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Comment by bookofjoe | Hacker News Reader

For perspective, when I learned to do nerve blocks (UCLA Department of Anesthesiology, 1977-1980 residency), portable ultrasound for guidance was a pipe dream.

For the axillary approach to brachial plexus blocks, we tried to elicit paresthesias from actual needle impaction on nerves and then pulled back a tad and injected a bolus of anesthetic.

We did that repeatedly, aiming to deposit anesthetic near each branch of the plexus.

Failing that, hitting the brachial artery with the needle and then continuing to advance the needle until no blood could be aspirated, injecting half the intended volume of anesthetic (2% lidocaine with epinephrine 1:1000) behind the vessel, then withdrawing the needle until no blood could be aspirated and then depositing the remainder of the anesthetic on the front side of the artery was the technique of choice.

Diff'rent strokes.

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Oh, sure. From U/S experience I would guess that transarterial method was probably the most likely to work. Never did one, but was taught the concept and it looks like it would work.

Did femorals and popliteals by stim, it was quicker than ultrasound. Now that we have ultrasound everywhere, there’s no reason not to use it.

Residency 06-09.

One facility I worked at had a family medicine guy who was in the National Guard who asked me about field treatment. I mentioned Valium rather than Versed for reducing dislocations and fractures, and said that he really should find someone to teach him interscalenes by stim, I would teach him popliteals. Just to get those ankle fractures and dislocated shoulders comfortable until they could be evacuated (this is training, not combat, so plenty of troops don’t get moved until next day at least). Unfortunately this was as U/S was really becoming standard of care so it would be hard to justify teaching stim for a brachial plexus block - but he can’t fit that u/s in a field kit.

Surprised to find a bunch of anesthesiologists hanging around here. How come?

Last time I counted there were three or four of us, but bookofjoe is a prolific reader and poster courtesy of being retired.

We have a lot of down time during the day, just in very short increments. Thus the stereotype that we’re all crossword/Sudoku nerds. HN is something you can pick up and put down in a moment.

Also, I have always thought of the job as a sort of human engineering, or a big physiology lab. Programmers have REPL; we have vital sign monitors for instant feedback. Thankfully it is difficult to crash a human accidentally.

People think doctors bought computers early because they were rich. They could, but it’s worth remembering that if you were a science-and-math kid in the post-WW2 era, medicine and engineering would be the fields you would be pushed toward. That is not as prominent now as tech has started paying better and medicine less, but it’s still not terrible reasoning. I would have to screw up a lot to be unemployable, even if it did take me a lot of school to get to that point. Doctors bought computers because they looked fun.

Only one of my partners has an engineering degree (MechE). I majored in chemistry. Two pharmacists, one accountant. Don’t know about the rest.

"I have always thought of the job as a sort of human engineering, or a big physiology lab."

I like this. I used to tell med students doing a month-long rotation that the specialty could be described as a combination of applied physiology/applied chemistry/applied anatomy with the great thing being you get to find out if you were right in the moment/that day, rather than having to wait days/weeks/months/forever to learn if you had done the right things.

P.S. I majored in political science

P.P.S. ChatGPT-4o just told me that "The use of nerve stimulators for brachial plexus blocks became more widespread in the late 1970s and 1980s."

I never used a nerve stimulator — or US — for brachial plexus blocks during my career (I retired in 2015). I guess I was just so used to doing it the way I learned back in the Dark Ages that as long as I got good results, I kept on keeping on.

Also, if you're doing a locum in some backwoods hospital in a small town in Virginia, you're unlikely to find a working nerve stimulator, much less a portable ultrasound.

I suppose this is why they have a mandatory retirement age for airline pilots.

Cool! Thanks for the perspective. They found a Vernitrol (basically copper kettle) at an older hospital I do a side gig at that was set up for cyclopropane and some other agent a few years ago; I pointed out that you could still do anesthesia with it today if you fixed a couple of broken pieces. Neat to look at even if it didn’t have the circular slide rule to determine through-kettle and bypass flows at each temperature.

I think you and I do/did side gigs at the same hospital aka Little Sisters of the Poor

Haha! No, but let’s just say that that would be a very appropriate name for its current condition.

I might reach out to you with a few tidbits you might enjoy out of HN - while this nickname isn’t sterile, I don’t want to doxx myself too easily.

HN is my favorite place on the internet. I only wish I'd discovered it before I stumbled on it in 2016.

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