Next Generation

I am very proud of each and every resident trained in the neurosurgery residency program at Oregon Health & Science University/Doernbecher Children’s Hospital. This week, we got some news that one of them will join us in the small but important specialty of pediatric neurosurgery, caring for children with surgical disorders of the brain and spinal cord.

Dr. Eric Thompson joined the OHSU neurosurgery training program in 2005. Raised and educated in Nebraska, Eric was a young and quiet resident, who developed and interest, and great talent, caring for children and their families. He also went into the laboratory to help develop better ways of treating children with brain tumors: understanding how to stop tumor growth and reduce the impact of chemotherapy on kids.

In the meantime, Dr. Thompson also developed a leader’s voice. He took a role in teaching students and younger residents. He spoke about his research at national meetings. He represented all OHSU residents on the institutional education committee and won a socioeconomic fellowship for leadership development from our national neurosurgical societies.

It was no surprise to me that my colleagues at the world leading pediatric brain tumor clinical and research program in Toronto, Canada, selected Dr. Thompson to serve as their 2013-14 Chief Fellow. They see both the accomplishment and promise for our field that he carries with him. I am excited to see our resident succeed, but also very excited for the future of my chosen field, pediatric neurosurgery. I am also delighted that the experience of caring for children at Doernbecher Children’s Hospital is inspiring the best of our young trainees, in many fields, to dedicate their careers to carrying on and improving the tradition of pediatric medicine and surgery.

Dr. Eric Thompson

A Stitch in Time Saves More Than Nine

One of the true challenges of neurosurgical care is that small details can have a big effect. In short, the central nervous system is one of the least tolerant organ systems in the body to irritation, injury, infection and other ill effects.

While I was training in general and then pediatric neurosurgery, I was troubled that despite careful attention, very delicate and important drains in the fluid spaces of the brain sometimes fell out. This often happened at night, required an additional procedure to replace the drain, and in the worst cases caused a temporary leak of cerebrospinal fluid (CSF) out of the drain site, resulting in infection. In some cases, with small fluid spaces, called ‘ventricles’, replacing the drain could also be tricky, and involved a small but important amount of risk.

So, throughout my career, whenever I worked with a new colleague (resident, fellow, or faculty member), I paid careful attention to details of how they liked to secure their CSF drains. I asked questions. I made notes.

When I started as the head of pediatric neurosurgery at Doernbecher Children’s Hospital, I combined what I found to be the best tricks and techniques into a very systematic way of stitching in CSF drains. I stuck with it. I taught every one of our residents how to do it, and I insisted they use my system. The method spread within our Department, but no further.

That was until 2011, when a senior and respected colleague of mine wrote me an email from Africa. He was running a neurosurgical service at a mission hospital in one of the poorest countries on earth. He had very little nursing support. His drains fell out all the time. His nurse practitioner had years before worked at Doernbecher. She mentioned to him that our drains “never fell out”. He did not believe it, but he sent me the note.

I told my friend how I do it. A month later, he sent another note. Not a single drain had fallen out. He insisted I describe the technique as an official scientific report. Moreover, he recommended that I send it to our top ranked journal. I wrote back to him complaining that this was just a curious way of securing a drain stitch. I would be a laughing stock for trying to publish a scientific paper on that. But my friend reminded me that scientific papers are there to improve patient care, and that drains falling out may not be fancy science, but are a real problem harming children literally all over the world.

So Nathaniel Whitney, one of our terrific OHSU neurosurgery residents, and I wrote the paper. With help from our world-class medical illustrator, Andy Rekito, we included detailed diagrams showing how to do it. To my surprise and delight, the Journal of Neurosurgery:Pediatrics accepted the paper immediately. Here is the link:

 http://www.ncbi.nlm.nih.gov/pubmed?term=selden%20external%20ventricular%20drain

My friend soon sent a wonderful congratulatory note, and thanked me for following through. He deserves thanks for a suggestion that did not occur to me, and for keeping a sharp eye as he always does on the welfare of our patients and new ways to promote it.

A month later, I got another wonderful note about this project. A friend and colleague in the Midwest, another pediatric neurosurgeon whom I used to work with, saw his resident tying in a drain exactly as I do it. He asked the resident who taught him that. “I just read it in the Journal of Neurosurgery” was the answer.

Helping children in Oregon & SW Washington is Doernbecher’s primary mission. By working with our colleagues around the world, in this case from Africa to Minnesota, we also strive to advance the welfare of all children.

This may be some of the least fancy academic work I have ever done. In some ways though, I think it may turn out to be some of the most impactful.

 

 

The problem with a traditional Roman sandal tie

Standing Up For the Team

Caring for children is both a critical mission and a gift. Those of us privileged to work at OHSU-Doernbecher Children’s Hospital are stewards of systems of care that are vital to the health of our children and the sustainability of our communities. Part of that vitality and sustainability are the training of the next generation of practitioners.

Doernbecher partners with the Schools of Medicine and Nursing at OHSU to train the doctors who will care for our children and their children in the future, long after our own work is done. The presence of trainees in the hospital enriches us. We think of new and improved ways to deliver care. There are additional doctors present in the hospital at night who can respond to a sudden change more quickly than in typical care settings. There are more people available to educate families and patients about their illness and their care.

This week, I was honored for my work as the Director of the neurosurgical residency training program that is housed at both Doernbecher Children’s and OHSU Hospitals. The Palmer J. Parker Courage to Teach Award is given to 10 residency or fellowship program directors in the United States each year to recognize the value and importance of medical and surgical training and of educators. Mentorship, promotion of excellent patient care and safety, and educational innovation are core attributes for the award.

Although the honor is in my name, it is clearly a reflection of the quality and expertise of the faculty and residents at Doernbecher and OHSU with whom I work, their commitment to the highest quality education, to innovation, and to world class patient care.

I am proud of the young neurosurgeons training at OHSU-Doernbecher. Mentoring them is one of the most fulfilling aspects of my job. They contribute directly to the safety and wonderful outcomes of patients we care for. I am honored and humbled that the ACGME has recognized the work we do together.

The team at work in the operating room

Simulation based training

Interrupting Storms in the Brain

Seizures are electrical storms that sweep across the surface of the brain, or cortex. The repeated occurrence of seizures is called epilepsy. According to the Centers for Disease Control and Prevention, epilepsy affects 2.2 million Americans, including hundreds of thousands of children.

Epilepsy is a damaging and dangerous disease in children for many reasons. First, children may be injured or lose oxygen during a seizure. Second, repeated seizures may eventually damage the brain. Third, the medicines used to control seizures are sedating and can themselves cause problems with development and brain function. Fourth, epilepsy causes educational, social and practical barriers to participation and progress during the important childhood years.

Surgical and computer technology offer a new and very effective treatment for children with epilepsy who respond poorly to medications: vagal nerve stimulation. The vagus carries information to and from the brain and the various organs in our bodies (such as the heart, lungs and intestines). Electrical stimulation of this nerve excites centers in the brainstem that in turn ‘quiet’ the excitability of widespread areas of the cerebral cortex. Researchers discovered this property of vagus nerve stimulation by accident, and introduced it as a therapy for seizures in the 1990s.

The pediatric epilepsy center at OHSU Doernbecher is the only accredited full service epilepsy center for children in the state. The center is also one of the most experienced in the country at using vagal nerve stimulation in children, from as young as 3 months of age. In the last 10 years, over 300 vagal nerve stimulation devices have been implanted at OHSU Doernbecher. During the procedure, surgeons wrap a tiny electrode around the vagus nerve in the neck and connect it beneath the skin to a small generator pack just below the clavicle (much like a heart pacemaker device).

Although vagal nerve stimulation is not a cure for epilepsy, it often helps dramatically in the most difficult cases, and those in which medication has largely failed. In a recent publication from OHSU Doernbecher, we report success rates of greater than 90%. The OHSU Doernbecher experience also documents excellent responses in children less than 12 years old and in children with some forms of generalized epilepsy, many of who are traditionally denied care using this device: 
                                    

http://www.ncbi.nlm.nih.gov/pubmed/22768964

The pediatric epilepsy center at OHSU Doernbecher also offers a full range of the most sophisticated functional imaging to diagnose epilepsy disorders, advanced epilepsy monitoring, medication trials, diet therapy, and surgery to remove an epilepsy focus (and potentially cure the disease).

Most important to the success of our patients are the terrific doctors and nurses who participate in the program and who have dedicated their careers to stamping out the ill effects of epilepsy in children. These include specialist pediatric epileptologists like Drs. Colin Roberts and Carter Wray, some of the most highly trained and compassionate pediatric epilepsy specialists around. One of the most rewarding aspects of my day-to-day work is serving as the surgeon for the OHSU Doernbecher pediatric epilepsy center and working with these terrific and dedicated specialists.

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'