Dr. Rhoton's Anatomy 2D and 3D

Medtronic and Dr. Rhoton put together an amazing YouTube series on "Rhoton Anatomy" in both 2D and 3D versions. I highly recommend checking them out. An incredible amount of effort and detail went into these!

 2D: https://www.youtube.com/playlist?list=PL6307C9E54B56AD87

3D: https://www.youtube.com/playlist?list=PL202A5006EB93D42D

Dr. Rhoton Biography

Dr. Albert L. Rhoton, Jr. attended Washington University School of Medicine, graduating with the highest academic standing in the class of 1959. He completed his neurosurgical training at Washington University and joined the staff of the Mayo Clinic in Rochester, Minnesota in 1965. He became Professor and Chairman of the Department of Neurological Surgery at the University of Florida in 1972.

Dr. Rhoton has served as President of the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the Society of Neurological Surgeons, the North American Skull Base Society, the International Interdisciplinary Congress on Craniofacial and Skull Base Surgery, the Florida Neurosurgical Society, and the International Society for Neurosurgical Technology and Instrument Invention. He served as the Honored Guest of the Congress of Neurological Surgeons and was awarded the Cushing Medal of the American Association of Neurological Surgeons in 1998, the highest honor given by the two largest neurosurgical societies in the United States. He has been awarded the Medal of Honor of the World Federation of Neurosurgical Societies, and has served as the Honored Guest or been elected to Honorary Membership in neurosurgical societies in Africa, Asia, Australia, Europe, and North and South America.

He has published over 400 scientific papers. He has received the Golden Neuron Award of the World Academy of Neurological Surgeons and was selected as the 2011 “Neurosurgeon of the Year” by the journal World Neurosurgery. He completed the Millennium and Anniversary Issues of Neurosurgery and a book entitled “Cranial Anatomy and Surgical Approaches,” which has been translated into several languages. He has received an Alumni Achievement Award from Washington University School of Medicine and both a Distinguished Faculty Award and a Lifetime Achievement Award from the University of Florida.

Friends, colleagues, and former residents contributed nearly $2 million to the University of Florida Foundation to create the Rhoton Chairman’s Endowed Professorship at the University of Florida, a gift that has grown to more than $6 million. This is in addition to 11 endowed chairs that Dr. Rhoton has raised for neurosurgery over the years. He and his wife, Joyce, have four children, all pursuing medical careers.

Source: http://www.stmeded.medtronic.com/anatomy-courses/rhoton-biography/index.htm

SMS Texting is Not HIPAA Compliant

Just wanted to share a great article on texting and HIPAA Compliance: Five Ways to Ensure Secure Text Messaging in Your Medical Practice

PAProgramSearch.com: Great Pre-PA Resource

I recently received an email from Ken Johnson, the developer of PAprogramsearch.com. Ken and his significant other went to the same process that many of us did when searching for PA programs and also encountered the same frustrations. It is difficult to find out which schools have which requirements. I ended up with a spreadsheet of the schools that I was going to apply to, their prerequisites, and checkboxes for the things that I had completed. Since there's no standardization of PA programs and their prerequisites at this time is difficult for students to keep track of.... in comes PAprogramsearch.com.

This website allows you to check off particular classes that you have taken as well as shadowing hours, etc. And then produces a list of schools with the "match percentage". The site is very easy to use it appears to be up to date. I always recommend going to be official program website to double check the prerequisites (as they can change at any time) but this is a great place to start.

Financial disclosure: 
I have no monetary or other connections to this website or the developers . Just sharing a resource. 

Home page

Check off the classes that you have completed and add your GPA/Experience in hours at the top.

A list of "matches" is generated.

Subcuticular Suturing

I came across this blog post on how to do a subcuticular closure. It is well written with step by step pictures so why reinvent the wheel. I am just going to repost. Enjoy!

Abnormal Facies: Running Subcuticular Suture Technique

Source: http://abnormalfacies.wordpress.com/2012/02/20/running-subcuticular-suture-technique/

Pain Control and Anti-Emetics

When prescribing pain medications you must also consider the side effects that those medications may have on your patient such as nausea, constipation, rash, etc.

We will talk about anti-emetics today.

There are many classes of anti-emetics to consider. Most services have their favorites, but due to patient allergies and the ineffectiveness of some medications on some patients - it is good to have a few back-ups in mind to try. You can also consult the pharmacy team that you work with for additional advice. This list is not comprehensive.

Dopamine antagonist: 
Prochlorperazine (good for opiod related nausea), Metoclopramide, Haloperidol

5HT3 antagonists: 
Ondansetron* (PO and IV)

Antihistamines: 
Diphenhydramine**

Anticholinergics: 
Scopolamine

Antipsychotics: 
Olanzapine


*can lead to headaches and constipation
**can be sedating





Source: MPR http://www.empr.com/antiemetic-treatments/article/125873/

Pain Control: Opiods

I will go over some general information regarding opioid use for analgesia. In subsequent entries I will go over different opioid use for 1) mild to moderate pain, 2) moderate to severe pain, and 3) severe pain. I would say for my practice most patients fall into the moderate to severe pain, but for a short period of time.

Opioids

Key Points:

• No ceiling effect (as a general statement this means the larger the dose, the larger the effect)
• Tolerance can develop with chronic use
• Overuse can lead to respiratory depression or seizures

Examples: 

Mild to moderate pain: codeine or tramadol

Moderate to severe pain: hydrocodone, oxycodone, hydromorphone

Severe pain: morphine, codeine, methadone

**Some of these can crossover between categories based on dosage.

Source: Handbook of Neurosurgery, Greenberg 6th ed

Pain Control: Toradol

Working in a surgical specialty, I have had to learn how to manage pain successfully.... and I must admit with some patients, I'm still learning. Pain is subjective so there is no magic recipe that works for every patient... you will have patients that 1) have intolerable side effects or allergies to your normal post op prescriptions, 2) have a history of narcotics abuse, 3) are drug seekers, 4) are people in true pain, and 5) are everything in between. It is good to have an idea of different pharmacological options to treat pain. Over the next few entries I will go over some of the main pain medications we use and some random ones as well.

TORADOL (ketoraolac tromethamine)

Key points:

• only parenteral NSAID approved for use in pain control in US
• Analgesic effect is more potent than anti-inflammatory
• Single dose administration = 30mg IV or 60mg IM (in healthy adult)
• Multiple doses = 30mg IV/IM q6hrs (max 120mg/day)
• PO is available, but used only as a continuation of IV/IM therapy - comes in 10mg tabs

Why might you use toradol?

• if constipation is an issue with your patient
• if you are worried about sedation/respiratory depression 
• patients with narcotic dependency
• if your patient gets nausea with narcotics

Cautions:

• do not use for > 72 hrs of pain control - some say 5 days is the max
• can prolong bleeding time (secondary to platelet inhibition) in post op patients - use caution 
• although injections bypass the GI system, patients can still get GI irritation
• monitor for renal side effects

Source: Handbook of Neurosurgery Greenberg, 6th Ed

Autism: Nuts & Bots

Autism is a disorder that we hear a good deal about in the media and you are likely to see some kids on the spectrum during your pediatric rotation. Here are the nuts, bolts, and key terms:

• Autism: impaired social interaction/communication/interests
• Prevalence: 0.4% of the general population (although I have seen wild variations of this number)
• More common in males than females (5 to 1)
• Symptoms generally seen before the age of 3
• Social sx: lack of peer relationships/failure to use non-verbal social cues
• Communication sx: absent or weird speech
• Behavioral sx: preoccupation with repetitive activities, rigid adherence to purposeless rituals, mental retardation (present in 75% of patients with autism), no parent-child bond
• Physical exam: generally normal, may see results of self-injurious behaviors (biting/head banging)
• Tx: family counseling, special education, antipsychotics can be considered for agitation

Source: Psychiatry for Medical Students and Residents by Nabell Kouka, MD, DO, MBA

Pic source: http://peteking.house.gov/issues/autism

What is a WADA exam?

What is a WADA exam?

A WADA exam is also known as an intracarotid amytal test. It is one of the “non-invasive” tests used to determine which hemisphere is language dominant in epileptic patients and also assess the ability of the non-affected side to maintain memory when isolated. For example, if you were to remove the R hippocampus – could the L side support language and memory alone?

No test is perfect... here are a couple of the WADA Shortcomings:

1. If patient has a high flow AVM – reading can be inaccurate
2. A portion of the hippocampus that you are trying to shut down could get its blood supply from posterior circulation making it hard to tell how accurately the patient will respond with full resection.

How is it done?

1. Get angiogram (to assess cross flow – which is a contraindication to shutting down the side of primary supply)
2. Cath ICA (usually start on lesion side)
3. Ask pt to hold opposite arm in the arm as amobarbital is rapidly injected into the ICA
4. What should happen? An almost immediate flaccid exam of the arm that begins to wear off in about 8 minutes. If it wears off faster (around 2 minutes) you may think about a high flow AVM.
5. Assess language by asking pt to name objects and remember them
6. Assess memory by asking pt to recall as many of the objects as possible 15 minutes later
7. Procedure can be repeated on the other side if needed

Photo source: http://www.instantanatomy.net/headneck/vessels/articinskull.html
Source: Handbook of Neurosurgery, Greenberg 6th Ed