American Society of Regional Anesthesia and Pain Medicine August 2016 - 5

Editorial - in Nabil's Corner
Collateral Damage
The subspecialty of regional anesthesiology and acute pain medicine
continues to evolve, and its fellowship training is now going through
the accreditation process. We now have guidelines and minimum
requirements for training for fellows and residents. After informally
surveying several colleagues from different institutions, the practice
model for the acute pain service (APS) can generally be described as
a group practice led by well-trained physicians, along with residents,
fellows, advance practice providers, or any combination of the
above. The team performs regional techniques and practices acute
pain management during the regular workday. After-hours coverage
varies by institution. Without a doubt, this team model offers
consistency in procedural performance and patients' outcomes and
provides a good learning environment for residents and fellows as
they train with experts in the field. However, this practice model
often leaves the remainder of the faculty group out of this APS pool.
Subsequently, their basic regional skills acquired during residency
training dwindle over time
until they get to the point at
which they are not comfortable
performing any peripheral nerve
blocks. These skills become
"collateral damage" for the
evolution of current practice
of regional anesthesiology
and acute pain medicine as a
subspecialty.

the APS because they likely do
not feel comfortable doing these
blocks any more.
So, where does this leave us? We are
left with more questions than answers.
However, it is good to start the
discussion. Dr Colin McCartney, chair
of the department of Anesthesiology
and Pain Medicine at the University of
Ottawa, recently visited our institution
and suggested that we can potentially
Nabil Elkassabany, MD MSCE
agree on a number (two, possibly
ASRA News Editor
three) of basic blocks with which all
anesthesiologists should be competent. This will allow us to provide
coverage for most surgical procedures around the clock. To do this, we
will need to change our expectations during residency training and also
create a system that maintains competence in practice for anesthesia
staff. Those who want to expand
their scope of regional anesthesia
practice should seek further
training. However, this approach
takes commitment to regional
anesthesia from the leadership as
well as individual motivation.

"Should regional anesthesia (peripheral
nerve blocks) be practiced by all
anesthesiologists? Or should it be
practiced by a subspecialty trained
group of physician anesthesiologists?"

This begs the question: Should regional anesthesia (mainly
peripheral nerve blocks) be practiced by all anesthesiologists?
Or should it be practiced by a well-trained group of physician
anesthesiologists? If the answer to the first question is "no," then
how can we logistically maintain competency in performing blocks
for the attending physicians who are not a part of the APS, and
which blocks they be competent to perform?
This phenomenon is most noticeable in mid-sized to large academic
centers where subspecialization within anesthesiology tends to be
the predominant model and coverage for the APS is robust enough
to field all requests for regional anesthesia around the clock.
We recently faced these questions in our institution. We are in
the process of implementing regional anesthesia as part of a
multimodal analgesia protocol for hip fracture patients as they
come to the emergency department. Our options are to
1. Train the emergency medicine physicians to do the blocks,
which starts a whole new debate as to who should be doing
these blocks.
2. Ask the call team to take on this responsibility if the admission
happens at a time that is not too busy. Obviously, we expect to
meet resistance from attending physicians who are not part of

This introduction takes us to an
article in this issue of the ASRA
News where Dr Stuart Grant
and colleagues describe their experience at Duke University in
tackling this very problem. They describe their experience getting
all anesthesiologists in the department to take part in offering
nerve blocks to hip fracture patients. You may find this experience
very helpful in your own practice. Next, Dr Mark Neuman gives us
an update on hip fracture outcomes research and introduces the
concept of pragmatic clinical trials and how this approach may be
the answer for some lingering questions in the field.
The opioid epidemic has received a lot of media attention lately. Dr
Chad Brummett shares his team's experience in an opioid recovery
campaign in Michigan. We also bring you another perspective
on prescribing naloxone for patients receiving opioid therapy for
chronic pain conditions in some states.
Most of you have probably encountered a patient with varying
degrees of nerve injury after surgery, which may or may not be
attributable to nerve blocks. You were probably not sure how to
handle the situation at the time. In this issue of the ASRA News,
we present to you the different points of view of the neurologist,
anesthesiologist, and the attorney on how to approach this
difficult situation. This issue is full of interesting articles covering
the spectrum of pain medicine and the regional anesthesiology.
However, you have to read it all to learn it all!

American Society of Regional Anesthesia and Pain Medicine
2016

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American Society of Regional Anesthesia and Pain Medicine August 2016 - 5
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