Positional Awareness

on Mar 30, 2020

In most medical cases, there is a need for the audience to understand the pertinent anatomy not in isolation, but in relationship to other structures. In a whiplash case, you need to understand the relationship of the brain and skull. In a gallbladder case, you need to understand the relationship of the cystic duct and the common bile duct. In a shoulder dystocia case, you need to understand the relationship of the baby’s shoulder to the mother’s pelvis. True understanding involved positional awareness.

This was just such a case. The opposition was arguing that a midline incision should have been made through the sternum (breastbone) to access the heart in a traditional fashion. We claimed that adhesions from a previous procedure made this risky, so an alternate approach was preferred. To make our argument, we had to make sure that the audience understood the relationship of the sternum to the underlying heart and great vessels and how this relationship was changed by the adhesions.

First, we established normal anatomy. This exhibit showed the outline of the ribcage and sternum over the heart in an anterior view showing the normal space between these structures in our lateral (side) view. These images allowed our experts to educate the laymen to the normal positions of these structures. But the second exhibit showed that in this patient widespread scar tissue made the heart and aorta closely adherent to the overlying sternum. Therefore, it would be highly dangerous to attempt to divide and retract the breastbone risking a traction tear of one of these vital structures.