Comanche Nation College

Best-practice guidelines have incorporated ultrasound in diagnostic and procedural medicine. Due to this demand, the Arizona College of Osteopathic Medicine initiated a comprehensive integration of ultrasound into its first-year anatomy course attended by more than 280 students. Ultrasound workshops were developed to enhance student conceptualization of musculoskeletal (MSK) anatomy through visualizing clinically important anatomical relationships, a simulated lumbar puncture during the back unit, carpal tunnel and shoulder evaluations during the upper limb unit, and plantar fascia, calcaneal tendon, and tarsal tunnel evaluations during the lower limb unit. A 5-point Likert scale survey evaluated if ultrasound improved students' self-perceived anatomical and clinical comprehension of relevant anatomy, improved students' ability to orient to ultrasound imagery, and prompted further independent investigation of the anatomical area. Ultrasound examination questions were added to the anatomy examinations. Two-tailed one-sample t-tests for the back, upper limb, and lower limb units were found to be significant across all Likert survey categories (P < 0.001). Positive student responses to the Likert survey in conjunction with examination question average of 84.3% (±10.3) demonstrated that the ultrasound workshops are beneficial to student education. Ultrasound enhances medical students' clinical and anatomical comprehension and ability to orient to ultrasound imagery for MSK anatomy. This study supports early ultrasound education as a mechanism to encourage students' independent learning as evidenced by many undertaking voluntary investigation of clinical concerns associated with MSK anatomy. This study establishes the successful integration of MSK ultrasound into a large medical school program and its benefit to student clinical education.

This article is part historical narrative and part personal memoir. The author begins by explaining the Comanche tribal history of kwasinaboo puha (snake medicine). She then discusses the knowledge of kwasinaboo puha that is passed down to Comanche children through an intergenerational process that combines empirical knowledge of snake taxonomy with cultural knowledge of the kwasinaboo puha story. The author then turns to her own initiation into Comanche tribal life by listening to her grandfather’s oral performance of the kwasinaboo puha story. Finally, the author reveals her adult memories of crossing paths with snakes and how kwasinaboo puha presents itself in her poetry. As a result, this article provides readers with an insight into the empirical and metaphorical practices necessary for the continuance of Comanche communal identity and survival in the Lawton area of Oklahoma.

Purpose: Luminal patency of obstructed biliary metal stents is difficult to accomplish after either tumor ingrowth or intimal hyperplasia. Balloon dilation almost always fails and most often another stent, either plastic or metal is placed through the obstructed stent. We report three cases in which luminal patency of obstructed biliary metal stents was established using the Erbe-Argon Plasma Coagulator. Case 1: 46 y.o. male presented with distal biliary obstruction secondary to pancreatic cancer. A 6cm long ZA-stent (Wilson-Cook) was placed across the malignant stricture. Six months post stent placement, he presented with jaundice after his chemotherapy has failed to control the cancer. At ERCP, the stent was completely occluded with tumor ingrowth. Using the Erbe-APC, set at 60wts/1 .4cc flow and giving short pulses with continously moving the probe, the stent lumen was cleared after coagulating all tumor ingrowth. The patient had no reccurence of the jaundice till he passed away three months later. Case 2: 75 y.o. male with obstructive jaundice thought to be secondary to pancreatic cancer had a Wallstent (Bston Scientific) placed across the distal biliary stricture. After a year he presented with jaundice, the stent was completely occluded and his local GI doctor referred him for a choledocho-duodenostomy. After his surgery he presented with multiple episodes of cholangitis secondary to Sump syndrom. At upper endoscopy the gastroscope was introduced to the biliary tree through the anastomosis. The proximal end of the Wallstent was localized and intimal hyperpla-sia was completely obstructing the stent lumen. Using the Erbe-APC set at 60Wts/1.4cc flow, from a proximal anterograde choledochoscopic ap-proach, and requiring two sessions, the lumen of the stent was cleaned. No complications occured. He did well with no episodes of cholangitis since. Case 3: a non-surgical 86 y.o. female required a biliary Za-stent (Wilson-Cook) for papillary adenocarcinoma. She presented 4 months later with jaundice. At ERCP the stent was occluded with tumor ingrowth and food debris. Using the Erbe-APC set at 60wts/1 .4cc flow the lumen was coagulated and the stent cleaned. She tolerated the procedure well but died 6 weeks later from a cardiovascular insult. Conclusion: At low flow rates, with short pulses and continously moving the probe Argon Plasma Coagulator for obstructed biliary metal stents seem to be a safe and cheaper alternative to re-stenting. Care should be taken to lessen injury to the bile ducts.

Large pancreatic pseudocyts with necrotic debris are difficult to drain en-docscopically or percutaneously. Most are drained by creating a large cyst-enterostomy after surgical exploration. Post operative complications range between 12–15%, and prolonged recovery time are major disadvantages of the open surgical approach. Two prior reports by Libby and Atabek, have described a combined endoscopic-laparoscopic technique to create a large cystgastrostomy. We report two cases in which two large pancreatic pseudo-cysts were drained by creating a large cystgastrostomy via a percutaneous transgastric approach. Case 1: a 67 y.o. Hispanic male with chronic alcoholism presented with abdominal pain. CT scan showed a 9cm pseudocyst in the pancreatic body, with septation and calcification. Case2: 36 y.o. Native american female developped a 7cm pseudocyst in the tail of the pancreas after an episode of severe gallstone pancreatitis. Both procedures were performed in the operating room with general anesthesia. First a therapeutic gastroscope was introduced. Then a 24 Fr gastrostomy tube(PEG) was inserted as opposite as possible to the bulge created by the pseudocyst on the gastric wall. The outer tubing of the PEG was cut to 5cm and secured. Under endoscopic guidance a needle was passed thru the PEG port for aspiration of Cystic fluid, proper localization and as a starter point for the large inscision. The needle is removed and again thru the PEG port a Harmonic scalpel (Ethicon, Ohio) was used to create a large 2cm cystgastrostomy. The scope then was passed to the cyst, debris were removed with biopsy forces and snares and the cyst washed with a jet washing probe. After cleaning the cyst, the PEG is removed transorally and the skin sutured. Procedure time ranged between 45–60 minutes, no complications occured, and both patients were discharged within 3 days. A second look endoscopy was performed in 7 days to make sure that the inscision was still open, and in both cases it was. A follow up CT scan was performed in 4 weeks and documented complete cyst resolution. Conclusion: Percutaneous transgastric laparo-endoscopic approach should be added to the drainage options for patients with debris in their pancreatic pseudocysts.