Reflecting on my second day teaching this year's Cadaver Lab.
For description of this series and reflections from Day 1, Click here.
On day two, we flip the donors into a prone position and reflect down to the layer of the deep fascia. For this particular five-day lab, the PA students spend the first half of the day on surface landmarks and suturing. So we only have a half day in the lab doing dissection. Here are some reflections from this day.
I got to practice suturing on the cadaver. This is something that is in the scope for PAs and the dissection lab is a good place from them to start the transition from suture kits to eventually a live person. Obviously, suturing uses a specialized needle. It seems like acupuncturists should be able to do this under our scope. I think as more acupuncturists work in hospitals, this would be a good skill to have and would put them more in demand.
When I show students how to uncover the medial plantar fascia, I describe using the scalpel to cut from the posterior calcaneus and have the blade skim the plantar surface of the calcaneus. The blade then continues directly over the plantar fascia as it removes the skin and adipose. You can use a similar method with palpation of the plantar fascia. You can palpate from the medial side of the foot and feel where the plantar surface of the calcaneus is. As you move more distal past the calcaneus, you would then be just inferior to the depth of the plantar fascia. This gives the depth of where to palpate for plantar fasciitis. However, I often find pain much deeper than this and feel that many times our patients presenting with plantar fasciitis, often are coming in with pain at the quadratus plantae muscle.
The scalpel and the dissection process directly relate to palpation skills. This is not just due to being able to see the structures we work with in dissection, but how you use the blade to uncover layers. One obvious aspect is that, when removing tissue over a muscle, it is best to sweep the blade perpendicular to the muscle fibers. If you sweep the blade parallel to the fibers, it is much more likely that the blade can find the grove between muscle fascicles and go too deep. You can try an experiment yourself that demonstrates this. Sweep your fingers pads of one hand perpendicular across the fingers of your other and notice how the finger pads glide over the fingers. Then do the same in a parallel direction and notice how the pads find the space between fingers and can easily go deep. This is one reason why it is so much easier to feel a muscle when you palpate across the fiber direction. However, when using a blade, you can direct the pressure too deep and start to cut into a muscle or you can come out too superficial and loose the fascial plane. The same can be said with palpation, You have to find the depth and then keep a consistent pressure or you will go too deep or retreat back too superficial and loose the structure you are palpating.
There is something else that the blade teaches you that expands on this idea of depth. I am going to use an example from day one. When you are reflecting the subcutaneous tissue of the thigh and following from the anterior thigh to the medial thigh, the blade follows the contours of the thigh over the quadriceps. However, you have to anticipate the sartorius muscle or the blade can easily follow this contour and go under the sartorius and cut into it. When you start to see the sartorius, you need to direct the pressure more superficial and over it. This is the same for palpation and I find practitioners struggle with palpating this muscle for the same reason. As you follow the contour of the thigh going in a medial direct, you need to anticipate this muscle and not push your fingers under and deep to it.
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