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.

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