
opioid phobic where they don't they're not gonna

00:48:06.400 --> 00:48:09.579
give anyone an opioid no matter what and i think

00:48:09.579 --> 00:48:11.059
that's where you can get yourself into problems

00:48:11.059 --> 00:48:13.579
so as long as you don't have that you understand

00:48:13.579 --> 00:48:16.179
that opioids are one of the weapons you have

00:48:16.179 --> 00:48:19.639
to combat pain it's just not the main one and

00:48:19.639 --> 00:48:23.579
i like to view like from my position i use local

00:48:23.579 --> 00:48:25.800
anesthetics nerve blocks as my main weapon that's

00:48:25.800 --> 00:48:28.630
how i'm trying to attack pain But if you ask

00:48:28.630 --> 00:48:31.750
me, if you took away one other option, I'm fine.

00:48:32.250 --> 00:48:34.050
And that's where I was like, if I tell certain

00:48:34.050 --> 00:48:36.929
anesthesia people like providers, like you can't

00:48:36.929 --> 00:48:39.349
use opioids, they don't know what to do. And

00:48:39.349 --> 00:48:41.349
that's a problem. Like to me, that's an issue.

00:48:41.869 --> 00:48:44.809
I had an attending and residency that would,

00:48:44.889 --> 00:48:46.949
every time I worked with them would just say,

00:48:47.010 --> 00:48:50.030
you can't use this medication today. How are

00:48:50.030 --> 00:48:52.309
you gonna get around it? And most of the time

00:48:52.309 --> 00:48:54.309
it was like, it was fine, but then. like took

00:48:54.309 --> 00:48:56.550
away propofol. I'm like, Oh, you know, it's like,

00:48:56.610 --> 00:48:58.929
that's a big one. Um, but you know, it's like,

00:48:58.929 --> 00:49:01.050
you can imagine like, okay, you can't use a paralytic

00:49:01.050 --> 00:49:02.730
today. How are you going to get through these

00:49:02.730 --> 00:49:05.110
cases? You know, in some cases you can, some

00:49:05.110 --> 00:49:07.210
like that's going to be harder, but it's just,

00:49:07.269 --> 00:49:08.710
I like to think of that in the pain sense. Like

00:49:08.710 --> 00:49:10.510
if, if I can, and that happens, right. You get

00:49:10.510 --> 00:49:12.949
an elderly patient, you get, you know, certain,

00:49:13.070 --> 00:49:15.050
certain patients, you know, on an opioid, you

00:49:15.050 --> 00:49:16.550
know, diversion therapy or something, you can't

00:49:16.550 --> 00:49:18.829
give up. You're going to take classes of analgesics

00:49:18.829 --> 00:49:21.139
away from you. And sometimes surgeons and surgical

00:49:21.139 --> 00:49:22.900
techniques, like I can't do a nerve block for

00:49:22.900 --> 00:49:25.099
it. How else, what else am I going to use? And

00:49:25.099 --> 00:49:28.719
so as long as you're always thinking about their

00:49:28.719 --> 00:49:31.179
pain and trying to do something for them, you're

00:49:31.179 --> 00:49:32.760
not going to undertreat them. But I think there

00:49:32.760 --> 00:49:35.019
are some people that have gone too far to the

00:49:35.019 --> 00:49:37.320
too scared of opioids, but don't know enough

00:49:37.320 --> 00:49:39.320
about all the other alternatives that they will

00:49:39.320 --> 00:49:41.480
be undertreating some people's acute pain, which

00:49:41.480 --> 00:49:44.500
is the number one thing you can't do because

00:49:44.500 --> 00:49:47.800
that will lead to potential chronic pain. Let's

00:49:47.800 --> 00:49:50.059
talk about your fellowship a little bit. Who's

00:49:50.059 --> 00:49:55.519
it for? Who's it not for? So the main reason

00:49:55.519 --> 00:49:57.980
why I would recommend anyone do a fellowship

00:49:57.980 --> 00:50:00.460
in regional anesthesia acute pain is you love

00:50:00.460 --> 00:50:05.480
it. You want it to be a part of your life. Regional

00:50:05.480 --> 00:50:07.820
anesthesia, everyone does it. Every anesthesiologist

00:50:07.820 --> 00:50:10.840
can do it, should do it. I'm a firm believer

00:50:10.840 --> 00:50:13.139
in regional anesthesia. As long as you can do

00:50:13.139 --> 00:50:15.579
it safely, do it. The more nerve blocks and injections

00:50:15.579 --> 00:50:19.610
we can do, the best. There is a whole nother

00:50:19.610 --> 00:50:22.150
layer of regional anesthesia and Q pain management

00:50:22.150 --> 00:50:25.769
that the fellowship gets you to. So we, we've

00:50:25.769 --> 00:50:28.070
had plenty of really brilliant CA threes that

00:50:28.070 --> 00:50:30.250
have like killed it through their whole career

00:50:30.250 --> 00:50:32.769
as residents here for regional anesthesia, Q

00:50:32.769 --> 00:50:36.050
pain. And there's still layers I can get them

00:50:36.050 --> 00:50:42.769
to. And so if you have that passion desire, I

00:50:42.769 --> 00:50:46.570
want this to be a key central point of my career.

00:50:47.159 --> 00:50:48.699
I want any practice I go to, I'm going to be

00:50:48.699 --> 00:50:50.860
the go -to person for blocks, the go -to person

00:50:50.860 --> 00:50:53.179
for pain. I want to set up an acute pain service.

00:50:53.320 --> 00:50:55.139
I want to run a surgery center. I want to have

00:50:55.139 --> 00:50:58.159
leadership opportunities. That's who should be

00:50:58.159 --> 00:50:59.940
doing a fellowship in regional anesthesia acute

00:50:59.940 --> 00:51:02.980
pain. There's no more money involved with it

00:51:02.980 --> 00:51:05.500
typically, which some of the fellowships can

00:51:05.500 --> 00:51:09.179
kind of hang their head on. There's no like preferential

00:51:09.179 --> 00:51:10.840
scheduling you get from it, which some other

00:51:10.840 --> 00:51:15.480
specialties can get. So those are the people

00:51:15.480 --> 00:51:17.400
that I'm looking for for the fellowship. People

00:51:17.400 --> 00:51:19.380
that are genuinely just interested in learning

00:51:19.380 --> 00:51:22.159
that deeper level of why do we do what we do

00:51:22.159 --> 00:51:24.960
and how do you do it. And honestly, if you think

00:51:24.960 --> 00:51:27.320
about your career and if you think like, oh,

00:51:27.420 --> 00:51:29.880
I can go take a job where if I do blocks rate,

00:51:29.960 --> 00:51:31.699
if I don't, I don't care. Probably don't need

00:51:31.699 --> 00:51:33.019
to do a fellowship. If you're thinking like,

00:51:33.079 --> 00:51:35.420
I can't have a job where I don't do this, then

00:51:35.420 --> 00:51:37.119
fellowship is probably the best spot for you.

00:51:38.570 --> 00:51:43.730
So how do you take that strong CA3 and take them

00:51:43.730 --> 00:51:45.489
through that year of fellowship and turn them

00:51:45.489 --> 00:51:50.150
into that person you're talking about? So understanding

00:51:50.150 --> 00:51:54.610
everything that there is to know about regional

00:51:54.610 --> 00:51:57.610
anesthesia and acute pain sets that individual

00:51:57.610 --> 00:52:00.329
up to have those conversations with the surgeons

00:52:00.329 --> 00:52:02.570
that we talked about earlier. It allows you to

00:52:02.570 --> 00:52:06.179
better explain. what you do, how you do it, and

00:52:06.179 --> 00:52:10.079
how you fit into their system and how you make

00:52:10.079 --> 00:52:14.340
it work. So I had a conversation with one of

00:52:14.340 --> 00:52:16.400
our colleagues a couple months ago. We have a

00:52:16.400 --> 00:52:18.239
new orthopedic surgeon. He wants to take a little

00:52:18.239 --> 00:52:19.719
bit of a different approach to some nerve box

00:52:19.719 --> 00:52:22.780
just because he's in his earlier career. And

00:52:22.780 --> 00:52:26.260
the question I got from our colleague was, why

00:52:26.260 --> 00:52:28.380
can't he just do the standard of care that we

00:52:28.380 --> 00:52:30.699
do here? I'm like, because we don't do standard

00:52:30.699 --> 00:52:34.599
of care here. I've used my position and my fellowship

00:52:34.599 --> 00:52:38.039
training, my knowledge base to fill in these

00:52:38.039 --> 00:52:41.300
surgeons' ideas of where we should fit into their

00:52:41.300 --> 00:52:45.219
life as orthopedic trauma surgeons. And so we

00:52:45.219 --> 00:52:48.079
do way more blocks and regionals here than anywhere

00:52:48.079 --> 00:52:50.699
else. And it's because I've been able to use

00:52:50.699 --> 00:52:52.820
that. So that's how I was able to set up and

00:52:52.820 --> 00:52:55.159
build our pain service basically through that.

00:52:57.400 --> 00:53:00.400
So the fellowship starts with building that knowledge

00:53:00.400 --> 00:53:02.539
and building that confidence in that you know

00:53:02.539 --> 00:53:03.860
this better than anyone else. And then you have

00:53:03.860 --> 00:53:06.659
to actually be able to do it, right? So we have

00:53:06.659 --> 00:53:08.599
our residents here graduate with hundreds of

00:53:08.599 --> 00:53:10.219
blocks, right, over the course of three years.

00:53:10.380 --> 00:53:13.960
Really good experience. They get exposure early

00:53:13.960 --> 00:53:18.460
and late. They get exposure throughout. But I

00:53:18.460 --> 00:53:20.860
still think it's not enough if you want to be

00:53:20.860 --> 00:53:25.699
the person. If we're going to plop someone into...

00:53:26.219 --> 00:53:27.760
orthopedic surgery center that's going to have

00:53:27.760 --> 00:53:30.219
eight rooms and you need to do all the blocks,

00:53:30.280 --> 00:53:32.280
spinals, everything, keep it efficient, keep

00:53:32.280 --> 00:53:34.119
it effective, keep it flowing because you can't

00:53:34.119 --> 00:53:36.179
have them pack you slowdowns. You got to have

00:53:36.179 --> 00:53:37.980
the reps and you got to have the familiarity

00:53:37.980 --> 00:53:40.820
with how to do that. And so we get the knowledge

00:53:40.820 --> 00:53:42.960
and we get the skill down for the fellows and

00:53:42.960 --> 00:53:46.400
that sets them up to be able to produce, but

00:53:46.400 --> 00:53:48.800
also to be able to set up and communicate to

00:53:48.800 --> 00:53:52.650
the surgeons how they fit into that mold. From

00:53:52.650 --> 00:53:54.789
my side, which I very much underappreciated that

00:53:54.789 --> 00:53:56.469
I got from my fellowship, is how do you also

00:53:56.469 --> 00:53:59.510
deal with administration? And how do you explain

00:53:59.510 --> 00:54:03.110
how you fit in and why are we here? Like, what

00:54:03.110 --> 00:54:04.869
are we doing? What value do we provide to the

00:54:04.869 --> 00:54:07.449
health system? And because a lot of them don't

00:54:07.449 --> 00:54:09.670
have the medical background to understand everything

00:54:09.670 --> 00:54:12.949
that's going on, but you can use your knowledge

00:54:12.949 --> 00:54:15.070
and understand a little bit more where they're

00:54:15.070 --> 00:54:17.250
lacking their knowledge and fill those gaps to

00:54:17.250 --> 00:54:19.550
then have them say, you are providing a very

00:54:19.550 --> 00:54:21.750
valuable service. That's great. How can we help

00:54:21.750 --> 00:54:23.670
you? And how can you get involved and stuff?

00:54:24.050 --> 00:54:26.869
And so it also, you know, having that fellowship

00:54:26.869 --> 00:54:29.110
training also gets you into positions where you

00:54:29.110 --> 00:54:32.269
can be on these committees and working with administration

00:54:32.269 --> 00:54:34.610
and leadership to try to figure out how to best,

00:54:34.630 --> 00:54:37.369
of course, the health system, but also to the

00:54:37.369 --> 00:54:39.570
benefit of you and what you're trying to do and

00:54:39.570 --> 00:54:41.269
how you're trying to help your trainees and patients.

00:54:42.949 --> 00:54:45.130
This has all been a really great conversation.

00:54:45.230 --> 00:54:47.329
I appreciate it. But I want to wrap up with my

00:54:47.329 --> 00:54:51.159
final style points question. are your personal

00:54:51.159 --> 00:54:53.340
style points or points of personal preference

00:54:53.340 --> 00:54:57.119
that have helped you build a pain service, that

00:54:57.119 --> 00:55:00.300
have helped you succeed? I'd love to hear them.

00:55:01.260 --> 00:55:04.159
So the number one thing that comes from my mind

00:55:04.159 --> 00:55:07.000
that took me a while to learn through my career

00:55:07.000 --> 00:55:10.739
is communication. You can never, ever over -communicate.

00:55:10.940 --> 00:55:14.300
And having toddlers, I've learned a lot from

00:55:14.300 --> 00:55:18.420
them. You have young kids. They may not know

00:55:18.420 --> 00:55:20.380
how to communicate, but when they want something,

00:55:20.519 --> 00:55:22.639
they make sure you understand that they want

00:55:22.639 --> 00:55:26.239
something, right? When they want to get a point

00:55:26.239 --> 00:55:27.920
across, they do it, but they communicate it.

00:55:28.039 --> 00:55:30.000
And if you're not understanding their first form

00:55:30.000 --> 00:55:31.840
of communication, they try a different one, and

00:55:31.840 --> 00:55:33.539
they try a different one. A louder one. A louder

00:55:33.539 --> 00:55:35.760
one, typically, right? That doesn't always work

00:55:35.760 --> 00:55:38.059
in the professional healthcare setting, as I've

00:55:38.059 --> 00:55:41.639
tried, but communication is so, so important.

00:55:42.119 --> 00:55:44.280
And I use it in my personal life. You know, I

00:55:44.280 --> 00:55:47.199
use it in my wife, my kids, my family, with my

00:55:47.199 --> 00:55:51.000
friends. It's trying to – communication is a

00:55:51.000 --> 00:55:53.719
two -way street, right? It's like I need to be

00:55:53.719 --> 00:55:56.460
expressing to my views and what I'm trying to

00:55:56.460 --> 00:55:59.320
get across, what my goals are. But I also need

00:55:59.320 --> 00:56:02.400
to be hearing whoever I'm working with what their

00:56:02.400 --> 00:56:05.019
goals are and how it fits. And, you know, doing

00:56:05.019 --> 00:56:08.420
that in a rational, calm, patient manner. really

00:56:08.420 --> 00:56:10.619
helps build build relationships so communication

00:56:10.619 --> 00:56:13.400
is the key point that starts then you build relationships

00:56:13.400 --> 00:56:16.340
and you know this if you have a relationship

00:56:16.340 --> 00:56:19.079
with a colleague in anesthesia or a surgical

00:56:19.079 --> 00:56:22.280
colleague or whoever it is it makes life so much

00:56:22.280 --> 00:56:24.920
easier right like hey hey buddy like you know

00:56:24.920 --> 00:56:27.679
like i i remember the story i was with i went

00:56:27.679 --> 00:56:29.800
golfing with one of the orthopedic surgeons right

00:56:29.800 --> 00:56:31.780
had a great time it was cool got to see him outside

00:56:31.780 --> 00:56:34.579
the hospital literally like two weeks later we're

00:56:34.579 --> 00:56:36.219
doing a case together we're finishing the case

00:56:36.690 --> 00:56:39.050
He happens to be walking through patient. All

00:56:39.050 --> 00:56:40.670
of a sudden we're waking up, not doing well.

00:56:41.409 --> 00:56:42.929
Patient happened to get a spontaneous pneumo

00:56:42.929 --> 00:56:46.110
randomly, but I just had, I just be able to look

00:56:46.110 --> 00:56:49.690
at him. Hey, we've got a problem here. He instinctively

00:56:49.690 --> 00:56:52.070
just got on the phone and called our ACS trauma

00:56:52.070 --> 00:56:53.570
backup and said, Hey, I need you to come to this

00:56:53.570 --> 00:56:55.889
OR like, and by the time he got there, like,

00:56:55.949 --> 00:56:57.829
Hey, we've got a new more than they, it was five

00:56:57.829 --> 00:56:59.269
minutes from when I told him we have a problem

00:56:59.269 --> 00:57:00.690
here. We got an x -ray. They did. They, they

00:57:00.690 --> 00:57:02.190
put the chest suit. It was in the patient was

00:57:02.190 --> 00:57:04.510
fine. And it was just like, it was easy. Cause

00:57:04.510 --> 00:57:06.650
I just, I had no problem to say, Hey man, like

00:57:06.650 --> 00:57:08.489
this, this is what I need. I need some help.

00:57:08.550 --> 00:57:09.909
And he, he knew kind of, you know, it's just,

00:57:09.929 --> 00:57:12.130
it makes life so much easier to ask for help,

00:57:12.150 --> 00:57:13.530
to understand where you're going, have communication.

00:57:13.849 --> 00:57:16.590
So starting with that communication, building

00:57:16.590 --> 00:57:19.949
relationships, it just, it just, it makes every,

00:57:19.969 --> 00:57:21.869
it makes life so much more enjoyable, so much

00:57:21.869 --> 00:57:27.269
better and so much easier for everyone. So really,

00:57:27.429 --> 00:57:30.329
I suppose. Everyone can learn from you is to

00:57:30.329 --> 00:57:36.250
be more of a buddy. Buddy with an E, yes. Brad,

00:57:36.349 --> 00:57:37.889
thank you so much for joining us. Thanks for

00:57:37.889 --> 00:57:41.429
having me on. This was fun. Well, that's it for

00:57:41.429 --> 00:57:44.170
this month's episode of Style Points. My thanks

00:57:44.170 --> 00:57:46.269
to Dr. Buddy for coming on and giving us his

00:57:46.269 --> 00:57:49.070
perspective. If this episode didn't teach you

00:57:49.070 --> 00:57:50.909
everything you wanted to know about acute pain,

00:57:51.130 --> 00:57:53.550
well, you'll just have to apply for his fellowship.

00:57:54.320 --> 00:57:56.599
If you got something out of this episode, the

00:57:56.599 --> 00:57:58.579
single best thing you can do to help other people

00:57:58.579 --> 00:58:00.840
find the show is to leave a rating or a written

00:58:00.840 --> 00:58:04.059
review. It really does work, even if I pretend

00:58:04.059 --> 00:58:06.840
that I don't look at them. As always, you can

00:58:06.840 --> 00:58:09.440
reach me at stylepointspodcast at gmail .com,

00:58:09.519 --> 00:58:12.300
and I'm still happy to mail you a free StylePoints

00:58:12.300 --> 00:58:15.119
sticker for your water bottle. Take a deep breath.

00:58:15.539 --> 00:58:17.880
Open your eyes. We're all done.