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

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

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!

Diabetes Insipidus, Part 2

Diagnosing DI

Polyuria = urine vol > 3L in 24 hrs - there are many causes of polyuria and it is important to figure out if the cause is DI or something else prior to establishing treatment

Urine osmolality (osm) of > 300 mOsmol/kg + high serum glucose --> think diabetes mellitus
Urine osmolality (osm) of > 300 mOsmol/kg + high serum urea --> think renal dz
Urine osmolality (osm) of < 200 mOsmol/kg + polyuria --> think DI

So you have a patient that has urine ohm < 200 + polyuria and you are thinking DI... how do you differentiate between central DI and nephrogenic DI?

Answer: water deprivation test

Findings:
Central DI
urine osm < plasma osm after dehydration
after ADH injections urine osm increases by >50%

Psychogenic DI

urine osm > plasma osm after dehydration

after ADH injections urine osm increases minimally

Nephrogenic DI

urine osm < plasma osm after dehydration

after ADH injections urine osm increases by <50%

Source: 
Makaryus/Mcfarlane. DI: diagnosis and treatement of a complex disease Cleveland Clinic Journal of Medicine Jan 2006 Vol 73:1
pic source: medicaltextboks.blogspot.com

Blog for Women in Surgery

I recently came across this blog... seems to just be starting up, but has lots of promise. I've added it to my favorites list.

Women in Surgery

Important Differentiation in Small Bowel Obstruction (SBO)

Small Bowel Obstruction

There are 3 main pts of differentiation to consider with SBO...

Click to enlarge

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

IV Therapy Complications

"Let's give him/her some IV fluids." Seems like a simple enough order. IV therapy is part of medicine, but it is not without risks. It is important to know the risks so that you know what complications to look for in the seconds, hours, days after an IV has been started.

Thrombophlebitis - usually manifests with erythema, inflammation, and/or pain at the IV site (think about changing the IV q3 days to help prevent this)

Infiltration - this happens when whatever you are giving through the IV (meds/fluids) starts to leak into the surrounding tissue (this can cause a big problem - compartment syndrome - if the volume is large enough)

Blockage - something, a blood clot for example, can clog the IV making it unusable (flushes can help minimize the risk of this)

Air embolus

Source: Step up to Medicine 2nd ED Agabegi and Agabegi

Pic source: http://en.wikipedia.org/wiki/Intravenous_therapy

In Honor of Dr. C. Everett Koop

Dr. C. Everett Koop, former Surgeons General, 1937 graduate of Dartmouth, and founder of the C. Everett Koop Institute at the Geisel School of Medicine died peacefully at his home in Hanover this afternoon.

I had the distinct pleasure and honor of meeting and dining with Dr. C. Everett Koop at a Dartmouth event a few years back. In addition to his numerous contributions to medicine, he was a kind man with great stories to share. 

He pioneered numerous advances in pediatric surgery, and trained and mentored many of the leaders now in this field. As one of our country’s greatest Surgeons General, he effectively promoted health and the prevention of disease, thereby improving millions of lives in our nation and across the globe. He founded the C. Everett Koop Institute at Dartmouth to transform healthcare and the process of educating health professionals.

To read more about Dr. Koop’s life and pioneering contributions to our world, please see: http://geiselmed.dartmouth.edu/koopmemoriam/.

Carpal Tunnel

Carpal Tunnel

See below for the answers.

What nerve is compressed in carpal tunnel?
What population is it most commonly seen in?
What are typical signs and symptoms?
Where is the anatomical location of the "carpal tunnel"?
Work up?
Treatment?

What nerve is compressed in carpal tunnel?
Median nerve

What population is it most commonly seen in?
Women 30-50 years old

What are typical signs and symptoms?
Wrist pain - numbness/tingling of thumb
Pain exacerbated with activities of wrist flexion
May awaken pt at night
Thenar atrophy

Where is the anatomical location of the "carpal tunnel"?
Between the carpal bones and the flexor retinaculum

Work up?
Clinical exams: Tinel's sign and Phalen's sign
EMG/nerve conduction study

Treatment?
neutral wrist orthosis
modification of activities that irritate
NSAIDs for inflammation control
steroid injections
surgery


Source: First Aid for the Wards (Le, Bhushan, Skapik)
Photos: www.methodistorthopedics.com , http://en.wikipedia.org/wiki/File:Carpal_Tunnel_Syndrome,_Operation.jpg

New PA Student Site

Check out the new microsite dedicated to PA Students! I was part of the team that worked hard to put this together and the AAPA was an integral part of giving us the funding to get this up and running. It is a "one stop shop" that was created BY PA students FOR PA students!

Check it out. Write a blog entry for the site. Submit a new scholarship that you found that is relevant. The continued success of the site is dependent on YOU the PA student to help keep it alive with content!

See the About Us section to know where to send your content!

www.PAStudentEssentials.com

Post-Brain Tumor Resection





The American Association of Neuroscience Nurses put together this awesome 40pg document: Guide to the Care of the Patient with Craniotomy Post–Brain Tumor Resection,

AANN Reference Series for Clinical Practice. Some of it is more relevant to nursing than PA practice, but I've found the majority of it VERY helpful in getting a general idea of what's going with tumor resection patients (especially as a new graduate). Of course, each institution is a bit different, but this is a great start.



Image:

http://medicalxtourism.com/wp-08/Top-Brain-Cancer-Treatment-Centers-Abroad.gif



Become Great At Knot Tying

Several months back during my surgery rotation, my preceptor and chief resident (Dr. Smith*) gave me some great advice becoming better at surgical knot tying so I thought I would share.

• Learn the square knot and be able to tie it by perfectly and quickly (by hand and instrument). There are lots of surgical knots to learn, but the square knot will get you through most situations. 

• Practice tying everyday. You often see medical students/residents walking around with string hanging from the tie their scrub pants or to a loop in their white coat.... this is because they are practicing tying in their down time. I started doing it and it is amazing how much practice you can get during the day - on the elevator, during rounds, on the T on the way to work. Dr. Smith said he still practices tying 100s of knots a day and he has been doing so since his first day of residency four years ago.

• Make it second nature. When you first start you will need to look at the string/thread and concentrate... however the goal is to be able to tie and tie well while doing something else. Dr. Smith recommended practicing knot tying during your favorite show at home while sitting on the couch. If you don't have scrubs on - place a coffee mug between your knees and use the handle of the mug as an anchor. 

• Materials. Since suture packs are expensive and I doubt the hospital would appreciate you snagging a bunch of $4-5 brand new suture packs to *practice* tying - there are other options. 1) after each of your OR cases, ask the scrub nurse if there are any opened, unused sutures left that you could have to practice with - if not, they get thrown away and 2) go to a sporting goods store and buy your own. Fishing line (mono filament and braided) are remarkably similar to suture material and you can buy 1800 yds of mono filament line for about $8 and 100 yds of braided for about $6.

This is the brand of braided line that I use. It is similar to "string ties". Purchased it at Dick's Sporting Goods for $6.

Using the arm of a mug as an anchor works great if you don't have scrubs on.

*Dr. Smith is a fictional name.