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/

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

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.

Atrial Fibrillation

AFib, The Basics

Characteristics

1. irregularly iregular
2. irregular RR intervals
3. not a P wave in front of every QRS
4. atrial rate = 400-600bpm, ventricular rate = 80-160bpm

Etiologies = PIRATES

P = pulmonary (COPD, PE)/pheo/pericarditis

I = ischemic heart dz +/- HTN

R = rheumatic heart dz

A= anemia/atrial myxoma

T = throtoxicosis

E = ethanol ("holiday heart)/cocaine

S = sepsis (post-operative)

Signs/Symptoms

1. fatigue (most common)
2. tachypnea
3. palpitations
4. lightheaded

Work Up

(Test yourself... why would you order each of these? what are you looking for?) - answers below

1. EKG
2. ECHO
3. TSH (?)
4. Baseline coags

1. EKG = narrow complex QRS (<120msec), variable RR, irregular or absent P waves
2. ECHO = maybe thrombi, maybe dilated L atrium
3. TSH (?) = hyperthyroidism can cause AF
4. Baseline coags = getting baseline prior to starting anticoagulation

Of note: if you are looking for THROMBI..."normal" ECHOs (transthoracic) has low sensitivity - transesophageal ECHOs allow for better visualization of L atrial appendage (location where most thrombi form) 

source: First Aid for the Wards by Le, Bhushan, Skapik

pic source: http://www.saintvincenthealth.com/Services/Heart/Heart-Resource-Library/Atrial-Fibrillation/default.aspx

Retractors and Suckers, Student Life in the OR

Most PA students go through some surgical rotation during their schooling... and let's be honest, with the rare exception of an end-of-the-rotation treat, many students do little more than retract and suck. Although frustrating at times, this isn't a bad thing. We all need to crawl before we walk. The surgeons that you will be working with have several years of experience - you can't expect to participate in a major surgery with 3 days of surgical experience. 

I suggest that you take each opportunity to watch the surgeons closely (don't just stare off or focus solely on the anatomy). How do they hold the scalpel? Do they apply tension to the skin? Which way to they cut? Which tool do they use and when? You will pick up more than you think and when given your opportunity to participate- you will at least have a clue what to do.

Frazier suckers (different sizes)

Below are some instruments that you may see during your rotations. The pics are from an OR Instrument book. I don't see a real need to purchase the whole book because its coverage of surgical instruments is too wide spread.... it is better for an OR Tech who may be working with cardiology, orthopedic, neurosurgical, etc kits. It is, however, worth checking it out of the library to browse through before or during your surgery rotation.

Adson tissue forceps

 

Ferris Smith tissue forceps

 

DeBakey vascular forceps

 

Left --> Right: Goelet retractors, Army Navy retractors, Richardson retractors (med, large)

Source:  Instrumentation for the Operating Room: A Photographic Manual, 7e Shirley M. Tighe RN BA

Heart Failure

Quick study material on heart failure:

LEFT SIDED

• dyspnea
• wheezing
• orthopnea
• S3/S4 gallop
• puLsus alternans

RIGHT

• peripheral edema
• nocturia
• JVD
• hepato/spleno-megaly

FUNCTIONAL CLASSES (1 = best, 4 = worst)

Pic source: http://www.remodulin.com/patient/diagnosing-pah.aspx
Source: Medical Boards Step 2 - Made Ridiculously Simple (Andreas Carl, MD)

Free Book for Your Surgical Rotation

Scribd is a great resource for free textbooks (and not just the cheap ones). You can buy a subscription to have total access (Premium) or you can upload non-copyrighted materials and get a Premium membership for free.

I found this surgical book written for students on their surgical rotations. It is pretty awesome and comprehensive. A snippet from the table of contents is below.

Surgical Techniques: Textbook for Medical Students

Reading a Chest Xray

You should feel confident reading a chest x-ray (CXR). It is one of the few films that will follow you from rotation to rotation. It doesn't matter if it is pediatrics, internal medicine, or surgery - You need to know how to read a CXR. Below are a couple sources to choose from because not everyone teaches or learns this in the same way. Here are a couple tips that I learned during my rotations from studying, my preceptors, or just plain screwing up!

• The first thing you should check is the name/date/type of film! (On one of my rotations, an intern (1st yr resident) was asked to read a chest X-ray for one of our patients who had just gotten a chest tube placed. He did a great job with lung pathology and describing the fluid - and he was also able to pick out that the chest tube was perfectly placed. I was impressed until the chief resident said "great job, you just harmed your patient." The chief had purposefully put up a CXR from 2 years ago when the pt had rec'd another chest tube. He then pulled up the current CXR to reveal that the tube was improperly placed. )
• Read every film in the same order every time. 
• Learn the anatomy of what you are reading. 

Step by Step Tip for reading CXRs

University of Washington's Method

1. PA or AP, supine or upright

2. Pt rotated? Check for vertebral and clavicle symmetry.

3. Lung volumes

4. Tube & line placement

- ETT 3-5 cm above carina

- NGT in stomach

- FT in stomach/duodenum

- Central line in SVC/R atrium

- Swan in PA

5. Pneumothorax: check apices on upright film, deep sulcus sign at bases

6. Pleural effusion, pleural thickening

7. Mediastinum: normal contour, wide

8. Heart: normal size, cardiomegaly

9. Lung parenchyma: masses, opacites, look for silhouette sign

10. Soft tissues: foreign bodies, SQ air, breast shadows

11. Bones: fractures, osteopenia, abnormalities

Silhouette Sign = obscuring of normal borders on radiograph caused by intrathoracic lesion.

Obscured R heart border = R middle lobe

Obscured L heart border = Lingula

Obscured diaphragm = Lower lobe

CT Surgery Starter Resource

This is an excellent starting resource for PAs starting out in CT surgery or PA students rotating in CT surgery. It is designed for CT surg residents starting out - but I have found it very helpful.

CTSWOT