High-Anxiety Head and Neck Trauma Cases: Lessons Learned

Program Description:

The management of head and neck trauma patients is challenging, and critically important trauma lessons have been learned in Iraq, Afghanistan, and busy U.S. trauma centers. These lessons learned are relevant to all otolaryngologists who may be faced with such challenges resulting from trauma to the airway, the neck, and the craniofacial skeleton. High-anxiety head and neck trauma cases will be presented, and the audience will use an interactive format to generate discussion on the best treatment options. The goal is to review the trauma pearls learned in the combat zone and in busy U.S. trauma centers.

Educational Objectives:

1) Apply the lessons learned with the head and neck trauma surgery performed in Iraq, Afghanistan, and busy U.S. trauma centers. 2) Implement trauma surgery pearls dealing with the traumatic airway, penetrating neck trauma, and fractures of the craniofacial skeleton. 3) Select the safest and most effective treatment option for challenging head and neck trauma cases presented to the audience.

Avoiding the “Deadly Sins” of Humanitarian Missions: How to “Do Good” Better

Program Description: Over the past several decades, the numbers of North American physicians and surgeons engaged in international humanitarian missions has increased dramatically. Such trips often provide an opportunity for needy individuals and communities to receive care that would otherwise be unavailable to them. They also provide the opportunity for participants to “give back” through providing direct patient care and teaching in an environment of extreme need. Personal motivations, level of ability of the individual practitioner, sophistication of the mission organization, as well as level of connectedness to “in country” providers varies dramatically among mission groups. This variability has contributed to some unfortunate patient outcomes. Accusations that “surgical safaris” represent a “form of Neo-colonialism” have cast doubt on the motivations of participants and brought significant scrutiny to the true benefits arising from these efforts. This interactive miniseminar will explore “deadly sins” which are common to medical humanitarian efforts as well as issues which are unique to surgical humanitarian missions. Panelists will discuss available data and areas in which there is a lack of data concerning humanitarian efforts. Finally, “best practices” for humanitarian missions will be discussed. Issues to be discussed include appropriate standard of care, duration, follow-up, conduct of research, resident trainee participation in surgical procedures, role of the media, and integration with local care systems.

Educational Objectives: 1) Identify common problems encountered during medical and surgical humanitarian mission trips. 2) Understand ethical concerns arising during international humanitarian efforts. 3) Apply best practices for conduct of humanitarian mission trips in which they are involved.

Making difficult ethical decisions in patient care during natural disasters and other mass casualty events

OBJECTIVE

Recent experiences in the United States with unprecedented terrorist attacks (9/11) and a devastating natural disaster (Hurricane Katrina) have demonstrated that the medical care of mass casualties during such disasters poses ethical problems not normally experienced in civilian health care. It is important to 1) identify the unique ethical challenges facing physicians who feel an obligation to care for victims of such disasters and 2) develop a national consensus on ethical guidelines as a resource for ethical decision making in medical disaster relief.

STUDY DESIGN

A survey of pertinent literature was performed to assess experience and opinions on the condition of medical care in terrorist attacks and natural disasters, the ethical challenges of disaster medical care, and the professional responsibilities and responsiveness in disasters.

CONCLUSIONS

It is necessary to develop a national consensus on the ethical guidelines for physicians who care for patients, victims, and casualties of disasters, and to formulate a virtue-based, yet practical, ethical approach to medical care under such extreme conditions. An educational curriculum for medical students, residents, and practicing physicians is required to best prepare all physicians who might be called upon, in the future, to triage patients, allocate resources, and make difficult decisions about treatment priorities and comfort care. It is not appropriate to address these questions at the time of the disaster, but rather in advance, as part of the ethics education of the medical profession. Important issues for resolution include inpatient and casualty triage and prioritization, medical liability, altered standards of care, justice and equity, informed consent and patient autonomy, expanding scope of practice in disaster medicine, and the moral and ethical responsibilities of physicians to care for disaster victims.

Project HOPE volunteers and the Navy Hospital Ship Mercy

This article describes, from the perspective of Project HOPE volunteers, the precedent-setting, military-civilian partnership in staffing the USNS Mercy as part of the rapid response of the United States to the overwhelming devastation and loss of life resulting from the tsunami off the coast of Indonesia. The article discusses the designation of Project HOPE as the non-governmental organization to be the single source of volunteers for the USNS Mercy mission (providing approximately 100 volunteers for each of two 30-day rotations), some issues facing Project HOPE and the contingent of volunteers in recruiting, orienting, training, and preparing for the mission, steps taken to make this a successful mission despite the ambiguity and uncertainties involved in arriving in the relief area 1 month after the disaster, and some recommendations for similar future missions. The Project HOPE volunteers quickly integrated with the cadre of Navy health professionals to deliver a broad range of high-quality care, including tertiary care, attesting to the professionalism and standards common to military and civilian medicine. The combined success of all organizations involved truly heralds a new era of medical diplomacy and goodwill in which the United States can take great pride.

The fate of fresh, layered, nonsutured and sutured, autogenous cartilage in the rabbit model

OBJECTIVE

To compare the thickness, area, and volume of sutured and nonsutured multilayered cartilage grafts in a rabbit population.

DESIGN

Autogenous rabbit cartilage grafts were harvested, layered, and placed in the contralateral auricle. Half the grafts were sutured; the other half were nonsutured. Graft thickness, area, and volume were measured before implantation, after 90 days in vivo, and after explantation.

RESULTS

The area and volume of the cartilage grafts increased during the 90-day period. Histologically, this was caused by increased fibrous tissue around the cartilage grafts. Minimal cartilage resorption was observed. No differences were noted between sutured and nonsutured grafts.

CONCLUSIONS

Autogenous, fresh, uncrushed, layered nonsutured or sutured cartilage grafts are well tolerated. Statistically significant increases in the area and volume of autogenous, fresh, uncrushed, layered cartilage grafts occurred primarily because of fibrous tissue formation at the margins of the layered grafts. Suturing had no effect on the postoperative volume retention of these layered grafts. This information will be helpful to the facial plastic surgeon when using fresh-layered autogenous cartilage grafts during cosmetic or reconstructive procedures. Arch Facial Plast Surg. 2000;2:256-259

Biomechanics of nasal septal trauma

Fractures of the nasal complex are the most common facial fracture. This is due to the fact that the nose is the most anteriorly projecting facial structure and is a composite structure of bone, cartilage, and soft tissue. Furthermore, the forces required to cause significant injury are less than that causing other facial fractures. Because of the wide range of activities and mishaps that cause nasal trauma, the instruments of injury range from bicycle handles to elbows. The causes, clinical anatomy, and future considerations regarding nasal septal trauma are discussed in this article.

Electrical interactions via the extracellular potential near cell bodies

Ephaptic interactions between a neuron and axons or dendrites passing by its cell body can be, in principle, more significant than ephaptic interactions among axons in a fiber tract. Extracellular action potentials outside axons are small in amplitude and spatially spread out, while they are larger in amplitude and much more spatially confined near cell bodies. We estimated the extracellular potentials associated with an action potential in a cortical pyramidal cell using standard one-dimensional cable theory and volume conductor theory. Their spatial and temporal pattern reveal much about the location and timing of currents in the cell, especially in combination with a known morphology, and simple experiments could resolve questions about spike initiation. From the extracellular potential we compute the ephaptically induced polarization in a nearby passive cable. The magnitude of this induced voltage can be several mV, does not spread electrotonically, and depends only weakly on the passive properties of the cable. We discuss their possible functional relevance.

Septorhinoplasty. Form versus function

Septorhinoplasty is the most difficult and complicated procedure in facial plastic surgery. Because of the complex interdependency of the anatomical parts, alteration of one may have an impact on another. Three-dimensional relationships are important, as is the maintenance of a proper framework for the internal and external nose. Form and function are completely interwoven in septorhinoplasty.

Shunting inhibition does not have a divisive effect on firing rates

Shunting inhibition, a conductance increase with a reversal potential close to the resting potential of the cell, has been shown to have a divisive effect on subthreshold excitatory postsynaptic potential amplitudes. It has therefore been assumed to have the same divisive effect on firing rates. We show that shunting inhibition actually has a subtractive effect on the firing rate in most circumstances. Averaged over several interspike intervals, the spiking mechanism effectively clamps the somatic membrane potential to a value significantly above the resting potential, so that the current through the shunting conductance is approximately independent of the firing rate. This leads to a subtractive rather than a divisive effect. In addition, at distal synapses, shunting inhibition will also have an approximately subtractive effect if the excitatory conductance is not small compared to the inhibitory conductance. Therefore regulating a cell's passive membrane conductance-for instance, via massive feedback-is not an adequate mechanism for normalizing or scaling its output.

Ulnar variance and age

Ulnar variance was determined on 1,023 radiographs of normal wrists taken in standardized fashion. There were 468 women and 555 men. The age range was 13 to 109 years. In both sexes, ulnar negative variance decreased significantly with increasing age. Possible reasons for this are discussed.

The interface of academic and community practice in medical and graduate medical education

Historically, the interaction between academic departments of otolaryngology-head and neck surgery and the community practice of the specialty has been erratic, anecdotal, and often strained. A general sense of autonomy and isolationism that has characterized many university programs coupled with a paranoia on the part of many practitioners with respect to concerns about protecting their patient base have led to an uneasy relationship. Difficulties with managed care now threaten this relationship even more. It is clearly time to seek a solution that can enhance the educational opportunities for medical students and residents.

Comparison of discharge variability in vitro and in vivo in cat visual cortex neurons

1. In neocortical slices, the majority of neurons fire quite regularly in response to constant current injections. But neurons in the intact animal fire irregularly in response to constant current injection as well as to visual stimuli. 2. To quantify this observation, we developed a new measure of variability, which compares only adjacent interspike intervals and is therefore less sensitive to rate variations than existing measures such as the coefficient of variation of interspike intervals. 3. We find that the variability of firing is much higher in cells of primary visual cortex in the anesthetized cat than in slice. The response to current injected from an intracellular electrode in vivo is also variable, but slightly more regular and less bursty than in response to visual stimuli. 4. Using a new technique for analyzing the variability of integrate-and-fire neurons, we prove that this behavior is consistent with a simple integrate-and-fire model receiving a large amount of synaptic background activity, but not with a noisy spiking mechanism.

Effects of Air Pollution on the Upper Aerodigestive Tract

The main route of contamination of the human body with airborne pollutants is through the upper air and food passages. Because of the delicate balance of the mucous membranes and special sensory organs of these passages with respect to mucociliary activity, local and recruited immune responses, rapid uptake of chemicals, and carcinogenic potential, the ingestion or inhalation of pollutants in the air can be harmful to these internal body barriers. The particular target organs for air pollution effects on the upper aerodigestive tract include the mucosa, olfactory epithelium, auditory receptor cells, glottic epithelium, and adjacent neural and muscular tissues. Hearing loss caused by noise exposure may be aggravated by the concomitant inhalation of solvents. The strongest evidence for the carcinogenic effect of occupational inhalants in the nasal cavity and paranasal sinuses is seen with exposure to hardwood dust, tobacco smoke, furniture making, and leather tanning. With the exception of tobacco smoke, which produces squamous cell carcinomas, the majority of the occupationally related cancers are adenocarcinomas, usually of the intestinal variety. Tobacco smoke, passive or active, may lead to end-artery obliteration at the level of the otic end organ, causing a progressive sensorineural hearing loss. Further environmental research in the upper aerodigestive tract should aim at developing biologic markers to determine early, premalignant tissue changes; identifying the effects of chronic, low-dose toxic exposure on mucous membranes and neurosensory organs; providing field-tested tools for the standardized screening of large at-risk populations.

Compensation, work status, and disability in low back pain patients

STUDY DESIGN

A prospectively designed study was performed to assess the influence of employment status and a compensation claim on patients experiencing low back pain.

OBJECTIVES

To determine the factor that most influences disability arising from low back pain, unemployment or a compensation claim.

SUMMARY OF BACKGROUND DATA

Two hundred sixty-nine consecutive patients were assessed from a low back pain clinic.

METHODS

Disability was assessed using the Oswestry Disability Score, and employment, and compensation status were recorded.

RESULTS

Both unemployment and patients involved in compensation had higher disability scores. However, by controlling the data for employment and assessing only the compensation group it was found that those claiming compensation, but still working had significantly less disability than those claiming compensation who were unemployed.

CONCLUSIONS

Both unemployment and compensation claims influence disability, but employment status is the most important factor.