work, we instruct the patient to call us and we will either ask them to
come in or send them to the ER. Educating patients both before and
after surgery may seem repetitive but making time for it is beneficial
for a couple reasons: 1) It gives the patient time to absorb the infor-
mation which means when you go over it again, they'll probably have
questions they didn't think of the first go round and 2) hearing things
more than once often helps people retain the information.
3. Ultrasound + nerve stimulation
Now that you have surgeon buy-in and educated patients, you can
focus on your block techniques. Ultrasound guidance is the gold stan-
dard for peripheral nerve block insertion. I also recommend combin-
ing nerve stimulation with ultrasound if you can.
Ultrasound helps you see all the structures and blood vessels sur-
rounding the nerves you're targeting. You can watch the needle the
entire time and see the anesthetic pooling around the nerves. This
provides visual confirmation that the anesthetic is not in the nerve
where it can cause damage or in a blood vessel where it can cause
local anesthetic toxicity (LAST). Visualizing the nerve is extremely
beneficial but not 100% reliable. Stimulating the nerves before you
administer the anesthetic allows you to verify that you are blocking
the correct nerve. A nerve stimulator uses specialized peripheral
nerve needles that are insulated except at the tip to find and stimulate
the nerve that we are trying to block. The device sends a small electri-
cal current through the tip to the nerve, which causes a muscle to
twitch, providing another useful visual confirmation that you've found
the right nerve. There are safety measures in place that limit the
amount of milliamps sent through the tip.
My procedure is as follows: I first use the ultrasound to find my
nerve on the ultrasound machine. For safety, I use the "in plane and
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