June 8, 2022 • 22 mins
The overuse of opioids in health care over the last two decades has had devastating effects. The development of the ultrasound-guided nerve block has revolutionized the field of anesthesia and is part of an important and necessary shift in the conversation about how we manage pain. Not only championing its use in the surgical setting, Joseph Marino, MD, Northwell’s senior vice president for anesthesia, is now expanding its use to emergency departments in Staten Island, Westchester and Long Island.
The team responsible for implementing this approach at Staten Island University Hospital share their experiences using the femoral nerve block for certain painful ailments, like hip fractures. They include:
- Joshua Greenstein, MD, Assistant Medical Director, Department of Emergency Medicine
- Maria Tama, MD, co-director, division of emergency ultrasound in the hospital’s Department of Emergency Medicine
- Simone Rudnin, DO, co-director, division of emergency ultrasound, Department of Emergency Medicine and director, emergency medicine clerkship
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Marino (00:02):
What's so beautiful about the nerve block
is that, God forbid, if you fracture your hip, you're going to come in
and people are going to perform a procedure that takes seconds and is
going to give you significant pain relief without the adverse effects
of morphine-like drugs.
This will be standard of care across every Northwell facility.
Host (00:30):
Welcome to 20-Minute Health Talk.
I'm your host Rob Hoell. The overuse of pain medications and narcotics
like opioids in health care over
the last two decades has had devastating effects.
Our guests today are leading the way in expanding the use of nerve
blocks.
The use of this long-lasting regional anesthetic has revolutionized
the field of anesthesia and is part of an important and necessary
(00:54):
shift in the conversation about how we manage pain
joining us in the studio is
Dr. Joseph Marino.
He is Northwell's senior, vice president for anesthesia who is not
only championing
the use of nerve blocks in the surgical setting.
Now expanding its use to other services, including emergency
departments; a game changing move that has immediate and potentially
(01:15):
life-saving results.
Here to share their experience and joining us virtually in implementing
this novel approach in an emergency department setting are:
Dr. Joshua, Greenstein, assistant medical director, the department of
emergency medicine at Staten Island.
Dr. Maria Tama, co-director for the division of emergency, ultrasound and
(01:35):
Dr. Simone Rudnin, co-director division of emergency ultrasound.
So, we'll get started with a question for you.
Dr. Marino. Tell us what exactly is a nerve block?
Dr. Marino (01:45):
So a nerve block is nothing more than the placement
of Novocaine or local anesthetic around the nerve.
visa-vie a needle tip. Under the guidance of an ultrasound probe
we're able to visualize the needle tip and also visualize the
novocaine or local anesthetic.
(02:07):
Bathe the surrounding nerve.
Host (02:10):
So, basically, what it's doing, it's like almost big being at the
dentist.
It's numbing the area, so you're not feeling pain, but you're not
feeling High?
Correct
That's awesome.
So you're saying that nerve blocks have revolutionized the field of
anesthesiology in the last two decades.
Why?
Dr. Marino (02:26):
So I just want to give the visual to the patients and two people out
there.
We used to put people to sleep and the only mechanism that we had to
treat their post-operative pain was intravenous morphine-like drugs
or narcotics.
So typically, you would find a patient in the recovery room
(02:47):
holding an emesis basin
nauseous and potentially vomiting because of the side effects
of that opioid and also very drowsy and very sedate.
In certain cases, if there was too much morphine or too much opioid given
there would be some respiratory rate or breathing decrease issues.
(03:12):
So, opioids, and I'm talking not too far ago
I'm talking probably 15 years ago, were the mainstay of post-operative
pain therapy. Now because of the advent of the nerve block, and the
ability for us
to anesthetize a certain part of the body that had surgery performed
(03:36):
on it
virtually eliminates the need for these post-operative opioids.
Host (03:42):
Dr. Greenstein the team at Staten Island University.
Hospital began using femoral nerve blocks for patients into the
emergency department in 2021.
Tell us about how this got started started.
Dr. Greenstein (03:52):
It started becoming described in the literature in the last decade, but it
really wasn't standard care.
I myself graduatedin 2015.
Never did a single one of these procedures who during my residency and so we
didn't really have the staff that was really trained to do it.
Even though it was something we thought we thought we'd be able to do.
We put a lot of needles
next targets.
We use ultrasound in many different procedure itself.
(04:13):
So Dr. Marino, the real visionary along with power chair at the time.
Dr. Birol, who's now, the associate medical director came together
and we said, how can we make this a reality for our patients?
How can we train our staff? Help
Provide some education. And furthermore it was a little complicated because
a lot of these patients were doing this for patients with hip fractures
So they're being admitted to other services.
Other surgeons are taking care of the patients.
(04:34):
They're gonna have to deal with the procedure that we do, and they're
going to manage it.
And so it's kind of like we're handing off or procedure and they're
going to then be left with the patient and self.
And so, we brought all the players involved, we brought
orthopaedics, we brought
Trauma, anesthesia, kind of explained what we're going to do.
We got brought in from all the major players, and we were able to
accomplish it.
And we're currently, we're aiming to get 100% by September of this
(04:55):
year.
We're currently at 70% of our emergency medicine, physicians, are all
trained
how to do this and
credentialed.
That's really really revolutionized
how many are getting it
Because instead of being one in a few that know how to do it
70% are doing it.
So, when you have this patients, it's not like, oh, I don't know how
to do it.
It's when can we do it?
Host (05:13):
Dr. Greenestein just talked a little bit about training
emergency room physicians in the use of femoral nerve blocks.
Dr. Rudnin
Can you tell us a little bit more about that process?
Dr. Rudnin (05:22):
Sure. So the ultrasound division in the ER is ensuring that all of our Ed
providers
are receiving training to perform these procedures. Our residents get
every several months, a procedure lab where they get to practice it.
Our attendings also.
We do faculty development for that.
(05:44):
So they have simulators where they can actually practice these
procedures and they ultimately get credentialed and are very excited
to go ahead and continue and providing these procedures to actual
patients.
Dr. Tama (05:57):
And we also
review a lot of these cases.
And so a lot of the residents and attendings are kind of still
reaching out to us.
Like, oh, we did this nerve block, can you take a look?
So we're still kind of, you know, making sure everyone's following the
rules and doing it appropriately.
Host (06:16):
It's awesome to hear about that enthusiasm Dr. Tama
right now, emergency departments at Northwell
are starting with femoral block, but there are many types of
nerve blocks. Are there plans expanding training to emergency
physicians in uses for others?
Dr. Marino (06:30):
So I love the question and just like the Staten Island team and I were
envisioning bringing this powerful tool to treat hip fractures
vis-à-vis, the femoral block and that can can essentially eliminate
pain leg knee
(06:52):
foot, if we have to. We already have visions of expanding the use of
ultrasound-guided nerve blocks for
Upper arm problems.
So somebody comes in with a shoulder dislocation or a
laceration to the arm, shoulder or hand
God willing
If we continue on this path of innovation, we're going to be able to
(07:16):
in service our emergency medicine physicians, in partnership and
collaboration with the anesthesiologist, to do these upper arm or
upper extremity nerve blocks and provide a reduction in pain.
A reduction in need for opioids and significant patient satisfaction.
Host (07:35):
So where exactly are the nerves that get the nerve blocks in the human
body?
Dr. Marino (07:40):
Yeah.
So, you know, I'm going to give you a little bit of an anatomy lesson
here.
So the brachial plexus or the upper extremity nerve bundle is just
above the shoulder and we could place novocaine around that brachial,
plexus to essentially numb the shoulder entire arm
and hand. The lumbar plexus is where the femoral nerve is located in
(08:04):
the groin.
And then the abdomen has a variety of different areas that we could
inject novocaine in under ultrasound guidance, to significantly
reduce some of those more provocative surgical operations of the
abdomen, like a hernia operation or a C-section.
Host (08:24):
It's great
Dr. Tama what types of patients are using are using nerve blocks for?
Dr. Tama (08:30):
So, the majority of patients are ones with hip fractures.
Sometimes, we'll get femur fractures as well.
You also can use it for patients that have like really bad laceration or
patients that have a significant burn to the thigh
We're kind of on the lookout for that. But those are other potential
uses for this nerve block.
Host (08:53):
Yeah.
I mean, I would imagine it hip fractures and extremely painful and
difficult to deal with.
So Dr. Marino
How does
the nerve block compared to the standard approach in this situation and
what has been the reaction from the patients who received the nerve
block?
Dr. Marino (09:08):
Yeah.
So excellent question and the reaction has been, you know, needless to
say, high satisfaction scores.
So, you know, just think about it.
Somebody is going to church.
They fall on the concrete and they don't know if they have a fractured
(09:28):
hip, but it's really
uncomfortable.
And by the time they get into the ambulance and bounce around on the
gurney, get taken to the hospital. Bounce Around even more.
That is a very provocative experience for the patient.
And again in the past all we did in all we had were IV morphine like
injections for these patients.
(09:49):
Now it worked it would take a little bit of the edge of the pain away.
But if you moved that patient, the pain would still be there.
And what's so beautiful
about the nerve block is that you can move these patients.
And the movement will not provoke that serious pain that you see with
(10:11):
the with the IV narcotic injection.
So, not only does it eliminate the need for narcotic, or I should say,
significantly reduce - its opioid sparing - but the movement of the
patient is appreciated with significant less provocation.
Host (10:28):
And when you talk about collaboration, you can only see this spreading
and the Innovation growing, you know, not only in Northwell but
in other places.
Dr. Marino (10:35):
Is correct hundred percent?
Yeah, it's only a matter of time.
I mean now we piloted this at Staten Island in their Brilliance and
success demonstrated that it works and it's safe.
We're rolling it out at South Shore [University Hospital] and before you know, what Northern
Westchester [Hospital], Phelps [Hospital], [LIJ] Forest Hills, they're all going to be a part of it.
(10:55):
And then before, you know it this will be standard of care across
every Northwell facility.
God forbid.
If you fracture your hip you're going to come in and people are going
perform a procedure that takes seconds and is going to give you significant
pain relief without the adverse effects of morphine like drugs
Host (11:14):
Dr. Tama.
What do you say to a patient?
Obviously, a patient's going to come in and excruciating pain and they
might be demanding, you know, some sort of pain medication.
What do you say to them?
And how do you can convince them that this is the right move?
Dr. Tama (11:26):
So it does take some finesse definitely, because it is something new
that a lot of patients or their families are not familiar with.
We tell them kind of what to expect.
And then we tell them that later on
they won't be able to move their legs and kind of the expectations of
what they should feel after the block is done and when it's done
correctly. And everyone is like signing the consent form, like right
(11:49):
then and there like a sure, sign me up.
No problem.
It definitely kind of
starts their treatment from the beginning
they walk into the emergency department.
and helps them kind of move along through
the hospital stay quicker.
Host (12:04):
So, Dr. Rudnin
does learning something like this, make you a better
physician?
Dr. Rudnin (12:10):
So learning a technique like a nerve block, as long as we were
familiar with the anatomy hitting that nerve kind of came as second
nature
once we were comfortable with the anatomy. When it comes to making you
a better physician
Absolutely.
You're able to do a procedure that spares a patient significant pain
without providing them, you know, the potential effects of opioids.
Dr. Tama (12:36):
Yeah, and the definitely the patients feel that also
We've had a few cases where we've had patients request, you know, they
didn't, they did not get their surgery within 24 hours because of
other Hospital complications and they have actually called and
requested to have the emergency department come and do another nerve
block.
(12:57):
And so they definitely feel the benefits of it as well.
Host (13:01):
Dr. Greenstein how satisfying is it to be leading this effort and to be
helping to, to get this message out and to be training others?
Dr. Greenstein (13:08):
Yeah.
I mean, it's absolutely amazing.
That what's really amazing is when the patient's family finds in the
hallway, the next day they tell you about how, like their mother,
their grandmother got a good night's sleep or how they didn't
take his another dose of pain medication till the surgery.
That's really get the ultimate satisfaction.
So, it's really great thing, and it's gone really
Well.
We've had no issues.
(13:31):
Using the ultrasound has really made it straightforward and simple
so it's really awesome.
Host (13:42):
We sort during Covid, such an increase in opioid use in opioid
overdoses.
While still necessary.
In some cases.
These dangerous narcotics can lead to addiction. About three to four
percent of patients undergoing
elective surgery who have never taken an opioid develop a dependency.
The addiction rate is higher for some types of procedures, and we
know it's also associated with longer hospital stays and a higher
(14:04):
rate of readmission. Can nerve blocks help stem that tide.
Dr. Marino (14:09):
Oh, it's always
Back to, you know, the concept of treating pain.
So procedurists in general, that would perform a surgical procedure,
would typically give a patient, you know, a couple of week or a month
supply of opioids.
We no longer do that.
We Now understand that giving a patient the appropriate dose of a pain
(14:32):
medication.
After a surgical procedure 3 to 5 days-worth; getting a nerve block,
which is going to essentially
significantly reduce the amount of pain in that very provocative first
post-operative day and then allow the pain to the patient to
transition to their pain medication for a three to four day
(14:55):
period is exactly how the medical community is looking to.
address and define success in reducing opioid dependency in surgical
population.
Host (15:05):
Have you seen any data yet showing that how this is reducing
addiction?
Dr. Marino (15:10):
So that's what the Statin Staten Island team and I are planning on
doing this collecting data.
So we have years of data of not doing a femoral nerve block and seeing
how much morphine like medication patients with a hip fracture
typically have received, and now, we're going to compare
this new cohort of patients that have received the femoral nerve
(15:34):
block and we're going to look at variables like how long it took them
to go to surgery?
What their Hospital length of stay is.
And without question what their pain scores and morphine consumption
was. And I think it's going to be easy to show that the morphine
consumption and the pain scores are significantly lower leading to
(15:55):
higher patient satisfaction scores.
Definitely, and Dr. Marino I'd like to add, I think also
So the patient outcome is going to be not only are they going to have lower
morphine, but their outcome; they'll be ambulatory more quickly
after surgery.
I think the all those things that you want, you want the person that
fell and has a fracture to be the same person before the surgery as
they are after the surgery.
This is going to help a lot.
Host (16:16):
We've been talking about using one type of nerve block in emergency
departments, but
Dr. Marino
How commonly do nerve blocks
get used in the surgical setting and at Northwell
what is the ratio of patients getting nerve blocks compared to
those other methods of pain management?
Dr. Marino (16:29):
I would say it's the overwhelming majority of patients who were having
some sort of a provocative Orthopedic procedure.
So total knee replacement, total hip replacement, total shoulder
replacement, standard of care is to get what we call a regional nerve
block.
In addition to some sort of either general anesthetic or sedation.
(16:51):
So that when the patient does wake up from the surgical procedure,
their body part is totally numb.
Host (17:00):
And what about when when, when it wears off the 18 to 24 hours is up
then just the pain come back?
Dr. Marino (17:06):
So we teach the patient that as they're getting that numb and tingling
feeling starting to come back because, you know, when the numbness is
starting to wear off, they should start their oral pain medication
regimen.
Host (17:21):
Ok. And what is that mostly is that mostly like ibuprofen?
Dr. Marino (17:23):
it's a, it's usually, a combination of Ibuprofen and Tylenol and a
very, very light narcotic.
Host (17:30):
Are there any side effects?
I know like sometimes with opioids, you could you get nauseous, you
could vomit, you could have itching.
Is there any side effects with with a nerve block
Before when we were doing the Poke and hope approach
We would put our finger on the femoral artery because the femoral
nerve lies right next to it.
And we would place the needle tip right next to the nerve.
(17:52):
And again, we would poke through the skin and hope that the local
anesthetic or novocaine was bathing
The periphery of that nerve.
Well, sometimes the needle tip would enter into a blood vessel and
that's not where that local anesthetic should go.
If that was the case, the patient may be afflicted with something called
(18:16):
local anesthetic before when we were
Where when the body when the blood vessels absorb quickly the local
anesthetic that is not a good place to be. Patients can get very
dizzy.
They could get numbness
around their lips; and in severe cases, it could lead to a seizure.
So the ultrasound has virtually eliminated that concept that Prospect
(18:40):
and that's why we're all as practitioners feel like we have power in
our hands.
So this is all exciting stuff, you know and here on 20-Minute Health Talk
We always like to end on a positive note.
So I like to ask each one of you, what gives you hope what gives you
optimism going forward and I'll start with you.
Dr. Rudnin.
Dr. Rudnin (19:00):
So, what gives us hope at least for me is the fact that patients their
overall satisfaction is going to be increased.
They're going to be having a significant reduction of their pain
without having the detrimental side effects of opioids
Host (19:16):
Dr. Tama, what gives you hope but gives you optimism.
Dr. Tama (19:21):
This collaboration that we have with anesthesia
gives us hope.
I think that
as physicians we want to encourage each other to continue to do better
and this kind of multidisciplinary team work
really gives me hope that there's so much more that us as emergency
department
doctors can do for our patients and even started from the beginning
(19:44):
because we are the entryway to the hospital.
So I definitely think that this opens the door for so much more work.
That could be done for them.
Host (19:53):
Has there been any
pushback from Physicians?
Because sometimes,
People don't want to do different things.
They're kind of set in their ways.
Dr. Greenstein (20:04):
Yes, I would say that.
That was probably one of my biggest concerns was teaching, you know,
new trick to some people that have their set ways and how they
managed their practice and manage other things.
And once somebody learned how to do it and do just that one of them
and saw the impact on the patient's, they want to do it, like they
wanted to become in their practice.
So we've been able to just want to none like people do one of them
(20:25):
like, oh, I need to do it for every single one of patients.
So it's really been amazing.
And that's really the hope for me is that we bought into this, this
culture of nerve blocks
is that the sky's the limit
We're a burn center here.
We have so many terrible burns of the extremities, imagine we can provide
them with an anesthetic right to that to the nerve, give them 18 hours
of pain control instead of pain medicine after pain medicine and pain medicine,
(20:47):
and the outcomes could be great.
Host (20:49):
Dr. Greenestein I loved how you answered both of those questions right
there.
Dr. Marino, what gives you hope?
What gives you optimism going forward?
Dr. Marino (20:56):
So, I'm the old guy of the group and you look at these three.
brilliant young physicians to my right. You know, sometimes I come off
as The Nutty Professor.
Hey guys, I got this idea.
I think it's going to work.
I think it's going to have an impact on patients and you really don't
know what the feedback or the buy-in is going to be.
(21:17):
But my hope really lies and I'm really echoing what
Maria said before, which is it all comes down to Innovation.
So if you change your thought process and you have
Courage to ask a question and then you have these young spirited,
brilliant minds
that look at you and have enough trust in you.
(21:38):
And to say, okay.
Let's try this.
Let's make sure if we're going to do it
Let's do it right.
But let's try this.
And just because of our partnership.
We're already able to impact people on a real visceral level, and my
hope lies in that.
As long as we continue to come up with the idea.
(22:00):
Continue to have the courage to ask the question.
Always try and overcome the hurdle, find the yes.
And together you could see that there are differences in generation
because of the age gap. But because of these brilliant minds, my hope
lies in them.
Host (22:18):
Thank you all so much for joining us here on 20-Minute Health Talk.
It was a great conversation.
Thank you.
Dr. Marino.
Dr. Greenstein.
Dr. Tama and Dr. Rudnin.
And thank you.
The Listener for tuning in.
I'm Rob Hoell
Have a great day and stay safe.
What's so beautiful about the nerve block
is that, God forbid, if you fracture your hip, you're going to come in
and people are going to perform a procedure that takes seconds and is
going to give you significant pain relief without the adverse effects
of morphine-like drugs.
This will be standard of care across every Northwell facility.
Host (00:30):
Welcome to 20-Minute Health Talk.
I'm your host Rob Hoell. The overuse of pain medications and narcotics
like opioids in health care over
the last two decades has had devastating effects.
Our guests today are leading the way in expanding the use of nerve
blocks.
The use of this long-lasting regional anesthetic has revolutionized
the field of anesthesia and is part of an important and necessary
(00:54):
shift in the conversation about how we manage pain
joining us in the studio is
Dr. Joseph Marino.
He is Northwell's senior, vice president for anesthesia who is not
only championing
the use of nerve blocks in the surgical setting.
Now expanding its use to other services, including emergency
departments; a game changing move that has immediate and potentially
(01:15):
life-saving results.
Here to share their experience and joining us virtually in implementing
this novel approach in an emergency department setting are:
Dr. Joshua, Greenstein, assistant medical director, the department of
emergency medicine at Staten Island.
Dr. Maria Tama, co-director for the division of emergency, ultrasound and
(01:35):
Dr. Simone Rudnin, co-director division of emergency ultrasound.
So, we'll get started with a question for you.
Dr. Marino. Tell us what exactly is a nerve block?
Dr. Marino (01:45):
So a nerve block is nothing more than the placement
of Novocaine or local anesthetic around the nerve.
visa-vie a needle tip. Under the guidance of an ultrasound probe
we're able to visualize the needle tip and also visualize the
novocaine or local anesthetic.
(02:07):
Bathe the surrounding nerve.
Host (02:10):
So, basically, what it's doing, it's like almost big being at the
dentist.
It's numbing the area, so you're not feeling pain, but you're not
feeling High?
Correct
That's awesome.
So you're saying that nerve blocks have revolutionized the field of
anesthesiology in the last two decades.
Why?
Dr. Marino (02:26):
So I just want to give the visual to the patients and two people out
there.
We used to put people to sleep and the only mechanism that we had to
treat their post-operative pain was intravenous morphine-like drugs
or narcotics.
So typically, you would find a patient in the recovery room
(02:47):
holding an emesis basin
nauseous and potentially vomiting because of the side effects
of that opioid and also very drowsy and very sedate.
In certain cases, if there was too much morphine or too much opioid given
there would be some respiratory rate or breathing decrease issues.
(03:12):
So, opioids, and I'm talking not too far ago
I'm talking probably 15 years ago, were the mainstay of post-operative
pain therapy. Now because of the advent of the nerve block, and the
ability for us
to anesthetize a certain part of the body that had surgery performed
(03:36):
on it
virtually eliminates the need for these post-operative opioids.
Host (03:42):
Dr. Greenstein the team at Staten Island University.
Hospital began using femoral nerve blocks for patients into the
emergency department in 2021.
Tell us about how this got started started.
Dr. Greenstein (03:52):
It started becoming described in the literature in the last decade, but it
really wasn't standard care.
I myself graduatedin 2015.
Never did a single one of these procedures who during my residency and so we
didn't really have the staff that was really trained to do it.
Even though it was something we thought we thought we'd be able to do.
We put a lot of needles
next targets.
We use ultrasound in many different procedure itself.
(04:13):
So Dr. Marino, the real visionary along with power chair at the time.
Dr. Birol, who's now, the associate medical director came together
and we said, how can we make this a reality for our patients?
How can we train our staff? Help
Provide some education. And furthermore it was a little complicated because
a lot of these patients were doing this for patients with hip fractures
So they're being admitted to other services.
Other surgeons are taking care of the patients.
(04:34):
They're gonna have to deal with the procedure that we do, and they're
going to manage it.
And so it's kind of like we're handing off or procedure and they're
going to then be left with the patient and self.
And so, we brought all the players involved, we brought
orthopaedics, we brought
Trauma, anesthesia, kind of explained what we're going to do.
We got brought in from all the major players, and we were able to
accomplish it.
And we're currently, we're aiming to get 100% by September of this
(04:55):
year.
We're currently at 70% of our emergency medicine, physicians, are all
trained
how to do this and
credentialed.
That's really really revolutionized
how many are getting it
Because instead of being one in a few that know how to do it
70% are doing it.
So, when you have this patients, it's not like, oh, I don't know how
to do it.
It's when can we do it?
Host (05:13):
Dr. Greenestein just talked a little bit about training
emergency room physicians in the use of femoral nerve blocks.
Dr. Rudnin
Can you tell us a little bit more about that process?
Dr. Rudnin (05:22):
Sure. So the ultrasound division in the ER is ensuring that all of our Ed
providers
are receiving training to perform these procedures. Our residents get
every several months, a procedure lab where they get to practice it.
Our attendings also.
We do faculty development for that.
(05:44):
So they have simulators where they can actually practice these
procedures and they ultimately get credentialed and are very excited
to go ahead and continue and providing these procedures to actual
patients.
Dr. Tama (05:57):
And we also
review a lot of these cases.
And so a lot of the residents and attendings are kind of still
reaching out to us.
Like, oh, we did this nerve block, can you take a look?
So we're still kind of, you know, making sure everyone's following the
rules and doing it appropriately.
Host (06:16):
It's awesome to hear about that enthusiasm Dr. Tama
right now, emergency departments at Northwell
are starting with femoral block, but there are many types of
nerve blocks. Are there plans expanding training to emergency
physicians in uses for others?
Dr. Marino (06:30):
So I love the question and just like the Staten Island team and I were
envisioning bringing this powerful tool to treat hip fractures
vis-à-vis, the femoral block and that can can essentially eliminate
pain leg knee
(06:52):
foot, if we have to. We already have visions of expanding the use of
ultrasound-guided nerve blocks for
Upper arm problems.
So somebody comes in with a shoulder dislocation or a
laceration to the arm, shoulder or hand
God willing
If we continue on this path of innovation, we're going to be able to
(07:16):
in service our emergency medicine physicians, in partnership and
collaboration with the anesthesiologist, to do these upper arm or
upper extremity nerve blocks and provide a reduction in pain.
A reduction in need for opioids and significant patient satisfaction.
Host (07:35):
So where exactly are the nerves that get the nerve blocks in the human
body?
Dr. Marino (07:40):
Yeah.
So, you know, I'm going to give you a little bit of an anatomy lesson
here.
So the brachial plexus or the upper extremity nerve bundle is just
above the shoulder and we could place novocaine around that brachial,
plexus to essentially numb the shoulder entire arm
and hand. The lumbar plexus is where the femoral nerve is located in
(08:04):
the groin.
And then the abdomen has a variety of different areas that we could
inject novocaine in under ultrasound guidance, to significantly
reduce some of those more provocative surgical operations of the
abdomen, like a hernia operation or a C-section.
Host (08:24):
It's great
Dr. Tama what types of patients are using are using nerve blocks for?
Dr. Tama (08:30):
So, the majority of patients are ones with hip fractures.
Sometimes, we'll get femur fractures as well.
You also can use it for patients that have like really bad laceration or
patients that have a significant burn to the thigh
We're kind of on the lookout for that. But those are other potential
uses for this nerve block.
Host (08:53):
Yeah.
I mean, I would imagine it hip fractures and extremely painful and
difficult to deal with.
So Dr. Marino
How does
the nerve block compared to the standard approach in this situation and
what has been the reaction from the patients who received the nerve
block?
Dr. Marino (09:08):
Yeah.
So excellent question and the reaction has been, you know, needless to
say, high satisfaction scores.
So, you know, just think about it.
Somebody is going to church.
They fall on the concrete and they don't know if they have a fractured
(09:28):
hip, but it's really
uncomfortable.
And by the time they get into the ambulance and bounce around on the
gurney, get taken to the hospital. Bounce Around even more.
That is a very provocative experience for the patient.
And again in the past all we did in all we had were IV morphine like
injections for these patients.
(09:49):
Now it worked it would take a little bit of the edge of the pain away.
But if you moved that patient, the pain would still be there.
And what's so beautiful
about the nerve block is that you can move these patients.
And the movement will not provoke that serious pain that you see with
(10:11):
the with the IV narcotic injection.
So, not only does it eliminate the need for narcotic, or I should say,
significantly reduce - its opioid sparing - but the movement of the
patient is appreciated with significant less provocation.
Host (10:28):
And when you talk about collaboration, you can only see this spreading
and the Innovation growing, you know, not only in Northwell but
in other places.
Dr. Marino (10:35):
Is correct hundred percent?
Yeah, it's only a matter of time.
I mean now we piloted this at Staten Island in their Brilliance and
success demonstrated that it works and it's safe.
We're rolling it out at South Shore [University Hospital] and before you know, what Northern
Westchester [Hospital], Phelps [Hospital], [LIJ] Forest Hills, they're all going to be a part of it.
(10:55):
And then before, you know it this will be standard of care across
every Northwell facility.
God forbid.
If you fracture your hip you're going to come in and people are going
perform a procedure that takes seconds and is going to give you significant
pain relief without the adverse effects of morphine like drugs
Host (11:14):
Dr. Tama.
What do you say to a patient?
Obviously, a patient's going to come in and excruciating pain and they
might be demanding, you know, some sort of pain medication.
What do you say to them?
And how do you can convince them that this is the right move?
Dr. Tama (11:26):
So it does take some finesse definitely, because it is something new
that a lot of patients or their families are not familiar with.
We tell them kind of what to expect.
And then we tell them that later on
they won't be able to move their legs and kind of the expectations of
what they should feel after the block is done and when it's done
correctly. And everyone is like signing the consent form, like right
(11:49):
then and there like a sure, sign me up.
No problem.
It definitely kind of
starts their treatment from the beginning
they walk into the emergency department.
and helps them kind of move along through
the hospital stay quicker.
Host (12:04):
So, Dr. Rudnin
does learning something like this, make you a better
physician?
Dr. Rudnin (12:10):
So learning a technique like a nerve block, as long as we were
familiar with the anatomy hitting that nerve kind of came as second
nature
once we were comfortable with the anatomy. When it comes to making you
a better physician
Absolutely.
You're able to do a procedure that spares a patient significant pain
without providing them, you know, the potential effects of opioids.
Dr. Tama (12:36):
Yeah, and the definitely the patients feel that also
We've had a few cases where we've had patients request, you know, they
didn't, they did not get their surgery within 24 hours because of
other Hospital complications and they have actually called and
requested to have the emergency department come and do another nerve
block.
(12:57):
And so they definitely feel the benefits of it as well.
Host (13:01):
Dr. Greenstein how satisfying is it to be leading this effort and to be
helping to, to get this message out and to be training others?
Dr. Greenstein (13:08):
Yeah.
I mean, it's absolutely amazing.
That what's really amazing is when the patient's family finds in the
hallway, the next day they tell you about how, like their mother,
their grandmother got a good night's sleep or how they didn't
take his another dose of pain medication till the surgery.
That's really get the ultimate satisfaction.
So, it's really great thing, and it's gone really
Well.
We've had no issues.
(13:31):
Using the ultrasound has really made it straightforward and simple
so it's really awesome.
Host (13:42):
We sort during Covid, such an increase in opioid use in opioid
overdoses.
While still necessary.
In some cases.
These dangerous narcotics can lead to addiction. About three to four
percent of patients undergoing
elective surgery who have never taken an opioid develop a dependency.
The addiction rate is higher for some types of procedures, and we
know it's also associated with longer hospital stays and a higher
(14:04):
rate of readmission. Can nerve blocks help stem that tide.
Dr. Marino (14:09):
Oh, it's always
Back to, you know, the concept of treating pain.
So procedurists in general, that would perform a surgical procedure,
would typically give a patient, you know, a couple of week or a month
supply of opioids.
We no longer do that.
We Now understand that giving a patient the appropriate dose of a pain
(14:32):
medication.
After a surgical procedure 3 to 5 days-worth; getting a nerve block,
which is going to essentially
significantly reduce the amount of pain in that very provocative first
post-operative day and then allow the pain to the patient to
transition to their pain medication for a three to four day
(14:55):
period is exactly how the medical community is looking to.
address and define success in reducing opioid dependency in surgical
population.
Host (15:05):
Have you seen any data yet showing that how this is reducing
addiction?
Dr. Marino (15:10):
So that's what the Statin Staten Island team and I are planning on
doing this collecting data.
So we have years of data of not doing a femoral nerve block and seeing
how much morphine like medication patients with a hip fracture
typically have received, and now, we're going to compare
this new cohort of patients that have received the femoral nerve
(15:34):
block and we're going to look at variables like how long it took them
to go to surgery?
What their Hospital length of stay is.
And without question what their pain scores and morphine consumption
was. And I think it's going to be easy to show that the morphine
consumption and the pain scores are significantly lower leading to
(15:55):
higher patient satisfaction scores.
Definitely, and Dr. Marino I'd like to add, I think also
So the patient outcome is going to be not only are they going to have lower
morphine, but their outcome; they'll be ambulatory more quickly
after surgery.
I think the all those things that you want, you want the person that
fell and has a fracture to be the same person before the surgery as
they are after the surgery.
This is going to help a lot.
Host (16:16):
We've been talking about using one type of nerve block in emergency
departments, but
Dr. Marino
How commonly do nerve blocks
get used in the surgical setting and at Northwell
what is the ratio of patients getting nerve blocks compared to
those other methods of pain management?
Dr. Marino (16:29):
I would say it's the overwhelming majority of patients who were having
some sort of a provocative Orthopedic procedure.
So total knee replacement, total hip replacement, total shoulder
replacement, standard of care is to get what we call a regional nerve
block.
In addition to some sort of either general anesthetic or sedation.
(16:51):
So that when the patient does wake up from the surgical procedure,
their body part is totally numb.
Host (17:00):
And what about when when, when it wears off the 18 to 24 hours is up
then just the pain come back?
Dr. Marino (17:06):
So we teach the patient that as they're getting that numb and tingling
feeling starting to come back because, you know, when the numbness is
starting to wear off, they should start their oral pain medication
regimen.
Host (17:21):
Ok. And what is that mostly is that mostly like ibuprofen?
Dr. Marino (17:23):
it's a, it's usually, a combination of Ibuprofen and Tylenol and a
very, very light narcotic.
Host (17:30):
Are there any side effects?
I know like sometimes with opioids, you could you get nauseous, you
could vomit, you could have itching.
Is there any side effects with with a nerve block
Before when we were doing the Poke and hope approach
We would put our finger on the femoral artery because the femoral
nerve lies right next to it.
And we would place the needle tip right next to the nerve.
(17:52):
And again, we would poke through the skin and hope that the local
anesthetic or novocaine was bathing
The periphery of that nerve.
Well, sometimes the needle tip would enter into a blood vessel and
that's not where that local anesthetic should go.
If that was the case, the patient may be afflicted with something called
(18:16):
local anesthetic before when we were
Where when the body when the blood vessels absorb quickly the local
anesthetic that is not a good place to be. Patients can get very
dizzy.
They could get numbness
around their lips; and in severe cases, it could lead to a seizure.
So the ultrasound has virtually eliminated that concept that Prospect
(18:40):
and that's why we're all as practitioners feel like we have power in
our hands.
So this is all exciting stuff, you know and here on 20-Minute Health Talk
We always like to end on a positive note.
So I like to ask each one of you, what gives you hope what gives you
optimism going forward and I'll start with you.
Dr. Rudnin.
Dr. Rudnin (19:00):
So, what gives us hope at least for me is the fact that patients their
overall satisfaction is going to be increased.
They're going to be having a significant reduction of their pain
without having the detrimental side effects of opioids
Host (19:16):
Dr. Tama, what gives you hope but gives you optimism.
Dr. Tama (19:21):
This collaboration that we have with anesthesia
gives us hope.
I think that
as physicians we want to encourage each other to continue to do better
and this kind of multidisciplinary team work
really gives me hope that there's so much more that us as emergency
department
doctors can do for our patients and even started from the beginning
(19:44):
because we are the entryway to the hospital.
So I definitely think that this opens the door for so much more work.
That could be done for them.
Host (19:53):
Has there been any
pushback from Physicians?
Because sometimes,
People don't want to do different things.
They're kind of set in their ways.
Dr. Greenstein (20:04):
Yes, I would say that.
That was probably one of my biggest concerns was teaching, you know,
new trick to some people that have their set ways and how they
managed their practice and manage other things.
And once somebody learned how to do it and do just that one of them
and saw the impact on the patient's, they want to do it, like they
wanted to become in their practice.
So we've been able to just want to none like people do one of them
(20:25):
like, oh, I need to do it for every single one of patients.
So it's really been amazing.
And that's really the hope for me is that we bought into this, this
culture of nerve blocks
is that the sky's the limit
We're a burn center here.
We have so many terrible burns of the extremities, imagine we can provide
them with an anesthetic right to that to the nerve, give them 18 hours
of pain control instead of pain medicine after pain medicine and pain medicine,
(20:47):
and the outcomes could be great.
Host (20:49):
Dr. Greenestein I loved how you answered both of those questions right
there.
Dr. Marino, what gives you hope?
What gives you optimism going forward?
Dr. Marino (20:56):
So, I'm the old guy of the group and you look at these three.
brilliant young physicians to my right. You know, sometimes I come off
as The Nutty Professor.
Hey guys, I got this idea.
I think it's going to work.
I think it's going to have an impact on patients and you really don't
know what the feedback or the buy-in is going to be.
(21:17):
But my hope really lies and I'm really echoing what
Maria said before, which is it all comes down to Innovation.
So if you change your thought process and you have
Courage to ask a question and then you have these young spirited,
brilliant minds
that look at you and have enough trust in you.
(21:38):
And to say, okay.
Let's try this.
Let's make sure if we're going to do it
Let's do it right.
But let's try this.
And just because of our partnership.
We're already able to impact people on a real visceral level, and my
hope lies in that.
As long as we continue to come up with the idea.
(22:00):
Continue to have the courage to ask the question.
Always try and overcome the hurdle, find the yes.
And together you could see that there are differences in generation
because of the age gap. But because of these brilliant minds, my hope
lies in them.
Host (22:18):
Thank you all so much for joining us here on 20-Minute Health Talk.
It was a great conversation.
Thank you.
Dr. Marino.
Dr. Greenstein.
Dr. Tama and Dr. Rudnin.
And thank you.
The Listener for tuning in.
I'm Rob Hoell
Have a great day and stay safe.
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