Anesth Analg 2000;91:771-772
© 2000 International Anesthesia Research Society
EDITORIALS
Don’t Try This at Home!
Denise J. Wedel, MD
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
Address correspondence and reprint requests to Denise J. Wedel, MD, Department of Anesthesiology, Mayo Clinic, 200 First St., SW, Rochester, MN 55905.
The article by Klaastad et al. (1) describes the use of magnetic resonance (MR) imaging to study a modification of the infraclavicular approach to brachial plexus blockade. The use of sophisticated imaging techniques to examine needle placement, local anesthetic spread, and anatomical relationships in regional anesthesia is an exciting trend with much to offer.
This article offers an interesting twist on this emerging technological approach. The authors, in the best tradition of medicine, attended a meeting in 1993 in which an innovative approach to a rarely performed technique, infraclavicular blockade of the brachial plexus, was described in a workshop setting. The described alteration in the original technique suggested a more lateral needle placement to improve block efficacy, theoretically by directing the needle closer to the cords, and to further decrease the risk of pneumothorax, a complication which is stated to be already minimized with this approach.
The authors designed the imaging study after trying the "new and improved" altered infraclavicular block with disappointing results on 161 patients. They found that they frequently had to reinsert the needle and, in 11% of the cases, abandoned the technique completely. At this point, the authors unsuccessfully tried to contact the workshop faculty member for further clarification. While many practitioners may have abandoned the whole educational experiment at this point, Klaastad’s group decided to approach the problem scientifically. Their results are interesting and support their clinical bias, a triumph for research and logical thought.
This study represents the ideal approach to medical problem solving. A new clinical idea is introduced, preliminary clinical data are collected, and ultimately, an appropriate study is designed to answer the questions raised. However, the sometimes tortuous road to the final kernel of truth described herein also illuminates potential problems with the workshop format for clinical education.
Workshops are a relatively new educational phenomenon. In the past two decades, this format has moved from the experimental to a major role in medical education. There are numerous reasons for this. Didactic lectures have a limited impact on learning for many individuals. The impersonal expert, droning in front of a large, bored audience for 60 minutes is largely a relic of the past. Modern educational techniques stress high-powered, focused presentations to smaller audiences with an emphasis on audience interaction.
The workshop setting is especially well suited to teaching technical skills. In some cases, such as fiberoptic intubation, a hands-on experience can be provided, allowing the clinician to develop confidence in a new skill. In the case of regional anesthesia, a well thought out presentation involving some audiovisual aids and a live model for demonstration of surface landmarks, positioning, and needle insertion angle, can offer a good introduction to beginners and helpful hints to the more experienced practitioner. A further attraction for specialty societies is the additional fee that is usually charged for these sessions. Clinicians are quite happy to pay extra for the individual attention and close proximity to a real "expert" available in these settings, and many of the faculty are outstanding teachers.
The downside is apparent in the present authors’ description. They attended a workshop as part of a well established meeting. The modified technique described had not been published, and no written description was provided. The block technique itself is not commonly performed; hence, the pool of "experts" is somewhat limited. The authors were impressed by the potential for improved efficacy and safety; however, no published data supported either claim. On returning to their own hospital, they applied their new knowledge, relying on their notes and memory for details. When the technique was less successful than expected, they faced a dilemma. Had they misinterpreted the workshop content? Was the modification useful? Should they abandon the technique entirely or proceed with the hope that their lack of success was related to experience and would be remedied by time? These authors chose the most scientific route to solving their dilemma, assessing the suggested modification as a theoretical question for further study.
The questions raised by this paper are several. Standardized regional anesthesia techniques, the mainstay of workshop topics, are well described in the literature and have a body of experience and research behind them. Many "new" blocks, at present the psoas block is fashionable, are actually rediscoveries of techniques with a rich publication history and a solid anatomic background that is a decade or two old. However, what responsibility do workshop faculty have in presenting new material? At a minimum, I believe that such material should be well described with anatomical details in a syllabus. Preferably, modifications of standard techniques and new applications should indicate the rationale for the "improvement." Such modifications would be more convincing if data from the presenter’s own experience could be provided. There should be evidence of both increased efficacy and safety before a novel technique is widely adopted. Regional anesthesia folklore is replete with new, improved techniques presented at workshops, which, like the above, rely on the enthusiasm and personality of the presenter and are not reproducible by the average member of the audience. Many examples spring to mind: multiple approaches to the sciatic nerve at the hip or knee, multiple nerves blocked with a single needle insertion, multiple approaches to the various plexi—all anecdotal except the occasional study such as this. Finally, appropriate description of complications, pitfalls, and problems should be included.
What responsibility belongs to the hosting program committee? Providing clinically experienced faculty who actually perform the techniques presented would be a minimum. Requiring appropriate syllabus materials and follow-up evaluations, as well as auditing the workshops, would be ideal. Are these suggestions realistic? They would require more effort, certainly, but the income from these activities should support adequate monitoring for quality. Cadaver workshops where anatomy and needle placement can be correlated with surface landmarks and imaging techniques are the epitome of this educational format. However, these are extremely difficult and expensive to organize and usually have very limited registration.
These authors’ experience has a scientifically happy ending. However, it is easy to imagine a darker scenario. Untested techniques can be ineffective and even harmful. The unsuspecting workshop attendees may take the proffered information at face value and persist in futile attempts at reproducing the claimed benefits. When complications or failure occur, they are on their own without even the benefit of published accounts to defend their actions. In such a scenario, the advice "don’t try this at home" would be appropriate!
Footnotes
DJW is the section editor of Regional Anesthesia and Pain Medicine.
References
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Klaastad Ø, Lille
 s FG, Røtnes JS, et al. A magnetic resonance imaging study of modifications to the infraclavicular brachial plexus block. Anesth Analg 2000; 91: 929–33.[Abstract/Free Full Text]
Accepted for publication June 15, 2000.
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