“Why is a plastic surgeon concerned about respiration?”

On Mar 13, 2017 In Tags: , , , ,

This was the most frequently asked question of this weekend at the Myokinematics course hosted by my friend Bill Hartman at IFAST. I am not going to reveal the second and third most frequently asked questions because some things that are asked at Myokin stay at Myokin.

1) Curiosity

I heard about PRI years ago, because Bill was learning and using it, and continues to evolve with it. As a surgeon with an interest in peripheral nerves, though, it was clear that there are overlapping areas of interest. You can’t talk about neuromuscular units without talking about the neuro, or the muscular. And every time I have visited IFAST after graduating from my residency, the topic of “spare parts” and what happens when you surgically remove something like say…a whole latissimus dorsi for reconstruction purposes; or how re-routing a muscle-tendon unit to do something completely different, crops up. The perspective of concepts like fascial integrity and certain recruitment chains (not necessarily to do with PRI) from the point of a surgeon (who cuts fascia or changes/removes entire muscles or bones) is…different.  I never had the time to devote to actually learning it though. But sometimes, a window of opportunity opens. Getting up to the upper extremity though, is apparently, not something you’re allowed to learn right off the bat. The pelvis is the ground level, and that’s where you have to get on. So when IFAST was hosting Myokinematics this year (which is considered Level 1), it was an opportunity too good to pass up.

2) Cross-pollination on different ways of looking at anatomy

“Fear of surgery is fear of anatomy.” –almost every mentor/preceptor I had in residency

While surgeons need to have a wide breadth of knowledge of both medicine and surgery, a surgeon is first, and foremost, an anatomist. Trepidation in surgery happens when you’re less certain of the area in which you are cutting. But similarly, fear of physical assessment and management is also a fear of anatomy, and of the relationships different parts have with one another. Not being able to reason your way through an assessment from first anatomical principles is a problem. PRI takes a different view to these anatomical relationships, putting a significant weight on the role of anatomical asymmetry and respiration in dysfunction. I might not use anything I learn here, but I can already see parallels to some of the problems that I also see and treat. The benefits of cross-pollination aren’t always obvious, but different perspectives can bear fruit in surprising ways.

3) The only way in or out is through.

The famous Bruce Lee quote, “Absorb what is useful; discard what is useless and add what is specifically your own,” is often used to justify the action associated with the second and third phrases of the quote: discarding, and making something “your own”. I think the most important part of this quote is the part that was implied but never explicitly stated: You can only decide to bring something in, throw it out or add what is your own to it, only once you actually own it. I don’t know if PRI will be directly or indirectly useful, and even after taking Myokinematics, I can see where certain assumptions need to be made in order for the “system” to work—whether I’m right about my (currently disorganized) thoughts or not have yet to be determined. But before I can decide whether this is something useful, useless or to be “my own”, I have to drink the Kool-Aid. And just like I couldn’t decide whether I was going to be the kind of surgeon who was going to perform soft-tissue-based surgeries for scapholunate dissociation before I had learned how to do them (I’m not), or vertical-scar breast reductions (I wasn’t before, but after spending time with a master breast surgeon, I am now), the only way PRI will stay in or get thrown out in my practice, is not to just view it from the outside, but to go through it on its own terms.

This isn’t about being “open-minded”. In the world of PRI, I am NOT an early adopter. In the world of surgery and medicine, I might be. It’s all relative, I suppose. I didn’t decide to start this journey because I have an “open mind” (If you’ve been reading this blog, I think that’s quite clear.) Is there “evidence” for PRI? There is certainly enough evidence to support many of their anatomical assumptions. And there is enough internal consistency thus far, to keep going and see where the path leads and, possibly, where the limits of knowledge (and “evidence”) lie.

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