- Pediatric Emergency Medicine
Clinical Assistant Professor, Emergency Medicine
Director of Pediatric Simulation, Department of Emergency Medicine (2021 - Present)
Director of Faculty Clinical Skills Training, Department of Emergency Medicine (2021 - Present)
Assistant Director of Faculty Development, Department of Emergency Medicine (2019 - 2021)
Boards, Advisory Committees, Professional Organizations
Education Committee Member, Society for Academic Emergency Medicine (2020 - 2021)
Program Committee Member, Society for Academic Emergency Medicine (2020 - Present)
Microsite Co-editor, Pediatric Emergency Medicine Section, American College of Emergency Physicians (2019 - 2021)
Education Committee Member, Society for Academic Emergency Medicine (2022 - Present)
Board Certification, American Board of Emergency Medicine, Pediatric Emergency Medicine (2021)
Fellowship, Rady Children's Hospital and UC San Diego Health System, Pediatric Emergency Medicine (2019)
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2018)
Residency: UCSD Emergency Medicine Residency (2017) CA
Medical Education: University of Southern California Keck School of Medicine (2013) CA
The OSSE: Development and validation of an "Objective Structured Supervision Evaluation".
AEM education and training
2022; 6 (4): e10784
Trainee supervision and teaching are distinct skills that both require faculty physician competence to ensure patient safety. No standard approach exists to teach physician supervisory competence, resulting in variable trainee oversight and safety threats. The Objective Structured Teaching Evaluation (OSTE) does not adequately incorporate the specific skills required for effective supervision. To address this continuing medical education gap, the authors aimed to develop and identify validity evidence for an "Objective Structured Supervision Evaluation" (OSSE) for attending physicians, conceptually modeled on the historic OSTE.An expert panel used an iterative process to create an OSSE instrument, which was a checklist of key supervision items to be evaluated during a simulated endotracheal intubation scenario. Three trained "standardized residents" scored faculty participants' performance using the instrument. Validity testing modeled a contemporary approach using Kane's framework. Participants underwent simulation-based mastery learning (SBML) with deliberate practice until meeting a minimum passing standard (MPS).The final instrument contained 19 items, including three global rating measures. Testing domains included supervision climate, participant control of patient care, trainee evaluation, instructional skills, case-specific measures, and overall supervisor rating. Reliability of the assessment tool was excellent (ICC range 0.84-0.89). The assessment tool had good internal consistency (Cronbach's α = 0.813). Out of 24 faculty participants, 17 (70.8%) met the MPS on initial assessment. All met the MPS after SBML and average score increased by 19.5% (95% CI of the difference 10.3%-28.8%, p = 0.002).
View details for DOI 10.1002/aet2.10784
View details for PubMedID 35903423
View details for PubMedCentralID PMC9305721
Simulation-Based Mastery Learning Improves the Performance of Donning and Doffing of Personal Protective Equipment by Medical Students.
The western journal of emergency medicine
2022; 23 (3): 318-323
Medical students lack adequate training on how to correctly don and doff personal protective equipment (PPE). Simulation-based mastery learning (SBML) is an effective technique for procedural education. The aim of this study was to determine whether SBML improves proper PPE donning and doffing by medical students.This was a prospective, pre-test/post-test study of 155 medical students on demonstration of correct PPE use before and after a SBML intervention. Subjects completed standard hospital training by viewing a US Centers for Disease Control and Prevention training video on proper PPE use prior to the intervention. They then participated in a SBML training session that included baseline testing, deliberate practice with expert feedback, and post-testing until mastery was achieved. Students were assessed using a previously developed 21-item checklist on donning and doffing PPE with a minimum passing standard (MPS) of 21/21 items. We analyzed differences between pre-test and post-test scores using paired t-tests. Students at preclinical and clinical levels of training were compared with an independent t-test.Two participants (1.3%) met the MPS on pre-test. Of the remaining 153 subjects who participated in the intervention, 151 (98.7%) reached mastery. Comparison of mean scores from pre-test to final post-test significantly improved from an average raw score of 12.55/21 (standard deviation [SD] = 2.86), to 21/21(SD = 0), t(150) = 36.3, P <0.001. There was no difference between pre-test scores of pre-clinical and clinical students.Simulation-based mastery learning improves medical student performance in PPE donning and doffing in a simulated environment. This approach standardizes PPE training for students in advance of clinical experiences.
View details for DOI 10.5811/westjem.2022.2.54748
View details for PubMedID 35679489
Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department.
Pediatric emergency care
OBJECTIVES: A growing number of children receive support from left ventricular assist devices (LVADs) in the outpatient setting. Unexpected complications of LVAD support occur that require emergent management, and no studies examine how pediatric LVAD patients present to the emergency department (ED). The goals of this study were (1) to describe frequency of visits, clinical characteristics, adverse events, and outcomes of LVAD-supported children treated in ED settings and (2) to evaluate for associations between specified patient outcomes and ED care location.METHODS: This was a retrospective cohort study of children in a single-center outpatient VAD program who presented to several EDs during a 10-year period. We defined adverse events according to the Advanced Cardiac Therapies Improving Outcomes Network registry guidelines. Secondary analysis evaluated for associations between specified patient outcomes (adverse events, hospitalizations, intensive care unit admissions) and ED care location (institutional vs other ED).RESULTS: Of 104 subjects with LVAD implantations during the study period, 30 (28.8%) transitioned to outpatient care. Among subjects in the outpatient VAD program, 24 (80%) of 30 had 54 visits to various EDs over 141.9 patient-months. The median age at time of ED visit was 13.5 years (range, 7.2-17.9 years). The median number of visits per subject was 1 (range, 0-6). The most common complaints on arrival to the ED were vomiting or abdominal pain (16.7%), fever (15.3%), and headache (13.9%). Seventeen adverse events occurred during 14 (25.9%) of 54 ED visits. The most common adverse events were major infection (33.3%) and right heart failure (16.7%). Hospital admission resulted from 41 (75.9%) of 54 ED visits, including 17 (41.5%) of 41 to a cardiovascular intensive care unit. Care at a nonspecialty ED was associated with a higher rate of hospitalization (93.8% vs 68.4%, P = 0.049). During the study period, 4 subjects (13.3%) died, including 1 patient on destination therapy, 1 with multisystem organ failure due to cardiogenic shock, and 2 with hemorrhagic stroke. No patient died while in the ED.CONCLUSIONS: Among subjects in a single outpatient pediatric VAD program presenting to the ED, the most common complaints were abdominal pain/vomiting, fever, and headache. The most common adverse events were major infection and right heart failure. Subjects had a high rate of ED utilization and hospital admission.
View details for DOI 10.1097/PEC.0000000000002493
View details for PubMedID 34225326
Mastery learning improves simulated central venous catheter insertion by emergency medicine teaching faculty
Academic Emergency Medicine Education & Training
View details for DOI 10.1002/aet2.10703
- Powering the Heart: Left Ventricular Assist Devices Critical Decisions in Emergency Medicine 2021
Teaching medical students about the impacts of climate change on human health
The Journal of Climate Change and Health
View details for DOI 10.1016/j.joclim.2021.100020
- Be Prepared to Manage Eye Lacerations Avoiding Common Errors in Pediatric Emergency Medicine edited by Woolridge, D. P. Wolters Kluwer. 2020; 1st ed: 92–93
Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.
Pediatric emergency care
Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment.In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97).Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.
View details for DOI 10.1097/PEC.0000000000002171
View details for PubMedID 32576791
A Large Discrepancy between Oral versus Rectal Temperatures as an Early Warning Sign in a Patient with Acute Infrarenal Aortic Occlusion.
The Journal of emergency medicine
Acute aortic occlusion is a rare condition that requires early diagnosis to help prevent considerable morbidity and mortality. Typical clinical findings, such as acute lower extremity pain, acute paralysis, and absent pedal pulses, may be masked by a variety of underlying medical conditions.We present a patient with altered mental status, hypothermia, and a large discrepancy between oral and rectal temperature measurements, who was ultimately diagnosed with aortic occlusion. This case report describes a marked difference between oral and rectal temperatures in a case of acute aortic occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute aortic occlusion is a true vascular emergency that, without early intervention, can lead to limb ischemia, bowel necrosis, paralysis, or death. Emergency physicians should consider acute aortic occlusion in a patient with a marked difference between oral and rectal temperature measurements who otherwise has a limited clinical evaluation.
View details for DOI 10.1016/j.jemermed.2020.01.014
View details for PubMedID 32204995
Emergency department treatment of asthma in children: A review
View details for DOI 10.1002/emp2.12224
- Male Genitourinary Disorders Harwood-Nuss' Clinical Practice of Emergency Medicine Wolters Kluwer. 2020; 7th ed: 1225–1229
- The Tactics and Tools to Manage Pediatric Heart Failure Pediatric Emergency Medicine Reports 2020
Mastery Learning Ensures Correct Personal Protective Equipment Use in Simulated Clinical Encounters of COVID-19.
The western journal of emergency medicine
2020; 21 (5): 1089–94
The correct use of personal protective equipment (PPE) limits transmission of serious communicable diseases to healthcare workers, which is critically important in the era of coronavirus disease 2019 (COVID-19). However, prior studies illustrated that healthcare workers frequently err during application and removal of PPE. The goal of this study was to determine whether a simulation-based, mastery learning intervention with deliberate practice improves correct use of PPE by physicians during a simulated clinical encounter with a COVID-19 patient.This was a pretest-posttest study performed in the emergency department at a large, academic tertiary care hospital between March 31-April 8, 2020. A total of 117 subjects participated, including 56 faculty members and 61 resident physicians. Prior to the intervention, all participants received institution-mandated education on PPE use via an online video and supplemental materials. Participants completed a pretest skills assessment using a 21-item checklist of steps to correctly don and doff PPE. Participants were expected to meet a minimum passing score (MPS) of 100%, determined by an expert panel using the Mastery Angoff and Patient Safety standard-setting techniques. Participants that met the MPS on pretest were exempt from the educational intervention. Testing occurred before and after an in-person demonstration of proper donning and doffing techniques and 20 minutes of deliberate practice. The primary outcome was a change in assessment scores of correct PPE use following our educational intervention. Secondary outcomes included differences in performance scores between faculty members and resident physicians, and differences in performance during donning vs doffing sequences.All participants had a mean pretest score of 73.1% (95% confidence interval [CI], 70.9-75.3%). Faculty member and resident pretest scores were similar (75.1% vs 71.3%, p = 0.082). Mean pretest doffing scores were lower than donning scores across all participants (65.8% vs 82.8%, p<0.001). Participant scores increased 26.9% (95% CI of the difference 24.7-29.1%, p<0.001) following our educational intervention resulting in all participants meeting the MPS of 100%.A mastery learning intervention with deliberate practice ensured the correct use of PPE by physician subjects in a simulated clinical encounter of a COVID-19 patient. Further study of translational outcomes is needed.
View details for DOI 10.5811/westjem.2020.6.48132
View details for PubMedID 32970559
During the Emergency Department Evaluation of a Well-Appearing Neonate with Fever, Should Empiric Acyclovir Be Initiated?
The Journal of emergency medicine
2018; 54 (2): 261-265
Herpes simplex virus (HSV) infection represents significant morbidity and mortality in the neonatal period. Although clear guidelines exist on the evaluation and management of the otherwise well-appearing febrile neonate pertaining to occult serious bacterial infections, there is no standardized approach regarding when to initiate testing and treatment for HSV infection. It is vital we establish a unified guideline based on available clinical research to aid in our decision to evaluate and initiate therapy for this disease.A PubMed search was performed using the keywords "neonate AND fever AND HSV" and "neonate AND fever AND acyclovir." The time period for the search was May 1982 to May 2016. Identified articles underwent further selection based on relevance to the clinical question. Selected articles then underwent detailed review and structured analysis.Our search identified 93 articles, of which 18 were found to be relevant to our clinical question. Recommendations were then made based on thorough review and analysis of the selected articles.Neonatal HSV infection carries significant morbidity and mortality if left untreated. High-quality clinical evidence on when to evaluate and treat for possible HSV infection is lacking. Based on available research, HSV infection in the febrile neonate should be strongly considered if age is < 21 days, or if presenting with concerning clinical features. If testing is performed, empiric treatment with high-dose acyclovir should be initiated. Additional research is needed to further clarify which cases mandate evaluation and treatment for HSV, and to better define treatment protocols.
View details for DOI 10.1016/j.jemermed.2017.10.016
View details for PubMedID 29198381
- Cardiac Implantable Electronic Device Infections Emergency Management of Infectious Diseases edited by Chin, R. L. Cambridge University Press. 2018; 2nd: 14–17
Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation
2017; 121: 76–80
Inpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA.Retrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution.29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups.Patients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.
View details for PubMedID 29032298
- Computed Tomography Imaging and Risk Factors for Clinically Important Diagnoses in Patients Presenting with Flank Pain. The Journal of emergency medicine 2017; 52 (1): 98-100