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Pain Points with Brad Budde · Style Points

0:10
anesthesia enthusiasts and welcome to this month's
0:12
episode of style points i'm your host john crow
0:15
today we're talking to my friend and colleague
0:18
dr brad buddy who directs the regional anesthesia
0:21
and acute pain fellowship here at the university
0:23
of cincinnati we'll talk about his perspective
0:26
on pain management and the philosophy behind
0:28
it we don't have an rsi for you this month so
0:31
let's jump right in so what was your radio experience
0:34
like in college it was um It was interesting
0:40
because I had, it was like a full studio. So
0:43
I had no idea what any of the stuff was doing,
0:46
but our one buddy did. And so we were just talking
0:48
sports and we had the Sunday evening time slot,
0:52
which rivaled Sopranos. So, so we, so we, we
0:57
got to, we got, I think we got up to 41 listeners
1:00
at one point. 41. That's the highest number of
1:03
listeners for any show on Miami student radio,
1:05
which is saying something about who we were broadcasting
1:08
to. Miami Student Radio. Yeah. What was the call
1:12
sign? I don't remember. Oh, come on. The name
1:17
of our show is Crunch Time. I remember that.
1:20
But other than that, I don't remember much about
1:23
it. Well, loyal listeners, welcome back to Crunch
1:26
Time with Proud Buddy. we would do trivia and
1:32
like, we'd all be like three, four of us would
1:33
be really into it. And people in the air, like
1:35
our buddies are Texas, like stop, like don't
1:37
care. It's about this. Like, but, but we're having
1:40
fun. Like that's all that matters. Well, people
1:42
text me all the time that they don't care about
1:43
what I'm doing. So yeah, it's, I mean, you have
1:46
kids, they never care what you're doing unless
1:49
you're doing exactly what you tell, they tell
1:50
you to do, but that's great. Brad, thank you
1:54
so much for joining us. Thanks for having me.
1:57
So. We have a lot to talk about in the world
2:00
of regional anesthesia, but before we do that,
2:02
I wonder if you could tell us a little bit about
2:04
yourself, what your interests are, and what we're
2:07
here to talk about. My name is Brad Buddy. I'm
2:10
an associate professor here at the University
2:12
of Cincinnati in anesthesia. My main interests
2:19
right now lie with my family. I'm married and
2:22
have two young boys, five and three years old.
2:24
So they keep me pretty busy. I've always had
2:28
an interest and passion for sports. So I like
2:31
watching sports, playing sports, mostly golf
2:32
these days. And then I have my career, which
2:36
has been mostly dedicated to regional anesthesia
2:39
and acute pain medicine. So much so that I've
2:41
started my own fellowship and run my own division
2:44
and really enjoy doing it. So why regional anesthesia?
2:49
What's so interesting about that? So it's a little
2:53
bit of a longer story, but it goes back to my
2:55
interest in sports. So when I was young, I really
2:58
liked playing sports with my friends. And I was
3:01
actually over at a friend's house, and his dad
3:03
actually happened to be an orthopedic surgeon,
3:04
a sports surgeon. So we were in their basement.
3:06
They had all this sports stuff. And my young
3:09
brain said, wow, if I'm an orthopedic surgeon,
3:12
I can have all this sports stuff in my house.
3:14
I'm like, I really want that. Found out later
3:17
that he actually played on a national championship
3:19
team for University of Louisville basketball,
3:20
which is why he had that stuff. But it still
3:23
piqued the interest. So I was so interested in
3:28
sports that I finished college and I didn't go
3:30
right into medical school. I went and got a master's
3:33
in sports studies at Miami University, thinking
3:36
about going into potentially coaching or athletic
3:38
administration. And there's still something about
3:40
that draw to orthopedic surgery and medicine
3:42
and kind of a sports surgeon. that I really couldn't
3:46
let go. So I applied and got into the medical
3:48
school, and I came in so tunnel vision, all I
3:51
cared about was orthopedics until match day came,
3:53
and I didn't match into orthopedics. Oh, wow.
3:55
Then I had to kind of go, huh, this whole drive
3:59
and passion is kind of a lot harder than I was
4:01
anticipating. It actually was my April of my
4:04
fourth year of medical school where I did my
4:07
anesthesia rotation. And at the time, even though
4:09
I didn't match, I told everyone, I'm doing orthopedics.
4:11
I'm going to do it. And so the anesthesiologist
4:14
that I was fortunate enough to rotate with here
4:18
at University of Cincinnati, as well as some
4:19
of our community hospitals, took my passion for
4:22
orthopedics and said, look what we can do to
4:23
help the orthopedic surgeons and showed me nerve
4:25
blocks, regional anesthesia. And I had no idea.
4:28
I'm like, this is really cool. And that really
4:30
kind of spiked the interest there. Then when
4:32
I was doing my preliminary intern year at Penn
4:35
State, I got to see and experience a little bit
4:39
more of anesthesia and regional anesthesia. So
4:41
then I said, this is kind of more of my passion
4:45
and interest. I want to go into this and be in
4:48
anesthesia. And then once I got to Rush, where
4:50
I did my residency. Our regional anesthesia director
4:53
there, her and I really connected and I learned
4:56
a lot from her and kind of really just drove
4:59
that passion forward about how I can use this
5:02
interest in sports, but to also help kind of
5:04
that patient population, but then expand it out
5:06
to, wow, I can actually help a bigger group of
5:08
people than just athletes with this. And so that's
5:11
what kind of led me to where I am now. It's so
5:15
interesting. that this podcast makes it much
5:19
easier for me to have these conversations with
5:20
people because I find all this really interesting
5:23
to find out about you for the first time because
5:25
I never knew any of that. But I don't know that
5:28
I would have ever asked you just in casual conversation.
5:31
Yet we've known each other for eight years now.
5:33
And this is, yeah, like you don't ever tell people
5:36
about the whole story of how you got here. Right.
5:38
And, you know, it's kind of interesting. Like,
5:40
why are you interested in what you're interested
5:41
in? It's usually more of a. I just liked it.
5:43
There's something else to it, usually. Yeah,
5:46
it's been really rewarding for me to find out
5:49
people's origin stories just at random and find
5:52
out more about them. Yeah, finding out the why
5:55
for people, I think, really helps you understand
5:59
why they are doing what they do, how they take
6:01
a little bit more and kind of makes you appreciative
6:04
of what they're doing and why they're doing it.
6:06
Especially if it's something that you don't really
6:08
see it the same way. It's like, well, at least
6:10
I understand. why they see it that way and that's
6:13
a little bit more of a uh collegial and collaborative
6:16
effort i think yeah i agree with you well let
6:20
me back up and ask you the famous dinner question
6:23
that i ask everybody uh i'm going to go out on
6:26
a limb here and guess you're going to pick somebody
6:28
sports related if you could go out to dinner
6:33
with anybody in the world could be somebody from
6:35
the past or from fiction who would you pick and
6:37
why I have been asked this question before, and
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it is not sports -related. It's family -related.
6:45
Wow, there you go. So I would pick my maternal
6:48
grandfather. I'm a pretty family -oriented person.
6:53
I grew up in a good family. I now have kids,
6:56
and I want to instill that into them. And I was
6:58
very fortunate that my dad's parents I was able
7:01
to connect with, they had a really super interesting
7:04
story of living in Germany, growing up in Germany.
7:07
living through the war. My grandpa was forced
7:09
to fight in the war for Germany and, like, beyond
7:12
his will, right after the war, they moved over
7:13
here and had my dad. So it was cool to kind of
7:16
get to connect with them. And on my mom's side,
7:18
I got to know my grandma, but my grandpa was
7:22
fought in the war on the American side. So my
7:24
grandparents actually, my grandpas actually fought
7:26
each other in World War II. Wow. Which is kind
7:28
of cool. Not directly, but... Well, not that
7:31
you know her. That's true. That's true. But apparently
7:34
he passed away when I was really young. I guess
7:36
he got exposed to some things during the war
7:39
that he could never really recover from. And
7:42
so I talked to my mom. She didn't know him that
7:45
great either just because he was in the war and
7:48
then he was kind of sickly after that. But apparently,
7:51
according to my grandma, he was a fighter pilot
7:55
for the Air Force. Apparently he was a pretty
7:56
well -renowned guy. And my mom has found some
7:59
interesting kind of articles and things, letters
8:01
from... you know, the Air Force stuff about him.
8:03
So I just would really like to sit down and kind
8:06
of know more about his trajectory, his path,
8:08
what got him into Air Force and flying and all
8:10
that kind of stuff. It's just kind of a piece
8:12
of my personal family history that I would really
8:14
like to know a little bit more about. That is
8:17
so interesting. Do you feel like you act as a
8:22
fighter pilot at work sometimes? Well, I mean,
8:24
there's the obvious correlation between the airline
8:27
industry and anesthesia. But not knowing anything
8:30
really about the airline industry, I have no
8:32
idea. I'm guessing yes, but maybe. Something
8:35
about checklists, I assume. Yeah, right. Yeah,
8:38
so maybe there's some of that in me from my grandpa
8:40
that I never really knew. So you have spent a
8:44
tremendous amount of time, and I know from my
8:47
experience with you that you have a lot of opinions
8:49
about pain management. and how to handle pain
8:52
in the perioperative setting. When you're thinking
8:56
about pain as a clinical problem generally, what
8:59
do you think most anesthesiologists don't get
9:02
right about it? I don't know how to put this
9:09
without being insulting, but there's a lack of
9:11
understanding of pain. And I think that's healthcare
9:13
-wide. I think it's culture -wide, society -wide.
9:17
Pain is very complex and it's very gray. And
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I explained this to a lot of our trainees that
9:22
a lot of times in medicine, we like objective
9:24
numbers. We like diagnoses. We like numbers to
9:28
point and say, this is why this is happening.
9:30
You can't do that with pain. What about the pain
9:33
scale? Isn't that an objective number? That was
9:37
the attempt to put an objective number on pain
9:39
that has failed miserably, but yet still maintains
9:42
today. So that's to me is pain is very complex
9:47
and it's very subjective. There's a lot of feelings
9:50
from the patient side that go into it. And obviously
9:52
there's a lot of bias from the provider side
9:54
that goes into it. And I think specifically anesthesia,
9:57
I think we deal with a little bit of a unique
10:00
situation that we don't have patients telling
10:02
us about their pain. Which I present this to
10:05
our fellows and some of our senior residents.
10:08
And I say, you know, can the patient under general
10:11
anesthesia experience pain? And if you look at
10:15
the definition of pain, they can't because it's
10:17
subjective. So they can't tell you about it.
10:19
They're not having it. And then most people are
10:21
like, nah, it doesn't make any sense. And it's
10:22
like, I get it. It's more of a philosophical
10:24
discussion. But I think. anesthesiologists or
10:28
anesthesia providers in general put a lot of
10:30
their own biases into what pain is and looking
10:33
over the drapes saying that hurt I'm gonna give
10:36
something for that versus really understanding
10:38
the complex complexity of the things that are
10:41
going into what's causing the pain and then on
10:45
the other side is you know there's a lot of historical
10:47
reasons why pain is treated the way it's treated
10:50
in the perioperative setting and I personally
10:52
think it's backwards. I think we use opioids
10:55
as a mainstay therapy. It's not as strong as
10:57
it was when you and I were training 10 years
10:59
ago or even 20 years ago. But I still think that's
11:03
the crutch that everyone leans on. And I think
11:06
that we have better alternatives now that can
11:08
help. And opioids have their role. It's just
11:11
not as expansive as it is currently being deployed
11:14
in anesthesia. So you wouldn't say that pain
11:17
is the fifth vital sign? I would not, and I would
11:21
hope that everyone understands what a massive
11:24
mistake that was when we went down that path.
11:26
Why don't you back up a little bit for our audience
11:29
and tell that story a little bit? So you can
11:34
tell this story in a number of different ways,
11:36
but I think it was back in the late 90s, early
11:39
2000s, there was this push that pain was being
11:44
undertreated and that we weren't. as a healthcare
11:47
community, we weren't taking care of pain with
11:50
enough compassion and doing enough for it. Now,
11:52
I believe and most people think that that push
11:56
was coming from the pharmaceutical industry that
11:59
had created these great medications called opioids
12:01
and that we have this medication that can fill
12:04
this void that you guys have created in healthcare.
12:08
I would argue there wasn't avoidant health care
12:10
with that, but it became this forefront of we
12:12
were not treating pain and we're not treating
12:14
patients' subjective feelings of pain well with
12:17
what we were doing. And so that's what kind of
12:20
pushed opioids to the front line. And that's
12:23
what generated the pain scale, you know, the
12:25
one, the zero to 10 scale that everyone knows.
12:28
It didn't take a full comprehensive look at it.
12:31
And again, I think it goes back to the underlying
12:32
of. why it kind of spiraled the way it did is
12:36
because not a lot of people in healthcare felt
12:38
comfortable with pain. They didn't understand
12:40
it well. They didn't really know about it. And
12:42
here came this new shiny thing of they're having
12:45
pain. You don't know what to do. Give them this.
12:47
And it's an opioid and that's Oxycontin. This
12:49
was the original one. And it, it, it works. Opioids
12:54
work for pain. And so I was like, wow, we did
12:56
it. We did it. Mission accomplished. Mission
12:59
accomplished. We can put our stamp on it. The
13:02
fifth vital sign is here to stay, and we know
13:04
how to treat it, and we're going to do it well.
13:07
So then what happened? Then, you know, despite
13:13
the pharmaceutical companies explaining to everyone
13:15
that, you know, as long as patients are having
13:16
pain, there are no side effects. We then found
13:19
out pretty harshly that there are side effects
13:21
and one of the main one being addiction. And
13:23
that's kind of what spiraled into the opioid
13:26
crisis that we saw. Going into like the 2007
13:30
to 8 is when it really kind of exploded and when
13:32
still everyone is very familiar with the opioid
13:34
crisis. Now I think they teach it a lot of medical
13:36
schools about what it is and what's going on.
13:38
And, you know, I. I still think that there is
13:41
a little bit, going back to the, what do the
13:43
anesthesiologists do wrong with pain, is assuming
13:46
that they aren't part of the opioid crisis problem.
13:49
If you are pushing or giving an opioid, you're
13:51
potentially part of the problem. And I don't
13:53
think people want to admit that or think that.
13:56
And the steps to get from giving someone a pain
14:00
medication when they're in pain to them developing
14:03
an addiction is a far step and a lot of steps
14:07
along the way to get there. the possibility exists
14:10
and there are many many famous examples from
14:12
athletes to actors that have been injured started
14:15
opioids get addicted most recent one in the news
14:19
is tiger woods he's he's i just saw today that
14:23
he's back from his six weeks rehab in switzerland
14:25
for his opioid addiction that he's got so um
14:28
started with back injuries and back surgeries
14:30
and you know kind of derailed him a little bit.
14:33
So even the most powerful and the most mighty
14:35
and the most famous can, can succumb to this.
14:37
And we just don't know who it's going to be.
14:39
And I think that's kind of the tenant I take
14:41
is that I look at every patient as a potential
14:43
future addict that I don't want to be the one
14:47
that starts them down that path. How well do
14:50
you think that residency does training people
14:52
to think about pain and anesthesia residency
14:55
specifically? I think anesthesia does a far better
15:00
job than the other residencies that at least
15:02
I've seen and been familiar with. I think pain
15:05
is a central component to the ACGMA structure.
15:08
You have to learn about acute pain, chronic pain,
15:11
regional anesthesia. So I think that there is
15:14
a good infrastructure curriculum there. I think
15:19
kind of one of my gripes with anesthesia training.
15:23
And where I think we're missing the ball on it
15:25
is the PACU recovery side. I think back in my
15:31
training, I remember our preoperative kind of
15:34
training was kind of limited. We did a little
15:36
bit of it. We had a clinic that we kind of went
15:39
to every once in a while. It's nowhere near as
15:41
robust as it is here at University of Cincinnati
15:43
or at other places I've seen now. So I think
15:45
our preoperative optimization has gotten better.
15:48
Interoperative training has always been spot
15:50
on. I think everywhere you go, everyone focuses
15:52
on it, does it, and does it well. I've seen people
15:54
from tons of universities that do interoperative
15:57
management well. What we don't do is we don't
16:00
follow these patients. We drop them off in PACU,
16:03
and that's about the extent of our knowledge
16:05
of how they've done. And everyone in anesthesia,
16:08
no matter who you are, lacks the follow through
16:11
to after they leave the PACU. Like we as faculty
16:15
get a little bit more experience in the PACU
16:16
because we get the phone calls or we make sure
16:18
the patients are safe when we get out of the
16:20
PACU. But even after that, we don't really follow
16:22
them that much afterwards to see how they do
16:24
unless we have a particular interest in a particular
16:26
patient. So I think that is the piece to the
16:30
pain puzzle that is missing. I think if people
16:34
could know fully how each of their patients have
16:37
done and look back at what they did for those
16:40
patients pre -op and intra -op and how it set
16:41
them up from a pain perspective, I think it would
16:44
really help lock in some of the stuff that we
16:46
try to teach and train when it comes to pain
16:50
management in the period of setting. And that's
16:53
what I really like about my position and what
16:55
we do as far as a pain service here at University
16:57
of Cincinnati and other pain services around
16:59
the country is. we follow these patients through.
17:01
Not all of them, but we get to follow these patients
17:04
and see how they're doing and how these things
17:05
affect them. And it's kind of a, it allows us
17:09
to get onto that side better because, you know,
17:11
when I was training, I always thought, if I can
17:14
get this patient who's either healthy, unhealthy,
17:16
whatever, get through this surgery, big, small,
17:17
and get them through to the PACU safely, like,
17:20
I did a great job. And then I started, when I
17:23
got into fellowship, what I really started to
17:24
learn and think about is like, can I do more
17:26
though? Can I make other decisions during those
17:29
time period to keep them safe through it, but
17:30
also set them up for success in the recovery,
17:33
which I think is a piece that's missing in general,
17:35
but I think is something that we try to incorporate
17:39
here, at least from our pain side. I really liked
17:44
how you mentioned that pain is gray. And I think
17:47
from my experience as well, there's a whole bunch
17:51
of different components and there's certainly
17:54
a lot of. what we do as far as relieving pain
17:58
that has to do with expectations and the patient's
18:05
psychological frame. I wonder what your take
18:08
is on the non -drug variables for how pain is
18:13
managed. I think that's a very undervalued part
18:18
of this because, as I mentioned, pain is subjective.
18:21
And so in order to In order to best treat their
18:25
pain, you've got to understand what they're experiencing
18:27
and how they are kind of experiencing it. And
18:30
it's a very challenging thing to do. And it's
18:32
a very uncomfortable thing for people to do too.
18:34
Because you've got to get into let them be vulnerable
18:38
with you and allow them to explain to you what
18:40
they're going through. And one of the things
18:44
I try and do a lot when we're rounding on patients,
18:46
seeing consults, is just listen. Listen to them.
18:50
And anyone that's been in academic medicine.
18:53
These patients have hundreds of people coming
18:54
in other rooms every day, and they all have a
18:56
particular agenda, right? And a lot of times
18:59
pain is one of the most important things on the
19:01
patient's mind, but not on all those 99 other
19:05
people that come in and out of their room. You're
19:07
there to talk about their pain, or even if you're
19:10
not there to talk about their pain, let them
19:11
talk about it. And there have been numerous times
19:13
where I've had our residents come to me and say,
19:15
we didn't do anything for that patient, but they
19:18
said their pain was better after they talked
19:19
to us. Just because you listen to them. And they
19:22
said, someone listens. I don't want anything
19:24
different. I don't want anything different. I
19:25
just want you to know what I'm experiencing.
19:27
And I think it's a huge, hugely undervalued part
19:30
of pain. And you don't always have to reach for
19:34
an opioid because their fifth vital sign tells
19:37
you that their pain score is a nine. And what
19:40
else goes into it? Like, why is it a nine? Like,
19:43
what makes you say nine versus eight versus 10
19:46
versus 20? Like, we've seen it all. all these
19:50
scales and all these scores, but like, what is
19:51
it really that is bothering you? And sometimes
19:53
it's like, I just want a glass of water. I just,
19:56
I want to watch my news at night and I can't
19:59
figure out how to get the TV on. Like it can
20:01
be simple things that think about when you're
20:03
at home and what makes you a little uncomfortable
20:05
with this. You just adjust and do things, not
20:07
stuff you can't do in the hospital that well.
20:08
Sometimes you just need a blanket. Sometimes
20:10
you need a backstretch. Somebody needs something
20:11
simple. And all of a sudden it's like, eh, it's
20:13
okay. It's better. There are some pains that
20:16
you can't just talk away or you can't do little
20:19
nuanced things. You can't do a Sudoku puzzle
20:20
and feel better about it and distract you from
20:22
it. And that's where the pharmaceuticals come
20:24
in. But there's a lot that we can do if we just
20:27
honestly just took the time to listen to people.
20:30
So often when you're doing nerve blocks or starting
20:35
IVs, you're doing something that causes some
20:38
degree of pain that you need to give them before
20:42
they can be relieved from. a larger pain. What's
20:46
your framework for approaching that with patients?
20:49
Are there any phrases that you recommend or that
20:52
you say to them? Do you think that this is going
20:56
to be a big pinch or a little pinch? Do any of
20:58
those phrases matter or what do you think? So
21:01
that depends on the patient. So some patients
21:04
don't want to hear anything. They know it's going
21:07
to hurt or you've already explained it. I think
21:09
a lot of it comes in explaining what you're going
21:11
to do before you do it. And you lean on them
21:14
to tell you, like, do you want to know when we're
21:16
starting? Some patients like to know, like, exaggerate
21:20
a little bit. Like, this is going to really hurt.
21:22
Or some people are like, don't tell me it's really
21:24
bad. Then that's where it's like, oh, small little
21:25
pinch versus, oh, this might hurt a little bit.
21:27
Like, oh, yeah, this might suck. But for nerve
21:31
blocks, it's pretty easy. Like, this is a very
21:32
minimal amount of time for discomfort to have
21:34
a much easier recovery, much better path going
21:37
forward. And that stuff can all be handled during
21:40
the kind of when you're talking to them pre -op
21:42
and, you know, it's part of the thing that we
21:45
learn as anesthesiologists. You got to build
21:47
a rapport and get to know that patient and what
21:49
they're looking for in a short period of time.
21:51
And I think we all come from varying walks of
21:55
life and backgrounds and we all tend to figure
21:57
out how to do that fairly well. And so I think
21:59
that's, I don't have any particular go -to phrases.
22:03
I like to try to be as positive I can with patients
22:05
when I can be and talk about a lot of the positives.
22:08
I don't try to dwell on the pain that might go
22:12
into getting to the positive side of stuff. That
22:16
makes sense. Focusing on the positive does tend
22:18
to make a big difference. And I think that I
22:21
guess reflecting, I think I do a lot of that
22:24
too. I think a lot of anesthesia providers do
22:27
it without really even noticing it, right? Right.
22:30
It's because it's our way of kind of making the
22:32
patient feel a little more comfortable because
22:34
we know what kind of the best path is for them,
22:38
what's going to create kind of the better outcomes
22:39
for them. And so it's an easier way to kind of
22:42
get them comfortable with the idea. versus if
22:45
you explain every little detail of pros, cons,
22:48
negatives, like this could go really, really
22:50
bad because we know that everything could go
22:52
bad in healthcare, but do they need to know about
22:54
all that? Or can we just talk about like, there's
22:57
some risks to this, but the benefits are huge
23:00
and we do this a lot. And so try to focus on
23:03
the positives, set them, get them more comfortable.
23:06
And a lot of people coming to surgery are more
23:08
worried about anesthesia than they are surgery,
23:10
which is wild to me. I agree. That sort of rhymes
23:13
with, talk that I often give to the residents
23:16
about how to pre -op a patient and how to talk
23:22
to the patient about risk. I frequently, and
23:25
not necessarily downplaying it, but I like to
23:28
compare it to something that the patients already
23:31
know and are comfortable with and familiar with,
23:33
which is why I tell patients that anesthesia
23:36
is safer than your car ride over here. It kind
23:39
of puts them in a frame of mind that's a little
23:41
easier for them. Yeah, it's interesting. I've
23:44
kind of used some of those things before, and
23:45
it's fascinating to me. I don't know your experience,
23:48
but some people are like, I don't care. I ride
23:51
in a car all the time. This is not my normal
23:53
Tuesday morning where I get anesthesia. So it's
23:56
interesting how sometimes those messaging can
23:59
make sense, but how it's going to be received
24:02
isn't as well. Well, you have to be careful.
24:04
You can't tell patients who have just gotten
24:06
in a car wreck. That's very true. What brings
24:09
you here, Carmack? Well, yeah, this is safer
24:11
than that. Probably. Okay. I want to talk about
24:17
something that I have heard in every single resident
24:22
presentation about a pain plan that I've ever
24:26
gotten, which is that they plan to do multimodal
24:29
anesthesia. That is the buzzword. What does that
24:34
mean? Can you explain to me what the residents
24:37
are talking about? I wish I could. I agree. It's
24:42
a little bit of a, every time I hear that, I'm
24:44
like, what does that mean? I always ask it. What
24:46
does that mean? So multimodal in and of itself
24:48
just means, you know, two or more of ways to
24:52
attack something. So you can do multimodal anesthesia,
24:55
multimodal analgesia. You know, it's interesting.
24:58
Just last week, I was, we're starting a. an orthopedic
25:02
surgery case. And I was talking to the provider
25:06
in the room with me. And we were talking about
25:07
how we're going to help, you know, tackle the
25:08
patient's pain. And, and the orthopedic surgery
25:11
resident goes, you guys can use multimodal. And
25:14
I'm like, what does that mean? He goes, isn't
25:15
that two types of opioids? And I'm like, Maybe
25:21
that could be a way to do it. Um, so, so yes,
25:26
it's a buzzword. People know how to talk about
25:28
it. They know what to say. Do they know what
25:30
it means? Probably not. Now I'll give our residents
25:33
credit. They know more than, than that orthopedic
25:35
surgery resident, which, you know, is what it
25:37
is. Wow. Um, but. But, you know, I think the
25:41
interesting thing about multimodal is that while
25:43
it's great on the surface, like, you know, we're
25:46
not as opioid -centric for our analgesic plans
25:49
as we used to be in anesthesia. I think the problem
25:54
with multimodal is a lot of people have either
25:57
jumped – they're swung the pendulum all the way
26:00
to the other side. Like, I'm not going to give
26:00
any opioids. So, therefore, I'm going to give
26:02
you every possible pain medication I have in
26:05
this drawer. There's no real thinking behind
26:10
it. Like, what's the goal? What are we trying
26:11
to do? And it kind of goes back to, you know,
26:15
what I think we fail on anesthesia a lot is we
26:18
just assume there's going to be pain. Like, we
26:20
have to be doing something for pain during surgery.
26:22
Now, everyone knows that surgery is pain. It's
26:25
going to be painful. That's why we exist in anesthesia,
26:27
because patients can't tolerate the level of
26:30
pain without us being there. It takes me one
26:34
of my, my, my favorite teachments when I'm working
26:36
with residents of the OR. And I asked like, okay,
26:37
take away all nerve blocks, everything else you've
26:39
done in pre -op in the OR. What's the best thing
26:41
you can do for this patient's pain? And they
26:44
start rolling off these things. And I'm like,
26:45
have you ever thought about not giving them something
26:48
might be the best thing for them? Like not exposing
26:51
them to opioids in the OR if you can avoid it.
26:53
And so that kind of my philosophy in anesthesia
26:56
is like, if you. Though everyone likes to get
26:58
the train tracks anesthesia. You want to have
26:59
the easy, even vital signs. You want to have
27:02
boring anesthesia. I'm assuming everyone likes
27:04
that. I like that. Maybe like Dr. France here
27:07
may not like that. He likes a little bit more
27:09
of the chaotic, crazy stuff. But I'm like, that's
27:11
finding the right depth of anesthesia for that
27:13
patient where you don't have to chase vital sign
27:16
changes or anything like that. That means that
27:17
they're not experiencing a lot of pain, a lot
27:19
of stimulus and things like that. So sometimes
27:21
you get to those perfect depths of anesthesia.
27:22
You don't need to give them anything for pain.
27:25
Just let the anesthesia do the job for you. And
27:27
so that's where I think multimodal anesthesia
27:29
can be helpful when you add a couple of different
27:31
elements to increase the depth of your anesthetic
27:33
without causing a bunch of hemodynamic variation.
27:36
Opioids can fit into that. We do that with neurosurgery,
27:39
spine surgeries, but you can also do it without
27:41
it. So I think the multimodal is a great concept,
27:45
but it's kind of pretty ill -conceived in what
27:48
it actually means and how to execute it. There
27:51
are so many things beyond opioids. Ketamine,
27:55
lidocaine infusions. Presidex has certainly come
27:59
into vogue in the past few years. Gabapentin,
28:01
Celebrex. What's overrated? What's underrated?
28:04
What do you think? I think now I speak kind of
28:12
more of our practice here. And what I see here,
28:14
I think ketamine is a little overused for what
28:19
it's worth. I don't complain about it because
28:23
if someone's going to grab for a little bit of
28:24
ketamine over a little bit of fentanyl, I prefer
28:27
that for a patient. I think that's better. When
28:30
you're thinking about long -term kind of recovery,
28:32
kind of getting through the PACU and kind of
28:34
better set them up for there. I think in the
28:38
current landscape, I think, I think the gabapentinoid
28:41
class of medications actually has a role. I know
28:43
that there was an article that came a couple
28:44
of years ago that said it shouldn't ever be used
28:46
for acute pain. And a lot of people have grabbed
28:47
that, but it goes to the lack of understanding.
28:50
What is that drug doing? What are we doing with
28:52
these medications? And I think it goes to people
28:56
have jumped on the multimodal and you're right.
28:58
There's a ton of options available for people
29:00
now. Like you don't have to just grab for an
29:02
open. I think that's great that people are doing
29:03
this is why I love working in an academic environment
29:05
to teach the residents about this, but. If you're
29:07
going to grab the ketamine, what are you trying
29:08
to do with that medication? You're grabbing Robaxin.
29:10
You're grabbing Celebrex. You're grabbing Gabapentin.
29:13
You're doing these things. What are you trying
29:15
to accomplish? What do you really want to come
29:17
from that? And what are you actually treating?
29:20
So pain, there actually is pathophysiology to
29:23
pain. So what is causing this person's pain?
29:26
Is it nerve -related pain? Is it inflammation?
29:30
Are they, do they take a bunch of opioids? Are
29:32
they opioid tolerant? And so therefore you need
29:34
to work on, you know, maybe a little bit of a
29:36
different mechanism. So there's a lot of different
29:38
options out there, but knowing what you're going
29:40
to target instead of just shotgunning it all
29:42
and blanking it all, which is some people tend
29:44
to do, I think it's best to tailor your approach
29:47
to each individual patient. And that allows you
29:49
to get a little bit more sophisticated with your
29:52
medications. But also when you're, when you're
29:53
treating the actual things that are going on,
29:55
you have less risk of the bad side effects coming
29:57
when you just kind of shotgun and give everything.
30:01
So let's say you've got an opioid -tolerant patient
30:04
coming in for surgery, and it's somebody who
30:07
is chronically taking massive amounts at home.
30:10
We've seen this plenty of times, each of us.
30:13
What framework would you want one of our residents
30:18
to approach that patient with? I think everyone
30:23
needs to come from an understanding of what does
30:25
that mean? What is that patient's body? How is
30:28
it going to react to pain? to a painful stimulus,
30:31
to any pain medication we give them, and which
30:34
of our options are best suited for those patients.
30:37
So, you know, when patients are opioid tolerant,
30:41
taking a lot of opioids, they need way bigger
30:45
doses than most people are in healthcare comfortable
30:47
giving them. We get a lot of consults on our
30:49
pain service saying, hey, we need help controlling
30:51
this person's pain. We don't feel comfortable
30:53
going up higher in doses. I'm like, you're giving
30:55
them a tenth of what they get at home. So, of
30:57
course, they're going to hurt like their body's
30:59
used to it. And so we see the anesthesia. And
31:02
what I find fascinating from my standpoint is
31:04
I have someone in that situation. You can give
31:07
them opioids, but it's not going to have the
31:08
effect you're going to have it. So you're going
31:09
to have to lean on your multimodals. You're going
31:10
to have to lean on your other medications. And
31:13
I think that freaks some people out sometimes
31:14
because I want to be able to give them my fentanyl
31:16
and Dilaudid and have the patient be comfortable,
31:18
and it's not going to happen. And so knowing,
31:22
again, all the different medications and options
31:24
you have, how do they interplay with each other?
31:26
That's one where I've seen those patients and
31:28
ketamine is not part of their analgesia plan.
31:31
I'm like, that doesn't make any sense to me because
31:33
that's the best medication you could give for
31:35
that patient. You know, then no one really thinks
31:37
about methadone in those patients. Like that's
31:39
a great option. Like there are so many options
31:42
like available. I don't know, like maybe it's
31:43
just my training or where I was, but when I was
31:45
a resident, I feel like we didn't have all the
31:47
options. Presidys was too expensive. Ketamine
31:49
was not really available. Gabapentin wasn't given,
31:53
Celebrex wasn't given. I don't know if it was
31:55
cost or whatever. Like I remember IV Tylenol
31:57
was like the Vogue thing, but it was too expensive.
32:00
So we're not supposed to give that. So it's like,
32:01
we're giving Tylenol and opiate is all we really
32:03
had. And now, you know, you think about all the
32:05
options we had, like you have a lot of things
32:07
you can do. And those patients that are opioid
32:09
tolerant or are on any kind of opioid use disorder
32:14
medications, that's where more of a shotgun approach
32:17
might be beneficial. You got to try to attack
32:19
every different receptor. pain pathway you can
32:23
find try to help them because you you're our
32:25
main our main gun that we have for analgesia
32:28
is opioids and they just aren't going to be as
32:30
useful as they are for opiate naive patients
32:32
so a lot of times you find yourself advocating
32:37
for doing more nerve blocks that makes sense
32:40
you're the director of regional anesthesia i
32:42
hope i am and i think you do a great job at it
32:46
but sort of what i want to know is What are these
32:51
conversations that you're having with surgeons
32:53
to advocate for those nerve blocks? So that's
32:58
a, it depends on the surgeon. So I treat my relationships
33:03
and communication with surgeons kind of like
33:04
with patients. Like I need to understand where
33:07
they're coming from. And I kind of had an aha
33:10
moment about two years into being faculty. I
33:13
was actually teaching. uh cadaver ultrasound
33:16
course at Walter Reed um University of Maryland
33:19
and um they had a guest speaker a surgical oncologist
33:23
and he was uh going over how he appreciates help
33:26
with pain and anesthesia and all these different
33:27
things and um and then he got to the Q &A part
33:31
and uh my old fellowship director at the time
33:33
was an older kind of a little bit more aggressive
33:36
individual he uh he tried to pin him down and
33:39
say why don't you like NSAIDs they're great Why
33:43
don't you like epidurals? Like they're great.
33:46
And the surgeon just admitted it and said, pain's
33:48
not number one on my list for this patient. It's
33:52
not my number one priority. It's not my number
33:53
one concern. He goes, it's maybe not even my
33:55
top 10. I'm worried about, can I get them through
33:58
surgery without blood loss? Can I get them without
34:01
infection? Can I get, can I not have their anastomosis?
34:04
So to me, that was my thing. So I'm coming at
34:08
it as, like, all I care about is pain. I want
34:09
to do everything from a pain side, from the regional
34:11
side, like, block side. What can I do to help
34:13
this patient? I'm like, I have the best block
34:15
for this case. I'm going to do it. And I go to
34:18
the surgeon, like, I don't want that. I'm like,
34:19
what's wrong with this person? Do you not care
34:20
about this pain? Do you not care about this?
34:22
Do you not care about, you know, them getting
34:23
opioids and all those things that I care about?
34:26
And that's down on their list. They would like
34:28
to have that happen, but they got to think, can
34:30
this patient walk after surgery? Can they do
34:32
this? Can they do that? Me really trying to talk
34:37
and understand what are their priorities and
34:39
then how can we fit our regional anesthetic into
34:42
that to not interfere with how they are trying
34:44
to get their patient to recover the best they
34:46
can for their surgery. And so that's where I
34:50
needed to have that aha moment to get rid of
34:52
this. Like I need to be, get away from this,
34:55
be a pain purist. Like I'm going to do everything
34:56
exactly perfect for everyone's pain. but fit
34:59
into the actual healthcare system? And how does
35:01
this help everyone and everything get the patient
35:05
to recover the best and have the most chance
35:07
for success after surgery? I had an experience
35:11
with a surgeon who will remain nameless that
35:14
I thought was really illuminating for me when
35:19
they were injecting local at the end of the procedure,
35:22
which I really appreciated by their surgical
35:25
site. They asked for local, and it got drawn
35:32
up for them, and the nurse in the room asked
35:34
them, do you want it with or without epi? And
35:37
the surgeon said, without. And I was confused
35:41
because what I know of epi is that it tends to
35:43
dents in the block and make it work better and
35:46
last longer. And I thought about it for a second.
35:49
I was a young attending, like second or third
35:51
year. And so finally I just asked the surgeon,
35:56
I was like, can you help me understand why you
36:00
didn't want epi as part of what you're injecting
36:04
there? And what he said really stuck with me
36:07
was, I don't know, what's the difference? I was
36:13
hoping that was going to go a different way.
36:16
So sometimes it's not necessarily that they have
36:22
a master plan in mind or that they, sort of have
36:27
thought that hard about it and they have a specific
36:29
preference. It's just that they are given two
36:31
options and they pick one. Yeah, that's the other
36:37
side of the relationship coin is I need to be
36:39
able to explain what we're trying to accomplish.
36:43
What's my goal for this patient? Why am I doing
36:45
this? And there are some surgeons that are very
36:50
interested in learning and understanding why
36:53
we're doing what we're doing. Like some would
36:55
answer that question and go, what's the difference?
36:57
And you would explain the difference and be like,
36:59
oh, okay. And maybe make a different decision.
37:02
And I did. Yeah. And did they make a different
37:04
decision? They did. There you go. And then there
37:07
would be others that would say, why are you asking
37:09
me that question? This is my decision. Right.
37:12
And so, you know, it's kind of interesting in
37:15
anesthesia where we are a consultant in every
37:18
aspect of it. We don't bring these patients to
37:21
the OR. We don't do any of this. So we need this
37:23
relationship with the surgeon. And some are a
37:26
lot more collaborative, a lot more willing to
37:29
have discussions and have a shared common goal.
37:31
And others are more of these are my goals. You
37:34
fit around them or you make them work. The nice
37:38
thing about regional anesthesia is that we have
37:41
a lot of options available to us where we can
37:43
fit in, and sometimes I don't like it. I don't
37:45
think it's the best bet for some patients to
37:47
be doing some of these things, but it does allow
37:50
them to get something, like you were saying,
37:51
injecting local anesthesia, better than nothing.
37:54
So if we can get a little bit of extra analgesia
37:57
from these things, then I'll fit within the system
38:00
and we'll try to do the best we can and work
38:02
with the surgeons on what their goals are as
38:04
well. I don't think about the post -surgical
38:08
outcomes that they're thinking about. So if we
38:10
can mesh it all together, I think we give all
38:14
these patients the best chance going forward.
38:16
I don't do as much regional anesthesia as I did
38:19
in residency, of course. I did lots of blocks
38:23
back then. I got pretty fast on. I still feel
38:26
comfortable doing basically all of the main blocks.
38:29
But I wonder if you can comment on some of the...
38:33
newer types of blocks that have uh come into
38:36
vogue what do you think's uh overutilized what
38:40
do you think's underutilized what's what's the
38:42
landscape look like in terms of the new nerve
38:44
blocks so the the newer thing in regional anesthesia
38:47
is fascia plane blocks um the it's again trying
38:52
to fit regional anesthesia into the surgical
38:55
outcomes that that surgeons are desiring and
38:58
Honestly, trying to catch up with surgical advancements.
39:01
A lot of the minimally invasive robotic laparoscopic
39:03
surgeries, you know, these patients aren't in
39:06
the hospital for a week or two like they were
39:08
before where you put an epidural in and manage
39:10
it for a couple days, manage their pain for a
39:12
couple days. They want these patients out in
39:13
the hospital in two or three days. So how do
39:15
we fit into it? And so a lot of it has been fascial
39:20
plane block related. And the reason why it's
39:22
fascial plane block related is because you minimize
39:24
your side effects. I think epidurals are great.
39:28
I think they're one of the more underutilized
39:30
things, especially here at University of Cincinnati,
39:31
but I know other systems have moved away from
39:33
them because you have to worry about side effects.
39:34
You have to worry about bleeding in and around
39:36
the spine. You have to worry about blood pressure
39:38
issues with the sympathectomy of it. I think
39:41
paravertebrals are great, but you still have
39:42
some of those issues and a little bit more of
39:43
a challenging block. So people have gone to some
39:47
of the newer blocks are erector spinae plane
39:48
blocks. um pex blocks serratus interior blocks
39:53
um there's always been tap blocks been around
39:56
for a long time i think tap blocks are by far
39:58
the most overutilized block that doesn't do a
40:00
lot of anything i think that's what has spurred
40:02
some of these newer blocks of fascia plane because
40:04
if tap blocks are doing really well we wouldn't
40:06
be looking for replacements of the of it so um
40:09
we don't do a lot of those here because i just
40:12
don't believe they're adding to any benefit to
40:15
the patient Now, some of these newer blocks,
40:17
the interesting thing with the regional anesthesia
40:19
is that someone comes up with a new block, and
40:22
they put out paper basically saying, here, look
40:24
what we did. The patients looked like they were
40:27
better, and people just start doing it. The most
40:30
recent example is something called a PENG block,
40:31
which was designed for hip replacement surgery.
40:35
I think I've seen something about EMG. Yeah,
40:38
pericapsular nerve group. It doesn't really fit
40:40
or make sense, but the guy who developed it was
40:42
Dr. PENG, so he had to make that work. So it
40:47
was just like, hey, they don't want us to do
40:48
ephemeral nerve blocks. They don't want these
40:49
patients weak. They don't want us to do a fasciolacca
40:51
block anymore because they might get weak because
40:54
you're going to hit the femoral nerve. So why
40:56
don't we just go deeper and just put local all
40:58
right by the hip joint itself? And he described
41:01
it and everyone started doing it. And now three,
41:05
four years later, studies are starting to come
41:06
out. Let's do randomized control trials of this
41:09
and, you know, placebo, whatever. It's not really.
41:12
not really faring too well against saline or
41:15
placebo. So, you know, I made that mistake early
41:17
in my career when erector spinae blocks came
41:19
out. We started implementing them for a couple
41:20
of our surgeons because they didn't want to do
41:22
epidurals for various reasons. And we didn't
41:25
see very good clinical success for them. And
41:27
we slowly weaned them out. And then a couple
41:30
of years later, when studies really started to
41:31
come out with them, they started to bear out
41:33
like maybe this isn't it. And so there's still,
41:36
there's still some trials out about some of these
41:38
about maybe refining the technique, but there's
41:41
a, there's a big push to do these fascial plane
41:42
blocks, get something new, get it out there,
41:44
let everyone start doing it. And then we'll figure
41:46
out, is it useful or not? And. kind of a frustrating
41:49
area to be because as the regional anesthesia
41:52
director, I get asked a lot from various leadership
41:54
people and trainees, like, why aren't we doing
41:57
this new thing? It's like, I don't know if it
42:00
works. And I don't want to be the one experimenting
42:02
on patients without it being an actual study.
42:05
Like, so we can set up an actual research study
42:07
and do it then. Yeah, that makes sense. But it
42:10
is interesting seeing how all these things come
42:12
out and then how they're implemented. And then
42:15
we wait for the evidence to show. whether it's
42:18
going to work or not. I couldn't let you get
42:21
away from here without getting your best hot
42:24
take on everyone's favorite drug to argue about,
42:27
which is Expirel. Can you talk about first maybe
42:32
explaining what Expirel is for maybe some of
42:36
our medical student listeners, and then give
42:39
us your take and maybe what the broader takes
42:41
on it have been? So Expirel is... Technically,
42:46
liposomal bupivacaine. So they take bupivacaine,
42:48
which is a very old local anesthetic that is
42:50
still used commonly today, and they put in these
42:53
little liposomes, and they are supposed to kind
42:55
of dissolve over time and release the medication
42:57
at a kind of a consistent rate over the course
43:00
of 72 hours. And so it was billed as a long -acting
43:03
local anesthetic. So now most of our single injection
43:06
nerve blocks last anywhere from 12, 18 to 24
43:08
hours. enough for some surgeries, but not enough
43:12
for other more painful surgeries. And so a lot
43:15
of people in the pain world think if you can
43:16
get three days of pain control with a nerve block
43:19
or renal, that's the reason why we place catheters
43:21
for some of these patients. That'd be the holy
43:25
grail of regional anesthesia. You would never
43:27
have to put a catheter anymore. You can never
43:28
do that. So when it came out, they did some small
43:33
studies to show, again, Does, can this be used?
43:36
And like, yeah, it can be used. And it has numbing
43:39
medicine, so it can numb things. And, and so
43:41
it just, they, the company that, that runs Expirel
43:45
is a brilliant company. They marketed it well.
43:47
They knew where to hit the trigger points. They
43:49
knew how to get surgeons mostly on board because
43:52
they go to the surgeon and say, you don't want
43:54
to deal with pain. You don't deal with opioids.
43:55
You don't want to deal with these pain catheters
43:57
or these pain people hanging around your patients.
43:59
You just inject this. There'll be three days
44:02
pain -free and then you don't have to worry about
44:03
it. and people sunk their teeth into it, and
44:07
it became a very, very popular medication. It's
44:10
been used. It's very expensive still. To get
44:15
a vial of plain bupivacaine is about $0 .30,
44:18
and a vial of Expril is about, I think, $350.
44:22
So it's a pretty big difference. Over the last
44:27
two to three years, maybe it's been a little
44:29
bit longer than that, some studies have started
44:31
to come out that were not funded by the company
44:33
that makes XBRL, comparing XBRL to plain bupivacaine.
44:37
And the results have not been good for XBRL.
44:40
At best, it's been equivalent, but some have
44:42
said it's worse than actual plain bupivacaine.
44:44
And whenever I've been around their representatives,
44:47
they don't like it because I just explain the
44:49
math to them. And it doesn't make sense to me.
44:54
To explain it to people in the simplest terms
44:57
is we inject around 150 milligrams of plain bupivacaine
45:02
in a typical nerve block. There's 266 milligrams
45:05
of bupivacaine in Expro. And so if you do the
45:10
math of 266 milligrams of bupivacaine over 72
45:14
hours, and if it's released continuously at a
45:17
slow rate like they say it is, you're getting
45:19
not enough local anesthetic to the nerves to
45:21
make a difference. And when you look at the math,
45:24
it'd be like us putting a catheter in and running
45:25
it at less than one CC an hour, whichever one,
45:28
if you think, if you look at it, it's like that
45:29
doesn't spread around on the nerve as well. So
45:31
that's why it doesn't work. It's a cool concept
45:34
and it would, it does work the way it's supposed
45:37
to, but problems when they're, when they're doing
45:39
their initial studies, they tried to put more
45:41
bupivacaine in the liposomes, but they had issues
45:43
with the. the subject animal subjects not making
45:47
it because of local anesthetic toxicity because
45:49
if it doesn't release in a consistent fashion
45:51
you release too much you're going to get toxicity
45:54
and so that's 266 the most they could get in
45:57
there safely and it's just not enough to achieve
46:00
the goal you're going to make it really hard
46:02
for me to get sponsored by xrel for this podcast
46:06
i think they'd still sponsor it they're looking
46:09
to sponsor anything they can get their hands
46:10
on so Well, so far I haven't run any specific
46:14
ads on the podcast, but advertisers, if you're
46:17
listening, if you would like to give me money.
46:22
We're interested. Please feel free. In general,
46:28
the opioid pendulum has definitely swung away
46:33
from opioids. People have realized that there's
46:35
the opioid crisis. And our residents, and I think
46:39
residents sort of. across the nation are starting
46:43
to understand that opioids aren't the way forward
46:45
and are coming around to your point of view maybe
46:48
a little bit more slowly than we would like.
46:52
However, do you think that it might be swinging
46:54
a little bit too far? Do you feel like maybe
46:57
we're not treating acute pain appropriately in
47:01
some of these populations? I think possibly,
47:06
yes. I think i don't like to have anyone have
47:11
the concept of if you're not giving an opioid
47:13
you're not treating pain well that's not true
47:15
um i personally think the pendulum in anesthesia
47:20
specifically has not swung far enough uh away
47:23
from opioids as opioid centric i don't know the
47:26
exact percentage but i would say probably 20
47:29
20 percent of cases should get opioids the other
47:31
70 75 should not I think that there's a lot of,
47:35
because we have so many options nowadays. And
47:37
now this is just pre -op and intra -op. I think
47:39
we can get them through. And if we deploy all
47:42
of our options that we think make the most sense
47:43
for that patient, that surgery, and they wake
47:46
up and they're in recovery and they're having
47:48
pain, then you can use a small amount of opioids.
47:50
And that usually works really, really well. And
47:52
you don't have to use a ton. And it usually helps
47:54
get rid of their pain very well. So I think that
47:57
the, I don't, I think there are some, particular
48:01
individuals that i become you know the term is
48:04
opioid phobic where they don't they're not gonna
48:06
give anyone an opioid no matter what and i think
48:09
that's where you can get yourself into problems
48:11
so as long as you don't have that you understand
48:13
that opioids are one of the weapons you have
48:16
to combat pain it's just not the main one and
48:19
i like to view like from my position i use local
48:23
anesthetics nerve blocks as my main weapon that's
48:25
how i'm trying to attack pain But if you ask
48:28
me, if you took away one other option, I'm fine.
48:32
And that's where I was like, if I tell certain
48:34
anesthesia people like providers, like you can't
48:36
use opioids, they don't know what to do. And
48:39
that's a problem. Like to me, that's an issue.
48:41
I had an attending and residency that would,
48:44
every time I worked with them would just say,
48:47
you can't use this medication today. How are
48:50
you gonna get around it? And most of the time
48:52
it was like, it was fine, but then. like took
48:54
away propofol. I'm like, Oh, you know, it's like,
48:56
that's a big one. Um, but you know, it's like,
48:58
you can imagine like, okay, you can't use a paralytic
49:01
today. How are you going to get through these
49:02
cases? You know, in some cases you can, some
49:05
like that's going to be harder, but it's just,
49:07
I like to think of that in the pain sense. Like
49:08
if, if I can, and that happens, right. You get
49:10
an elderly patient, you get, you know, certain,
49:13
certain patients, you know, on an opioid, you
49:15
know, diversion therapy or something, you can't
49:16
give up. You're going to take classes of analgesics
49:18
away from you. And sometimes surgeons and surgical
49:21
techniques, like I can't do a nerve block for
49:22
it. How else, what else am I going to use? And
49:25
so as long as you're always thinking about their
49:28
pain and trying to do something for them, you're
49:31
not going to undertreat them. But I think there
49:32
are some people that have gone too far to the
49:35
too scared of opioids, but don't know enough
49:37
about all the other alternatives that they will
49:39
be undertreating some people's acute pain, which
49:41
is the number one thing you can't do because
49:44
that will lead to potential chronic pain. Let's
49:47
talk about your fellowship a little bit. Who's
49:50
it for? Who's it not for? So the main reason
49:55
why I would recommend anyone do a fellowship
49:57
in regional anesthesia acute pain is you love
50:00
it. You want it to be a part of your life. Regional
50:05
anesthesia, everyone does it. Every anesthesiologist
50:07
can do it, should do it. I'm a firm believer
50:10
in regional anesthesia. As long as you can do
50:13
it safely, do it. The more nerve blocks and injections
50:15
we can do, the best. There is a whole nother
50:19
layer of regional anesthesia and Q pain management
50:22
that the fellowship gets you to. So we, we've
50:25
had plenty of really brilliant CA threes that
50:28
have like killed it through their whole career
50:30
as residents here for regional anesthesia, Q
50:32
pain. And there's still layers I can get them
50:36
to. And so if you have that passion desire, I
50:42
want this to be a key central point of my career.
50:47
I want any practice I go to, I'm going to be
50:48
the go -to person for blocks, the go -to person
50:50
for pain. I want to set up an acute pain service.
50:53
I want to run a surgery center. I want to have
50:55
leadership opportunities. That's who should be
50:58
doing a fellowship in regional anesthesia acute
50:59
pain. There's no more money involved with it
51:02
typically, which some of the fellowships can
51:05
kind of hang their head on. There's no like preferential
51:09
scheduling you get from it, which some other
51:10
specialties can get. So those are the people
51:15
that I'm looking for for the fellowship. People
51:17
that are genuinely just interested in learning
51:19
that deeper level of why do we do what we do
51:22
and how do you do it. And honestly, if you think
51:24
about your career and if you think like, oh,
51:27
I can go take a job where if I do blocks rate,
51:29
if I don't, I don't care. Probably don't need
51:31
to do a fellowship. If you're thinking like,
51:33
I can't have a job where I don't do this, then
51:35
fellowship is probably the best spot for you.
51:38
So how do you take that strong CA3 and take them
51:43
through that year of fellowship and turn them
51:45
into that person you're talking about? So understanding
51:50
everything that there is to know about regional
51:54
anesthesia and acute pain sets that individual
51:57
up to have those conversations with the surgeons
52:00
that we talked about earlier. It allows you to
52:02
better explain. what you do, how you do it, and
52:06
how you fit into their system and how you make
52:10
it work. So I had a conversation with one of
52:14
our colleagues a couple months ago. We have a
52:16
new orthopedic surgeon. He wants to take a little
52:18
bit of a different approach to some nerve box
52:19
just because he's in his earlier career. And
52:22
the question I got from our colleague was, why
52:26
can't he just do the standard of care that we
52:28
do here? I'm like, because we don't do standard
52:30
of care here. I've used my position and my fellowship
52:34
training, my knowledge base to fill in these
52:38
surgeons' ideas of where we should fit into their
52:41
life as orthopedic trauma surgeons. And so we
52:45
do way more blocks and regionals here than anywhere
52:48
else. And it's because I've been able to use
52:50
that. So that's how I was able to set up and
52:52
build our pain service basically through that.
52:57
So the fellowship starts with building that knowledge
53:00
and building that confidence in that you know
53:02
this better than anyone else. And then you have
53:03
to actually be able to do it, right? So we have
53:06
our residents here graduate with hundreds of
53:08
blocks, right, over the course of three years.
53:10
Really good experience. They get exposure early
53:13
and late. They get exposure throughout. But I
53:18
still think it's not enough if you want to be
53:20
the person. If we're going to plop someone into...
53:26
orthopedic surgery center that's going to have
53:27
eight rooms and you need to do all the blocks,
53:30
spinals, everything, keep it efficient, keep
53:32
it effective, keep it flowing because you can't
53:34
have them pack you slowdowns. You got to have
53:36
the reps and you got to have the familiarity
53:37
with how to do that. And so we get the knowledge
53:40
and we get the skill down for the fellows and
53:42
that sets them up to be able to produce, but
53:46
also to be able to set up and communicate to
53:48
the surgeons how they fit into that mold. From
53:52
my side, which I very much underappreciated that
53:54
I got from my fellowship, is how do you also
53:56
deal with administration? And how do you explain
53:59
how you fit in and why are we here? Like, what
54:03
are we doing? What value do we provide to the
54:04
health system? And because a lot of them don't
54:07
have the medical background to understand everything
54:09
that's going on, but you can use your knowledge
54:12
and understand a little bit more where they're
54:15
lacking their knowledge and fill those gaps to
54:17
then have them say, you are providing a very
54:19
valuable service. That's great. How can we help
54:21
you? And how can you get involved and stuff?
54:24
And so it also, you know, having that fellowship
54:26
training also gets you into positions where you
54:29
can be on these committees and working with administration
54:32
and leadership to try to figure out how to best,
54:34
of course, the health system, but also to the
54:37
benefit of you and what you're trying to do and
54:39
how you're trying to help your trainees and patients.
54:42
This has all been a really great conversation.
54:45
I appreciate it. But I want to wrap up with my
54:47
final style points question. are your personal
54:51
style points or points of personal preference
54:53
that have helped you build a pain service, that
54:57
have helped you succeed? I'd love to hear them.
55:01
So the number one thing that comes from my mind
55:04
that took me a while to learn through my career
55:07
is communication. You can never, ever over -communicate.
55:10
And having toddlers, I've learned a lot from
55:14
them. You have young kids. They may not know
55:18
how to communicate, but when they want something,
55:20
they make sure you understand that they want
55:22
something, right? When they want to get a point
55:26
across, they do it, but they communicate it.
55:28
And if you're not understanding their first form
55:30
of communication, they try a different one, and
55:31
they try a different one. A louder one. A louder
55:33
one, typically, right? That doesn't always work
55:35
in the professional healthcare setting, as I've
55:38
tried, but communication is so, so important.
55:42
And I use it in my personal life. You know, I
55:44
use it in my wife, my kids, my family, with my
55:47
friends. It's trying to – communication is a
55:51
two -way street, right? It's like I need to be
55:53
expressing to my views and what I'm trying to
55:56
get across, what my goals are. But I also need
55:59
to be hearing whoever I'm working with what their
56:02
goals are and how it fits. And, you know, doing
56:05
that in a rational, calm, patient manner. really
56:08
helps build build relationships so communication
56:10
is the key point that starts then you build relationships
56:13
and you know this if you have a relationship
56:16
with a colleague in anesthesia or a surgical
56:19
colleague or whoever it is it makes life so much
56:22
easier right like hey hey buddy like you know
56:24
like i i remember the story i was with i went
56:27
golfing with one of the orthopedic surgeons right
56:29
had a great time it was cool got to see him outside
56:31
the hospital literally like two weeks later we're
56:34
doing a case together we're finishing the case
56:36
He happens to be walking through patient. All
56:39
of a sudden we're waking up, not doing well.
56:41
Patient happened to get a spontaneous pneumo
56:42
randomly, but I just had, I just be able to look
56:46
at him. Hey, we've got a problem here. He instinctively
56:49
just got on the phone and called our ACS trauma
56:52
backup and said, Hey, I need you to come to this
56:53
OR like, and by the time he got there, like,
56:55
Hey, we've got a new more than they, it was five
56:57
minutes from when I told him we have a problem
56:59
here. We got an x -ray. They did. They, they
57:00
put the chest suit. It was in the patient was
57:02
fine. And it was just like, it was easy. Cause
57:04
I just, I had no problem to say, Hey man, like
57:06
this, this is what I need. I need some help.
57:08
And he, he knew kind of, you know, it's just,
57:09
it makes life so much easier to ask for help,
57:12
to understand where you're going, have communication.
57:13
So starting with that communication, building
57:16
relationships, it just, it just, it makes every,
57:19
it makes life so much more enjoyable, so much
57:21
better and so much easier for everyone. So really,
57:27
I suppose. Everyone can learn from you is to
57:30
be more of a buddy. Buddy with an E, yes. Brad,
57:36
thank you so much for joining us. Thanks for
57:37
having me on. This was fun. Well, that's it for
57:41
this month's episode of Style Points. My thanks
57:44
to Dr. Buddy for coming on and giving us his
57:46
perspective. If this episode didn't teach you
57:49
everything you wanted to know about acute pain,
57:51
well, you'll just have to apply for his fellowship.
57:54
If you got something out of this episode, the
57:56
single best thing you can do to help other people
57:58
find the show is to leave a rating or a written
58:00
review. It really does work, even if I pretend
58:04
that I don't look at them. As always, you can
58:06
reach me at stylepointspodcast at gmail .com,
58:09
and I'm still happy to mail you a free StylePoints
58:12
sticker for your water bottle. Take a deep breath.
58:15
Open your eyes. We're all done.