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Discussing the use of ultrasound for pain management

by Gus Iversen, Editor in Chief | May 03, 2022
Ultrasound
Dr. Arun Nagdev
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.

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