- Emergency Medicine
- Pediatric Emergency Medicine
Clinical Assistant Professor, Emergency Medicine
Clinical Assistant Professor, Pediatrics
Program Director, Pediatric Emergency Medicine Fellowship (2019 - Present)
Associate Program Director, Pediatric Emergency Medicine Fellowship (2018 - 2019)
Medical School, University of California, San Francisco (2009)
Residency, Harbor-UCLA Medical Center, Emergency Medicine (2013)
Fellowship, Harbor-UCLA Medical Center, Pediatric Emergency Medicine (2015)
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2014)
Board Certification: American Board of Emergency Medicine, Pediatric Emergency Medicine (2017)
- A Four-Week-Old Infant With Respiratory Distress: An Emergency Department Case Presentation of Congenital Lobar Emphysema CUREUS 2021; 13 (3)
Protecting the emergency physician workforce during the coronavirus disease 2019 pandemic through precision scheduling at an academic tertiary care trauma center.
Journal of the American College of Emergency Physicians open
2021; 2 (1): e12221
The coronavirus disease 2019 (COVID-19) pandemic created new emergency physician staffing challenges. Emergency physicians may be taken out of the workforce because of respiratory symptoms or pending severe acute respiratory syndrome coronavirus 2 test results. Vulnerable emergency physician populations with increased risk of serious disease and death from COVID-19 include physicians at older ages; those with chronic medical conditions, including cardiac and pulmonary diseases and immunosuppression; and potentially pregnancy. We present our approach to planning for staffing issues through precision scheduling. We describe the actions taken to protect our vulnerable physicians and maximize our physician coverage. Measures include optimizing workforce; increasing backup call system; adjusting shifts based on patient arrival times, volume, and surge predictions; minimizing exposure to COVID-19 and reduce personal protective equipment use through telemedicine, huddles, and, creating lower risk emergency department care areas; and standardizing intubations to limit exposure.
View details for DOI 10.1002/emp2.12221
View details for PubMedID 33615307
Here to chair: Gender differences in the path to leadership.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
The progress of women professionals across all sectors including academia in the past several decades has resulted in few reaching the highest echelons of leadership.1 Since the early 1990s, women have made up greater than 40% of United States (U.S.) medical school classes, yet are less likely to become full professors or hold senior leadership positions as compared to men.2.
View details for DOI 10.1111/acem.14221
View details for PubMedID 33511736
A Four-Week-Old Infant With Respiratory Distress: An Emergency Department Case Presentation of Congenital Lobar Emphysema.
2021; 13 (3): e13814
Congenital lobar emphysema (CLE) and congenital pulmonary lymphangiectasis (CPL) are rare conditions that are most often identified with prenatal ultrasonography. Occasionally, this disease process is first identified in the emergency department (ED), where the physician should avoid common pitfalls in order to prevent acute decompensation. To the best of our knowledge, there are no prior reports in the emergency medicine literature of CLE or CPL presenting to the ED as undifferentiated respiratory distress in an infant. Here, we describe one such case and then discuss the importance of differentiating these congenital anomalies from more commonly encountered emergency diagnoses, such as pneumothorax and pneumonia. Management differs radically, and the use of chest tubes and positive pressure ventilation in CLE may precipitate acute cardiovascular decompensation.
View details for DOI 10.7759/cureus.13814
View details for PubMedID 33850674
View details for PubMedCentralID PMC8035594
Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System.
Journal of the American Heart Association
2020; 9 (24): e016652
Background Despite the benefits of targeted temperature management (TTM) for out-of-hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban-suburban regional system of care. Methods and Results This was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10million residents. All adult patients aged ≥18years with non-traumatic out-of-hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non-White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM. Conclusions Within this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.
View details for DOI 10.1161/JAHA.120.016652
View details for PubMedID 33317367
- Emancipated Minor StatPearls 2020
- Pediatric Facial Trauma StatPearls 2020
Emergency department implementation of abbreviated magnetic resonance imaging for pediatric traumatic brain injury.
Journal of the American College of Emergency Physicians open
2020; 1 (5): 994–99
Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.
View details for DOI 10.1002/emp2.12055
View details for PubMedID 33145550
View details for PubMedCentralID PMC7593499
Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and blacks may fare worse than non-Hispanic whites.
BACKGROUND: This study evaluates differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes by race/ethnicity.METHODS: This is a retrospective analysis from a regionalized cardiac system. Outcomes for all adult patients treated for OHCA with return of spontaneous circulation (ROSC) were identified from 2011-2014. Stratifying by race/ethnicity with White as the reference group, patient characteristics, treatment, and outcomes were evaluated. The adjusted odds ratios (OR) for survival with good neurologic outcome (cerebral performance category 1 or 2) were calculated.RESULTS: There were 5178 patients with OHCA; 290 patients excluded for unknown race, leaving 4888 patients: 50% White, 14% Black, 12% Asian, 23% Hispanic. In univariate analysis, compared with Whites, Blacks had fewer witnessed arrests (83% vs 86%, p=0.03) and less bystander CPR (37% vs 44%, p=0.005), were less likely to undergo coronary angiography (14% vs 22%, p<0.0001), and less likely to receive PCI (32% vs 54%, p<0.0001). Asians presented less often with a shockable rhythm (27% vs 34%, p=0.001) and were less likely to undergo angiography (15% vs 22%, p<0.0001). Hispanics presented less often with a shockable rhythm (31% vs 34%, p=0.03), had fewer witnessed arrests (82% vs 86%, p=0.001) and less bystander CPR (37% vs 44%, p=0.0001). In multivariable analysis, Hispanic ethnicity was associated with decreased favorable neurologic outcome (OR 0.78 [95%CI 0.63-0.96]). Outcomes for Asians and Blacks did not differ from Whites. When accounting for clustering by hospital, race was no longer statistically significantly associated with survival with good neurologic outcome.CONCLUSION: We identified important differences in patients with OHCA according to race/ethnicity. Such differences may have implications for interventions; for example, emphasis on bystander CPR instruction in Black and Hispanic communities.
View details for PubMedID 30753852
- Update in Urinary Tract Infections in Children: What’s New in 2019 Pediatric Emergency Medicine Reports 2019; 24 (3): 25-35
2018 AEM Consensus Conference: Advancing PEM Education through Research & Scholarship.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
Successful Pediatric Emergency Medicine (PEM) education research and scholarship can alter the varied landscape of care that is delivered outside of children's hospitals in the U.S. It is well established that most pediatric emergency care occurs in general emergency departments and urgent care centers by a diverse group of providers, whose core training and experience in treating acutely ill or injured children can be quite limited.1 Beyond gaps in fundamental PEM education, there are no systems, processes, or even standards that fully assure an ongoing communication of best practices between tertiary pediatric institutions and general (non-children's) hospital emergency departments. To achieve high quality emergency care for pediatric patients nationwide, there will need to be a significant shift both in core training and in dissemination of state-of-the-art practices. Large scale PEM education research and innovative scholarship are vital to future progress that can unify standards for core training, and delineate effective continuing education pathways that integrate program-based and online modalities. Our consensus session therefore focused on defining the essential goals for PEM education and scholarship that would help establish a continuum of high quality pediatric emergency care in all centers. This article is protected by copyright. All rights reserved.
View details for PubMedID 30311285
Regional "Call 911" Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST-Segment-Elevation Myocardial Infarction.
Journal of the American Heart Association
2017; 6 (12)
We evaluated the first-medical-contact-to-balloon (FMC2B) time after implementation of a "Call 911" protocol for ST-segment-elevation myocardial infarction (STEMI) interfacility transfers in a regional system.This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention-capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4-year period (2011-2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120-minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52-71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88-153) with 56% of patients meeting the 120-minute goal. The median STEMI referring hospital door-in-door-out time was 53 minutes (IQR 37-89), emergency medical services transport time was 9 minutes (IQR 7-12), and SRC door-to-balloon time was 44 minutes (IQR 32-60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67-97).Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120-minute goal.
View details for PubMedID 29275369
View details for PubMedCentralID PMC5779010
- Approach to Pediatric Eye Discharge and Periorbital Swelling Pediatric Emergency Medicine Reports 2017; 22 (12): 153-168
Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care
JOURNAL OF THE AMERICAN HEART ASSOCIATION
2016; 5 (9)
The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes.This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1).Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.
View details for DOI 10.1161/JAHA.116.004131
View details for Web of Science ID 000386716900053
View details for PubMedID 27633392
View details for PubMedCentralID PMC5079051
Pediatric Acute Bacterial Sinusitis Diagnostic and Treatment Dilemmas
PEDIATRIC EMERGENCY CARE
2015; 31 (11): 789-794
Acute bacterial sinusitis (ABS) is a common complication of a simple upper respiratory infection. Acute bacterial sinusitis and an upper respiratory infection, however, have different management plans. This article will help clinicians establish when a diagnosis of ABS can be made based on the latest guidelines from the American Academy of Pediatrics. Also covered will be the pathophysiology of ABS, the role of diagnostic imaging, the recognition of complications of ABS, and treatment options.
View details for DOI 10.1097/PEC.0000000000000599
View details for Web of Science ID 000364544400012
View details for PubMedID 26535501
Risk Factors for Apnea in Pediatric Patients Transported by Paramedics for Out-of-Hospital Seizure
ANNALS OF EMERGENCY MEDICINE
2014; 63 (3): 302-308
Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure.This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival.There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7).We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.
View details for DOI 10.1016/j.annemergmed.2013.09.015
View details for Web of Science ID 000332751500009
View details for PubMedID 24120630
CONSTIPATION IN A 7-YEAR-OLD BOY: CONGENITAL BAND CAUSING A STRANGULATED SMALL BOWEL AND PULSELESS ELECTRICAL ACTIVITY
JOURNAL OF EMERGENCY MEDICINE
2012; 42 (3): 283-287
Constipation in pediatric patients is a common diagnosis in the emergency department (ED) and may occasionally arise from a significant underlying illness.To discuss a rare cause of constipation that led to a strangulated small bowel and cardiac arrest.A 7-year-old boy presented in pulseless electrical activity. The patient had been seen in the ED 2 days prior with the complaint of abdominal pain, which was diagnosed as constipation. The boy had emigrated from Mexico 18 months earlier. The patient was resuscitated in the ED and taken emergently to the operating room. During surgery he was discovered to have a congenital abdominal adhesive band that led to a strangulated small bowel. He suffered subsequent multi-organ failure, including hypoxic ischemic encephalopathy, and was hospitalized for 5 months. One month after discharge he was improving and being followed by multiple providers.Congenital adhesive bands, although rare, may be life-threatening anomalies. We present this case to increase awareness of this condition among emergency physicians.
View details for DOI 10.1016/j.jemermed.2010.05.092
View details for Web of Science ID 000302272500008
View details for PubMedID 20832966
Effect of a Minimum Lymph Node Policy In Radical Cystectomy and Pelvic Lymphadenectomy on Lymph Node Yields, Lymph Node Positivity Rates, Lymph Node Density, and Survivorship in Patients With Bladder Cancer
2010; 116 (8): 1901-1908
Extended pelvic lymphadenectomy (PLND) during radical cystectomy (RC) reportedly improves bladder cancer-specific survival. Lymph node counts are often a proxy for the extensiveness of a dissection. In the current study, the impact of an institutional policy requiring a minimum number of lymph nodes was assessed.Patients undergoing RC and PLND for invasive bladder cancer between March 2000 and February 2008 were retrospectively reviewed at the study institution. Beginning March 1, 2004, a policy was established that at least 16 lymph nodes had to be examined. Specimens with <16 lymph nodes were resubmitted (including any fat) to detect additional lymph nodes. Lymph node yields, lymph node positivity, lymph node density (LND), and survivorship before and after policy implementation were compared.A total of 147 patients underwent surgery 4 years before policy implementation and 202 underwent surgery 4 years after. The median number of lymph nodes increased from 15 to 20. Percentage of cases with >or=16 lymph nodes increased from 42.9% to 69.3% (P <.01). The lymph node positivity rates did not change significantly, but the proportion of patients with LND <20% increased from 43.9% to 65.5% (P = .04). Overall survival increased from 41.5% to 72.3% (P <.01). Univariate and multivariate regression demonstrated that policy implementation, and subsequent increase in median lymph node yield, decreased mortality risk by 30% (hazards ratio [HR], 0.70; P = .04) and 48% (HR, 0.52; P = .01), respectively.Thorough evaluation of PLND specimens obtained at RC can be influenced by an institutional policy mandating a minimum number of lymph nodes. This could lead to greater confidence in pathologic staging and reliability of LND as a predictor of prognosis. Survival can improve due to increased awareness to perform a more thorough PLND.
View details for DOI 10.1002/cncr.25011
View details for Web of Science ID 000276584700009
View details for PubMedID 20186823