Infrastructure

THE CART AND THE HORSE

     Improving your nerve block program will come in the form of learning or improving technical skills or from organization of your infrastructure. I commonly emphasize in my lectures about the habit that most people have of focusing primarily or exclusively on learning technical skills in order to build their program. The first questions people ask when they have the chance are about the particular needle I use or the amount and concentration of local or why I choose a particular approach or what block I would do for this or that surgery. No one asks how we get the patient in the holding room early or how we let the Pharmacy know to have 7 pumps filled and ready next Wednesday morning.

     Early in my lecture, I show a picture of a guy on a chariot holding a whip (though I pretend that it is a very long needle) facing the wrong way with the horse behind him facing the same direction. It is obviously a ‘cart before the horse’ reference meant to remind everyone that without a good ‘horse’, it doesn’t matter how good you are with your needle. Though your program certainly will not go anywhere if no one knows how technically to do nerve blocks, if you have not invested in the organization of the program, it will not go anywhere for long. When I evaluate a program that is starting or struggling, I look at them in terms of ‘cart’ and ‘horse’ issues and find which areas are in greatest need of improvement. The cart represents technical skills, and the horse represents the organization of the system.

     Remember that if were not doing a lot of blocks before, your infrastructure is not going to be set up to accommodate the additional time spent in performing nerve blocks or know how to safely manage your patients. Though it may mean that ‘we are not set up to do all those blocks here’, it doesn’t mean that you have to keep things the way they are right now. There are certainly going to be some growing pains and some work to do, but typically it does not require the hiring of extra personnel to do the extra work. That is because there will be a significant decrease in work done ‘downstream’ after the nerve block is in place. Look at your own program in terms of ‘cart’ and ‘horse’ improvements that need to be made, and remember not to put the cart before the horse.