Arun Nagdev, M.D., is senior director of clinical education at Exo and the director of emergency ultrasound at Highland Hospital, as well as a clinical associate professor of emergency medicine at the University of California, San Francisco (UCSF). He’s been using point-of-care ultrasound (POCUS) for decades to deliver improved patient care and even started the POCUS program and fellowship at Brown University. Exo recently had this conversation with him related to using ultrasound for pain management.

HCB News: How does ultrasound help in pain management for patients?
Dr. Arun Nagdev: About 20 years ago, forward-thinking anesthesiologists recognized the utility of using ultrasound technology to visualize the location of nerve bundles. At the time, most anesthesiologists were performing landmark-based blocks with the help of nerve stimulators. As ultrasound became more commonplace and technology allowed for smaller “point-of-care” systems, more anesthesiologists employed ultrasound guidance to increase their nerve block success while reducing mechanical complications (hitting vasculature or other structures). Over the past two decades, ultrasound-guided regional anesthesia has grown tremendously, allowing clinicians to perform these critical procedures safely in all patients.

HCB News: How does this use case specifically apply to emergency medicine?
AN: About 15 years ago, my colleagues and I were thinking about our population at an inner-city county emergency department (ED). Our hospital anesthesiologists were not available to come down to the ED whenever a patient had a painful acute injury (especially in the middle of the night). Our standard arsenal for pain control was intravenous pain medication and primarily opioids. Also, when we had to drain a large abscess or reduce fluid in a dislocated joint, our standard procedure was to put patients to sleep (procedural sedation), which involves a large amount of nursing and physician resources, often making patients wait even longer. Ultrasound-guided pain management with nerve blocks was an amazing solution for our ED’s challenges. We wanted to offer excellent care and pain control to populations that didn’t have the resources that other large academic centers offer. With help from our anesthesiology colleagues from various academic centers, we learned how to perform ultrasound-guided nerve blocks for the needs of the emergency department patient (different in some ways than why and how our anesthesiology colleagues perform these procedures). These blocks were the starting point for our entry into using ultrasound as a method to effectively take care of our patients. We initially started publishing our experience of offering pain control for our patients with hip fractures and hand injuries. This initial entry into a more active method to control our patient’s pain, slowly grew into more varied indications, leading to our department becoming the leader in ultrasound-guided nerve blocks in emergency medicine. Even though we saw the utility right away, many of my colleagues around the country thought it was a niche concept that would only happen in hospitals like ours (smaller and lacking 24-hour anesthesia coverage). With the rise of the opioid epidemic there came a rapid desire to employ a multimodal pain management strategy, making ultrasound-guided nerve blocks suddenly an important cornerstone of care in the emergency department. I guess we were just a little ahead of our time.

HCB News: When did you personally start using ultrasound for guidance?
AN: That’s an important term. Ultrasound for guidance has been around for a while—since I think the mid-nineties—as people have been using ultrasound to put in central lines, intravenous lines into the deep circulation via the neck or groin, and other peripheral lines like upper and lower arm veins. Using ultrasound at the bedside to safely guide your needle seems obvious now, but was radical only a couple of decades ago. I have been giving an ultrasound-guided procedure talk at our national conference for American College of Emergency Physicians (ACEP) for the past decade and I can see that a growing number of clinicians are learning procedures with the aid of ultrasound, making the process safer for patients. It is really amazing, how ultrasound visualization has changed the way that almost all procedures are performed in the emergency department and intensive care unit (ICU).

In terms of using ultrasound for nerve blocks, we can see from our colleagues in anesthesia that visualization increased safety as well as allows the deposition of anesthetic in the correct location. There are numerous well-respected and well-published anesthesiologists who are pushing the limits of ultrasound-guided regional anesthesia so that patients get the best pain control in the safest possible manner.

HCB News: Can you think of a specific use case that made you a believer in using ultrasound for pain management?
AN: I have a ton. It always comes down to the patients. A few years back I had just arrived at a clinical shift in a small rural hospital in central California. Another emergency physician was signing out (leaving for the day) and informed me of a young man with an arm injury that was being transferred to the regional academic trauma center because of the need for orthopedic surgery to repair his arm. The patient had suffered a degloving injury of his hand/arm while working with farming machinery – he had essentially gotten his arm stuck in a conveyer belt and stripped skin and muscle off the arm. After receiving a large amount of opioids from the doctor, the patient was still in extreme pain, literally crying. The analogy I commonly use to help people understand the power of a block is when anyone goes to the dentist, the injection or “block” the dentist performs numbs the jaw. The commonly used anesthetic, Lidocaine, numbs the nerve so that the dentist can work on your tooth without pain. You would not want him/her to give you some ibuprofen and then drill into your tooth. Anyway, I walked over to the patient and performed a brachial plexus block using ultrasound with a long-acting anesthetic. In about 5 minutes the patient’s pain had started to decrease, and he fell asleep in 15 minutes.

I went on to see other patients in the emergency department when the mother of the patient came up to me. She hugged me and started crying on my shoulder, thanking me for taking care of her child. She told me that she could not have watched her son suffer any longer. Seems trite, but the case made me realize that taking an active role in offering great pain control to my patients is central to my job. I have taught these ultrasound-guided blocks to numerous emergency medicine physicians around the country, and I often get emails of similar stories. This reinforces my desire to continue my educational efforts to help clinicians understand the importance of using ultrasound to assist in great pain control.

It seems to be a nebulous term—doctors taking care of somebody’s pain—as it should be something all doctors do. But it’s not always easy. Giving doctors different methods to address pain, be it an ankle sprain or a tooth infection, is an important skill to teach. Having pain control tailored around the injury rather than just a simple algorithm of pain meds must be something we teach the next generation of clinicians. Learning how to incorporate ultrasound specifically for nerve blocks is an important skill for any emergency medicine provider today.

HCB News: Let’s talk more about the multimodal approach you hinted at. Many parts of the United States are reeling from the opioid epidemic. How can ultrasound for pain management help groups impacted by this crisis?
AN: This is a complicated question. I think the opioid epidemic is a complex problem and I don’t want to ascribe it to one thing because it removes its complexity and difficulty. It goes deeper than just pain, but some data point out that giving patients long-term opioids for pain control can lead to dependence. Thinking of pain as monomodal with increasing opioid doses as the only pathway has been shown to cause downstream problems.

If clinicians are thinking more about multimodal therapies, we have more choices: opioids, ketamine, acetaminophen, NSAIDs delivered intravenously, nerve blocks, etc. This multimodal way of thinking of controlling our patients’ pain reduces the reliance on opioids. A simple example is when we manage pain in elderly patients after suffering a hip fracture. The classic teaching is to give intravenous morphine (or another opioid), but we have learned that along with increasing rates of confusion, this monomodal pathway can cause patients to stop breathing or lower their blood pressure to a dangerous level. I want more physicians to use the minimal effective dose of a drug, add in another drug or perform an ultrasound-guided nerve block. It’s the job of the clinician to think about the patient and offer them great care, which is the central tenant of multimodal pain management.

HCB News: How do you think clinicians will use ultrasound-guided nerve blocks in the future? How will it evolve?
AN: When I started as an emergency physician, ultrasound-guided nerve blocks were niche. Now it’s a hot topic in emergency medicine because we’ve realized that pain management in the opioid epidemic is complicated and an integral part of our job. It’s part and parcel of the emergency physician’s job to treat pain in a multimodal fashion, be it intravenous medications or nerve blocks. Organizations like the American College of Emergency Physicians (ACEP) recognized the need for emergency doctors to integrate this skill into their practice. It’s slowly becoming more common as centers are teaching all their clinicians how to perform ultrasound-guided nerve blocks. Large health systems like Kaiser Northern California have protocolized ultrasound-guided femoral nerve blocks for hip fractures in their emergency departments. I think the change has started and I am very excited to see smart clinicians pushing for a patient-centered outcome – better safe pain management.

HCB News: What sort of technological changes do you foresee happening or needing to happen to better accommodate this use of ultrasound for pain management?
AN: I think we’re at the nexus or tipping point for ultrasound. In the next couple of years or so, we will see exceptional technologists build probes that are inexpensive, easy to use, and easily integrated into the current medical IT infrastructure. To use a camera analogy, the functionality and technology on our camera phones rival that of the larger DSL cameras that many of us owned a decade ago. This miniaturization comes from both hardware and software innovation. I think this is quickly happening in the world of point-of-care ultrasound (POCUS). The beauty of this technology is that, along with making products that every physician will carry in their pocket, it will allow for improved patient care. Doctors, nurses, and paramedics will detect diseases earlier, make more objective decisions based on imaging, and change the way we will practice medicine. I am really excited for the future of medicine.