Safety

ANOTHER ARROW IN THE QUIVER

     I was happy to receive a round of texts this morning from a good friend of mine about a case that he had just performed. My friend, Dr Chip Criswell, has become quite proficient at performing ultrasound-guided nerve blocks, and I could brag about him and about other cases that he has performed that have had amazing results. Today, he was challenged on multiple fronts and, certainly in my opinion, he came through like a champ!

     Dr. Criswell was at a facility where he did not have ultrasound access (nor the equipment or infrastructure support for continuous nerve blocks -which is the only thing that would have made this story even better!) and had an elderly woman going for a distal radius ORIF. This patient had a pneumonia, and he could hear her wheezing from the hallway outside her room. He is, like myself, more of a supraclavicular block person than an infraclavicular block person, but without ultrasound availability and potentially greater negative effects from a phrenic nerve palsy, he was not comfortable with his ‘go to’ supraclavicular approach. He successfully performed a single-injection infraclavicular nerve block with nerve stimulation and avoided intubation of this patient. He used an oxygen mask and gave her a total of 2mg of versed for the case.

     So, what would you have done? Do you have another arrow in your quiver that you could have reached for in this extenuating circumstance? Do you have another arrow in your quiver beyond a general anesthetic? Do you think that Dr Criswell had a meaningful impact on this patient and her recovery? I will be interested to hear the rest of the hospital course, but I am thoroughly convinced that this patient’s outcome will be improved because of his knowledge and skill and because of his willingness to extend himself several years ago to learn the techniques he employs today. More to the point, because of his extensive ongoing utilization of his ‘usual’ techniques, he was more capable of extending his ability today to overcome additional obstacles in order to provide optimal care for his patient.

     Utilizing these techniques does have an obvious impact on analgesia. What I hope you can see from this ‘real life’ scenario is that once you have made the commitment to add these arrows to your quiver, you will have opportunities to impact patient outcomes as well as the ability to improve the safety of the anesthetics that you choose to perform. For example, is it too crazy to think that this patient had fallen just after eating lunch and that her fracture was open (or there was vascular compromise)? Again, kudos to Dr Criswell for providing exceptional care…and hopefully providing some meaningful motivation for you and the rest of your practice!