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Basilar skull fractures, usually caused by substantial blunt force trauma, involve at least one of the bones that compose the base of the skull. Basilar skull fractures most commonly involve the temporal bones but may involve the... more
Basilar skull fractures, usually caused by substantial blunt force trauma, involve at least one of the bones that compose the base of the skull. Basilar skull fractures most commonly involve the temporal bones but may involve the occipital, sphenoid, ethmoid, and the orbital plate of the frontal bone as well. Several clinical exam findings highly predictive of basilar skull fractures include hemotympanum, cerebrospinal fluid (CSF) otorrhea or rhinorrhea, Battle sign (retroauricular or mastoid ecchymosis), and raccoon eyes (periorbital ecchymosis). Basilar skull fractures are commonly associated with facial fractures, cervical spine injury, intracranial hemorrhage, cranial nerve injury, vascular injury, and meningitis.Basilar skull fractures are most commonly seen in younger people due to their propensity to do high-risk activities. The majority of basilar skull fractures are managed with conservative care.
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Simulation-based education is an essential instructional modality to facilitate learning for nearly every healthcare professional. There are a variety of reasons simulation may be incorporated into the curriculum, including the teaching... more
Simulation-based education is an essential instructional modality to facilitate learning for nearly every healthcare professional. There are a variety of reasons simulation may be incorporated into the curriculum, including the teaching of procedural skills, and assessment of communication skills, teamwork, and clinical decision making. This modality is implementable just in time education, formative, and summative evaluation, along with implementation in reviewing clinical competence.
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Saint Louis encephalitis virus is transmitted to humans from the bite of an infected Culex species mosquito. It is a flavivirus, a single-stranded positive-sense RNA virus, which is closely related to the Japanese encephalitis, Powassan,... more
Saint Louis encephalitis virus is transmitted to humans from the bite of an infected Culex species mosquito. It is a flavivirus, a single-stranded positive-sense RNA virus, which is closely related to the Japanese encephalitis, Powassan, and West Nile virus. Most cases occur in the eastern and central United States during the summer and early fall. Most cases are asymptomatic or present with flu-like symptoms such as fatigue, headaches, nausea, vomiting, and body aches. Most patients will spontaneously recover without progression to encephalitis. Severe, invasive disease resulting in encephalitis is unusual and is more common in older adults. Encephalitis or inflammation of the brain and meninges presents as dizziness, agitation, confusion, tremors, or coma following the flu-like prodrome. For patients with encephalitis, the overall case fatality rate is 5% to 15%. There is no specific treatment for St. Louis encephalitis beyond supportive care. Antivirals have not been shown to alt...
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Simulation-based education is a widely utilized tool for experiential learning. Simulation techniques can employ a range of fidelity to incorporate realism; moulage is one such technique. Moulage was once the art of wax model making to... more
Simulation-based education is a widely utilized tool for experiential learning. Simulation techniques can employ a range of fidelity to incorporate realism; moulage is one such technique. Moulage was once the art of wax model making to depict certain conditions for medical education. As medical training has evolved, moulage has transformed into the art of special effects makeup to replicate various disease processes and injuries. Some simulation centers have the advantage of having an experienced moulage artist on staff; however, with some brief training, other individuals can learn this technique.
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Simulation training has its roots in the aviation industry, with the first flight simulators built in the 1930s. The military, NASA, and commercial airlines further pioneered simulation techniques to improve pilot training and safety. The... more
Simulation training has its roots in the aviation industry, with the first flight simulators built in the 1930s. The military, NASA, and commercial airlines further pioneered simulation techniques to improve pilot training and safety. The field of medicine implemented forms of simulation for training as early as the 1950s, but it wasn’t until the turn of the century that medical simulation took off. Anesthesia was an early adopter of simulation; a first simulator appeared in the 1960s, which could reproduce some physiology, respond to drugs, and teach basic airway management. Since then, medical simulation has expanded across all disciplines of medicine. In particular, internal medicine residencies are increasingly making use of simulation to teach their house-staff, mediate deficiencies, and maintain proficiency in key areas of practice.The medical simulation utilizes multiple diverse modalities to teach learners in internal medicine. For example, scenarios with standardized patien...
This case illustrates the classic injury pattern seen in primary blast injury. Primary blast injury, caused only by high-order explosives, is the result of the blast wave’s compressive effect on tissue. Effects are greatest at the... more
This case illustrates the classic injury pattern seen in primary blast injury. Primary blast injury, caused only by high-order explosives, is the result of the blast wave’s compressive effect on tissue. Effects are greatest at the tissue-air interface. Ear damage is the most common and pulmonary injury is the most lethal. Gastrointestinal injury and brain injury are also common. Traumatic amputations due to primary blast injury were extremely rare in survivors prior to Operations Iraqi and Enduring Freedom. Primary blast injury is usually associated with secondary, tertiary, and quaternary blast injuries. Blast victims require a meticulous approach because the dramatic nature of the obvious soft tissue injuries may distract even experienced trauma providers from focusing on more lethal occult injuries.
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A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. Designing an effective simulation scenario requires careful planning and can be broken into several... more
A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. Designing an effective simulation scenario requires careful planning and can be broken into several steps. Simulation scenarios are designed to assess, educate, and help learners to self-identify gaps in their understanding of material or application of knowledge. Simulation may also be used to address patient safety issues, clinical cases, teamwork opportunities, communication challenges, procedural competencies, and leadership skills. Designing an effective scenario requires planning, including knowledge of the target learners, goals and objectives, intended outcomes, and context. Knowledge of educational principles, including Bloom's Taxonomy, which describes the progression from novice to expert, is helpful with the development of educational goals. Scenario design must also include consideration of the level of fidelity, use of props, moula...
This case illustrates penetrating hand trauma due to secondary blast injury. Secondary blast injury is due to objects accelerated by the blast wind and is the most commonly encountered type of blast injury. Depending on the size of the... more
This case illustrates penetrating hand trauma due to secondary blast injury. Secondary blast injury is due to objects accelerated by the blast wind and is the most commonly encountered type of blast injury. Depending on the size of the fragments, secondary blast injury may present as blunt or penetrating trauma. This case addresses the evaluation of hand trauma after exposure blast caused by suicide bomber, management of foreign bodies due to blast injury, field management of flexor tendon laceration, open joints, and burns. The case also addresses postexposure prophylaxis in the setting of biological fragment exposure. Complicated causes often require specialist referral.
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Introduction Pelvic inflammatory disease (PID) is a spectrum of illness ranging from mild illness to more severe forms including tubo-ovarian abscess, hydrosalpinx, pyosalpinx, oophoritis (THPO). The objective of the study was to report... more
Introduction Pelvic inflammatory disease (PID) is a spectrum of illness ranging from mild illness to more severe forms including tubo-ovarian abscess, hydrosalpinx, pyosalpinx, oophoritis (THPO). The objective of the study was to report rates and clinical characteristics of females presenting to the ED with a diagnosis of THPO in relationship to the presence or absence of sexually transmitted infections (STIs). Methods A database of ED patient encounters occurring from April 18, 2014, to March 7, 2017 was created. Analysis of women diagnosed with THPO and who had testing for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing or who had a vaginal wet preparation was performed. Patient demographics, ED diagnoses, laboratory tests, medications administered in the ED, and medications prescribed were examined. Categorical variables were summarized as count and percentages and analyzed using the Chi-square test. Continuous variables were summarized as the mean and ...
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Background Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and... more
Background Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution. Methods This was a prospective, before–after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. S...
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We developed and implemented a project incorporating ACPE Standard 11 and all Core IPEC competencies at a public University located at a medical center. The project was a collaboration between the colleges of nursing, pharmacy, and... more
We developed and implemented a project incorporating ACPE Standard 11 and all Core IPEC competencies at a public University located at a medical center. The project was a collaboration between the colleges of nursing, pharmacy, and medicine at a distance campus location. Our Interprofessional Education Activity, which targeted all three elements of ACPE Standard 11, provided TeamSTEPPS training followed by four medical error simulations. A debriefing took place after each scenario within a team as well as with all four groups following each simulation session. The Teamwork Attitudes Questionnaire (TTAQ) was used to evaluate the activity. Findings from our interprofessional education activity indicate that while students entered the activity already perceiving teamwork as a positive aspect of safe care delivery, significant improvement in attitudes post training toward specific team constructs was seen across all five domains. The project helped inform the structure of a replication ...
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No information is available on the distribution of cervicocephalic atherosclerosis in Amerindians. We aimed to assess the distribution of these lesions and their correlation with cardiovascular risk factors in Amerindians living in rural... more
No information is available on the distribution of cervicocephalic atherosclerosis in Amerindians. We aimed to assess the distribution of these lesions and their correlation with cardiovascular risk factors in Amerindians living in rural Ecuador. Atahualpa residents aged ≥40years underwent head CT for assessment of carotid siphon calcifications (CSC) and sonographic examination for measurement of the carotid intima media thickness (cIMT). CSC were used as a surrogate of intracranial atherosclerosis and the cIMT as a surrogate of extracranial atherosclerosis. Linear regression and multinomial logistic regression models were fitted to assess the association between cIMT and CSC, and to evaluate differences in risk factors across individuals with atherosclerosis involving both arterial beds when compared with those with extra- or intracranial atherosclerosis alone, or no atherosclerosis. Of 590 participants, 145 had high calcium content in the carotid siphons and 87 had a cIMT >1mm ...
Research Interests: Ecuador, Linear models, Multivariate Analysis, Rural Health, Humans, and 15 moreSouth American Indians, Female, Male, Risk factors, Clinical Sciences, Aged, Middle Aged, Odds ratio, Chi Square Distribution, Risk Factors, The Carotid Artery Intima Media Thickness, Vascular Calcification, Neurosciences, Logistic Models, and Multidetector Computed Tomography
The carotid intima media thickness (cIMT) is a predictor of cardiovascular events. The neck circumference (NC) has been investigated as a risk factor for increased cIMT with contradictory results. This study assessed the relationship... more
The carotid intima media thickness (cIMT) is a predictor of cardiovascular events. The neck circumference (NC) has been investigated as a risk factor for increased cIMT with contradictory results. This study assessed the relationship between NC and cIMT in Atahualpa residents aged ≥40 years who had sonographic examination of carotid arteries (n = 590). We also discussed on potential pathogenetic mechanisms underlying this association. Participants belonged to the Native Ecuadorian (Amerindians) ethnic group. Non-parametric regression models were used to assess the aforementioned relationship, after adjusting for relevant confounders. The mean age of participants was 60.9 ± 12.7 years (58% women). The mean value of the cIMT was 0.85 ± 0.19 mm. The mean NC was 35.8 ± 34 cm. The NC was normally distributed, but the cIMT was not. Mean values of NC and cIMT were significantly greater in men than in women. Non-parametric models showed significant differences in median cIMT values accordin...
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Training adult learners to use ultrasound in clinical practice relies on the ability of the learner to apply visuospatial concepts to the anatomy of the human body. We describe a visuospatial trainer that replicates the housing of an... more
Training adult learners to use ultrasound in clinical practice relies on the ability of the learner to apply visuospatial concepts to the anatomy of the human body. We describe a visuospatial trainer that replicates the housing of an ultrasound transducer, through which a linear laser projects light in the same plane and orientation as the ultrasonic sound waves. We use this trainer in combination with a porcine heart dissection laboratory to teach bedside cardiac ultrasound and transthoracic echocardiography (TTE). Off-the-shelf components, including an on/off switch, a laser, and 2 ampere batteries are connected in series and placed inside the 3-dimensional (3D)-printed housing. The trainer's laser emission projects a red line that visually represents the ultrasound's field. Learners project the laser against a porcine or human heart in the orientation of the TTE window they wish to obtain and then dissect the heart in that plane, allowing for visualization of how grayscale images are obtained from 3D structures. Previous research has demonstrated that visuospatial aptitude is correlated with ultrasound procedural performance. We present this trainer and educational method as a specific training intervention that could enhance the visuospatial ability of the ultrasound learner. This visuospatial trainer and educational method present a novel process for enhancing learner understanding of 2-dimensional ultrasound images as they relate to 3D structures. Having a clear understanding of how images are generated in cross section may translate into more proficient adaptation of cardiac ultrasound and TTE.
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The Pittsburgh Decision Rule (PDR) is a rule for ordering knee radiographs in patients with acute knee injuries. This study was designed to compare the utilization of the PDR between triage nurses and physicians. Consecutive patients... more
The Pittsburgh Decision Rule (PDR) is a rule for ordering knee radiographs in patients with acute knee injuries. This study was designed to compare the utilization of the PDR between triage nurses and physicians. Consecutive patients presenting to the Emergency Department were enrolled. Nurses and physicians were blinded to each other's examinations. Of 182 subjects approached, 30 were excluded for incomplete data or refusal to obtain radiographs, leaving 152 subjects enrolled. Thirteen fractures (8.6%) were identified. Kappa scores were high for each component of the rule: mechanism of injury (fall or blunt trauma) kappa = 0.67, age (< 12 or > 50 years) kappa = 1, inability to ambulate kappa = 0.67 and overall kappa = 0.83. Four of 13 fractures (31%) would have been missed using the PDR, resulting in a sensitivity of 77% for both physicians and nurses, and a specificity of 57% for physicians and 58% for nurses. Triage nurses and physicians were able to apply the PDR to patients who presented with acute knee injuries with a high level of agreement. However, the PDR demonstrated poor sensitivity in this patient population.