Thread by @OBsleepmerchant

Okay @amit_pawa vs @jeffgadsden debate just completed at #RAUK23 - fantastic Pro/Con debate. @garrettsbarry, as promised, here it is

First the PRE-debate audience poll - the NO’s have it. Looks like @amit_pawahas an easy job today

@jeffgadsden takes the Pro argument, in what he feels shouldn’t really be a face off. Note: tearing off the nerve stimulator cord is a tad aggressive #RAUK23

@jeffgadsden proposes the 4 pillars of his argument. 1. A means to avoid intraneural needle tip placement. Seems to shoot himself in the foot immediately by pointing out poor sensitivity #RAUK23

Ah, good recovery from @jeffgadsden. It may not be sensitive BUT it’s very specific #RAUK23

Triple monitoring reduced false negatives. With US alone are we 100% sure we’re not too close every time - No. Not much literature to support, but consequences of error are massive. Worth having a belt and braces approach? Probably. #RAUK23

And it’s easy to do - 6 seconds. What an awesome slowmo replay! #RAUK23

2. A way to avoid skewering neighbouring nerves. RAPTIR block illustrates tiger territory - suprascapular nerve. #RAUK23

A solution = stimulation. Note: hand placement to detect a twitch while advancing the needle #RAUK23

Also during Adductor Canal Block that regionalists perform daily - nerve to Vastus Medialis not always visible on US #RAUK23

Sure dissection with saline helps, but stimulation adds efficacy and safety (twitch means stop). Consequences are notable. #RAUK23

3. Help identify nerve when US fails. Not sure how much of USA constitutes the “Biscuit Belt” but we all have obese patients where US does NOT visualize the nerves - stimulation keeps us safe? #RAUK23

4. Help identify correct fascial plane. QLB needs to avoid injection into Psoas Major - otherwise you end up with lumbar plexus block (effective but can’t move leg). If psoas muscle twitches = bad! Know you’re there when QL stops twitching. #RAUK23

Summary of how stimulation helps. Equates to seatbelt vs airbags debate (seatbelts so last season once airbags arrived) - but both = better! #RAUK23

@jeffgadsden argues US and nerve stimulation should be a bromance… somewhat like @BlockIt_Hot_Pod #RAUK23

Oh dear. @amit_pawa caught on tape expressing his love of nerve stimulation... #RAUK23

… a strong finish to the Pro side from @jeffgadsden #RAUK23

@amit_pawa up for the CON side of the debate. Keeping the patient in sight as the real winner of the debate no matter which way it goes. #RAUK23

Oh dear, a sign of weakness from @amit_pawa - altering the parameters of the debate? Will it hurt him? #RAUK23

Appealing to emotions of the audience - excellent debate strategy from @amit_pawa (I’m sure @RegionalAnaesUK will miss him). But his talk will be serious with no-subliminal messages whatsoever #RAUK23

Does nerve stimulation really separate these bromance partners of @BlockIt_Hot_Pod? @amit_pawa has cried foul on tape - says it was AI. #RAUK23

@amit_pawa focusing the point of the debate - or more specifically where the needle’s point SHOULDN’T be. #RAUK23

Despite advances in regional anesthesia, long term nerve injury remains unchanged. Do we need a belt and braces (or triple check) approach. Ooh early but has @amit_pawa delivered his mic-drop moment quoting @jeffgadsden from the literature? #RAUK23

Illustrating the premise, but is it always reliable? Right @jeffgadsden spoke about 0.2mA, but most use higher values… #RAUK23

A tale of two pigs (no third found @amit_pawa?): NO twitches with INTRANEURAL needles - not very sensitive. Ultrasound DOES detect intraneural injection #RAUK23

Humans now: Parasthesia is old school (even me an #OBAnes agrees) but parasthesia occurs in absence of twitch, may not detect neural contact. PNS did not prevent intraneural injection. Good solid literature argument from @amit_pawa - definitely negates sensitivity #RAUK23

Extra points for the Star Wars reference! This is the Way! Mat the fourth be with you #RAUK23

Addressing the bromance directly - nerve stimulation did not prevent intraneural injection. Still skewering nerves (now I’m hungry) #RAUK23

@amit_pawa addresses the 6 second claim from @jeffgadsden - if it’s so easy why is it less efficient? #RAUK23

Does dual guidance prevent harm? Apparently not. Question in my mind is that we know it’s not sensitive, but is that the point? Clearly stimulation is not sensitive enough - but if it’s specific… will @amit_pawa address that? #RAUK23

Do we need to get that close to the nerve that stimulation would be useful? Can stay 1.6mm away from nerve with effect in 95%. If Yoda says it, I believe it - but literature added as well #RAUK23

Ah @jeffgadsden quoted again (@ajrmacfarlane this is Kylo Ren from sequel trilogy, Darth Vader’s grandchild IYKYK) Summary of the argument so far - specificity missing? #RAUK23

Ripping off the stimulator cord does like quite satisfying though #RAUK23

DO NOT TRY THIS AT HOME! #RAUK23

Single slide acknowledgement of exceptions - probably wise not to dwell on @jeffgadsden’s 4 pillar Pro argument? #RAUK23

Great summary format @amit_pawa #RAUK23

The moment of truth…

@jeffgadsden not only wins debate, but successfully overturns the pre-debate poll! Well done! But as @amit_pawa pointed out, the patient is the real winner! (And @amit_pawa may have been prejudiced by a few Trekkies in the audience) #RAUK23