Peripheral nerve blocks
1 Can you tell a bit about yourself, your background and studies?
I was born & raised in a beautiful city called Zahle in the Bekaa valley in Lebanon. When I finished high school I had to move to the
«At AUB, I spent 11 amazing years where I received a bachelor’s degree in Biology followed by a doctor’s degree in medicine.»
Lebanese capital, Beirut to follow my university studies at the American University of Beirut (AUB), one of the leading universities in the middle east. At AUB, I spent 11 amazing years where I received a bachelor’s degree in Biology followed by a doctor’s degree in medicine. After 4 years of residency, I graduated as an anesthesiologist.
2 Can you describe how you came to UZ Leuven for a fellowship and what your motivation was?
During my residency, I have always felt that we need extra training in regional anesthesia. So, I was in a constant search of programs that offer a good training in this field. UZ Leuven fulfilled these criteria. I was startled by the large number of regional anesthesia techniques performed yearly there. I emailed Dr. Steve Coppens, the fellowship director and head of clinic of regional anesthesia and acute pain therapy for the possibility of following a 1year fellowship in regional anesthesia. I was delighted when he replied to my email and offered me a skype interview along with a meeting with the Chairperson of the Anesthesia Department, Prof. Marc Van de Velde. They were both very welcoming & friendly. They guided me through a very lengthy accreditation process with the Belgian Ministry of Health to get a temporary license to follow training in Belgium. Though the path was full of obstacles, Dr. Coppens & Prof. Van de Velde supported me in every single step of the way. In retrospect, all the wait & effort was absolutely worth it!!!
3 Can you give a brief description of your time at UZ Leuven. Amount of blocks, teaching and the general experience. Also how is living in Leuven, general ambiance, did you make friends, how was social life and food?
I had a great experience at UZ Leuven. It was way more than I expected. I arrived anticipating to learn basic regional anesthesia techniques and left with an expert level in performing peripheral nerve blocks and thoracic epidurals. By the time I finished my training, I had performed more than 1800 loco-regional blocks. The staff anesthesiologists put a lot of weight on teaching. The nurses were absolutely excellent & very professional. I could say that I left a piece of my heart in UZ Leuven.
«I had a great experience at UZ Leuven. It was way more than I expected. »
As for Leuven, it is a university city with a student friendly atmosphere with biking trails all over the city. You could find a variety of international restaurants & cuisines. It is very safe. The Oude Markt is a hub of pubs & meeting place for students throughout the days of the week. Plus, the central location of Belgium is perfect for you to explore Europe on weekends.
4 Can you describe what happened in Beirut and where you were at the time of explosion?
On Tuesday the 4th of August, I was having a normal afternoon at my husband’s family’s workplace in Bourj Hammoud. We heard the sounds of aircarfts circling Beirut. I remember my husband & I going towards the window to check out what was happening. Around 40 seconds later, we heard the sound of an explosion. The electricity went out, we ran away from the windows towards the center of the building and a second explosion happened. The second explosion was wayyy stronger with a blast after-shock. The windows shattered, the aluminum borders of the windows flew inside. The whole building shook real hard. At that point, we thought something happened really close to the building. It was the strongest sound we have ever heard in our lives.
5 Hopefully none of your loved ones or friends were wounded, how did you check or got news?
Moments of sheer panic followed the explosion, as we were checking on all our loved ones. The lines were jammed. Thankfully, none of our close friends and family members were seriously injured. Looking out the window, we could see smoke in the area of the port. Nobody knew what really happened. Different scenarios were out on the news. Regardless of what could have caused the explosion, one sure thing is that our government is so corrupt & negligent that officials previously knew about tons of combustible material stored in the heart of Beirut at the Port and they did nothing about it.
6 How did you react, were you on call? Did they call you to the hospital?
Just after the explosion, I was still unaware of the severity of the hit. We could see the damage around us but we did not realize the extent of injuries & fatalities that this explosion had created in many areas similar to ours. Many major hospitals at the center of Beirut were destroyed and paralyzed moments after the blast with interruption of power supply. Four nurses passed away while on duty. Many doctors were injured. Some patients on ventilators in intensive care units also passed away due to power interruption. Ambulances could not reach the areas with the most damage. People were carrying the injured on foot to the hospitals only to find that the hospitals themselves were overloaded and semi-functional. Doctors, residents and nurses were treating patients in parking lots outside the hospital. Ambulances soon started carrying the injured to hospitals outside the circle most affected. One of those hospitals was the hospital I am currently working in, the Middle East Institute of Health (12 km away from blast location). I was not on call. I got a notification from the administration that we have received an enormous number of casualties at the emergency room. Code D was activated in most hospitals even as far as 40 km away from the blast. All the staff whether on call or not came back to the hospital to help.
Beirut explosion: CCTV captures moment blast struck hospital: https://youtu.be/4hmj6BegDUU
7 How was the initial casualty uptake organized?
Throughout history, Lebanese hospitals have always had to deal with casualties from some sort of disaster; be it the Lebanese civil war from 1975-1991 or the June 2006 Israel-Hezbollah war or series of political assassinations by bomb in the early 2000s. As Lebanese medical students, we are trained to deal with mass casualties in the emergency department. However, this disaster was like no other. None of this experience fully prepared us for this scene. The emergency rooms were full of casualties way higher than their capacity. Triaging was key. There was an attempt to separate the emergency department into four zones of acuity. If you could walk & talk, and had no injuries to the torso, head or neck, you were assessed carefully and rapidly sent to the low acuity zone. The red zone was where the most critical patients who needed immediate life-saving treatment were sent. However, the load of patients arriving who needed urgent care was way above our capacity. To put things in perspective, on the night of the blast, we received over 300 patients at the emergency department. Compared to the scale of UZ Leuven, the Middle East Institute of Health is a small hospital with 4 functional operating rooms. You could imagine how chaotic the situation was amidst the Covid-19 pandemic. The scene of patients waiting in line compressing their own wounds and applying clothing as tourniquets to stop the bleeding resembled a scene from an apocalyptic movie with one small difference that it was pure reality. I intubated an unconscious patient while his poor brother assisted me. We had to urgently bring a man down to the operating theater for control of bleed while his sister had arrested in the cubicle next to him and the team was performing CPR. And countless other stories…
8 You used regional anesthesia, can you describe us what you did, how many patients etc…
Regional anesthesia came in pretty handy in the management of many casualties. Specially that most of these patients arrived shaken and not in their right state of mind to give us a proper history about their medical background. A major chunk of patients had traumatic fractures secondary to the blast wave or they suffered from tendon lacerations secondary to the shattered glass or needed digital replantations… Doing peripheral nerve blocks for patients with all sorts of limb injuries allowed us to do some minor surgeries in the emergency department and free up space in the operating theater for more major cases. We worked overnight in the operating theater and emergency department. We started with the most urgent cases and kept the closed wounds and the less pressing operations for the next days to follow. I did around 60 blocks in 3 days. That is considered a huge number compared to our regular load. For example, during the whole month before the blast I had performed around 15 blocks.
9 Do you think regional anesthesia played a big part on the outcome of these patients? Did you do follow-up?
The use of regional anesthetic techniques as the sole source of surgical anesthesia proved to be the safer option for several reasons. First, all casualties were major trauma victims that are considered “full stomach”. Second, many of these victims had multiple comorbidities that ideally needed to be optimized pre-operatively had they not arrived in the emergency setting. Also, some patients suffered from head trauma and required monitoring of their neurologic status for at least 48 hours. Keeping them awake during surgery was the safest option. Let alone patients who had lung contusions, hemothorax, who were placed on neck collars for possible cervical spine injury or elderly patients at heightened risk of developing delirium in the trauma setting.
In addition, I believe that regional anesthesia was such a plus in the outcome of a specific category of patients with crush injuries who were at higher risk of developing chronic pain. Those patients benefited the most from a follow-up assessment where I did a second single shot block the next day when the initial block wore off. Of course, these patients would have been perfect candidates for continuous catheter techniques. That is a limitation that I had to deal with since we do not have needles or pumps for continuous catheter placement.
To sum up, regional anesthesia was a safer alternative to general anesthesia, conferred excellent site-specific pain relief that is free from major side effects, post-operatively reduced opioid requirements and lowered the risk of developing chronic pain.
10 Can you explain us your set-up, Ultrasound, place where you perform blocks, your needles and all material in pictures?
We have a very modest setup compared to UZ Leuven. Our anesthesia department does not own an ultrasound machine. I borrow an ultrasound from the radiology department (Siemens Acuson X300) whenever I want to do any blocks (see pic 1). We have a nerve stimulator and PaJunk single shot needles. We do not have continuous catheter needles. We do not have a space allocated specifically to perform nerve blocks. I either do the block in the operating theater (see pic 2) or whenever we have enough nurses to monitor the patient, I ask for the patient slightly earlier and I do the block in the recovery room (see pic 3) to save some time.
11 Can you tell us how the situation is now in Beirut and if your regional practice has changed?
The explosion that tore through Beirut was so strong that shockwaves were felt on the island of Cyprus, over 200 kilometers away. It caused at least 200 deaths, 3 reported missing and 6500 injuries. It left an estimated 300,000 people homeless with an estimated property damage of $10-15 billion US dollars.
Such devastation would be difficult to deal with at the best of times but it hit us in the midst of a severe economic crisis that has only been compounded by the COVID-19 pandemic. The Lebanese currency had lost more than 80% its value in less than a year. The country has gone bankrupt and the national bank has applied restrictions on our personal bank accounts. Simply put, we do not have access to the money in our own bank accounts.
As for my regional practice, I strive to follow the same standard of care that I have learnt in UZ Leuven. I would love to introduce continuous catheters to our daily practice. However, now is not the right time to expand. We have a lot of restrictions. We have a shortage of many drugs. Currently, we are only doing what is absolutely necessary.
12 Can you tell us your plans for the future maybe?
The Beirut explosion left us traumatized. We do not feel safe in our own homes anymore. Though we had previously made our plans to stay in Lebanon. We are now considering moving to a place that offers more stability and peace of mind.
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