Category Archives: Regional Anesthesiology

Regional Anesthesia and Compartment Syndrome

Originally included in my editorial for the May 2013 issue of ASRA News.

ASRA News May 2013In the May 2013 issue of ASRA News, I want to highlight a special Pro-Con feature dedicated to the controversial topic of regional anesthesia and analgesia in the patient at risk for acute compartment syndrome.  I want to personally thank our surgical colleagues from the University of Alberta who were willing to write a thoughtful “Con” article for our newsletter.  Before jumping to debate each of their points, we need to give them careful consideration.  With the paucity of evidence-based recommendations on this topic, it is crucial to have an open honest dialogue between all members of the healthcare team.  This Pro-Con is not meant to provide answers but to provide talking points for an ongoing conversation.

In my previous position at UCSD, we had a Level 1 trauma center where we would keep one operating room (OR) set up and warm at all times for the occasional direct-to-OR resuscitation. We saw all types of acute and subacute orthopedic trauma, and no two cases were approached the same way. Did I consider regional analgesia for each of these patients? Yes.  Did I perform regional analgesia for all of them? No.

In order to have a meaningful discussion on this topic with our surgical colleagues, we must first be part of the conversation.  In the specialty of Regional Anesthesia and Acute Pain Medicine, this means emphasizing more the “Acute Pain Medicine” part than the “Regional Anesthesia” part.  The value that we bring to perioperative patient care must be more than just a set of interventional peripheral nerve and neuraxial block techniques.  We have to know when these techniques are and are not indicated and have other modalities for analgesia at our disposal when providing consultation on complicated trauma patients.  In addition, the service we provide cannot be time-limited.  How can we say that superior pain control is only available from 7 am to 5 pm not including weekends and holidays?

When it comes down to it, managing patients at risk for compartment syndrome is tough.  The benefits of analgesia have to be weighed with the potential for neurovascular compromise.  Sometimes you will perform regional analgesic techniques for them; other times you won’t.  Sometimes, you will place catheters that you can dose later when the risk profile improves; other times you may be consulted for help later in the hospital stay.  Sometimes you will convince the surgeon to preemptively perform fasciotomies in a patient in whom you anticipate a difficult postoperative course.  The context for this decision-making will vary from institution to institution, but ongoing communication with the surgical team is indispensible.  Be a consultant; be available; and continue to be part of the conversation.

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Global Humanitarian Aid and Medical Missions

Originally included in my editorial for the November 2013 issue of ASRA News.

ASRA News Nov 2013In November 2013 issue of ASRA News, we feature two very special articles that touch on the common theme of global humanitarian aid and volunteerism.  Our Resident Section Committee article by Dr. Anish Doshi provides us with an overview of the paucity of pain management and palliative care services in the developing world.  As a new column for ASRA News, the Member Spotlight, we present the amazing work of Dr. Randy Malchow and his team in bringing regional anesthesia and perioperative pain management services and education to Kijabe Hospital in Kenya.

I should say that the contents of this editorial/blog are my own opinions and do not necessarily represent the official views of ASRA.  The subject of medical volunteerism and global humanitarian aid is important to me, having personally participated in multiple medical missions to underserved communities in the Philippines and Ecuador over the last decade.  Many of our ASRA members have dedicated their time and resources to similar causes at home and abroad, and the American Society of Anesthesiologists (ASA) has its own Global Humanitarian Outreach (GHO) Program.  The statistics related to anesthesia and pain management in the developing world are quite shocking.  It is not uncommon for developing countries to have a ratio of less than 1 anesthesiologist for every 100,000 people!  In the realm of pain management and palliative care, the article by Dr. Doshi is particularly eye-opening and should serve as a strong motivator for our members to get involved in helping the underserved.  What is the best way to do that?

The GHO offers a search engine for ASA members to look up volunteer opportunities abroad.  Not everyone can take weeks or months off work to travel to far-away places.  I have been fortunate in that my wife and I have been able to volunteer together—that is, until recently when we started our latest adventure (parenting).  In addition, although not naturally a cynic, I find myself questioning the real difference certain medical mission groups make.  Even though the before and after photos look great, how much difference does it make to a community when a medical mission group swoops in, repairs some cleft lips, and leaves without every returning?  Yes, I understand the social stigma associated with congenital deformities; I have seen it firsthand.  However, I also know that there is a bigger picture to consider—patient education on nutrition, prenatal care, and health care maintenance; access to basic resources, including food, shelter, and transportation; and infrastructure improvements that are required to sustain change.  Furthermore, does this paternalism actually do damage to future relationships with local health officials and governments within the countries in need, especially when late complications arise after the medical mission groups are long gone?

When you read Dr. Malchow’s article, one of the most impressive features of this program is its sustainability.  Not only does this volunteer group provide medical and surgical services to patients in need—a critical part of its “mission” is education of local providers.  Under the direction of Dr. Mark Newton, the Vanderbilt International Anesthesia (VIA) program is engaged in an ongoing relationship with Kijabe Hospital; and by training future generations of local anesthesia providers, VIA is raising the quality and safety of anesthesia and pain management services for the entire region.  One of the most important messages in Dr. Malchow’s article is that you don’t have to fly to Kenya to make a difference.  VIA would not be able to accomplish its goals without the countless people who have donated medical supplies and money for equipment and shipping.

I have been very fortunate to have joined medical mission groups that generally return to the same communities year after year.  One of the most rewarding aspects of participating, in my experience, has been developing relationships—with team members, local physicians and nurses, students and residents, government officials, and patients and families.  Although we can congratulate ourselves on what we have accomplished so far, there is still so much work left to do.

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Essentials of Regional Anesthesia Now Available

essentials-of-regional-anesthesiaThe textbook Essentials of Regional Anesthesia is now available from online booksellers. All of the chapters are written by Regional Anesthesia fellowship directors and fellows and cover various topics including regional anesthesia procedures and acute pain management for complex patients of all ages and various co-morbidities. This book is full of clinical pearls and also includes over 400 test questions based on the book’s content to assess your knowledge of the subject matter. My chapter, co-authored by my wife who has been educating nurses on regional anesthesia techniques and acute pain management for years, focuses on the practice management aspects of regional anesthesia and offers strategies to develop effective systems that emphasize teamwork with all providers involved in caring for the perioperative patient.

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Point of Care Resource for Regional Anesthesia

visual-guide-to-regional-anesthesiaThe Visual Guide to Regional Anesthesia

This companion to the recently-released Manual of Clinical Anesthesiology (Chu and Fuller, eds.) focuses on what the clinician needs to know when performing the latest ultrasound-guided regional anesthesia procedures. The format of this book is compact and spiral bound, filled with useful cognitive aids, and each page is laminated to make it fluid-proof (perfect for the operating room).

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Stanford Regional Anesthesiology and Acute Pain Medicine Fellowship

stanfordThe application cycle for the 2014-15 Stanford Regional Anesthesiology and Acute Pain Medicine Fellowship class is still open for 1 off-cycle spot scheduled to start in Winter 2015.  The application cycle for 2015-16 is also open now and will remain open until Summer 2014.  I co-direct this training program along with Dr. Lindsey Vokach-Brodsky.  In addition to being the only fellowship in this specialty located in Northern California, the Stanford program provides its fellows with a unique training experience in a beautiful setting.  Throughout the training year, various clinical rotations at Stanford Medical Center, Stanford Medicine Outpatient Center, and the VA Palo Alto immerse fellows in an environment focused on teaching them advanced regional anesthesia techniques and perioperative pain medicine.  Fellows have ample opportunity to participate in clinical research projects and to teach basic and intermediate techniques to residents and other practitioners at educational workshops and study anatomy in the cadaver lab.

 

If you are interested in applying, please see the Stanford Anesthesia website for further information.  To compare programs, visit ASRA.com.

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