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

Rheumatology/Orthopedic Buzz Terms

Rheumatology. I'm not sure there is a more gray area of medicine... perhaps that's why I don't like it that much. I remember sitting in rheumatology class listening to cases thinking, "it could be any of the rheum diseases that we've talked about!" They all sound the same and there is no ONE test that gives you the answer. I find it immensely frustrating (perhaps why I ended up in a surgical field), but I tip my hats to the providers that work in it. It is so difficult to pin down a diagnosis and successfully treat a patient with rheum issues... so for me, I stick to the basics.

See below for my knowledge extent on these rheum/orthopedic PANCE/PANRE test-able gems:

Osteoarthritis (OA)
Exercise, PT
If knee joints involves - encourage weight loss indicting
Pool activities
NSAIDS

Rheumatoid arthritis (RA)
Aspirin, other NSAIDS
methotrexate for severe cases
benefits take months to see after therapy initiation

Ankylosing Spondylitis
PT
Indomethacin
Bamboo spine on plain films

SLE
NSAIDs for joint symptoms
Benign cases only need supportive care
Systemic corticosteroids for serious complications
Could be a cause of thrombosis in young women (oral contraceptives can also cause this)

Rickets
Vit D deficiency

Osteomyelitis
Aspirate and culture
Immobilize
Generally start with IV antibiotics then follow with PO antibiotics




Source: Medical boards Step 2 Made Ridiculously Simple - A. Carl, MD, PhD
Photo: wiki.cns.org

Postoperative management of temporal lobectomy

Postoperative management of temporal lobectomy:

1.     OR to PACU x 1 day to floor x 1-2 day – aim for D/C on POD3
2. ·      Early rise in body temp post op, think about incentive spirometery
3. ·      Hep lock as soon as patient starts taking PO fluids
4. ·      Encourage sitting and ambulating
5. ·     Patient remains on preop AEDs for 1-2 years post op (managed by Epilepsy folks)

·      Possible complications to look for:

o   Hemiparesis

§  Usually happens after cauterization/tearing of perforating vessels (from posterior communicating vessels or anterior choroidal a.)

§  Paralysis usually occurs immediately – this would be known before post op check

o   Visual field defects

§  Contralateral superior quadrant anopsia from damage of the Meyer loop

§  Always check visual fields

o   Dysphasia

§  Usually transient (1-3 weeks post op)

§  Approx 50% of dominant temp. lobe resections have dysphasia

o   Aseptic meningitis

§  A complication that usually presents 72 hrs – 1 week post op

§  Stiff neck, severe HA, nausea, elevated body temp

§  Diagnosis of exclusion with LP

o   Post operative seizures

§  Sz w/in 1^st 24hrs does not correlate to poor long term outcomes

§  Sz after 48hrs (with adequate AED blood levels) indicate poor long term outcome

Source: Neurosurgical Operative Atlas 2nd Ed- Starr, Barbaro, Larson

Pic source: http://www.neuros.net/en/epilepsy_surgery.php

Preoperative Patients on Coumadin

If you work in surgery or with the elderly - anticoagulation is an every day part of life. INRs, PTs, PTTs, etc... it is important to know what measures what and what reversal agents (if any) are available. Let's talk about Coumadin today.

Scenario: 79 yo patient is coming in for a surgical procedure, but he is on Coumadin. You did your due diligence and had them stop it about 5 days pre-op, but their INR is still 1.6 on preoperative blood work. What are your next steps?

Generally if you are going to bring someone to the OR you'd like their INR to be less than 1.5. If it is higher, you would consider a reversal agent.

Your 1st option for reversal is Vit K. 

• PO is most predictable and is preferred to IV if rapid reversal is not needed. PO Vit K lowers INR in about 24-48 hours. 
• IV works in approximately 12-24 hrs, but you run a greater risk of anaphylaxis and it must be administered over a longer period of time (approx 20 minutes). 

Your 2nd option for reversal is Fresh Frozen Plasma (FFP).

• FFP is more expensive than Vit K, but works within 12 hrs. FFP replaces clotting factors.

So, even though you did your due diligence, why was the INR still high? There are several reasons that can delay the drop of a patient's INR:

1. Age - Elderly pts
2. Malignancy (active)
3. Liver disease
4. CHF, unstable
5. Meds that keep Coumadin around in the blood (check their med list)

Sources:

Ansell, J, Hirsh, J, Poller, L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:204S. 

Normalization of INR After Stopping Coumadin: http://www.fpnotebook.com/mobile/HemeOnc/Surgery/PrprtvAntcgltn.htm

Surgical Training for Neurosurgical PAs

Laminectomy

Last week I had the privilege of attending a surgical training in San Francisco, California. The event was created by the Association of Neurosurgical Physician Assistants (ANSPA) in conjunction with Ethicon. I must say it was a fantastic experience. I was able to spend a half a day in a live porcine wet lab. The lab was for PAs only so it enabled me to spend more time with the surgical instruments and take the lead on certain aspects of the surgeries that we performed - both opportunities that I don't necessarily get on a day to day basis. It was successful in building my confidence.

We performed a craniotomy and tumor removal as well as a laminectomy with a focus on hemostasis. This is an unusual experience and I learned a great deal from both the PAs that attended and the Ethicon reps regarding hemostasis products. I had the least amount of surgical experience of all the PAs that were there (9 months), however all of the PAs were friendly and helpful and I learned quite a few new techniques. It was also inspirational to see what other PAs around the nation were doing as part of their daily grind. It ranged from PAs that spent the majority of their time in the OR as co-surgeons to those that split their time 50-50 between OR and floor work.

I was able to meet and spend some time with Josh, a neurosurgical PA for over 10 years, who is the current president of ANSPA. The AAPA recently completed a video on him and his contributions to his neurosurgical practice. The surgeons that he works with on a daily basis speak very highly of his surgical and patient skill sets. Mike Nido, PA-C and Dean Barone, PA-C were also instrumental in making this event happen.

All in all, hats off to ANSPA for working hard to make this happen for PAs. They hope to create more of these learning opportunities for neurosurgical PAs in the near future. If you are not a member, I highly encourage you to do so if you're interested in neurosurgery as a physician assistant.





*Disclosure: I am in no way financial tied to Ethicon. Just attended the event.

Antibiotics for Appendicitis?

I have had quite the hiatus from blog entries recently. Life gets busy somehow. Ha. I recently had hip surgery and had some blog worthy experiences as a patient that I hope to write about soon - but for now, I came across this interesting article on a PA (Andrew Gray, PA-C) that refused an appendectomy in lieu of antibiotic treatment for his acute appendicitis. He made his choice based on the fact that he did not have insurance and the results of a Swedish study. It is a short read, but very interesting and have evoked some feisty comments.

Saving My Appendix: http://www.pulsemagazine.org

Passing the Time on the T with JAAPA

So the PA Journal (JAAPA) now has an application for the iPad. It has been out for a while now and I really like it! I download the most recent journal and am able to read it on the T on the way to work. It is great... it helps me keep up on the newest issues and clinical articles. The only downside is that it is only for the iPad currently... sorry no iPhones or iPods.

If you are an AAPA member, you get the journal for free along with the free CMEs in each issue.

Down load it at the Apple App Store:  Journal of the American Academy of Physician Assistants

Aphasia

I have always found aphasia incredibly interesting and terrifying all at the same time. Imagine not being able to communicate with language as smoothly as you do everyday. It is something that many of us take for granted.

Definition:
the loss or defect of language (speaking fluency, reading, writing, understanding of written or spoke words)

What are the 4 types of aphasia?
1. Wernicke's 
2. Broca's
3. conduction
4. global

Potential causes:

• stroke
• brain trauma
• brain tumor
• alzheimer's disease

Wernicke's

-receptive, fluent aphasia

-pt has hard time comprehending written or spoken language

-fluid speech, but difficult to understand

Broca's

-expressive, nonfluent aphasia

-speech is slow and requires effort

-few words used

-good comprehension of language

Conduction

-disturbance in repetition

-pathology involves the connections between Wernicke's and Broca's

Global

-often associated with RIGHT hemiparesis

-defect in all areas of language

How to treat
-many recover spontaneously in 4-6 weeks
-speech therapy



Photo source: emedia.leeward.hawaii.edu
Source: Step Up to Medicine by Agabegi and Agabegi

ACA Stroke Basics

Anterior Cerebral Artery (ACA) Stroke

The Anatomy

What deficits might you expect to see in a patient?

• contralateral leg weakness (both motor and sensory), frontal lobe behavioral issues, +/- aphasia if prefrontal cortex involved, grasp reflex

Where does the ACA receive its blood supply from?

• Carotid arteries

Source: http://www.neuroanatomy.ca/stroke_model/aca_info.html
Photo sources: http://missinglink.ucsf.edu/lm/ids_104_cns_injury/response%20_to_injury/watershed.htm

Oliguria

As always... back to the basics:

What is oliguria?
Low urine output (UOP)

What is "normal" adult UOP?
About 30cc/hr

How might you write a post op floor order for this?
"call house officer if 2 hour UOP is < 60cc"

What are the possible causes?
Think pre renal/renal/post renal causes

What is the most common cause?
Pre renal!

Causes of Renal Failure

Causes of Renal Failure broken down by pre-renal, renal, and post-renal.

Source: Clinical Survival Guide for PA Students by G.Broughton, MD, PhD

What if PAs Couldn't Suture Anymore?

This a repost from a call sent out by the AAPA based on a resolution brought to the AMA's House of Delegates. Read it and take part in your future scope of practice as a PA.

Join AAPA in responding to negative AMA resolution

While workforce experts are predicting a shortage of providers with the implementation of the Affordable Care Act, the American Medical Association Board of Trustess is proposing a resolution for its House of Delegates that could severely restrict PAs' ability to provide care to patients. PAs should be very concerned about the resolution, which will be considered by the AMA HOD when it convenes on Saturday, June 15. The recommendations are very restrictive and display a misunderstanding of the way PAs and doctors provide care as part of a team. Among other restrictions, the resolution expands the definition of surgery to include repair and removal of human tissue and, although parts of the resolution are somewhat unclear, states that surgery as defined in the resolution is to be performed ONLY BY PHYSICIANS. If adopted as presented, the resolution will call into question procedures like suturing, punch biopsies and vein harvesting, which PAs perform on a daily basis across many medical specialties. The resolution also proposes that only physicians should perform invasive procedures that utilize radiologic imaging. You can read Report 16 of the AMA Board of Trustees in full here.

AAPA is spreading the word about the negative impact this resolution would have on patient care and PA practice, but we need your help. Please review the list of AMA delegates in your state or specialty, and if you have a connection, please let that physician know the true damage that this resolution could create. Also, talk with and encourage physicians in your practice to speak with other physician leaders about the resolution. AAPA's suggestion is that the resolution should be defeated, or modified to specifically state that it does not apply to PAs practicing within the parameters of state law.

For more information on the AMA resolution please contact Ann Davis, PA-C, MS, Senior Director of Constituent Organization Outreach and Advocacy, at ann@aapa.org.