Although it is not a particularly difficult concept, sometimes students have trouble remembering the different names that the subclavian artery takes on as it passes through the superior mediastinum and base of the neck into the axilla (as the axillary artery) and arm (as the brachial artery), or they don’t quite get that it is the same vessel with three different names.
Every one of my students has to drive along these roads to get to school.
One thing I do in lecture and lab is to analogize this name change using name changes for streets in town. Fortunately, I work at a university (Benedictine University in Lisle, IL) that is situated on a road (College Road) that changes name to the north (Yackley Avenue) and to the south (Wehrli Road) without changing direction appreciably. Every student has to drive along these roads to get to school. I tell my students that the subclavian artery is like Yackley Avenue, and when it crosses the lateral edge of the first rib (in this analogy, Maple Avenue, see Figure), it changes name to the axillary artery (College Avenue); it changes name again after crossing the inferior margin of the teres major muscle (Hobson Road, see Figure), at which point it becomes the brachial artery (Wehrli Road). I would wager that many (most?) towns in the United States have roads that change names in the same way, so that the analogy could be adapted to local conditions. A particularly good example, in Washington, DC, is Constitution Avenue, which starts as I-66E, changes to US-50E/Constitution Avenue after crossing Roosevelt Bridge, and then turns into Maryland Avenue after crossing 2nd Street NE.
Of course, every semester the students and I question the sanity of anatomists and city planners alike for changing a perfectly good name again and again. I wonder how many students, driving home from my anatomy class, are thinking about the different names for the main artery of the upper limb as they drive along Yackley Avenue/College Road/Wehrli Road?
Robert McCarthy is an assistant professor in the Department of Biological Sciences at Benedictine University in Lisle, IL, where he teaches human anatomy and evolution to undergraduate biology and health science students. Robert is a biological anthropologist who studies the evolution of speech and language, the primate skull, hominin evolution, and human anatomic variation.
When I teach endocrinology students our unit on the adrenal gland cortical hormones, I always post a PowerPoint slide which depicts a Wikipedia image of the renin-aldosterone-angiotensin-system (RAAS).
Its author does an elegant job of elaborating angiotensin II’s targets and responses, which include increases in sympathetic nervous system activity, tubular Na+ reabsorption and K+ excretion and H2O retention, adrenal cortex release of aldosterone, arteriolar vasoconstriction with a concomitant increase in blood pressure, and posterior pituitary release of ADH (arginine vasopressin) leading to reabsorption of H2O by the collecting duct. Overall there is an increase in the perfusion of the juxtaglomerular apparatus (JGA), which offers the negative feedback signal to reduce renin output by the JGA.
I point out to students this elegant, multiple-organ defense of falling blood pressure: the kidney (for renin release), liver, lung, adrenal cortex, hypothalamus (for both CRH and ADH), and kidney (for elevated perfusion) is all automatic. But when I show diagrams from multiple sources, including texts, I offer this question, “What is missing from these images?” I do prompt them with a clue about loss of perspiration during workouts, but the ‘lights don’t go on’ until I reveal a PowerPoint shape with this on it, “Glug, glug, glug” – then they smile …. because they realize that drinking fluids provides the fastest return from hypovolemia…
Be thorough. Connect the dots.
Post comes from Robert S. Rawding, Ph.D., Professor in the Department of Biology at Gannon University in Erie, PA.
A message from HAPS President Emeritus, Margaret Weck!
Have you ever noticed how variable the depth of learning is amongst students in your classroom – even when you have students with very similar backgrounds and levels of preparation? Perhaps you’ve looked for patterns or specific characteristics that might help explain this variability. After all, if you can find consistent and predictable behavioral patterns, you might discover the key to motivating and assisting those who are struggling with coursework. One useful tool for doing just that is to identify each student’s preferred “learning style,” a method that groups students based on their preferred means of learning. Interestingly, this very topic was the focus of a HAPS –L discussion forum this past summer. Following is a brief summary of the main points of that discussion supplemented with a little additional information.
A 2004 book by Coffield, et al. (1) identified 71 different learning style models, most of which are variations of two particular general themes. One of these themes is psychologically-oriented and looks at how individuals make sense of their personal experiences. Examples include David Kolb’s Learning Styles Inventory (LSI) and Zubin Austin’s Health Professionals Inventory of Learning Styles (H-PILS). The second major theme focuses more on neurological sensory information processing. Examples include the right-brain vs. left-brain dominance tests and Neil Fleming’s Visual, Aural, Read/Write, Kinesthetic (VARK) inventory, a tool that indicates a person’s preferences for sensory modalities that most smoothly facilitate the mastering of new information.
Will I be able to definitively resolve the central issues of learning styles in this post? Of course not. As we all know, it is notoriously difficult to “prove” anything, even without the additional handicap of measuring psychological processes through self-report. In my opinion, it’s not worth the necessary paper or electrons to engage in a heated debate over this, especially since the take-home message is pretty much the same regardless of the outcome.
Even those who strongly advocate the use of learning styles are aware of the limitations of each specific model and the instruments used to categorize individual learners. Furthermore, the results of every inventory are full of questions of validity, reliability, and stability. In other words, what does it really mean for someone to be an “assimilator,” or a “kinesthetic learner,” or “right brained?” Are people with one tendency actually incapable of learning in any other way? Are these tendencies fixed, or can one improve or broaden native capabilities or preferences with enough effort and exposure to new types of learning? The questions are endless, and addressing them is beyond the scope of this article; however, Edutopia (2015) has an overview of the various opinions and positions held by education leaders on learning styles: http://www.edutopia.org/article/learning-styles-real-and-useful-todd-finley.
Since 2008 (2) rigorous educational research has not shown that specific instruction targeted toward a student’s learning style produces any statistically significant improvement in measured learning as compared to a non-preferred learning style. Yet the debate over the usefulness/uselessness of learning styles persists.
As far as course design is concerned, “universal” instructional design already encourages the use of multiple delivery modes to both present and assess student understanding of the most important ideas in our content. Using multiple forms of representing and expressing key information automatically helps students find at least one point of entry into the content. So if preferred learning styles are real facilitators of learning, universal design already addresses them to a large degree. Additionally, multiple presentation and assessment modalities provide reinforcement and a variety of possible retrieval cues which should help everyone – regardless of learning style.
One big positive offered by learning styles is that they are a non-threatening way to engage students in conversations about their learning. Many students do not routinely participate in systematic self-reflection, but we can encourage them to talk about how they learn and what it means to demonstrate their own understanding of a subject by using easy-to-understand terminology found in the learning styles inventory. As long as we don’t affix permanent labels to our students, which in effect “excuses” them from mastering the material, learning styles can provide students with insight into their own learning and offer a source of concrete strategies for engaging with course material.
Coffield, F., Moseley, d., Hall, E., & Ecclestone, K. (2004) Learning styles and pedagogy in post-16 Learning: A systematic and critical review. London: Learning and Skills Research Centre.
Pashler, H., McDanierl, M., Rohrer, D. & Bjork, R. (2008) Learning Styles: Concepts and Evidence. Psychological Science in the Public Interest 9(3):105-119.
My last week in Sacramento, in addition to trying to pack and get everything back in my car, I was sent follow a resident in the Emergency Department. This service is especially difficult because its patients range from the mentally agitated to those in car accidents. While the interns may only have to cut away clothing, someone must be ready to open the patient. The cases I saw, in quick succession, give a hint of the diversity one resident had to deal with the same evening.
Case number one: an adult male, previously treated for injuries sustained when he fell of his bicycle a week earlier. Had been sent home with broken ribs. Difficulty breathing brought him back. Imaging showed a light region where the lung should be. He had developed a hemopneumothorax. Blood and air needed to be removed, if not successfully in the ER then by a surgeon. Under local anesthetic an incision was made and the whisper or air was followed by gurgling blood. He was sent home with a chest tube.
Case two: teenage girl on bike hit by car. Imaging shows no internal injury but a large wound to her left thigh needed debridement and dressing.
Case three: 20 month old boy bitten around the right eye by pit bull. No one saw the attack. The mother carried the screaming child in. Once calmed by medication, images were taken to look for fractures to the skull and facial bones. The wounds were deep punctures, probably needing eventual cosmetic repair.
Case four: adult male with continuous abdominal pain since previous evening’s meal. All symptoms point to blocked gallbladder…he was the only one scheduled for surgery.
Every case gave me a little more knowledge about some system in the body which I’ll now be able to weave into my anatomy lectures. Classes start next Monday so my summer of shadowing is over. If you ever get a similar opportunity, I encourage you to take it…but not if it involves renting an un-airconditioned room in Sacramento for the summer! Teri
Of all of the medical specialties I knew I’d be seeing, I’ve had the most history with cancer. The first operation I ever learned of was my mother’s mastectomy. She much later was treated for bone cancer. My father and I have had skin cancers removed. So the idea of seeing a patient under the knife was both interesting and hard to dissociate from.
The first major cancer operation I observed was one of the longest. A soft tissue cancer near the chin had invaded the mandible. A team of surgeons from both Oncology and ENT worked in shifts. First they cancer was removed, then the jaw was rebuilt and the neck closed. The most frightening part was that while the surface tissue looked different, to my untrained eyes, I could not fathom how they knew when to stop cutting. Leaving stray cancer cells behind after a surgery of this length would be horrifying. They of course can follow up with chemotherapy or radiation, but the tissues heal more slowly in those cases.
A much more common and shorter surgery is the one my mother had so long ago. A total mastectomy. Not as a pre-emptive strike before cancer, but to remove one that has been found. Working with plastic surgeons the breast can be reconstructed, but not until after the initial wound heals and if necessary extra skin is stretched by an implant. During the mastectomies I witnessed, it was hard not to think of my mom or my own potential risk. I’m glad to know that there are both medical doctors and specialized surgeons training to fight this insidious disease.
Just blood vessels? It struck me as too narrow a field to specialize in. Not as glorious as Cardiothoracic. But now that I have seen them in action, the vascular surgeons are some of my most admired. They deal with some of the sickest patients, for the longest times, and unfortunately for many there is no cure…only help. Here are the three stages of help I’ve seen these surgeons provide.
First, the rarer problem I watched repaired. With no symptoms, only caught by luck on images for something else (yet can run in families so people may have forewarning). An aortic aneurysm that ruptures is lethal, usually even in a hospital setting. So, if one is found they are watched for changes in size. The surgery is risky enough not to go in prematurely. Endovascular surgery allows only puncture wounds in the groin to deploy elaborate stents, but the open surgery is still the standard.
Example of a Stent used in an Endovascular aneurysm repair (Photo credit: Wikipedia)
Similar stents can be used in the all too common arterial blockages. Whether anatomical anomaly or the build up of plaque in walls, ballooning the vessel is least invasive, and stenting it a secondary option. We all have at least fatty streaks in our vessels, said one of the surgeons, but hopefully they are not causing ischemia in out tissues. The original surgery (I’ve not observed) to remove the atherosclerotic region especially of carotid arteries is an arterectomy. The area is bypassed, opened, the lining stripped away, and the vessel patched back up. Because it has not foreign material added, the vessel heals itself relatively well but the surgery is much harder on the patient than femoral access for newer methods.
Finally, the sad result of the tissue ischemia. Due to the vessel injuries by diabetes, many will develop neuropathy. The most distal tissues have the longest paths so blood resistance is highest to the feet. When blockages in the lower limbs occur, muscle and skin of toes often die leading to gangrene. The saddest day of surgery I observed was when a whole shift was scheduled for amputations. However, the doctor gave me this bit of encouragement. The sooner he removes a small dead area (single toe at best), the faster the patient is able to get back to their lives.
English: Vascular of the toes with the characteristic . (Photo credit: Wikipedia)
In my previous post about Anatomia Italiana 2013 our group had just visited the La Specola anatomical wax museum at the University of Florence. Since then we visited two other collections of anatomical waxes, and the historic anatomy theater at the University of Bologna. Present here also are Luigi Galvani’s tools for his neurophysiology experiments. Amazing! Pictured above, Prof. Alessandro Ruggeri discusses the historic collection of specimens at the Luigi Cattaneo Museum, which is in the present anatomy department at the University of Bologna.
Once we moved onto to a four day stay in Venice, we took a brief train ride for a day visit to the University of Padau. Here we got to see the oldest permanent anatomy theatre (1595), the location of anatomic study by the likes of William Harvey. Was it here that Harvey entertained his first thoughts on the nature of the circulatory system? An added bonus was to sit within the lecture hall of Galileo, and stand before his podium.
The sense of history that our group experienced was personally rewarding, and truly a professional development exercise. We often shared ideas on how to incorporate what we learned on this venture into our classes.
Anatomia Italian 2013 concluded this weekend after two weeks in Italy. Most of us have returned home by now, while a few in the group extended their stay in Europe. All of us, however, will never forget our journey back in time to the venues where anatomy as a science in medical education began.
The exciting idea about all of this is that in 2014 HAPS members can participate in Anatomia Italiana and also enroll in a three-unit HAPS-I course. A month of online readings prior to the travel experience, followed by the submission of a teaching element after a visit to Italy is the essence of the course. If the 2014 HAPS-I Anatomia Italiana course is something you are considering, you can download the syllabus by clicking here. Details are also on the HAPS-I registration page, which can be visited by clicking here. The entire travel program can be reviewed at the Anatomia Italianawebpage. Keep in mind that it is also an option to travel with Anatomia Italiana and not enroll in the HAPS-I course.
After multiple shifts with plastic surgeons in the OR they take over after mastectomies or other cancers are removed. They are called to the Emergency room to evaluate superficial , I appreciate not only their physical skill, but the variety of their patients trauma. In clinic, they see those hoping for cosmetic fixes (closing a diastasis between the rectus muscles) and those needing long-term wound care from paralysis. They also work on the damage caused by gunshots (sometimes while the patient is under police guard).
In clinic the residents and medical students do a first pass with each patient, then the attending joins them to finish up. Though a slow process, the teaching that occurs is obvious. One particular case highlighted the need for remembering or reviewing anatomy. The patient, a woman in her early thirties, went to the emergency department on the weekend. She claims to have grabbed the wrong end of a “butter-knife” in order to cut some cake. The cuts on her dominant right hand were located at the metacarophalangeal joints of fingers four and five. After her wounds were cleaned she was asked to move each digit. The pinkie finger would not comply. The residents opened the skin wider to confirm the flexor tendons were intact. While they saw and pulled on one, getting the appropriate response, at this site the superficialis divides and hides. Though they stitched her up and expected all would be well in a week, at clinic the attending took one look at the straight finger and suggested surgery to repair a cut tendon. The residents did no harm, and learned to be a bit more thorough even when called in on such a small injury.
A cardiothoracic surgery to remove masses from the lung amazed me by not only the coordination of the surgeons, but their ability to use imaging and touch. The patient was ventilated as needed for the doctors to reduce the size of the lung tissue to see around inside the chest. Seeing the wounds closed with preloaded rows of staples was an “aha” moment for me.
Angiography of an aneurysm in a cerebral artery. Source: Wikipedia.
Wednesday morning: oncology. The patient had previously had their cancerous gallbladder removed by laproscopy, but the margins came back still positive for cancer. Today the surgeons had to open the patient to take out part of the liver. A row of staples won’t work in this case. Cautery, fibrin laced mesh and a tissue gel all helped seal the remaining organ.
Last shift of the week, Friday afternoon to evening. The neurosurgeons had an aneurism to clip. By the time I arrived the right temporal and meninges had already been reflected. The angiogram was displayed on video screens in the operating room. Doppler was used to “hear” if the clipped vessel was completely closed. Before they closed the skull I noted to myself that the brain does not appear as impressive as its many functions truly are, and I don’t think I could be a neurosurgeon. Not due to the physical talents necessary, but for the mental risks involved.
Things I learned in my first week as an intern. Don’t use the elevators or stairs closest to the operating rooms! It was no big deal when the elevator wouldn’t go, it let me back out. The stairs though…require a special card to get out of. Meaning once you get to correct floor you better hope someone else shows up. And when you are supposed to be “early to be on time” waiting around just won’t work.
Plastic surgery isn’t a service I looked forward to observing. It has always struck me as a combination of elective and gruesome. If I got to see reconstructive surgery of an injured child with cleft palate or some other noble procedure that would be great, but no such luck. I got to watch the end of a “bilateral blepharectomy” (eyelid tucks) and facelift. It was amazing the amount of spare skin snipped off after the surgeon finished “loosening up” all that tissue. I wondered if the patient would deem her appearance that big of an improvement…I overheard she’s a college professor.
Urology service had a lecture and their “M&M’s” (morbidity & mortality conference) which wasn’t as exciting as TV. Learned more about catheters than I hope I ever need to know, but still wonder why the bladder’s smooth muscle gets a title (the “detrusor” muscle instead of just calling it the muscularis layer).
Spent whole neurology shift in the OR watching bones being pinned together from osteomyelitis. Lots of titanium went in to hold everything from T-10 to the pelvis together. The surgery was a success, but the patient is elderly, and in renal failure…making me wonder if it was worthwhile.
The HAPS Blog 
