S2:E4 "Top Tap Tips for Tums: Abdominal Wall Blocks (Part 1)"

Planks are used to make cabinets and to tone up your six pack. We'll talk about both types here, so grab your seven layer bean dip and settle in. I'm Jeff Gadsten. Raps, taps, two pack and carpentry. There is so much in this episode you won't want to miss. I'm Amit Power. And this is. Block it like it's hot. Hey Jeff, we are cruising through our season two. I'm doing great man. How about you? Did you realize you just wrapped that intro? I don't know what to say man. Sometimes it just comes naturally. Yeah. When you got it, you got it. Well of course I planned that, but how are you? Honestly, how are you doing? I'm a good man, thanks. What have you been up to? Tell me. We're getting most of the way through our fellow years, so we're trying to wrap up or push forwards and projects. Kids are busy on the home front. Got sports, soccer, across. It never ends right? There's so many things going on. Yeah, I'm building some dog houses for our three months. You're building them yourself? Well, we have three sheets used, and so they're small dogs. They're eight pounds each. But they sleep overnight and these little crates, wire crates in the kitchen. But it's not that attractive and they're kind of the wrong size. Now that we added a third one of a Christmas, the third one kind of sticks out from the alcohol of a bit. I mean, custom dog houses for these little guys. Wow. Then I'm just going to fit just nicely in that little area. Oh my god. Okay, I mean, and you had skills, but that's like next level, isn't there? I was, you know, there was one time when I, and we had an old desk at home and my wife, who wasn't my wife at the time, she was my girlfriend. She said to me, okay, she said to me, are you going to get rid of this desk? We're not using it anymore. I was like, no, I'm going to turn it into a drinks cabinet. Oh nice. So she went away for the afternoon and all I had at home was a junior hacksaw. And this thing wasn't really up to much. So I spent about an hour trying to trim off the lower part of a door. I went through three blades and then I gave up and then she came back and just saw it on the floor. So I think your carpentry skills must be legendary. Oh, you haven't seen them yet. I mean, they could be a total travesty, but I just hope the dogs are safe inside. Yeah, I'm sure they will. Yeah, how about you? Well, Jeff, you know what, it's been quite a week. We were initially planning on recording this podcast a couple of weeks ago. So initially I kind of thought we would talk about how nervous I was for R.E.K. But you know what, it's happened. R.E.K. It happened. We've had the conference. Well, Alan at Farlin, Toby Ashkin, Maria Pasabasjan and Nat Hauslin. I think the guys that organized that along with the whole of the R.E.K. board, they did an amazing job. It was, I think it was our best conference yet. I say hour, I'm not part of R.E.K. anymore, but you know, I still feel like it's part of, it runs through my veins. The conference was great. Amazing. They treated me very well and everything went according to plans. I'm feeling on a real high, actually. That, I bet you are. I mean, I was following along on Twitter, different lectures and workshops and stuff that was going on. But of course, the crown jewel, as it were, was the brusque. They were talking about my crown jewels on that. It was the brusque lecture that you delivered on Friday. Yeah. I haven't yet seen it. I'm looking forward to the recording when it comes out, but what was really cool was to see the reactions of people on social media react to your lecture. It was clearly an incredible lecture and emotional and personal and people had amazing, amazing reactions. Well, listen, thank you so much. It's really kind of you to say that all I can tell you was, I've never quite given a lecture like that before. So, it was very different from what I've done before. It's like this is not how this is how you do this block or the evidence for this block says the following. I really, very much, I decided to present it as my personal journey. Yeah, of course, that there are some emotional components to that. You suddenly realise that you're not as young as you think you are. And then you're most importantly, you go back and realise how many people have influenced your career. And actually, for me, it was really great to be able to give certain people the thanks and recognition they deserve. So yeah, it was cool. I wasn't expecting the reaction that I got, but it made me feel very special. And as you know now, and as we can reveal, there were a few cameos that made it into the lecture. Back in. Tanya Salack, what a gongascar made it in there. You recorded something very nicely and Claibreganza from Behold and the Philippines. And actually, although I couldn't have planned it the way that it went, all the video, they just came in at just the right point, gave me a little chance to take a breather. Oh, that's good. Nice to introduce the podcast. Actually, Claib's video very summarised my talk. So, yeah, I'm very grateful to everybody for their support and I'm happy it all went well. So it was a blast. And if you're still interested, I'm sure you can still purchase some access to the conference. But you know what, at some stage, you want to have a chance at all digest. I might record the Bruce Got lecture in a slightly less emotional manner. Pop up on my YouTube channel. I can't wait to see it. That's amazing. Congratulations again, man. You're well deserved. Thank you so much. And thank you to everybody else for their support. But you know what? On a non-RUK subject, the other thing we did that was quite cool was we live right by the start of the London marathon. And so we, our friends of Soulsbees, who featured nearly regularly on this show, and they live on the road where the marathon runners for one particular start run down. So we went to stand there with a cup of coffee and a quess. And so for the start of the London marathon, actually, we saw Nick Gill fillin, who's one of my consultant colleagues from Cleveland Clinic London. We knew he was going to be on that run and I managed to track him on the app. And I got a video of him running passes right at the beginning of the race. So that was super cool. Oh, that's amazing. I hear it's a good chorus as well. Do you run? Do you run it all? Yeah, in my mind. Thoughts run through my mind. That's the extent of my running. I've never done a marathon before. I've keep thinking like one day. I've done a half marathon. In fact, I did an event with my brothers once in Lake Placid where there was an out and back half marathon and then you could do that again and make it a full marathon. And so I knew I wasn't going to do a full marathon, but they did. And so I did the half. Then I said, "See ya." And I went to the bar and then you could have said that. Well, that's how you recover from half marathon. It was enough for me. But ever since then, they refer to themselves as athletes and me as a half-lead. Oh, half-lead. I like that. Yeah. Yeah. So. You know, there's one last thing before we get into it. One last thing I've been looking forward to and planning. So we're being visited by two North American families this summer. Number one, the Gantzans and the other, the Mariano. So actually, I've been looking forward to planning some entertainment for those families and can't wait to see you guys. Yeah. No, we talk about it every day. So we can't wait. We just can't wait. Yeah. We know one of the things that I've planned for us is to go and to check out some Indian food. I'm not going to give away free advertisements for the location, but maybe we can do it afterwards if we get some sponsorship. Although, yes. I'm not saying one response for us. Yeah. Sure. So you like Indian food, right? Oh my God. It's my favorite. And I know that London is the best. Chapel Hill Indian is okay. But yeah, really looking forward to it. Yeah, we think you're going to like it. But listen, I know you've got a lot of connections to Indian. So how is it that you've become an honorary desi? What's the story here? I don't know. I just, I had this affinity for all things Indian for decades. And guys, what you can't see is, as Jeff is saying that his head is just slowly rolling from side to side in a way that you only have if you know. I might have a small Bollywood collection of DVDs. Oh my God. Well, the night case, you were ahead of me, man. You were ahead of me. Well, yeah, we can't wait. We're looking forward to hanging out with you guys. And finally meeting, um, Kat and the girls, I've heard so much about them. I feel like they're almost family. Exactly. Likewise, man. Likewise. Okay. So what, what are we going to talk about today? Well, you know, it's another controversial area that was kind of triggered in my mind by something that Lloyd Herbert once said. I remember he, he did this on social media and he put a tweet out and it was like, the tap block is dead. Who? And it kind of got me thinking, should we take on the whole abdominal wall thing? It's like, it's a really big deal. Are you ready for this? Ah, yeah. That's a, that's a massive topic. But, uh, ooh, it might be a two-parter. But anyway, let's, let's, let's try. Okay. So Jeff, tell me when you think abdominal surgery in the US and your hospital, and were you're thinking regional, what's the reflex first thing you think about in terms of analgesia? It's funny. That's changed over the years, right? So when I was growing up in anesthesia, it was thoracic epidural. That was what you did for every major abdominal case unless it was laparoscopic. So that would be reflex. Open abdominal surgery, big midline, big midline incision, automatically, you think about thoracic epidural, right? Yeah. Yeah. And you're telling me that's now not your reflex reaction? Yeah, that's changed. I mean, we, I mean, thoracic epidurals are amazing. And if I were getting a big belly whack, I think. I would want a thoracic epidural because I think it's a gold standard, but they have baggage, right? And the big problem that we have had at our institution is that the hypotension on the floor is problematic. So, you know, you're running these patients on the the brink of uvelemia and then you can get them through with a bit of phenolephyron in the OR. And then by the time they get to the floor, the epidural is still running and their pressure is sagging and then someone turns it off and then they have pain, etc., etc. And there are ways around this and I wish that I worked in a hospital where you could run a phenolephyron infusion on the floor, but you can't. So, the thoracic epidural has gone really by the wayside and we're doing way more facial plane blocks. How about you? You know, I think the UK practice hasn't quite made that full shift yet. So I remember probably the gold standard for use of thoracic epidurals in my career was when I did my liver transplant fellowship at King's College London and they had a phenomenal so when we used to do our compatibility cases, the default, now you might cringe when I say this, but the default used to be GA, flip them on the side, a sleep thoracic epidural, that was that was where we did it. They then have their surgery that wake up, you know, uvelemic, perfectly analges and they'd be nursed in an HDU setting for 24 to 48 hours and you would go and see these patients the next day and they did not look like they'd had surgery. These were the, you know, the Hepatectomy or the Whip-Halls or those cases that were slightly long, they were done by the transplant surgeons but they weren't liver transplant to big juicies about the ability cases. You look at them the next day and they looked amazing when the epidural worked well. That's what I mean. I mean, that's what I want as a patient to not look like I've had surgery. So you said to me, interesting, there you said when it works. So tell me more about that. Well, you know, I've definitely had, you know, you remember those days when you put it up during the day and it kind of feels okay, you get that, you know, you get that meniscus drop when you hold your catheter and I'd be thinking, yeah, I'm pretty sure that's there. And you give the bolus, but then you know, do you get a drop in blood pressure prior to the knife to skin and then, you know, the surgery will stick to knife and you get, you know, a rise in blood pressure and a rise in heart, are you thinking, is this going to work? Is it not going to work? And I said, you hold day stressing about it and then you wake them up and then they're great or they're not great. And sometimes they're one sided. If it doesn't work first time, once you've got to start fiddling, then I think it's a nightmare or if you get your level wrong. So there's a lot of planning, right? Yeah. Yeah. And sometimes I just think the epidural space is finicky in terms of where the local goes. Yeah. I have a slide I get I put up sometimes I'm talking about this showing fairly contemporary literature, an overall rate of epidural failure of 25%. That could mean patchy or one sided to not just like outright failure, but you know, that's high. That's really high. That is really high. Now, I've just suddenly got something coming to my mind. Do you remember this whole talk about the Sui? Was it the Sui test? So Gordon Lance lot and Quasi Quofi talked about using stimulating epidural catharsis or converting an epidural cath into a stimulating one. So you pop it in, you put some electricity through it and you can look at the intercostal muscles twitching to work out where the cath is placed. Have you ever done this? I've never done that. No. It sounds crazy, right? But also sounds like why aren't we doing this? I mean, my admittedly, I haven't like used a catheter that would chop on X-ray and done fluoride or stuff. But my impression is that these little nylon catheters that we use coil up a lot and don't head straight up the epidural space towards the head. I mean, the Sui catheter was different. Okay. Would you have hold on a minute? Another way to comment there that I want to pick up when you mentioned the term flurrow. Now I remember Asra did this. I believe it actually may be at Brian Sight's institution, the editor-in-chief of RAPM. They use fluoroscopy to identify the epidural catheters. What do you think about that? That seems like a lot of work, but maybe one way of definitively knowing where your epidural catheter is. To me, it seems like a lot of work in ionizing radiation and for something that we get in routinely and works well most of the time. It seems like a lot if you weren't going to be using fluorophapart of the case. So one of my colleagues does a list in the end of the urology unit and they've got fluoroscopy there because they use it for the case. And if he's going to do an ESP or a paraphrase for all, he'll do it, oh, some guided. And just people with administers, the drug could give it a bit of contrast and look at the fluoro to double check. Now that's cool because it's set up and actually they're going to be using fluorophapart of the case. The flip side is he does it in an anaesthetic room and says right now let me move them to the fluoris suite to test that I'm in the right place. That seems a bit much of it. It wasn't part of your practice, but I don't know. It's interesting. I'd be interested to hear what people think about that. Yeah. It seemed to me like people that were using fluororotinely like pain physicians were quite comfortable with it, which makes sense. And so it has no big deal where someone like me is like, wow, that's, I don't know, it wouldn't even know how to turn the machine on. And I got to put lead on. I don't know. It just seems like a lot of work. You know, it may be fear of the unknown as well, or you know, it's not standard practice. Yeah. Now, see one of the advantages of the epidurals, of course, is the ability to continuously administer the medication. And if you do a, we'd compare that with a spinal, of course, we've got a shorter duration of action, but has anyone ever done, you know, have you ever considered doing a single shock epidural? Is that something that people do? I've only ever heard of epidurals being done as part of a, you do the epidural, you thread it cast and then continue to see it administer the staff. But is there a role for single short epidurals? I've never heard anyone doing them. I, oh god, that's pretty rare, right? I, I, no, I don't think I have. So I know one guy that used to, he didn't want to have the hassle of dealing with a lumbar epidural. This is back in the days when we used to do lumbar epidurals a lot for gyne surgery. Right. And so you didn't want to have to deal with the hassle of you, of having lumbar epidurals running on the water afterwards, but he would do a single shot lumbar epidural and put in some opioid. We'll get onto that. And, and then he was like, listen, it's so much better than doing a single shot spinal. I get prolonged duration of analgesia. And then tomorrow, the next day, by the time the epidural bolus and the opioid is worn off, patients up and about and they're through the worst of the pains. That was one indication I've heard people using it for lumbar epidurals, but I've never heard people use it for thoracic. So I just wondered, no, I've never, I've never seen that. Okay. So Jeff, listen, I'm worried here, right? You're saying that you're doing less and less thoracic epidurals for major abdominal surgery. So if you're doing less, that means you're teaching less. And then so who's going to do your epidural when you need to have your major abdominal surgery? God forbid you do. But how are we going to train people to do that? I'm getting on the plane and coming to London, I guess. Now, we still, we still do them. But just far less, I think we were a very high user centred when I first arrived at Duke 10 years ago, but it was really part of our e-rass protocol. Everybody who was, even the laparoscopic stuff that may have a small incision to deliver the colon, got an epidural. And so those have gone away. And we've, we're, we're serving them for kind of the stuff that you're talking about, like the big hepatic biliary cases and so on and so forth. But you're right. I mean, it's, it's we're doing less of them now. I mean, obviously it's been a long time since I was a trainee, but what I can tell you is that yes, the centers where, it's really key, slash useful to have them. So people that are doing a soft ejectemies, they tend to get thoracic epidurals. A lot of our thoracic surgeries are either getting surgically administered paraverterals or anestist administered paraverterals. And then the major abdominal surgery, it depends very much on the anestist and the institution as to where they get them. So I am seeing a fall off in the training opportunities for thoracic epidural, which makes me nervous. And it used to be a right of passage. You knew you were good enough to be a senior registrar on call overnight when you could do that thoracic epidural by yourself. And once that was a tick, you're like, yeah, now I can do everything. But now it's not a given. I don't think it's a given. I want the trainees who are listening to correct me if I'm wrong. But I think you sometimes have to search for those. I still think it's something that people aspire to make sure they've got. And we don't feel complete as an esti-s-ness. We can do it. But I'm definitely worried that the training opportunities are diminishing for that. And that used to be something you say, yep, I know we're going to have enough of those done. And you know what we're moving to, man? For most of our procedures, we are moving to single-shot, inter-thecal/spinal injections with varying doses of opioid in there. And that seems to have taken over. Really? Yeah. So my heart take on that is it seems like there's a step backwards from moving away from opioids and keeping patients in hospital because they have paritis and nausea. Well, this is the whole thing, right? So there's a big push/desire to get this opioid-free anesthesia. But you know, sometimes we don't really need to be completely opioid-free. Maybe we need to reduce opioids. But the inter-thecal root of administration is something that I still don't really understand. What's fascinating is I was listening to Eric Elbrecht present some of the evidence on inter-thecal opioids for hip-artoroplasty, for example. And if you're talking about inter-thecal morphine, there seems to be a ceiling effect at about 1 milligram, 100 mics of morphine. You know, like if you go any more than that, you don't seem to get analgesia. But then you do tend to get side effects. Now flip that to dye morphine. And I have been working at the London and learning for one of my colleagues at Chapco, Jeremy Prout, who incidentally is the only triple fellowship at the end. qualified in East-Sys, I know he's got the physician exams, the surgeon exams, and the anaesthetic exams like a super- and he's got a law degree. Anyway, so just see how time to work. I mean, getting on with this. I don't know how he does it, but anyway, he's a legend. Wow, impressive. So Jeremy has been using gradually increasing doses of dimorphine to the point where he's been putting in a milligram or a milligram of a half and a half of dimorphine in the spinal space. And these patients have got like 24 hours plus of incredible analgesia. I don't know where the ceiling point is for dimorphine, but I suspect it's different from morphine. And I remember an old fellow of mine, a chap called Tom Boychekovich, he did some work in patients with obstructive sleep, apparently, are having bariatric surgery and looking at the various doses of opioids. So, I think there's something there, and I don't think you need to be as scared about it in the same way that you think of the US, you think of opioids and get nervous. I think there may be something there, well, I don't disagree. I think that their, you know, use the right dose, right route can be very, very safe. And I think for the neuractual opioids, the reticence is not so much about the opioid crisis that we've been going through here and getting somebody hooked on opioids, post-operatively, it's more about the side effect profile. Because as you mentioned, if 100 mics is the ceiling effect, anything over that is just going to increase your side effects, you start to get nausea and vomiting and itchiness and all that stuff. The only place we still do that a lot routinely is in OB. We know this kind of segue is very nicely in what I wanted to lead on to next, because my understanding from this in great work being done by Neil DeSai, Karim, DeSai on Watchay, looking at facial plane blocks in Siserin sections, and my understanding is that if you add in an integral opioid into your spinal, there's less clear benefit to adding in a facial plane block after a Siserin section. So, I'm sure you're familiar with those papers and the things I'm talking about. So, that kind of leads us nicely onto our facial plane block. So, you said when you're moving away from Thrasia epidurus, facial plane blocks sort of come to the forefront. So, what options have we got, Joe? Well, that is a loaded question because there are tons of options. Right? So, we got the old, the old tridentrue tap block. The one that Lloyd said is dead, and that was an interesting comment. Obviously, he did it to be controversial, but. Sure. I think he felt that to a certain degree. I think a lot of us have felt that, and I'll say it. I don't enjoy doing tap blocks, and I'll get into that more a bit later. So, to me, when I think about the abdomen, when I'm called to the room and they say, "Hey, the surgeon had to open, we wanted to do a facial plane block. Can you guys come and do one?" My first question is, was it midline? And if it's midline, I breathe a sigh of relief. I grab my team, put my cape on, and I run to the room, and do a rectus sheath block for the midline. I love a good rectus sheath. And if it's lateral, so out like a fan and steel incision, and below the umbilicus, that to me is a good indication for a tap. If it's above the umbilicus exclusively, then we used to do subcostal taps. Now we're doing more external oblique intercostal blocks. And then if it's all over the place, rather than do a combination of those, which we used to do this thing called a four point tap, which is tap tap, and then again, tap tap subcostal taps, one, two, three, four, or more likely now to put them on their side and do a QL. Or an ESP. Holy moly. So like that, what did I say? That's six or seven different different blocks you could do. It's almost as if you knew what I was hoping we'd be talking about on this episode, because you basically ticked all the boxes that I'm looking at over here. So this is great. Okay, so let's let's wind it back. Let's wind it back. So when we're doing, I was waiting. There was a first sound effect we've had so far. Thank you. So what we're doing these abdominal wall blocks, what are we aiming to target? We're aiming to get the intercostal nerves, right? And so somewhere between kind of T6 down to T12 L1, just to get that abdominal wall analgesia, that you agree? Am I missing anything out there? No, that's a good, yep, good summary. Now tell me, do we expect our facial plane blocks to give us both somatic and visceral analgesia? Because of course, when we're doing our thoracic abusurus, we're hoping to take the whole kaboo kit and kaboodle out. But when we're doing our facial plane blocks, we're not going to do the same. Maybe. So I would say there's a line you can draw and say on one side of the line, you've got tap, sub-costal tap, rectus sheath, external oblique intercostal. And those are just somatic, right? They just get the kind of round the front. Yeah, lateral and anterior and possibly anterior containerous branches of the intercostal nerves, as you mentioned. And then QL and the ESP, there have been some cataviric and clinical data to suggest that those do get the visceral component because they get into the pair of a tubular gutter and so on and so forth. And so you might expect a better response from those blocks from that point of view. So I remember speaking to John McDonald about his, because of course, he didn't invent the tap block. There was this raffi block that we described before, but he was working in a hospital where if you were going to be doing a major abdominal mid-lancergery, you wanted to put an epidural in, the patient had to be nurse. And intensive care afterwards. And they didn't have intensive care beds for this particular operation. So he was asked by his professor to go and research a different approach to doing some abdominal wall analogies. And he sat there with, and with some research and text books and he sort of looked at this landmark approach to the tap block, which at that stage was called the raffi block, but he then called it the tap block, going through the triangular peti. But the story was amazing. So they did this block and this lady had a surgery in the next morning he went to follow her up on the ward and she wasn't there. I was like, oh my goodness, what's happened. And she was outside the front of the hospital, I was smoking a cigarette because she felt so good. So, so, so I guess what I'm saying by giving you that story, which may well be a story of fiction, but he tells it was such truth, I believe him. Is that actually, it can't just be a somatic block. If you do it where he did it, for the lady to feel so good afterwards. So, the landmark tap block that was done at the triangle of peti was that the same as the old sanghadi tap block that we all started doing afterwards. And if not, why not? Well, that's a good question. I've never done the landmark one in the triangle of peti. And let me just say this at the, at the outset regarding tap. It may be it's just me, but I find difficult sometimes to get that plane to open. So, I'm using a really good ultrasound machine, best needle we've got and all the skills I can muster, which may not be all that good, but you know, try try to land that needle in the plane between transversus and internal oblique. I struggle many days. I'm like, I'm in the muscle and I pull back and then I'm in the other muscle. And then, you know, back and forth and then you do a little bolus. The way we failed with taps initially, we were so excited, right? We read McDonald's papers and thought, oh, this ends great. We'll do tap blocks for everything now. And we didn't have good success. One of the reasons was because we were putting the needle in at one spot and injecting a little blob of local in one spot. And sure enough, we got this weird pattern of sensory analogies that didn't correspond to the incision or may not have corresponded to the incision. And we learned over time that you really got to work to open that plane up and move your needle and move squirt, move squirt, move squirt, kind of thing throughout that plane. I think this is a real thing that's coming to the forefront now when we're thinking about facial plane blocks. It's not the case of popping into the plane, keeping you in a little static and doing nothing because fascia is kind of like a spider webby type thing, kind of got to work your needle through and break open some of those, these adhesions and open things up. So I think that's a really key point. You've got to keep working your needle, right? You did a cool little thing with your hand there when you said spider webby, kind of makes me think you were just watching Spider-Man, you got the, I feel, I couldn't help myself from doing that. I talk with my hands maybe too much. So I think, I guess what I was leading you to say is I think that the landmark tap block that John McDonald did back in the day was basically a quadrater slumber and block and we're going to maybe talk about that in another episode, but I think when we, when we walked ultrasound to the foreground, forward the foreground, we were like, okay, we've got to see these three muscle layers. That's what we would describe and it's much easier to see them all anteriorly. So if you can see them anteriorly, you get great, that's perfect. Then you've got to work on getting in the plane, but maybe all we were doing was getting this kind of surface infiltration type analgesia and the local land, so they never went where the landmark tap or the post-territory tap should have been and never went into the parovirtual space. So that's why I think we were getting that difference. And also while we weren't seeing good coverage with an ultrasound guided tap above the umbilikus, we were basically getting T10 and below, right? Absolutely. Yeah, and I was, I kind of distracted there with my with my dietribe against the tap plane, but what it's good to say was I I can't imagine where John's needle was, blindly to get a great block, but I think you're right. I think he must have been doing something much closer to the Naraxis in the sort of Thorical Lumber fascia than we were ever doing with the ultrasound guy to tap. So yeah, totally agree. Okay, so you've all had some interesting things there, which is, you know, we've heard a world famous expert in regional anesthesia, AK Jeff Gazzin say he doesn't find it easy to open up the tap planes. And that should give all of us some guidance, oh, not some reassurance. You know, if we find it hard, even someone like Jeff can find it hard. But where do you think the perfect location for the tap lock is? I have in my mind that I know I teach workshops for people to do. But if you were, if you had to teach in a workshop, people to find the correct, I'd, number one, find the correct plane. But number two, find the correct injection endpoint. What would you tell them to do? And by the way, I'm going to give you a shout out to one of your YouTube shorts this year, or last year, about plate tectonics and moving your, your probe up and down and seeing the abdominal muscles moving in different directions. That was super cool. Well, man, I like simple tricks to keep me honest. So another way we failed early on, I'm telling you all my failures. This is, this is like a concept running theme for the podcast. But, um, was again, we got excited about John's reports and I was like, yeah, let's do a tap lock and we put the probe relatively close to the, um, like on the anterior abdomen, not on the side. And of course, you can see the three muscles there fairly well. I mean, got excited and we did our little thing and didn't get my great results. And over time, learned a, we were, we were downstream of the take off of the lateral continuous branch. So really what we were doing was a complicated rectus sheath block. So we kind of learn, oh, I guess I'm going to, I got to move the probe back further, posterior, further posterior, where I tend to like to do it now is I still started in the int sort of interior lateral abdomen because I can see things nicely. And then I'll move the probe around the side of the flank until I see where transverses of dominus ends. Phew. Thank goodness. I was hoping you're going to say that. Is that what you did to? Yeah, yeah, yeah. So that's what you aim for, right? Yeah, because I feel, I feel like the bulk of the evidence and our clinical experience in possible years as well shows that the further back you are, the better it gets. Yep. Cool. So I mean, so I, I, in my mind, I call that the posterior tap block. And I think, I think the key is you've got to go back as far as you can. Although the thing that you said that we can't underestimate how useful it is to start off on the anterior abdomen because patients with different body mass index, a different body habitus can provide some slight confusing sonographic images where you place the probe on the abdomen. You're like, whoa, where's the right layer? And sometimes starting at the midline allows you to identify the rectus sheath, tethered to the three abdominal muscles. And then you can work out where you are, right? Oh, thousand percent. Yeah. So we'll put the probe on sort of closer to the midline and often see rectus or sometimes see the three tap muscles. But I mean, you look at some of these videos and it's a very nice three layer cake with a little bit of adipose tissue. But you know, the reality is where I work. It's more like a seven layer bean dip. And so you're trying to figure out which, which ones the, which ones the, which ones the not to cheese and which ones the sour cream and which ones the lettuce and everything. But so, so to pick up on what you said a second ago, what I'll do is fan the probe cephalocod ad and all the fat kind of stays the same. And those two oblique muscles, which are naturally oriented at 90 degrees to each other, will appear to move in different directions. And it really, it's amazing how much that little moot maneuver brings those two planes out of the background, right? Aha, for sure. Now listen, before we head into a little joke break here, and I want to just touch on this sub-costal oblique tap. So I understand. I think Peter Hebrew was, was instrumental in describing this. This is starting from the midline along the coastal margin, identifying rectus sheath. And you see the transversus abdominis muscle just sneak underneath the rectus sheath in the midline and use a long needle from the midline gauging or, you know, directing out the lateral to open up that plane, but just above transversus abdominis. It seems like quite a long needle path. And it seems like a relatively aggressive, aggressive block technique. Does it work well? And do you think with the advent now of the external oblique into coastal where we can put local antennae between the external oblique and the intercostal on the, on the coastal margin, do you think that's going to get rid of out the use for the sub-costal oblique tap? So short answer, yes. I do think, I do think the sub-costal tap doesn't have much of a place anymore. Because A, we're often being asked to do this in exactly the place the surgeons are operating. Like for it upper, you know, epigastric surgery, you know, they've converted a lapcoly to an open coly. Well, guess what? Now you're addressing or your glue is right there where you want your probe to go. Because external oblique is up on the, on the ribs and so you're well out of the way. The other thing that has been shown in cadavers and clinically is that the sub-costal tap, a lot of the time, really only gets the anterior, cataneous nerve. So you're, what you're really doing is a rectus sheath block. Essentially, like the, the midline, you're missing that lateral part, whereas the external oblique intercostal block gets both the anterior and the, the lateral, cataneous branches. So you do get the whole upper quadrant. So I kind of see what you're saying. If you've got a full midline incision, rectus sheath block is basically a go to, right? Because the moment you break it down into tap blocks, you need something for the upper component. And maybe the sub-costal oblique tap isn't, isn't the answer. Yeah, I, I do think so. I will say though, Peter Hebert, absolute legend. Oh, complete. And he visited, I've known Peter for, man, over 10 years, I think. And he came to visit us in New York once and he showed us, well, he didn't, he didn't do the block. He kind of talked us through it, but he goes, he goes, all right, it might take out the longest 16 gauge IV catheter you had. So we, so we pull out this thing. I swear it was like 30 or 40 centimeters long. He goes, now put a good bend on it. And he started, he started with a bend up, the tip so that you go in near the rectus and the tip is up. And then he goes, now flip it 180. And then as you go down along, it was, it was incredible. It was, you know, he got the entire plane in one thing and then you pull that whole thing back and inject it. Wow, wow. I agree. It seemed, it seemed aggressive at the time, but, but kind of a cool experience to see. You know what that reminds me of Brian O'Donnell does a transpectoral serratus anterior plane block. And he gets the longest needle he can and he goes in from pet majors, if you're doing a standard pex block and he then passes it through pet major pet minor all the way down the lateral chest wall for his awake breast surgery. That's how he does his serratus plane block. But, but with a long needle. And I've never managed to go longer than an 80, but that's, that's an interesting thing. Now, before, before, before, before, before, before, I'm not doing an Irish accent today. Do you know what? As I was doing, I was like, don't do it, I'm it. And that's the first time I listen to my inner amits. There we go. That's such a, such a hard accent. I mean, I can't, that, that inside African, I've got to work on that. South African, I can't do Irish. I think I can, but, but I know a few people that may differ. And on that opinion, before we go to the joke, we talked about the external bleak intercostal rather flippantly, but we didn't really explain to people what we're talking about. Now, this is a relatively new technique. And if I remember correctly, Hesse Em El-Shakar, we was one of the, one of the people that, that described it, right? Yeah. Tell us a bit more about it, Jeff, from your understanding. So this is a technique designed to get the lateral and anterior-cutaneous nerves of the upper abdomen. So it's sort of T6 down to, down to about T9 is, I think, where most of the clinical and cataviric evidence has, has led us. But the cool thing about this is I didn't realize the, the external bleak muscle, an abdominal muscle comes up over top of the ribs and, and inserts on the, superficial surface of the, of the rib cage. Absolutely. Nor, nor, still learning, still learning. So he, so, Hesse Em El-Khalik took advantage of this and said, well, look, if we put, put a needle about the level of the cypheroid process on the lateral rib cage, just sort of, lateral to the nipple line, hit a rib there, usually like, seven-thraith rib, deep to the external bleak muscle and lay it right out between the rib and the external bleak, it'll, it'll flood that space. And, and the anatomy is a little complex here. It took me a while to get my head around this, but it gets into the space that gets both of those components, the anterior and the lateral continuous branches. So essentially, with one easy injection, because I remember it, as I keep saying, anytime you, the direction is hit a bone, it's an easy block to do. And it works great. We have, so now we're doing this for a lot of our hepatobiliary, as I said, some of them still get epidurals, but liver transplants, love them. Like they, they are waking up many of our liver transplants much earlier than we normally would have, and sort of, you know, we take into the ICU, intubated, many more are being woken up on the table and feel great right away. Those cases where you have an incision that gets up into the, the lateral upper abdomen and you want to do a combination of, we haven't talked about combinations of blocks, but sometimes we'll come in and we'll go, well, let's do a tap lock on this. and we'll do a rectus, a high rectus on this side and we'll touch it up with an external oblique so you can kind of pick and choose depending on the pattern of what you're doing. But this is a good one. It's been really effective in our hands. - We know one of my colleagues, another colleague from Cleveland Clinic London, a chap called Mont Edsel, he's an iconic, a cardiothoracic anestist. He, his institution does replating surgery for rib branches. And we were talking to him about this technique so Ravi Nia and I, myself from Cleveland Clinic, we're talking to him about it. And he watched your Duke video, your block tour of the video, he's like, okay, do you know what, let me try and he started using it for a rib plating. He is not, he wouldn't considered himself to be a classic regional anesthesis. There's a technique he learned from these, you know, digital education and he said, wow, actually, he's getting great analogies of outcomes. So I think we're finding more and more potential uses for this technique. - Oh, that's great. Since you mentioned cardiothoracic, the other place we're using it is for epigastric chest tubes. We started with a parasturnal blocks for stronautomy as an analogies of technique for mid-lenchronautomy. And that was great, except that, and we'll have a whole different episode on cardiothoracic blocks or at least one. But that didn't seem to be the place that hurt them quite as much. It was the epigastric chest tubes, just underneath the zyphoid process. And so we would do, we put them to sleep, come in and do the parasturnals and then do a high rectus sheath block with a little bit of local in that rectus sheath and got that. And that was fine, except that, you couldn't do it postoperatively. Like if your choice was, let's do this at the end of the case, well now the test tubes are there. So we have gone a lot to the external oblique to again, get out of the way of the abdomen but get the same effect. - That is fascinating. That is really fascinating. Well listen, you know what, before, I think I'm just looking, we're probably heading for about an hour here. So it may be that we do a little joke break and then call the episode a done deal there. What do you think? - Return for episode part two. - Part two, there may even be part two and a part three. Who knows? Well listen, there were too many good gangs that I saw on social media that I had to share. So I'm gonna move on to this one, right? So Andrew Loveot from Twitter, he's Andy Roo's 22, gave us a joke from his daughter. Why do people say break a leg for acting auditions? - Hmm, I don't know, I've always wondered that. - Because I wanna see you in a cast. - Oh, I can't. - I think that was very clever. - That was good. Good. Well thanks, thanks, junior Loveot. - Exactly. And listen, I've got another one. This is from Bob von Nikota, who I met for the first time in person and I had a really great catcher. I met Bob here. - You met Bob? I feel like I know Bob, but you know, just virtually. - Well I felt like I knew him, and he's exactly as he appears, by the way. But this is one of his jokes from X, okay? And I asked a barista why they were wearing a surgical mask. They answered, "It's not a surgical mask. It's a coffee filter." - Coffee filter. - Oh, coffee, like coffee, yeah, yeah, yeah. - Sorry, you had to see it written about again. - No, no, I, yeah, it took me a second, but that's good. - I'll see, I'll do it. - I'd see, it's all in the delivery bump. It was funny, I think it was funny. You blamed the question. - No, it was good. No, no, no, no, no. It took, it just, it's five o'clock in the morning here. So, have you got anything for me? - I do. Have you tried blind folded archery yet? This is the new thing. Blind folded archery? - Yeah, have you ever heard of this? Have you tried this? - No, I have not, I have not. It sounds very scary to me. - You don't know what you're missing. (laughing) - Okay, that was very good. I've got, this is my last one, this is my last one. What do you call a wrapper with small abdominal muscles? - Okay. I can't believe you found, this is another one of the social, the AI ones. - I did Google this one. - Okay. - So, I'm impressed that you found a related joke. Okay, no, what? - Two-puck. (laughing) - There's about six times, right? - That's good. - Oh my god, okay, okay. - I'm a one pack myself. - Yeah, whatever, I'm a 12 pack. Anyway, we're getting to that. Listen, Jeff, I didn't realize it would get so stuck into talking about taps and everything at the front. There's so much more that we can cover. - There is so much to talk about here, but so let's wrap it up for this week and then we'll carry on with our abdominal magical mystery tour. - That sounds great. I'm really excited. And now it means I've got less to think about in terms of producing episode, no, it's because we're halfway there. So this is brilliant. Guys, you know what to do. Please do like, subscribe, and give us a rating from a usual podcast provider. Let us know what you want us to talk about next. Jeff, where can they follow us? - Well, we got Twitter, X, Apple Locket, underscore hot underscore pod. We've got YouTube at block it like it's hot. - Hey, and we've got Instagram, block it like it's hot with underscores in between each word, no apostrophe, and don't forget our abbreviated hashtag #bilih, or you can write it out full hand if you want to. But we hope you enjoyed this episode. We've got lots more to come on our abdominal wall blocks. Until next time, we hope you all block it like it's hot. (upbeat music) (upbeat music)