<p begin="00:00:05.730" end="00:00:08.860">- Okay, so now that we have<br />already prepped the dog,</p>
<p begin="00:00:08.860" end="00:00:10.430">so we actually scrubbed.</p>
<p begin="00:00:10.430" end="00:00:13.940">Everything is prepped,<br />put sterile gloves on.</p>
<p begin="00:00:13.940" end="00:00:15.360">I have everything set up.</p>
<p begin="00:00:15.360" end="00:00:18.110">My neurostimulator is already on,</p>
<p begin="00:00:18.110" end="00:00:19.680">and I have the needle flush here,</p>
<p begin="00:00:19.680" end="00:00:21.770">and obviously someone's<br />going to need to come help me</p>
<p begin="00:00:21.770" end="00:00:23.180">to inject this.</p>
<p begin="00:00:23.180" end="00:00:25.300">Now, my needle is sterile, and I'm gonna</p>
<p begin="00:00:25.300" end="00:00:27.260">use my right hand to be injecting,</p>
<p begin="00:00:27.260" end="00:00:30.130">so, I don't wanna be touching<br />anything but my needle,</p>
<p begin="00:00:30.130" end="00:00:31.940">and keep that sterile.</p>
<p begin="00:00:31.940" end="00:00:34.500">Obviously, when I'm using<br />the ultrasound here,</p>
<p begin="00:00:34.500" end="00:00:35.430">that is not covered.</p>
<p begin="00:00:35.430" end="00:00:37.700">This, my left hand is<br />not gonna be sterile,</p>
<p begin="00:00:37.700" end="00:00:39.970">so I'm gonna need to try to make sure</p>
<p begin="00:00:39.970" end="00:00:42.680">I'm not touching the<br />needle with my left hand,</p>
<p begin="00:00:42.680" end="00:00:46.620">just a dirty portion of<br />this procedure, okay.</p>
<p begin="00:00:46.620" end="00:00:50.930">So, with my probe here,<br />and using the Edge Vet II</p>
<p begin="00:00:50.930" end="00:00:55.930">from Sonosite, I'm using this<br />three and a half inch probe.</p>
<p begin="00:00:56.800" end="00:00:59.817">I'm gonna be in a<br />transverse position, here.</p>
<p begin="00:00:59.817" end="00:01:03.560">I'm gonna do, I scout,</p>
<p begin="00:01:03.560" end="00:01:06.650">and notice that I'm using<br />actually the position</p>
<p begin="00:01:06.650" end="00:01:09.370">of the probe with the same direction</p>
<p begin="00:01:09.370" end="00:01:11.860">that I'm gonna be injecting, penetrating</p>
<p begin="00:01:11.860" end="00:01:14.890">with my needle so it makes<br />it easier for me, intuitively</p>
<p begin="00:01:14.890" end="00:01:17.060">to actually inject and watch it</p>
<p begin="00:01:17.060" end="00:01:18.543">in the same direction, okay.</p>
<p begin="00:01:20.870" end="00:01:24.150">Now, we're gonna be<br />implanting on this block,</p>
<p begin="00:01:24.150" end="00:01:29.150">so what I'm gonna do is identify<br />my pectineus muscle, okay,</p>
<p begin="00:01:29.300" end="00:01:33.470">and once I do that I'm<br />going to be coming cranially</p>
<p begin="00:01:33.470" end="00:01:36.310">and find my vascular bundle,</p>
<p begin="00:01:36.310" end="00:01:38.320">and we're gonna follow<br />the artery and vein,</p>
<p begin="00:01:38.320" end="00:01:41.340">and you can tell if I collapse and I push</p>
<p begin="00:01:41.340" end="00:01:42.530">a little harder on my probe</p>
<p begin="00:01:42.530" end="00:01:44.400">I can collapse my vein and identify</p>
<p begin="00:01:44.400" end="00:01:46.770">which one is the vein and the artery,</p>
<p begin="00:01:46.770" end="00:01:49.330">and I'm gonna be coming proximally</p>
<p begin="00:01:49.330" end="00:01:52.600">to the limb, and what<br />I'm trying to identify</p>
<p begin="00:01:52.600" end="00:01:56.950">is when this femoral artery<br />will actually give up</p>
<p begin="00:01:56.950" end="00:02:01.260">a bundle, a branch, the circumflex branch,</p>
<p begin="00:02:01.260" end="00:02:04.830">and this circumflex branch<br />is going to be helping me</p>
<p begin="00:02:04.830" end="00:02:07.810">to identify my femoral nerve just medial</p>
<p begin="00:02:07.810" end="00:02:09.700">to that structure, okay?</p>
<p begin="00:02:09.700" end="00:02:12.590">So if you look the hypoechoic tail</p>
<p begin="00:02:12.590" end="00:02:15.500">that I'm creating on this femoral artery,</p>
<p begin="00:02:15.500" end="00:02:17.760">you see that just under that you have</p>
<p begin="00:02:17.760" end="00:02:22.760">a hypoechoic structure that<br />looks like a honeycomb,</p>
<p begin="00:02:23.280" end="00:02:26.070">and that's our femoral nerve, okay.</p>
<p begin="00:02:26.070" end="00:02:29.251">So once I identify this<br />image, I need to be careful</p>
<p begin="00:02:29.251" end="00:02:33.967">to make sure I'm not<br />injecting my local anesthetic</p>
<p begin="00:02:36.280" end="00:02:38.120">into that vascular tube, obviously,</p>
<p begin="00:02:38.120" end="00:02:41.570">so I need to try to make it a little bit</p>
<p begin="00:02:41.570" end="00:02:43.670">out of the plane of that once I identify</p>
<p begin="00:02:43.670" end="00:02:45.120">my femoral nerve.</p>
<p begin="00:02:45.120" end="00:02:48.030">So, once I find my femoral<br />nerve I'm just gonna move</p>
<p begin="00:02:48.030" end="00:02:49.820">a little bit to the side.</p>
<p begin="00:02:49.820" end="00:02:52.260">I'm gonna get my needle, okay,</p>
<p begin="00:02:52.260" end="00:02:56.830">and notice that the nerve is<br />about a centimeter in depth,</p>
<p begin="00:02:56.830" end="00:03:00.763">so I'm gonna go a centimeter<br />on the side of my leg.</p>

<p begin="00:00:00.408" end="00:00:03.325">(soft piano music)</p>
<p begin="00:00:38.950" end="00:00:39.783">- Hello.</p>
<p begin="00:00:39.783" end="00:00:41.010">My name is Fernando Garcia.</p>
<p begin="00:00:41.010" end="00:00:43.400">I'm a veterinary anesthesiologist,</p>
<p begin="00:00:43.400" end="00:00:45.770">Assistant Professor University of Florida.</p>
<p begin="00:00:45.770" end="00:00:48.960">And I'm here today with<br />Sonosite to demonstrate</p>
<p begin="00:00:48.960" end="00:00:52.479">a femoral block using ultrasound guided</p>
<p begin="00:00:52.479" end="00:00:55.340">on the inguinal region of the dog.</p>
<p begin="00:00:55.340" end="00:00:58.180">So the first thing we want to see here is</p>
<p begin="00:00:58.180" end="00:01:00.050">a little bit of the anatomy</p>
<p begin="00:01:00.050" end="00:01:02.120">that's gonna be helpful for you.</p>
<p begin="00:01:02.120" end="00:01:05.810">And as you can see, I have<br />the dog in lateral recumbency</p>
<p begin="00:01:05.810" end="00:01:09.300">and with the limb to be blocked, extended,</p>
<p begin="00:01:09.300" end="00:01:11.674">and with that I will be<br />able to actually palpate</p>
<p begin="00:01:11.674" end="00:01:16.030">some of the anatomic<br />landmarks that I need.</p>
<p begin="00:01:16.030" end="00:01:17.880">So first thing that I want to palpate</p>
<p begin="00:01:17.880" end="00:01:19.630">is the pectineus muscle.</p>
<p begin="00:01:19.630" end="00:01:22.350">Okay, you can see right<br />here, and once the animal</p>
<p begin="00:01:22.350" end="00:01:25.410">has the stretched limb,<br />you can actually palpate</p>
<p begin="00:01:25.410" end="00:01:28.110">quite well 'cause it is<br />stretched out, the muscle.</p>
<p begin="00:01:28.110" end="00:01:31.939">Then just lateral to that<br />you're gonna see your</p>
<p begin="00:01:31.939" end="00:01:35.430">vasculature, so the vein<br />and the femoral artery.</p>
<p begin="00:01:35.430" end="00:01:39.210">And then still lateral<br />to that you're gonna see</p>
<p begin="00:01:39.210" end="00:01:40.380">your femoral nerve.</p>
<p begin="00:01:40.380" end="00:01:44.440">Okay, now it's still lateral<br />to it, you're gonna see</p>
<p begin="00:01:44.440" end="00:01:46.310">the sartorius muscle<br />which is gonna be also</p>
<p begin="00:01:46.310" end="00:01:49.180">important when you're doing<br />the ultrasound imaging.</p>
<p begin="00:01:49.180" end="00:01:53.600">And what you want to see<br />here, is you're gonna do</p>
<p begin="00:01:53.600" end="00:01:58.600">a transverse image with your ultrasound.</p>
<p begin="00:01:58.740" end="00:02:03.048">And we gonna be looking<br />at finding, in my opinion,</p>
<p begin="00:02:03.048" end="00:02:05.820">a way to find very<br />easily the femoral nerve</p>
<p begin="00:02:05.820" end="00:02:10.340">is looking into our lateral<br />circumflex iliac artery.</p>
<p begin="00:02:10.340" end="00:02:12.860">And I find that that really helps out</p>
<p begin="00:02:12.860" end="00:02:15.080">in finding the femoral nerve.</p>
<p begin="00:02:15.080" end="00:02:18.570">We're gonna also use a nervous stimulation</p>
<p begin="00:02:18.570" end="00:02:20.740">together with the ultrasound to help to</p>
<p begin="00:02:20.740" end="00:02:24.450">find the contraction and<br />actually also help me</p>
<p begin="00:02:24.450" end="00:02:26.840">to make sure that I am<br />actually on the right</p>
<p begin="00:02:26.840" end="00:02:29.560">ischiatic structure that<br />I'm trying to block.</p>
<p begin="00:02:29.560" end="00:02:33.080">Now a caveat to using a<br />stimulator on this type of block</p>
<p begin="00:02:33.080" end="00:02:35.530">is that you wanna make<br />sure that you are more</p>
<p begin="00:02:35.530" end="00:02:38.030">(mumbles) enough to<br />get the branches of the</p>
<p begin="00:02:38.030" end="00:02:41.580">femoral nerve that goes to the quadriceps.</p>
<p begin="00:02:41.580" end="00:02:44.350">If you don't get that<br />and you block actually</p>
<p begin="00:02:44.350" end="00:02:47.020">the saphenous nerve,<br />which is a only sensory</p>
<p begin="00:02:47.020" end="00:02:49.750">nerve, you gonna miss that contraction</p>
<p begin="00:02:49.750" end="00:02:51.860">even though you have a<br />decent image of the nerve</p>
<p begin="00:02:51.860" end="00:02:53.230">you might, you're not gonna have any</p>
<p begin="00:02:53.230" end="00:02:55.250">contraction from your nerve stimulator</p>
<p begin="00:02:55.250" end="00:02:56.460">and you might think that you're not</p>
<p begin="00:02:56.460" end="00:02:58.000">in the right place.</p>
<p begin="00:02:58.000" end="00:03:00.050">So for this block what I'm gonna use</p>
<p begin="00:03:00.050" end="00:03:02.100">is I have some sterile gloves,</p>
<p begin="00:03:02.100" end="00:03:05.220">I have an insulated needle that is</p>
<p begin="00:03:05.220" end="00:03:06.970">already primed with fluid,</p>
<p begin="00:03:06.970" end="00:03:10.150">I don't wanna inject any air in my region</p>
<p begin="00:03:10.150" end="00:03:13.094">because that would really make my</p>
<p begin="00:03:13.094" end="00:03:16.230">ultrasound image very poor.</p>
<p begin="00:03:16.230" end="00:03:18.190">I'm using a neurostimulator here that's</p>
<p begin="00:03:18.190" end="00:03:20.480">already connected also to this needle.</p>
<p begin="00:03:20.480" end="00:03:22.120">And you'll notice here that my needle is</p>
<p begin="00:03:22.120" end="00:03:24.412">in a sterile field but actually the wire</p>
<p begin="00:03:24.412" end="00:03:28.270">and the fluid is not because, in general,</p>
<p begin="00:03:28.270" end="00:03:30.330">I would have someone else do the injection</p>
<p begin="00:03:30.330" end="00:03:33.560">and do the base stimulation for me.</p>
<p begin="00:03:33.560" end="00:03:34.970">As far as prepping here,</p>
<p begin="00:03:34.970" end="00:03:37.780">this femoral nerve is generally blocked</p>
<p begin="00:03:37.780" end="00:03:40.210">together with the sciatic nerve for</p>
<p begin="00:03:40.210" end="00:03:42.670">procedures on the pelvic limb.</p>
<p begin="00:03:42.670" end="00:03:44.790">And in this case just<br />for the demonstration,</p>
<p begin="00:03:44.790" end="00:03:48.350">we don't have the limb completely clipped</p>
<p begin="00:03:48.350" end="00:03:50.140">but obviously for surgery this would be</p>
<p begin="00:03:50.140" end="00:03:51.540">completely clipped.</p>
<p begin="00:03:51.540" end="00:03:53.890">We're gonna use the<br />mid-portion of the thigh</p>
<p begin="00:03:53.890" end="00:03:55.710">here for doing image</p>
<p begin="00:03:55.710" end="00:03:59.843">and gonna start quite distal on the limb</p>
<p begin="00:03:59.843" end="00:04:03.090">to actually find the pectineus muscle</p>
<p begin="00:04:03.090" end="00:04:05.870">and the vascular bundle.</p>
<p begin="00:04:05.870" end="00:04:08.761">And I'm gonna follow<br />this bundle proximately</p>
<p begin="00:04:08.761" end="00:04:11.750">until I find the circumflex artery that</p>
<p begin="00:04:11.750" end="00:04:13.090">we were talking about.</p>
<p begin="00:04:13.090" end="00:04:15.109">And then the femoral<br />nerve is going to be just</p>
<p begin="00:04:15.109" end="00:04:17.860">medial to that, okay?</p>
<p begin="00:04:17.860" end="00:04:20.460">So now I'm gonna scrub this animal,</p>
<p begin="00:04:20.460" end="00:04:23.570">and wear my sterile gloves,</p>
<p begin="00:04:23.570" end="00:04:25.020">and then start the procedure.</p>

<p begin="00:00:06.610" end="00:00:07.443">- Hello.</p>
<p begin="00:00:07.443" end="00:00:09.010" tts:origin="0% 0%">My name is Dr. Carrie Schlachter.</p>
<p begin="00:00:09.010" end="00:00:12.400" tts:origin="0% 0%">this is Dr. Melanie<br />Tissier and this is Linus.</p>
<p begin="00:00:12.400" end="00:00:13.750" tts:origin="0% 0%">And we are all here today</p>
<p begin="00:00:13.750" end="00:00:16.550">in Petaluma, California<br />at Circle Oak Equine</p>
<p begin="00:00:16.550" end="00:00:18.300">to talk to you about how</p>
<p begin="00:00:18.300" end="00:00:21.483">to get an excellent image on ultrasound.</p>
<p begin="00:00:23.050" end="00:00:26.010">For this next section of video<br />we're going to be talking</p>
<p begin="00:00:26.010" end="00:00:30.760">about how to prepare a<br />horse's body for ultrasound</p>
<p begin="00:00:30.760" end="00:00:34.270">in situations where<br />you possibly can't clip</p>
<p begin="00:00:34.270" end="00:00:36.830">or where you could only<br />possibly clip with a 10 blade</p>
<p begin="00:00:36.830" end="00:00:39.720">and then we'll go ahead and<br />show you how to prepare a leg</p>
<p begin="00:00:39.720" end="00:00:42.280">that's been clipped with a 40 blade</p>
<p begin="00:00:42.280" end="00:00:45.080">in order to get the best<br />possible ultrasound image.</p>
<p begin="00:00:45.080" end="00:00:47.170">And the tools that<br />we're gonna be using are</p>
<p begin="00:00:47.170" end="00:00:49.400">a good quality ultrasound machine.</p>
<p begin="00:00:49.400" end="00:00:52.850">We're gonna be using a<br />standoff for some situations.</p>
<p begin="00:00:52.850" end="00:00:55.183">We're going to be using ultrasound gel.</p>
<p begin="00:00:56.110" end="00:00:58.070">Also we're gonna be using rubbing alcohol</p>
<p begin="00:00:58.070" end="00:00:59.690">in either a spray bottle or you can use</p>
<p begin="00:00:59.690" end="00:01:01.950">it in a pour bottle as well.</p>
<p begin="00:01:01.950" end="00:01:03.300">And then, most importantly</p>
<p begin="00:01:03.300" end="00:01:07.360">we're gonna be using a<br />bucket full of warm water</p>
<p begin="00:01:07.360" end="00:01:09.380">with a little bit of chlorhexidine soap</p>
<p begin="00:01:09.380" end="00:01:12.110">and solution in it and a rag.</p>
<p begin="00:01:12.110" end="00:01:16.110">I found that the rag does a<br />much better job than roll cotton</p>
<p begin="00:01:16.110" end="00:01:18.600">because the roll cotton<br />tends to leave a little bit</p>
<p begin="00:01:18.600" end="00:01:22.090">of debris behind when you're<br />scrubbing it on a leg.</p>
<p begin="00:01:22.090" end="00:01:25.430">So, you can imagine that<br />with all this hair that we</p>
<p begin="00:01:25.430" end="00:01:29.920">also have a lot of debris that<br />gets caught up underneath it.</p>
<p begin="00:01:29.920" end="00:01:33.460">So, we're gonna give it a<br />really good quality scrub</p>
<p begin="00:01:33.460" end="00:01:34.950">in the area of the ultrasound.</p>
<p begin="00:01:34.950" end="00:01:37.650">In fact, expanding beyond<br />the area of the ultrasound</p>
<p begin="00:01:37.650" end="00:01:38.630">that we're going to do.</p>
<p begin="00:01:38.630" end="00:01:43.020">It's really important you<br />don't use too much sudsy soap</p>
<p begin="00:01:43.020" end="00:01:45.460">in scrubbing especially with hair on</p>
<p begin="00:01:45.460" end="00:01:47.120">because the sudsy soap will get,</p>
<p begin="00:01:47.120" end="00:01:49.890">the air bubbles will get<br />caught underneath the hair</p>
<p begin="00:01:49.890" end="00:01:51.580">and that'll prevent your image</p>
<p begin="00:01:51.580" end="00:01:54.072">from being a good quality image.</p>
<p begin="00:01:54.072" end="00:01:56.310">So, a lot of times while I'm scrubbing</p>
<p begin="00:01:56.310" end="00:01:58.610">at the end of the scrub<br />I'll wipe downward,</p>
<p begin="00:01:58.610" end="00:02:01.070">wipe with the hair as I go.</p>
<p begin="00:02:01.070" end="00:02:02.850">The next step in the process is</p>
<p begin="00:02:02.850" end="00:02:04.990">to go ahead and take ultrasound gel</p>
<p begin="00:02:04.990" end="00:02:07.670">and put it on the area of interest.</p>
<p begin="00:02:07.670" end="00:02:10.560">Put the ultrasound gel on<br />going against the grain</p>
<p begin="00:02:10.560" end="00:02:14.100">of the hair and that will<br />work the ultrasound gel up</p>
<p begin="00:02:14.100" end="00:02:16.960">into and in between the hair</p>
<p begin="00:02:16.960" end="00:02:20.310">and that will oftentimes help</p>
<p begin="00:02:20.310" end="00:02:22.860">again by filling in all<br />the little air bubbles</p>
<p begin="00:02:22.860" end="00:02:25.050">and air gaps that are in that area.</p>
<p begin="00:02:25.050" end="00:02:26.550">And then the last thing I'll use is</p>
<p begin="00:02:26.550" end="00:02:28.660">once I'm ultrasounding actively</p>
<p begin="00:02:28.660" end="00:02:31.040">I'll use alcohol on the leg to try</p>
<p begin="00:02:31.040" end="00:02:34.800">and to fill any of the<br />little gaps that are left.</p>
<p begin="00:02:34.800" end="00:02:36.010">So, then we'll go ahead and start</p>
<p begin="00:02:36.010" end="00:02:38.030">our scan with just the gel on.</p>
<p begin="00:02:38.030" end="00:02:40.937">Oftentimes I'm scanning without a standoff</p>
<p begin="00:02:40.937" end="00:02:43.040">and I'm scanning an unclipped leg.</p>
<p begin="00:02:43.040" end="00:02:46.640">I find you get a much better<br />image in that situation.</p>
<p begin="00:02:46.640" end="00:02:51.610">I will also label the unclipped situation</p>
<p begin="00:02:51.610" end="00:02:55.970">so that we know that I<br />was scanning the images</p>
<p begin="00:02:57.082" end="00:02:59.130">unclipped for their record.</p>
<p begin="00:02:59.130" end="00:03:02.060">I'll just go ahead and spray<br />some alcohol onto the area</p>
<p begin="00:03:03.050" end="00:03:05.100">and see if that improves my image at all.</p>
<p begin="00:03:07.270" end="00:03:09.160">I find if I have good preparation</p>
<p begin="00:03:09.160" end="00:03:11.760">I don't use a standoff in the lower legs</p>
<p begin="00:03:11.760" end="00:03:13.780">and I have a good quality machine,</p>
<p begin="00:03:13.780" end="00:03:17.720">I can often get by with very<br />little difference in my gain</p>
<p begin="00:03:17.720" end="00:03:20.940">than I would need a clipped situation.</p>
<p begin="00:03:20.940" end="00:03:22.990">Then I would go ahead and scan the leg.</p>
<p begin="00:03:22.990" end="00:03:25.780">And now we're gonna talk about how</p>
<p begin="00:03:25.780" end="00:03:28.960">to best prepare a leg to<br />get a good quality image</p>
<p begin="00:03:28.960" end="00:03:30.952">that's been clipped with a 10 blade.</p>
<p begin="00:03:30.952" end="00:03:32.090">(clippers buzzing)</p>
<p begin="00:03:32.090" end="00:03:36.190">So, when I'm clipping I like to clip</p>
<p begin="00:03:36.190" end="00:03:38.670">as wide an area as possible</p>
<p begin="00:03:38.670" end="00:03:41.760">so that I know that I can<br />clean that area even better</p>
<p begin="00:03:41.760" end="00:03:45.610">and so that if my probe slides<br />out of the area of interest</p>
<p begin="00:03:45.610" end="00:03:49.000">that I'm ultrasounding, it<br />doesn't slide into a dirty area.</p>
<p begin="00:03:49.000" end="00:03:51.590">And so, that leaves just a short amount</p>
<p begin="00:03:51.590" end="00:03:54.420">of hair on their legs and while that</p>
<p begin="00:03:54.420" end="00:03:58.430">certainly can decrease image<br />quality in a lot of situations,</p>
<p begin="00:03:58.430" end="00:04:00.620">if you're able to image<br />what you're looking at</p>
<p begin="00:04:00.620" end="00:04:03.110">without a standoff, I actually feel like</p>
<p begin="00:04:03.110" end="00:04:07.460">it can increase image quality<br />in a lot of situations</p>
<p begin="00:04:07.460" end="00:04:10.870">because the 10 blade<br />leaves just enough hair</p>
<p begin="00:04:10.870" end="00:04:14.490">to create enough room<br />for the gel to sit in it</p>
<p begin="00:04:14.490" end="00:04:17.390">and act as a little bit<br />of its own standoff.</p>
<p begin="00:04:17.390" end="00:04:22.310">So, after I've clipped<br />an area with a 10 blade</p>
<p begin="00:04:22.310" end="00:04:25.130">then I go ahead and scrub it really well</p>
<p begin="00:04:25.130" end="00:04:27.450">to get rid of all the dirt and the debris</p>
<p begin="00:04:27.450" end="00:04:29.770">and hair from the clipping and again</p>
<p begin="00:04:29.770" end="00:04:32.930">I'll scrub outside of my clipped area</p>
<p begin="00:04:32.930" end="00:04:35.810">to make sure that I'm not<br />going to drag any of the dirt</p>
<p begin="00:04:35.810" end="00:04:38.530">and the debris into the clipped area</p>
<p begin="00:04:38.530" end="00:04:41.020">which will decrease image quality again.</p>
<p begin="00:04:41.020" end="00:04:43.290">And then I'm going to use the same method</p>
<p begin="00:04:43.290" end="00:04:45.410">that I used when I had hair on the leg.</p>
<p begin="00:04:45.410" end="00:04:50.410">I'm gonna put gel on against<br />the grain of the hair</p>
<p begin="00:04:50.550" end="00:04:54.190">and that's going to help<br />fill in all of the gaps</p>
<p begin="00:04:54.190" end="00:04:57.550">in between the hair and the skin.</p>
<p begin="00:04:57.550" end="00:05:00.260">So, I'll put the gel on<br />going against the grain</p>
<p begin="00:05:00.260" end="00:05:02.820">and then going with the grain</p>
<p begin="00:05:02.820" end="00:05:04.740">and then going against the grain</p>
<p begin="00:05:04.740" end="00:05:09.740">until it fills in the whole<br />area and becomes a nice film</p>
<p begin="00:05:10.150" end="00:05:12.090">of gel over the surface of the skin.</p>
<p begin="00:05:12.090" end="00:05:15.510">And then some of these guys<br />I do scan with a standoff.</p>
<p begin="00:05:15.510" end="00:05:17.020">Some I can without.</p>
<p begin="00:05:17.020" end="00:05:20.000">It just depends on the<br />actual image quality.</p>
<p begin="00:05:20.000" end="00:05:23.020">So, I'll go ahead at this point<br />and put my probe on the leg</p>
<p begin="00:05:23.020" end="00:05:26.190">and see what the level of<br />image quality I'll get is.</p>
<p begin="00:05:26.190" end="00:05:28.530">I'll adjust my depth and my gain.</p>
<p begin="00:05:28.530" end="00:05:30.350">I do like to label that</p>
<p begin="00:05:30.350" end="00:05:32.780">it's only been clipped with a 10 blade</p>
<p begin="00:05:32.780" end="00:05:35.636">just like I would label<br />it if it was unclipped.</p>
<p begin="00:05:35.636" end="00:05:37.340">And then again, I will check it</p>
<p begin="00:05:37.340" end="00:05:40.740">at that situation with alcohol as well.</p>
<p begin="00:05:40.740" end="00:05:43.440">And so again, in this situation<br />I may go ahead and just put</p>
<p begin="00:05:43.440" end="00:05:46.710">the standoff on and see if that improves</p>
<p begin="00:05:47.800" end="00:05:49.203">my image quality at all.</p>
<p begin="00:05:52.660" end="00:05:55.650">He's giving us a very<br />acceptable image actually.</p>
<p begin="00:05:55.650" end="00:05:58.340">And so, even with just a 10 blade,</p>
<p begin="00:05:58.340" end="00:06:00.660">we're getting a very diagnostic image.</p>
<p begin="00:06:00.660" end="00:06:02.670">And then in the next section we'll talk</p>
<p begin="00:06:02.670" end="00:06:06.500">about how to go about preparing an area</p>
<p begin="00:06:06.500" end="00:06:09.803">for really good image<br />quality using a 40 blade.</p>
<p begin="00:06:10.920" end="00:06:13.010">In the ideal situation,<br />you're going to be able</p>
<p begin="00:06:13.010" end="00:06:16.910">to clip with a 40 blade<br />and take off as much hair</p>
<p begin="00:06:16.910" end="00:06:19.927">as is possible in the area of interest.</p>
<p begin="00:06:19.927" end="00:06:23.430">(clippers buzzing)</p>
<p begin="00:06:23.430" end="00:06:25.960">That's what we're going to go<br />ahead and do next is take off</p>
<p begin="00:06:25.960" end="00:06:28.480">as much hair as possible<br />and then we're gonna talk</p>
<p begin="00:06:28.480" end="00:06:30.100">about some tips as to how</p>
<p begin="00:06:30.100" end="00:06:33.093">to get the best image quality<br />in the ideal situation.</p>
<p begin="00:06:35.580" end="00:06:37.660">So, once we've gone ahead and clipped</p>
<p begin="00:06:37.660" end="00:06:42.360">then the next goal is to get<br />the area as clean as we can</p>
<p begin="00:06:42.360" end="00:06:46.310">to get as much debris and dirt<br />off the area as is possible.</p>
<p begin="00:06:46.310" end="00:06:49.950">So, again I'm going to<br />scrub using warm water,</p>
<p begin="00:06:49.950" end="00:06:54.950">a little bit of dilute<br />chlorhexidine soap and solution</p>
<p begin="00:06:55.150" end="00:06:57.380">and a rag to go ahead and clean the area</p>
<p begin="00:06:57.380" end="00:06:58.960">as best as possible.</p>
<p begin="00:06:58.960" end="00:07:03.520">Again, I like to scrub not<br />only the area that I've clipped</p>
<p begin="00:07:03.520" end="00:07:04.980">but the area surrounding it</p>
<p begin="00:07:04.980" end="00:07:09.720">so that the dirt doesn't bleed<br />into my ultrasound location</p>
<p begin="00:07:09.720" end="00:07:11.410">and decrease the image quality.</p>
<p begin="00:07:11.410" end="00:07:15.470">We go ahead and start<br />with some gel on the leg</p>
<p begin="00:07:15.470" end="00:07:17.670">and on the probe without a standoff.</p>
<p begin="00:07:17.670" end="00:07:21.860">I put a thin coating of gel<br />on the leg in the clipped area</p>
<p begin="00:07:21.860" end="00:07:24.330">and right to the outside<br />edge of the clipped area</p>
<p begin="00:07:24.330" end="00:07:26.100">and then I use a little bit of gel</p>
<p begin="00:07:27.330" end="00:07:29.070">on the end of the probe as well</p>
<p begin="00:07:29.070" end="00:07:32.280">and then I go ahead and<br />assess image quality</p>
<p begin="00:07:32.280" end="00:07:36.370">turn the gain up and<br />down, get my depth set.</p>
<p begin="00:07:36.370" end="00:07:38.550">Then I might continue on and scan</p>
<p begin="00:07:38.550" end="00:07:40.670">or at that point I'll go ahead and assess</p>
<p begin="00:07:40.670" end="00:07:42.800">what the image looks like with a standoff.</p>
<p begin="00:07:42.800" end="00:07:45.970">The object of interest should be as close</p>
<p begin="00:07:45.970" end="00:07:49.080">to the center of the<br />screen as you can get it.</p>
<p begin="00:07:49.080" end="00:07:54.050">And so, a stand off helps<br />you move the superficial</p>
<p begin="00:07:54.050" end="00:07:57.290">structures closer to<br />the center of the screen</p>
<p begin="00:07:57.290" end="00:07:59.290">and you're gonna get your best imaging</p>
<p begin="00:07:59.290" end="00:08:00.990">at the center of your screen.</p>
<p begin="00:08:00.990" end="00:08:03.020">The other reason to use a standoff is</p>
<p begin="00:08:03.020" end="00:08:06.365">because horses' lower limbs<br />don't have a lot of soft tissue.</p>
<p begin="00:08:06.365" end="00:08:09.940">They're very tendinous<br />and bony and so that means</p>
<p begin="00:08:09.940" end="00:08:11.570">that you're putting a hard structure</p>
<p begin="00:08:11.570" end="00:08:13.890">against a hard structure and that means</p>
<p begin="00:08:13.890" end="00:08:16.560">that your image that<br />you get is very narrow.</p>
<p begin="00:08:16.560" end="00:08:19.640">You can use a standoff<br />to widen that image field</p>
<p begin="00:08:19.640" end="00:08:22.610">just a little bit by using<br />pressure and having it wrap</p>
<p begin="00:08:22.610" end="00:08:25.200">around the edges of the structure.</p>
<p begin="00:08:25.200" end="00:08:28.620">And so you can get much<br />better image quality</p>
<p begin="00:08:28.620" end="00:08:31.900">and much wider view of image.</p>
<p begin="00:08:31.900" end="00:08:35.220">When I'm using a standoff<br />I rarely use alcohol</p>
<p begin="00:08:35.220" end="00:08:36.790">in combination with the standoff.</p>
<p begin="00:08:36.790" end="00:08:38.500">I find that the rubbing alcohol</p>
<p begin="00:08:38.500" end="00:08:41.410">over time dries out the standoffs.</p>
<p begin="00:08:41.410" end="00:08:44.260">As well I find that it<br />doesn't add anything</p>
<p begin="00:08:44.260" end="00:08:47.620">to the image quality when I'm<br />using alcohol and a standoff.</p>
<p begin="00:08:47.620" end="00:08:50.130">If I'm starting to lose image quality,</p>
<p begin="00:08:50.130" end="00:08:53.310">I'll either add more gel<br />or I'll rewash the leg</p>
<p begin="00:08:53.310" end="00:08:55.080">and get rid of the gel that's on it</p>
<p begin="00:08:55.080" end="00:08:57.590">and then start anew with fresh gel</p>
<p begin="00:08:57.590" end="00:08:59.340">and then in that type of situation</p>
<p begin="00:08:59.340" end="00:09:02.210">I get the best image possible.</p>
<p begin="00:09:02.210" end="00:09:03.400">Thank you for watching the video.</p>
<p begin="00:09:03.400" end="00:09:05.950">This is Dr. Carrie Schlacter,<br />Dr. Melanie Tissier</p>
<p begin="00:09:05.950" end="00:09:08.840">and Linus telling you<br />that for more information</p>
<p begin="00:09:08.840" end="00:09:12.163" tts:origin="0% 0%">please go to sonosite.com/veterinary.</p>

<p begin="00:00:00.015" end="00:00:03.120">(dramatic music)</p>
<p begin="00:00:03.120" end="00:00:06.120">- [Voiceover] You're not in<br />this job for the technology.</p>
<p begin="00:00:06.120" end="00:00:07.620">You're in it for the patients.</p>
<p begin="00:00:08.810" end="00:00:10.847">You don't care about adjusting settings.</p>
<p begin="00:00:10.847" end="00:00:13.613">You don't have time to wait<br />for the machine to warm up.</p>
<p begin="00:00:14.620" end="00:00:17.553">And you don't need a system<br />that's too confusing to use.</p>
<p begin="00:00:19.859" end="00:00:23.160">All you want is access<br />to the answers you need,</p>
<p begin="00:00:23.160" end="00:00:25.220">confidence in the images you see,</p>
<p begin="00:00:25.220" end="00:00:28.033">from an ultrasound<br />system that simply works.</p>
<p begin="00:00:31.480" end="00:00:33.890">This is point of care ultrasound.</p>
<p begin="00:00:33.890" end="00:00:35.593">This is Sonosite.</p>

<p begin="00:00:06.800" end="00:00:08.157">- So now that I have an image,</p>
<p begin="00:00:08.157" end="00:00:11.690">you'll notice that I<br />have my first rib here</p>
<p begin="00:00:11.690" end="00:00:14.400">on the right side of the screen,</p>
<p begin="00:00:14.400" end="00:00:16.860">and you can see the hyperechoic</p>
<p begin="00:00:16.860" end="00:00:18.920">surrounding of the nerve roots.</p>
<p begin="00:00:18.920" end="00:00:20.350">They're hyperechoic on the meter.</p>
<p begin="00:00:20.350" end="00:00:21.490">They're pretty rounded there,</p>
<p begin="00:00:21.490" end="00:00:23.390">and they're kind of in a row.</p>
<p begin="00:00:23.390" end="00:00:24.300">Look like almost</p>
<p begin="00:00:25.835" end="00:00:29.990">a little pearl necklace right there.</p>
<p begin="00:00:29.990" end="00:00:33.520">Basically, we can actually<br />get all those roots blocked.</p>
<p begin="00:00:33.520" end="00:00:37.110">Notice also the presence of<br />two major arteries in here.</p>
<p begin="00:00:37.110" end="00:00:39.030">One is a vertebral artery,</p>
<p begin="00:00:39.030" end="00:00:42.710">and the other is the cervico-costal trunk.</p>
<p begin="00:00:42.710" end="00:00:45.280">And there you can see<br />them bouncing just below</p>
<p begin="00:00:45.280" end="00:00:48.270">the most caudal portion of this plexus.</p>
<p begin="00:00:48.270" end="00:00:49.340">So you gotta be very careful</p>
<p begin="00:00:49.340" end="00:00:51.743">to not do a intra-arterial injection.</p>
<p begin="00:00:53.601" end="00:00:56.893">I'm gonna come from cranial<br />to caudal with my needle.</p>
<p begin="00:00:59.270" end="00:01:02.070">And you gotta be careful that<br />you not hit the jugular vein,</p>
<p begin="00:01:02.070" end="00:01:05.093">which is just ventral to where we are.</p>
<p begin="00:01:06.220" end="00:01:08.340">And you're gonna see then</p>
<p begin="00:01:08.340" end="00:01:10.700">my needle coming in,</p>
<p begin="00:01:10.700" end="00:01:13.430">and I'm gonna try to primary</p>
<p begin="00:01:13.430" end="00:01:17.420">hit the most ventral portion<br />of this plexus first.</p>
<p begin="00:01:17.420" end="00:01:19.739">And you can tell the tip of my needle</p>
<p begin="00:01:19.739" end="00:01:22.733">is right where the plexus is.</p>
<p begin="00:01:23.710" end="00:01:25.770">I kind of lost a little bit,</p>
<p begin="00:01:25.770" end="00:01:28.830">here we go, now I can<br />see most of my needle.</p>
<p begin="00:01:28.830" end="00:01:31.560">And you can see the needle<br />where we're gonna be injecting</p>
<p begin="00:01:31.560" end="00:01:35.180">on the most caudal potion of the plexus,</p>
<p begin="00:01:35.180" end="00:01:39.310">and with that I'm gonna be<br />moving my needle cranially</p>
<p begin="00:01:43.300" end="00:01:44.210">towards</p>
<p begin="00:01:45.420" end="00:01:46.490">a more</p>
<p begin="00:01:47.570" end="00:01:49.500">cranial portion of that.</p>
<p begin="00:01:49.500" end="00:01:52.480">Block again, and then you<br />see when I'm doing this,</p>
<p begin="00:01:52.480" end="00:01:54.530">if the neurostimulator is on,</p>
<p begin="00:01:54.530" end="00:01:56.360">you're gonna see the contraction changing</p>
<p begin="00:01:56.360" end="00:01:58.390">because you're changing the nerve roots</p>
<p begin="00:01:58.390" end="00:02:01.223">responsible for the innervation<br />of different muscles.</p>
<p begin="00:02:02.380" end="00:02:05.200">And then now I'm gonna come to the most</p>
<p begin="00:02:05.200" end="00:02:07.713">cranial portion of this plexus.</p>
<p begin="00:02:09.290" end="00:02:13.130">And you can see my needle</p>
<p begin="00:02:13.130" end="00:02:15.910">on that most cranial portion of it.</p>
<p begin="00:02:15.910" end="00:02:17.270">I will inject another portion</p>
<p begin="00:02:17.270" end="00:02:19.253">of my local anesthetic on this area.</p>
<p begin="00:02:21.270" end="00:02:23.800">And then with that, I withdraw my needle,</p>
<p begin="00:02:23.800" end="00:02:26.163">and we have a complete blockade there.</p>

<p begin="00:00:06.310" end="00:00:08.920">- Okay, so now I have scrubbed the area,</p>
<p begin="00:00:08.920" end="00:00:11.050">that we are gonna be blocking.</p>
<p begin="00:00:11.050" end="00:00:13.010">The animal is connected<br />to my nerve stimulator,</p>
<p begin="00:00:13.010" end="00:00:15.190">at point seven milliamps.</p>
<p begin="00:00:15.190" end="00:00:17.590">My needle is already primed<br />with a local anesthetic.</p>
<p begin="00:00:17.590" end="00:00:19.580">I don't wanna inject any air there.</p>
<p begin="00:00:19.580" end="00:00:21.580">Now I have, you know, sterile gloves on,</p>
<p begin="00:00:22.490" end="00:00:24.120">obviously the ultrasound, is not covered,</p>
<p begin="00:00:24.120" end="00:00:27.600">so my right hand is gonna be unsterile,</p>
<p begin="00:00:27.600" end="00:00:31.230">so I will try to avoid touching<br />my needle with this hand.</p>
<p begin="00:00:31.230" end="00:00:34.460">Only my left hand is gonna be<br />touching my sterile needle.</p>
<p begin="00:00:34.460" end="00:00:36.210">So I'm just gonna remove the cover,</p>
<p begin="00:00:37.140" end="00:00:39.470">and have my needle ready for me.</p>
<p begin="00:00:39.470" end="00:00:42.540">So now when we look at<br />the structures here,</p>
<p begin="00:00:42.540" end="00:00:45.320">okay, we can scout this image,</p>
<p begin="00:00:45.320" end="00:00:50.320">and I'll put the probe just<br />on the top of my first rib,</p>
<p begin="00:00:51.170" end="00:00:54.040">and as soon as I do that I can actually,</p>
<p begin="00:00:54.040" end="00:00:56.580">come from the most ventral portion.</p>
<p begin="00:00:56.580" end="00:00:58.760">I find the rings of the trachea.</p>
<p begin="00:00:58.760" end="00:01:03.442">I can keep moving up until<br />I find finally the rib,</p>
<p begin="00:01:03.442" end="00:01:05.930">and basically the roots,</p>
<p begin="00:01:05.930" end="00:01:08.690">are still off of the<br />brachial plexus, okay,</p>
<p begin="00:01:08.690" end="00:01:11.700">just coming out of under<br />the scalene muscle.</p>
<p begin="00:01:11.700" end="00:01:13.590">Notice that there is two major arteries,</p>
<p begin="00:01:13.590" end="00:01:18.250">right cranial to the first rib,</p>
<p begin="00:01:18.250" end="00:01:20.870">you have actually the vertebral artery,</p>
<p begin="00:01:20.870" end="00:01:25.140">and the cervical coastal<br />trunk that are just under,</p>
<p begin="00:01:25.140" end="00:01:28.970">those blocks, those nerve roots, so.</p>
<p begin="00:01:28.970" end="00:01:31.970">Here you can see from<br />the left to the right,</p>
<p begin="00:01:31.970" end="00:01:34.210">the roots from C6 to T2,</p>
<p begin="00:01:34.210" end="00:01:36.760">and you obviously have<br />already innervations,</p>
<p begin="00:01:36.760" end="00:01:41.530">there are innervation<br />that are nerve roots,</p>
<p begin="00:01:41.530" end="00:01:44.770">already splitting out and<br />some ramifications in there,</p>
<p begin="00:01:44.770" end="00:01:46.470">that's why you don't see only just,</p>
<p begin="00:01:46.470" end="00:01:50.860">four or five dots in<br />there, is hypoechoic dots,</p>
<p begin="00:01:50.860" end="00:01:52.410">that will be your roots.</p>
<p begin="00:01:52.410" end="00:01:54.750">So the first injection I'm gonna do,</p>
<p begin="00:01:54.750" end="00:01:56.340">is when I'm gonna do this block,</p>
<p begin="00:01:56.340" end="00:02:00.493">I am going to come pretty<br />superficial, close to my probe,</p>
<p begin="00:02:10.040" end="00:02:12.983">and once I actually visualize my needle,</p>
<p begin="00:02:24.050" end="00:02:29.050">I'm gonna go and move it<br />to the most distal portion,</p>
<p begin="00:02:32.290" end="00:02:35.850">and you can see that<br />the limbs start moving,</p>
<p begin="00:02:35.850" end="00:02:38.600">and we are getting probably some ulnar,</p>
<p begin="00:02:38.600" end="00:02:42.210">and medial nerve because I'm really lower,</p>
<p begin="00:02:42.210" end="00:02:44.220">on the brachial plexus right there,</p>
<p begin="00:02:44.220" end="00:02:47.310">and you can see my needle, okay.</p>
<p begin="00:02:47.310" end="00:02:49.590">After I do an injection here,</p>
<p begin="00:02:49.590" end="00:02:52.060">I'm gonna move a little bit cranial,</p>
<p begin="00:02:52.060" end="00:02:54.110">and you can see that the<br />contraction of the limb,</p>
<p begin="00:02:54.110" end="00:02:57.820">will change because, now I'm<br />going to a different root,</p>
<p begin="00:02:57.820" end="00:03:00.373">and different nerves, okay.</p>
<p begin="00:03:01.500" end="00:03:05.750">And I will be trying to quote<br />most of those nerve roots,</p>
<p begin="00:03:05.750" end="00:03:08.590">and this is a great technique, you know,</p>
<p begin="00:03:08.590" end="00:03:13.030">and is a good alternative<br />for the axillary area,</p>
<p begin="00:03:13.030" end="00:03:15.670">because you have less<br />branching of those roots,</p>
<p begin="00:03:15.670" end="00:03:19.120">so Dr. Pablo Ter-r-o did this description,</p>
<p begin="00:03:19.120" end="00:03:21.300">I find that is much easier,</p>
<p begin="00:03:21.300" end="00:03:25.190">as far as making sure that<br />you have a complete block.</p>
<p begin="00:03:25.190" end="00:03:29.010">However, is a much more<br />skilled dependent block,</p>
<p begin="00:03:29.010" end="00:03:31.800">and it can be quite tricky, because of,</p>
<p begin="00:03:31.800" end="00:03:36.800">due to the proximity to major<br />vessels and the trachea.</p>
<p begin="00:03:44.703" end="00:03:49.536">And you can see again, the<br />needle coming out on proximity,</p>
<p begin="00:03:50.740" end="00:03:53.030">to the cranial portion of that,</p>
<p begin="00:03:53.030" end="00:03:56.440">and a lot of times I will<br />turn off my stimulator,</p>
<p begin="00:03:56.440" end="00:04:00.150">once I get to this point<br />so I don't actually get,</p>
<p begin="00:04:00.150" end="00:04:03.333">so much interference when<br />I am doing this blockade.</p>
<p begin="00:04:11.090" end="00:04:14.983">And then I am moving again,<br />cranially, to get the nerves,</p>
<p begin="00:04:17.120" end="00:04:20.320">and you know because of this<br />very superficial blockade,</p>
<p begin="00:04:20.320" end="00:04:22.070">actually the needle is,</p>
<p begin="00:04:22.070" end="00:04:25.070">just on the subcutaneous tissue almost,</p>
<p begin="00:04:25.070" end="00:04:28.400">not much muscle over, so<br />is trickier sometimes,</p>
<p begin="00:04:28.400" end="00:04:32.620">to get this, an image of<br />your needle, and a complete,</p>
<p begin="00:04:32.620" end="00:04:34.023">you know a complete block,</p>
<p begin="00:04:35.900" end="00:04:36.903">and that's about it.</p>
<p begin="00:04:38.190" end="00:04:40.480">So, once I see the contractions,</p>
<p begin="00:04:40.480" end="00:04:43.190">and find the whole plexus,</p>
<p begin="00:04:43.190" end="00:04:46.980">I'm then ready to inject this<br />plexus with local anesthetic,</p>
<p begin="00:04:46.980" end="00:04:50.210">starting from the most<br />caudal portion of the plexus,</p>
<p begin="00:04:50.210" end="00:04:51.360">to the cranial portion.</p>

<p begin="00:00:00.423" end="00:00:03.506">(gentle piano music)</p>
<p begin="00:00:38.570" end="00:00:40.640">- Hello, my name is Fernando Garcia.</p>
<p begin="00:00:40.640" end="00:00:42.160">I am an anesthesiologist</p>
<p begin="00:00:42.160" end="00:00:44.630">board certified on the<br />American College of Veterinary</p>
<p begin="00:00:44.630" end="00:00:46.330">Anesthesia and Analgesia,</p>
<p begin="00:00:46.330" end="00:00:49.270">and also assistant professor,<br />University of Florida.</p>
<p begin="00:00:49.270" end="00:00:51.320">I'm here today with Sonosite</p>
<p begin="00:00:51.320" end="00:00:53.900">and using the S Vet II</p>
<p begin="00:00:53.900" end="00:00:57.420">to demonstrate to you<br />a brachial plexus block</p>
<p begin="00:00:57.420" end="00:00:59.400">with the suprascalene approach</p>
<p begin="00:00:59.400" end="00:01:01.523">that was described by Dr. Pablo Terol.</p>
<p begin="00:01:03.140" end="00:01:04.870">First of all, what I wanna show you</p>
<p begin="00:01:04.870" end="00:01:06.483">is a little bit of the anatomy.</p>
<p begin="00:01:07.340" end="00:01:12.110">The dog is actually<br />pried with rolled towels,</p>
<p begin="00:01:12.110" end="00:01:15.640">so the scapula of the limb to be blocked</p>
<p begin="00:01:15.640" end="00:01:17.690">will be moved caudally,</p>
<p begin="00:01:17.690" end="00:01:20.670">and that will expose your first rib.</p>
<p begin="00:01:20.670" end="00:01:22.240">Remember, the whole brachial plexus</p>
<p begin="00:01:22.240" end="00:01:25.110">is gonna be coming out</p>
<p begin="00:01:25.110" end="00:01:27.960">to innervate the limb</p>
<p begin="00:01:27.960" end="00:01:32.520">just under the ventral<br />to the scalene muscle.</p>
<p begin="00:01:32.520" end="00:01:34.510">That way, you can actually get</p>
<p begin="00:01:34.510" end="00:01:37.020">the whole plexus right here.</p>
<p begin="00:01:37.020" end="00:01:40.560">So all the nerve roots<br />of the brachial plexus</p>
<p begin="00:01:40.560" end="00:01:42.860">will be coming out on this region.</p>
<p begin="00:01:42.860" end="00:01:46.300">It makes it kind of<br />easier for you to block.</p>
<p begin="00:01:46.300" end="00:01:48.790">This block is useful for you</p>
<p begin="00:01:48.790" end="00:01:53.360">to do any procedure on the thoracic limb,</p>
<p begin="00:01:53.360" end="00:01:55.410">including amputations.</p>
<p begin="00:01:55.410" end="00:01:59.169">Even a scapula would be blocked this way.</p>
<p begin="00:01:59.169" end="00:02:00.980">A little bit of the skin over the scapula</p>
<p begin="00:02:00.980" end="00:02:02.240">there on the cranial portion</p>
<p begin="00:02:02.240" end="00:02:04.910">is actually innervated by C5 root,</p>
<p begin="00:02:04.910" end="00:02:09.330">so you might need a paravertebral<br />block on C5 as well,</p>
<p begin="00:02:09.330" end="00:02:11.800">depending on how cranial and dorsal</p>
<p begin="00:02:11.800" end="00:02:14.250">you're gonna come with the procedure.</p>
<p begin="00:02:14.250" end="00:02:16.500">Couple of structures<br />that you wanna know here.</p>
<p begin="00:02:16.500" end="00:02:17.920">So I'm gonna palpate.</p>
<p begin="00:02:17.920" end="00:02:19.803">This is the tip of your shoulder,</p>
<p begin="00:02:21.610" end="00:02:24.460">scapulo-humeral joint,</p>
<p begin="00:02:24.460" end="00:02:26.150">and you're gonna see, just under here,</p>
<p begin="00:02:26.150" end="00:02:28.710">you can palate the first rib of the dog,</p>
<p begin="00:02:28.710" end="00:02:31.060">transverse process of C6,</p>
<p begin="00:02:31.060" end="00:02:32.620">jugular vein right here,</p>
<p begin="00:02:32.620" end="00:02:34.120">you could palpate the trachea,</p>
<p begin="00:02:35.272" end="00:02:37.660">and our block region<br />is gonna be right here.</p>
<p begin="00:02:40.140" end="00:02:42.470">The equipment that we're gonna use today,</p>
<p begin="00:02:42.470" end="00:02:47.290">I do have .3 mills per kilo<br />of local anesthetic solution,</p>
<p begin="00:02:47.290" end="00:02:51.440">in this case bupivacaine of .75%,</p>
<p begin="00:02:51.440" end="00:02:55.390">using a insulated needle<br />connected to a stimulator,</p>
<p begin="00:02:55.390" end="00:02:57.320">and sterile gloves.</p>
<p begin="00:02:57.320" end="00:03:01.923">We're using a<br />three-and-a-half-centimeter linear probe,</p>
<p begin="00:03:03.010" end="00:03:05.003">and we're gonna do a in-plane block.</p>
<p begin="00:03:06.160" end="00:03:09.800">So we're gonna be scrubbing this dog,</p>
<p begin="00:03:09.800" end="00:03:11.320">making sure everything is prepared,</p>
<p begin="00:03:11.320" end="00:03:13.960">then put my gloves on to do the procedure.</p>
<p begin="00:03:13.960" end="00:03:18.350">The dog is not obviously<br />prepared for surgery.</p>
<p begin="00:03:18.350" end="00:03:19.610">This is just a demonstration;</p>
<p begin="00:03:19.610" end="00:03:22.550">therefore the animal is<br />not clipped completely,</p>
<p begin="00:03:22.550" end="00:03:25.653">but it's clipped enough<br />for the block itself.</p>

<p begin="00:00:00.220" end="00:00:01.200">- The reason we chose this machine</p>
<p begin="00:00:01.200" end="00:00:03.770" tts:origin="0% 0%">is because it actually<br />has a neonatal probe</p>
<p begin="00:00:03.770" end="00:00:04.603" tts:origin="0% 0%">and it's great</p>
<p begin="00:00:04.603" end="00:00:06.220" tts:origin="0% 0%">because once we put the neonatal probe on</p>
<p begin="00:00:06.220" end="00:00:07.520" tts:origin="0% 0%">the machine knows</p>
<p begin="00:00:07.520" end="00:00:09.340" tts:origin="0% 0%">that we are going to be scanning a baby</p>
<p begin="00:00:09.340" end="00:00:11.920" tts:origin="0% 0%">and then we can actually select</p>
<p begin="00:00:11.920" end="00:00:14.040">what scan we want to do on the baby.</p>
<p begin="00:00:14.040" end="00:00:16.080">So we can do a nerve scan, abdomen,</p>
<p begin="00:00:16.080" end="00:00:18.730">vascular or a general neonatal scan.</p>
<p begin="00:00:18.730" end="00:00:20.480">So we're gonna look at the liver</p>
<p begin="00:00:20.480" end="00:00:22.250">and choose the abdomen.</p>
<p begin="00:00:22.250" end="00:00:25.810">And now,<br />(dramatic drum music)</p>
<p begin="00:00:25.810" end="00:00:28.050">- [Woman] So these follow-up<br />clinics are a great opportunity</p>
<p begin="00:00:28.050" end="00:00:29.487">to do a bit of teaching<br />with the students as well.</p>
<p begin="00:00:29.487" end="00:00:31.220">'Cause I guess we do have a bit more time</p>
<p begin="00:00:31.220" end="00:00:33.690">and we can go a bit<br />more into the pathology</p>
<p begin="00:00:33.690" end="00:00:34.523">and what you should be looking</p>
<p begin="00:00:34.523" end="00:00:35.356" tts:origin="0% 0%">for when you examine</p>
<p begin="00:00:35.356" end="00:00:37.403" tts:origin="0% 0%">or when your using the ultrasound machine.</p>

<p begin="00:00:00.220" end="00:00:01.700">- The reason we chose<br />this machine is because</p>
<p begin="00:00:01.700" end="00:00:03.770">it actually has a neonatal probe,</p>
<p begin="00:00:03.770" end="00:00:06.220" tts:origin="0% 0%">and it's great because once<br />we put the neonatal probe on</p>
<p begin="00:00:06.220" end="00:00:09.340" tts:origin="0% 0%">the machine knows that we're<br />going to be scanning a baby,</p>
<p begin="00:00:09.340" end="00:00:11.258">and then we can actually select</p>
<p begin="00:00:11.258" end="00:00:14.040">what scan we wanna do on the baby.</p>
<p begin="00:00:14.040" end="00:00:16.690">So we can do a nerve<br />scan, abdomen, vascular,</p>
<p begin="00:00:16.690" end="00:00:18.730">or general neonatal scan.</p>
<p begin="00:00:18.730" end="00:00:20.480">So we're going to look at the liver</p>
<p begin="00:00:20.480" end="00:00:23.223">and choose the abdomen right now.</p>
<p begin="00:00:25.810" end="00:00:27.100">- [Narrator] So these follow-up clinics</p>
<p begin="00:00:27.100" end="00:00:28.870">are a great opportunity<br />to do a bit of teaching</p>
<p begin="00:00:28.870" end="00:00:29.810">with the students as well,</p>
<p begin="00:00:29.810" end="00:00:31.220">cause I guess we do have a bit more time</p>
<p begin="00:00:31.220" end="00:00:33.690">and we can go a bit<br />more into the pathology,</p>
<p begin="00:00:33.690" end="00:00:35.660">and what you should be<br />looking for when you examine</p>
<p begin="00:00:35.660" end="00:00:37.860">or when you're using<br />the ultrasound machine.</p>

<p begin="00:00:00.610" end="00:00:02.040">- We're gonna go and do,</p>
<p begin="00:00:02.040" end="00:00:03.840" tts:origin="0% 0%">we're gonna do an ultrasound<br />of the left kidney</p>
<p begin="00:00:03.840" end="00:00:08.040" tts:origin="0% 0%">on Rigoberto, the<br />headmaster for the school</p>
<p begin="00:00:08.040" end="00:00:10.580">in this community and one of<br />our main community contacts</p>
<p begin="00:00:10.580" end="00:00:12.867">here in the community.</p>
<p begin="00:00:12.867" end="00:00:15.534" tts:origin="0% 0%">(intense music)</p>
<p begin="00:00:28.195" end="00:00:30.759">I can see air getting through the little</p>
<p begin="00:00:30.759" end="00:00:31.706">(mumbles)</p>
<p begin="00:00:31.706" end="00:00:32.548">- [Mackenzie] Hmm.</p>
<p begin="00:00:32.548" end="00:00:33.414">- [Ben] There.</p>
<p begin="00:00:33.414" end="00:00:35.097">- [Mackenzie] Yeah.</p>
<p begin="00:00:35.097" end="00:00:36.423">- [Ben] There we go.</p>
<p begin="00:00:36.423" end="00:00:38.480">- [Mackenzie] Yeah, oh now I can see that.</p>
<p begin="00:00:38.480" end="00:00:41.699">- Right there, oh hold on, right there.</p>
<p begin="00:00:41.699" end="00:00:42.532">And...</p>
<p begin="00:00:44.630" end="00:00:46.667">Stop, perfect, yeah, right there, trying</p>
<p begin="00:00:46.667" end="00:00:48.298">to get that black, right there.</p>
<p begin="00:00:48.298" end="00:00:49.131">- [Mackenzie] Yeah.</p>
<p begin="00:00:49.131" end="00:00:50.606">- [Ben] Yeah look at that.</p>
<p begin="00:00:50.606" end="00:00:54.423">Alright, well I think we<br />know what we wanna know.</p>