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 R. Shane Tubbs, MS, PA-C, PhD
The author works in pediatric neurosurgery at Children’s Hospital, Birmingham, Ala, and is one of four anatomists in the School of Medicine at the University of Alabama at Birmingham. He has indicated no relationships to disclose relating to the content of this article.
Photos: © Marc Bondarenko
My days combine practicing as a physician assistant and teaching the basic sciences (gross anatomy, neuroanatomy, embryology, and histology) to students in a number of medical programs. My schedule varies depending on scheduled surgeries and teaching load, but a typical day looks like this:
5:00 AM
I arrive at the hospital and round on in-house patients and see preoperative patients not on the wards. Today we have 20 in-house patients, 10 of whom are in the ICU. I have three surgeries scheduled, including one for a posterior cranial fossa brain tumor that the patient’s MRI suggests is probably a juvenile pilocytic astrocytoma, and one for a tethered cord release in a child born with anorectal atresia. The little boy with the brain tumor presented last week with gait ataxia and chronic emesis. After reviewing his MRI, my first thought was, “God, please let this be a benign tumor that surgery will potentially cure.” The tethered cord was found on MRI and demonstrated a conus medullaris at the L5 vertebral body and a fatty infiltrated filum terminale.
5:30 AM
In my office I review papers for the Journal of Neurosurgery and Clinical Anatomy. One paper from Turkey looks at the outcome in children undergoing a third ventriculostomy for treatment of hydrocephalus. Another reviews experience with endoscopically assisted craniosynostosis repair in an effort to make this surgery less invasive. I find it a pleasure and an honor to be one of the first to review cutting-edge material that may improve the way we treat our patients.
6:00 AM I collect data and information for various laboratory projects I am currently exploring. For the past 6 months, I have focused on spinal cord “seizures” and vagus nerve stimulation. One of my current experiments has developed a model for such seizures by applying a paste of penicillin (a GABA antagonist) to the dorsal columns of the exposed spinal cord in a porcine model. Once seizures are under way, the previously isolated cervical portion of the left vagus nerve is stimulated and the effects on the seizures when a proximal cranial nerve is stimulated are observed. We hope these data will improve our current limited knowledge of seizures and the mechanisms behind which vagus nerve stimulation can alter these abnormal firings of the brain. With this knowledge, better treatments may be found for patients suffering from epilepsy. (Incidentally, we have recently patented a technique for stimulating the carotid sinus nerve in a dog model, which effectively causes cessation of the majority of cortically induced seizures.) 7:00 AM I attend morning report where we—neurosurgeons, clinical faculty, fellows, residents, and medical students—review our patient inhouse list, new admissions, and operative cases for the day. Students and residents are quizzed on surgical and clinical situations, as well as on anatomy. I try to engage their minds, not just push them to regurgitate random facts. This is where didactics and good clinical medicine can come together. We also assign students to report on small topics related to a previous case and undergo a brief question and answer session. Today one of the students reported on the incidence of myelomeningocele births from various regions around the world. 7:30 AM to 1:00 PM
I move to the operating room, where I first assist on most days. Procedures that we perform include excision of brain tumors, CSF diversion for hydrocephalus (eg, ventriculoperitoneal shunt, third ventriculostomy), posterior fossa decompressions for Chiari I malformations, and closure of myelomeningoceles. We also perform peripheral nerve surgery, including procedures such as brachial plexus repair following birth injury. I always try to remind myself of the honor I have to be involved in such cases as a non-physician. Today we decompressed the posterior fossa (occipital craniectomy and removal of the posterior arch of the atlas with duraplasty) in a child with hindbrain hernia (Chiari I malformation). I saw this little girl in clinic 2 weeks ago and remembered that she was very upset with the idea of surgery and the separation from her doll named “Lilly” that would result. I tried to comfort her by saying she could bring Lilly with her to the operating room.
1:00 PM to 2:00 PM
I give lectures on gross anatomy or neuroanatomy to groups of students. Depending on the time of the year, I might lecture to students studying medicine, dentistry, optometry, anesthesia, or occupational or physical therapy. I also lecture to physician assistant students and residents in surgical specialties such as neurosurgery, ENT, or obstetrics and gynecology. Today’s lecture, to 50 first-year optometry students, is on the pterygopalatine fossa and its contents. For this group, I emphasize the potential for injury to the nerves emanating from this region and the resultant dry eye that may occur—the salient feature of the topic for a group with special interest in the eye. Keeping material fresh and clinically applicable is my main goal, no matter how many times I present it. I try to read different descriptions of each topic to see how various authors interpret and present the material.
Shane Tubbs reviews imaging studies with one of his colleagues at Children’s Hospital.
2:00 PM to 4:00 PM I travel to our gross anatomy laboratory to teach lab. Today’s session is focused on the pterygopalatine fossa for the optometry students. These are all dissection classes using human cadavers. This is one of the best parts of my day. Being able to use what I think is one of the greatest gifts in life—the donation of the human body—to teach medical students is one of the most fulfilling things I do. In fact, one of my favorite phrases is a Greek quote that is translated, “Let the dead teach the living.” 4:00 PM to 5:00 PM I attend the weekly conference for neurosurgery. This afternoon’s conference is focused on the outcomes of surgically versus intravascularly treated cerebral aneurysms. After the presentations, we faculty pose questions to the residents. 5:00 PM to 6:00 PM I return to the laboratory and gather more data for the anatomy and neurosurgical projects in the cadaver and animal labs. I start formulating and writing a paper based on these data. This afternoon’s data pertained to measurements of the vertebral artery within the vertebral triangle. This geometric region houses the first part of the vertebral artery once it originates from the subclavian artery and is important to surgeons who might need access for ligation or bypass procedures. This project—as with the majority of my experiments—originated following a surgical procedure in our operating room where this information would have been useful. 6:00 PM to 7:00 PM I check email and organize laboratory data for various projects. I organize my schedule for the following day. Tomorrow I will lecture on the anterior cervical triangle to firstyear medical students. This topic is difficult to cover in just 1 hour—the students are typically overwhelmed by the vast amount of anatomy lodged in this small area of the body. 7:00 PM
I return home and see Susan, my wife of 13 years, and my 7-year-old son Isaiah. This is where the real work begins! Homework needs to be finished, and bedtime stories need to be told.
My days seem chaotic, but they are actually fluid and regimented. At the end of each day, I like to reflect on what’s happened and know that I have helped my fellow man (or child, in my case). And I like to think I have passed along knowledge to students who will use it to improve the care they give to their patients. |
