The Best and Brightest Come to Doernbecher

Doernbecher is not the country’s largest children’s hospital, but I think it is one of the best. The reason? Great people.

That is why I was so proud to be joined by one of the top young pediatric neurosurgeons in the country, who began her practice at Doernbecher Children’s Hospital today.

Dr. Lissa Baird graduated from Brigham Young and earned her MD degree from Columbia University College of Physicians and Surgeons. She underwent residency training at the University of California, San Diego, during which time she also completed an infolded fellowship in skull base neurosurgery at Louisiana State University, Shreveport (where I originally met her while a visiting professor there). She just finished as the 2011-12 Shillito Fellow in pediatric neurosurgery at Boston Children's Hospital. 

Dr. Baird has clinical and scientific interests in pediatric brain tumors and in new approaches using an endoscope to remove some tumors through the nose.

It would be an understatement to say that pediatric neurosurgeons are in demand around the United States. Dr. Baird was a top faculty candidate this year. I am proud that the opportunities, collegiality, and clinical and scientific talents evident across the institution attracted her to join the faculty at Oregon Health & Science University.

I think she will be a terrific addition to the program and will advance the goals and values we have been working on, most particularly technically excellent and compassionate care of Oregon’s children, and those of the region and nation.

Dr. Lissa Baird

Looking Back, Reaching Forward

In the United States, July is a time for celebrating heritage. In Oregon and Southwest Washington, the Scottish community comes together every year on the 3^rd Saturday at the Portland Highland Games. Today’s games, the 60^th, hark back to clan celebrations in the highlands a thousand years ago.

Around the world, the games today promote heritage and preserve the Scottish arts of piping, drumming, dancing and heavy sports. The games embody tradition, competition, and community.

Scots in America have contributed greatly to our larger national community, part of a tradition that has enabled the exceptional contributions of our society to the arts and sciences, and to the advancement of freedom around the world. Many cultures and societies have contributed to this unprecedented American success, and more are joining the ‘great experiment’ every year. The only invariable characteristics and requirements for participation are devotion to intellectual, political, and economic freedom.

Highland games also remind us of the tremendous contributions of Scots to American and world society. No fewer than nine Scots are amongst the 56 signers of the Declaration of Independence. Among them was Rev. John Witherspoon, who immigrated to New Jersey from Edinburgh, and served as the first President of Princeton University.

The foundations of modern society are inextricably linked to Scots, both at home and in the Scottish diaspora around the world. Carnegie and dozens of other Scots were central to the advances of the industrial revolution. Malthus and other Scottish philosophers created entire fields of modern thought. Neil Armstrong (a humble and brave pilot I had the privilege of spending time with when his son and I were classmates and dorm mates at Stanford) was the first human being to walk upon another world.

Modern medicine was largely invented and for 150 years found its greatest expression in the medical schools of Edinburgh and Glasgow. We think of my field, neurosurgery, as being founded by British and American surgeons, such as Victor Horsley and Harvey Cushing. In reality, the daring Scottish surgeon Sir William Macewen was the the true pioneer of modern neurosurgery. In 1876, Macewen operated on a young woman with right sided motor seizures based on clinical findings alone, identifying and removing a left frontal meningioma and granting her 8 further years of useful life. This was the first successful craniotomy for a non-traumatic, intracranial process in history.

By ancestry, I am not a Scot. My progenitors hail from the Welsh borders of England (where, generations ago, they were weavers), and Germany. Through my children, though, I have developed a love for the Scottish culture and people, and in the tradition of American and Scottish inclusiveness, count myself amongst them. My wife’s ancestors, the McIlrath’s, were artists and warriors from the western isles, allied to the MacDonald Clan. Their ancestral homelands are among the most beautiful places on earth (and not dissimilar to Oregon, where many Scots including the “founder of Oregon,” Dr. John McLoughlin, have settled).

So it is with considerable pleasure that I joined 10,000 or so of my compatriots at the Portland Games today. It was also with great pride that I watched my daughters compete in the highland dances and my son in highland bagpipes.

Scots promote tradition, competition and community. They welcome us to their grand tradition. They remind us how a great nation was built.

Scottish Highland Bagpipes (Playing a 2-4 March for the Judges)

Scottish Highland Dancing

Scottish National Dancing

500 Scottish Highland Pipers and Drummers Thunder Forward in a "Massed Band" at the 2012 Portland Highland Games!

Magnets and Shunt Valves

In 1955, a child with severe spina bifida and hydrocephalus, or water on the brain, was born to John W. Holter, a toolmaker in Stamford, Connecticut, and his wife. Charles Casey Holter, like other children at the time, did not survive this severe congenital disorder. His condition, however, prompted his father to invent the first hydrocephalus shunt valve, allowing the excess cerebrospinal fluid (CSF) in the brain to be diverted to other parts of the body and absorbed.

Although not a cure for hydrocephalus, Holter’s valve system was the first effective treatment. Descendants of the first Holter valve have saved the lives of millions of children. I used one just this morning to treat a tiny baby here at Doernbecher Children’s Hospital.

Modern shunt valves work on basically the same design, over 50 years later. There have, however, been improvements. Some valves, for example, have different settings to slow down or speed up the flow of CSF, making adjustments for a particular patient’s condition. Before these ‘programmable’ valves, neurosurgeons like myself had to perform an operation to change a valve setting (by going under the skin and changing the entire valve!). Now, we just use a magnetized programming device to non-invasively change a valve’s setting.

Like everything, programmable valves have drawbacks. One is that magnetic fields out in the day-to-day patient environment can accidentally reset a valve, and cause headaches or even dangerous shunt failure and return of acute hydrocephalus.

According to some manufacturers, accidental resetting should not generally occur from exposure to most day to day magnetic fields, such as security scanners at the airport, home kitchen microwave ovens, and smart phones (http://www.medtronic.com/for-healthcare-professionals/products-therapies/neurological/shunts/strata-nsc-lumboperitoneal-adjustable-pressure-shunts/indications-safety-warnings/index.htm).

Recently, though, physicians have reported accidental valve resets by a number of day-to-day devices. My friends and colleagues at the University of Michigan have just reported that iPad 2s can reset some valves (although only if placed within a couple of inches of the valve): http://thejns.org/doi/full/10.3171/2012.3.PEDS1211.

A Japanese group has even reported valve resets caused by the Nintendo DS video game: http://www.ncbi.nlm.nih.gov/pubmed/21946726.

Unfortunately, which valve might be reset by which magnet, at what distance, and under what circumstance, is often unknown. So what should patients and parents do?

My advice is: when in doubt, play it safe. Keep toy magnets or electronic devices with magnetic fields, away from a programmable shunt valve whenever possible. If you are unsure, ask your doctor’s office. Most importantly, if a patient with a hydrocephalus shunt and a programmable valve experiences symptoms of shunt malfunction (for example, severe headache, change in mental function, altered level of consciousness, or sudden loss of vision), seek immediate medical attention.

Hydrocephalus shunt valves, including magnetically programmable ones, are terrific advances, especially when safely and properly used.

Hydrocephalus - 'water on the brain'

Making Safety and Education Go Together

I graduated from medical school in the early 1990’s, and went to work in a major US hospital to train as a neurological surgeon. Like my compatriots around the country, within a few weeks of starting training, I began to perform invasive procedures needed by patients in the hospital. The first spinal tap I performed was on an actual patient. The first time I drilled a hole in the skull to relieve pressure … also an actual patient. Passing a catheter deep inside the brain to drain excess fluid? A patient.

Everyone doctor will have to get past his or her first of any procedure they need to perform in practice. And we need to train the next generation of doctors. So how can we do it, without sacrificing patient safety and the highest quality of care?

As the director of residency training in neurosurgery at OHSU, I have thought about this problem a lot. Having residents in the hospital 24 hours a day, seconds away from a patient’s bedside in the intensive care unit, has saved countless lives. But the emergency bedside procedures we do are some of the most impactful and risky in medicine.

In 2009, my colleagues and I hosted a ‘Boot Camp’ for 19 brand new neurosurgical trainees, only a few weeks out from medical school graduation. They came from 5 residency programs in the Pacific NW and California. We used a skills lab to teach, so the first skull drilling, the first lumbar puncture, the first fluid drain, were all carefully taught and mastered in a safe, simulated environment. While we had them all together, we also taught the residents about our perspectives on professionalism, careers, and respectful, effective communications with patients.

Three years later, the descendants of that first effort, the Society of Neurological Surgeons PGY1 Boot Camp Courses, are a universal part of residency training at all 100 neurosurgery training programs in the United States. They are endorsed by the American Council for Graduate Medical Education (ACGME), and they have been funded for 5 years by an unprecedented $1.9 million grant. Six courses are held each July, during the first few days of practice by new residents, at 6 centers around the country. OHSU continues to host the western region course and stay involved in curricular leadership of the courses nationally.

Today, OHSU for the 4th year hosted the Western Region PGY1 Bootcamp. What a great event!

OHSU is proud to share advances in safety and education with our colleagues around the US. Read more about the results at:

2009 Course Report in NEUROSURGERY

2010 National Course Report in NEUROSURGERY

Dr. Nate Selden with SNS PGY1 Boot Camp residents

Independence Day, Ideals, and Optimism

Happy 4th of July my fellow Americans!

I hope that everyone has a wonderful holiday, like me, with friends and family, in beautiful sunlight, enjoying a calm afternoon breeze, an American flag overhead, and the safety, security, and well being that our forbearers have earned us.

We are very blessed to be here, and with this blessing comes responsibility: to contribute to our communities, to treat each other with respect, to do the right thing, and to help others in the world achieve the type of fair and principled society we live in.

We spend a lot of time, particularly around the 4th, thinking about the way the world views us. I have been lucky to spend 4 years of my life living in two other countries, learning clearly about their view of ours. I spent three years as a graduate student in England, and a year as an overseas undergraduate in Italy. Even when I heard a particular American action or policy questioned, I never once heard American ideals, nor America's founding principles, questioned. That is a particularly remarkable statement given that we fought a brutal war against the British for independence and founded our nation in opposition to their system of constitutional monarchy.

The American experiment of republican self-government, freedom of ideas, and adherence above all to principled ideals, has been a sublime success. While not yielding perfection, our system has provided a history (including a record of generosity around the world) that I believe is objectively unmatched. It is certainly reasonable, and eminently rational, to evaluate our nation's principles by comparison to other systems and their results. I think the comparison speaks volumes in favor of the United States.

Like many others, we may have come late to cleansing the scourge of slavery from our nation, but we eventually adopted the spectacular ideals and vision of Dr. Martin Luther King, Jr., and made them part of our national fabric, while electing an American president of African descent far before even the most enlightened of our international peers. Our troops, like every army in human history, have on incredibly rare occasions engaged in atrocities, but hundreds of thousands of Americans have selflessly given their lives in two world and countless other just wars to protect and extend freedom far beyond our own economic or cultural spheres. As I write this, incredibly brave young Americans are far from home today defending my family, and my American ideals. Thank you.

The other characteristic opinion of America held in other nations is particular to our citizens. Even the most skeptical Britons I encountered during my three years, filled with disdain for 'loud' or 'arrogant' Americans, were more than willing to admire our nearly universal optimism, and all the positive achievements it has led to.

I got an example of that today. I went in to Doernbecher Children's Hospital to make rounds on a few patients I have in the hospital over the holiday. While I was there, I stopped by the University Hospital operating room where my younger partner, Dr. Nicholas Coppa, was carrying out a complex procedure with great skill and dedication. In the midst of a sunny holiday morning, all I heard from Dr. Coppa and our colleague and Chair of the Anesthesia Department, Dr. Jeffrey Kirsch, was enthusiasm and high expectations for the results of their work. Outstanding and talented physicians putting their professionalism forward in all circumstances to help others are emblematic of America, and of the ideals I grew up with. I am proud to count such people as my colleagues, and most of all today, I am proud to be an American!