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Fall Winter 2009


									 Brown University
  Department of
    Emergency                  Department of

                          Emergency M edicine
  Our newsletter is
  published twice a
year to provide news
  about Emergency                   AND SERVICE TO THE PEOPLE OF R HODE I SLAND AND BEYOND .
    Medicine to the
 health system, medi-       VOLUME 3, ISSUE 2                                   FALL/WINTER 2009
cal school, our alumni
      and friends.                              Message from the Chair
                                          U.S. Health-      cial Security. In 1965 it was   changes that we have seen
                                          Care Reform       Medicare and Medicaid.          in our professional lives. The
                                            and the         Now in 2009 and 2010 it is a    big question is: What will it
                                           Future of        major reform of health care     mean for the future of emer-
                                          Emergency         insurance and financing that    gency medicine? I would
 INSIDE THIS                               Medicine         seeks to address the large      offer these predictions:
                                                            number of uninsured Ameri-
    ISSUE:                                   As for the
                                                            cans and the spiraling costs
                                                                                            Emergency Department
                         future, your task is not to see                                    Utilization Will Rise. At least
                                                            of health care. The bills are
                          it, but to enable it. - Antoine                                   for the short term, any legis-
                                                            making their way through
Anderson EC         3         de Saint-Exuphery                                             lation that increases the
                                                            Congress, and the outcome
                                                                                            number of insured people
Brown Faculty       16   Every few decades in the US        is still very much undecided,
                                                                                            and families without increas-
                         social pressures, economic         but it appears that signifi-
Chest Pain Unit      5                                                                      ing access to care will drive
                         concerns, and the political        cant change will occur. After
                                                                                            people to emergency de-
EM Residency        14   winds align to push forward        years of experiencing the
                                                                                            partments for care. We have
                         a major government-driven          vagaries of our health
EMS                 20                                                                      seen this with the 2006 Mas-
                         social change that affects         “system” we in emergency
                                                                                            sachusetts health care re-
Grand Rounds        12   the health and welfare of          medicine will now encoun-
                                                                                            forms, where ED visits in-
                         citizens. In 1935 it was So-       ter the most dramatic
In the Spotlight    16                                                                                  (continued on page 2)
Injury Prevention    6
Mid-levels           9       Completing the Circle for Brown Emergency Medicine –
The Miriam ED        3            The Resident Scholarly Development Fund
New Attendings      13   From it’s origin in 1992 the Emergency            The Department of Emergency Medicine
                &   19   Medicine Residency Program at Brown               and University Emergency Medicine Foun-
                         University and Rhode Island Hospital had          dation have supported the scholarly de-
Pediatric EM         4
                         a strong academic focus. It was founded           velopment of emergency medicine resi-
Publications         9   as a 4 year program at a time when there          dents by funding training opportunities,
Regional/National 11
                         were few 4 year programs. Faculty mem-            travel, and research projects. Residents
                         bers were selected for their strength as          can apply to the Research Committee for
Research             8   educators and researchers. As the pro-            funding up to $10,000 for mentored re-
Simulation Center 18     gram developed Brown emergency medi-              search projects. This seed funding has
                         cine residents became known for their             been the stimulus for academic careers for
Sports Medicine      7   outstanding clinical training. But in addi-       residents. Unfortunately, we do not have
Ultrasound           7   tion they have honed their skills during          enough funds to support every great idea
                         residency as teachers and researchers.            that residents develop.
                         Our graduates have made their mark as
                                                                           In order to further promote and foster the
                         clinical emergency physicians, master
                                                                           academic development of our superb
                         educators, researchers, and in govern-
                                                                           Brown emergency medicine residents I
                         ment and industry.
                                                                                                       (continued on page 10)
             PAGE 2

                                              Chair’s Message                                 (continued from page 1)

creased by 7% in the first year of the program. None of        on reducing health care costs. In the quality realm,
the proposed bills in Congress will have an immediate          emergency medicine has been a leader in developing
effect on improving access to primary care – the solu-         metrics, deriving and implementing clinical decision
tions to the access problem will likely take a decade or       guidelines and evidence-based practices. If we can con-
more. In the meantime EMTALA will still apply, people          tinue this push, we will stand to benefit when quality
who have no other access will come to ED’s, and we             measures are tied to reimbursement.
can expect our ED volumes to be robust for at least
                                                               Academic Medicine Makeover. The pressures of health
several years to come. It is possible that financial disin-
                                                               care reform will hit our academic medical centers hard.
centives for ED visits will eventually be built in to fed-
                                                               Large teaching hospitals that are inefficient, slow to
eral or state legislation, but that does not appear to be
                                                               react, and unable to reduce costs will suffer. As it ap-
likely any time soon. Given that we have a shortage of
                                                               pears likely that resident duty hours will be again re-
emergency physicians, we should endeavor to train as
                                                               duced, teaching hospitals will increasingly rely on mid-
many qualified physicians as possible, as jobs will be
                                                               level providers or other options (like attending physi-
plentiful. However, we should keep an eye on the
                                                               cians!) to provide care. The focus on quality and safety
longer term as pressure to enhance primary care and
                                                               will increase the demand for medical simulation educa-
reduce ED utilization may reduce ED visits.
                                                               tion and training activities for trainees. As medical stu-
The Acute Care Hospital. In some cases, this is already        dent class sizes rise to meet the physician shortage,
happening: ED’s account for the vast majority of admis-        health systems will struggle to find enough clinical
sions to the hospital. Almost all diagnoses of acutely ill     training sites and educators to train students.
and injured patients occur in the ED. Observation
                                                               These predictions may lead you to believe that I am not
Units, Chest Pain Centers and other short stay pro-
                                                               very optimistic about the future of emergency medi-
grams focus on efficient diagnosis and management
                                                               cine. That is not the case. Although I believe we will
and discharge. Hospitalists take care of the acutely ill.
                                                               face short term challenges, the long term picture is
Acute care surgeons handle surgical emergencies and
                                                               much more favorable than we have been used to
short stays. Intensivists run the intensive care units. Pri-
                                                               imagining. Emergency medicine became the default
vate physicians increasingly have non-hospital-based
                                                               solution to many of the problems in US health care. In
practices. What the hospital of the future is likely to
                                                               some ways we were the enablers – allowing a sick sys-
look like is a large ED and Observation area, ICU’s and
                                                               tem (or lack of a system) to remain alive by always ex-
step down units, a few medical/surgical beds, OR’s,
                                                               panding, taking on more patients and responsibilities,
and support services. Everything else will be pushed to
                                                               coming up with creative solutions to poor health care
the outpatient, long-term care, or rehabilitation set-
                                                               delivery. We have also been primary players in the
tings. If reimbursements to hospitals and physicians
                                                               slow but inevitable movement to have meaningful
become bundled or capitated, this will increase the
                                                               change. This is a much different from 30 years ago
pressure for physicians and hospitals to join forces to
                                                               when we were not serious participants in these big
reduce hospital stays and resource utilization. The
                                                               picture discussions. Health care leaders of today under-
Mayo Clinic or Geisinger Health System models will be
                                                               stand the key role that emergency physicians have
the favored approach.
                                                               played as practical, pragmatic problem-solvers. We will
Focus on Costs and Quality. Coverage is the mainstay           continue to be at the table and in our ED’s, carrying
of the current legislation, but once the government            out the message of this African proverb: For tomorrow
realizes that enhancing coverage does not reduce               belongs to the people who prepare for it today.
health care costs, there will be significant pressure to
rein in costs while improving quality. Most if not all
emergency physicians observe and contribute to costly           With best regards,
practices that do not improve health for our patients.
Whether it is eliminating a CT scan that may not really
be needed, reducing unnecessary blood tests, or avoid-
ing futile end of life care, we can have a significant role
in reducing costs. Of course, our most high ticket deci-
sion, as our recent Grand Rounds speaker, Brent Asplin          Brian J. Zink, MD
of the Mayo Clinic noted, is whether or not to admit            Professor & Chair, Physician-in-Chief
the patient. If in the future we have the resources (case       Department of Emergency Medicine
management, social work, alternative care sites) to             Alpert Medical School of Brown University
avoid costly admissions, this will have the most effect         Rhode Island & The Miriam Hospitals

                                                                                                           PAGE 3

                                                                            Frantz Gibbs, MD, Medical Director,
       Anderson Emergency Center                             Rhode Island Hospital, Anderson Emergency Center

              The Andrew F. Anderson Emer-          ticularly the manner in
              gency Center ended the fiscal year    which patients enter our         ...a didactic program
              with a strong patient census. The     system from triage, are             on patient service
              operations of the department con-     underway.                               has been
              tinue to adjust and streamline to                                           implemented
                                                    The recent new addition
              address patient demand. Taking a                                         in the department.
                                                    to the emergency center,
              page from process improvement         designated D-Pod, has
              strategies in other industries, our   enhanced our care of substance abuse and psy-
staff is participating and implementing projects    chiatric patients. Our partnership with the Acute
through our 5S and Flow and Function commit-        Psychiatric Service has promoted this advance in
tees. These committees have enhanced proc-          emergent patient management. This is further
esses like chart flow and access to clinician re-   supported by the innovations in the unit’s de-
sources. Analyses regarding how patients pro-       sign and patient care protocols.
gress through their stay in the department, par-
                                                                                        (continued on page 15)

                                                                            Daniel Savitt, MD, Medical Director,
The Miriam Hospital Emergency Department                           The Miriam Hospital, Emergency Department

           TMHED remained extremely busy            lead ECG review per-
           this quarter. Our new physicians         tinent to prehospital
           have been oriented and integrated        providers,    current
           quite smoothly. The comments from        percutaneous inter-
           staff about our docs have been over-     ventions for acute
           whelmingly positive. Patient satisfac-   coronary syndrome
           tion remains fairly high as well.        and the presenta-
Physician and nursing staff have universally em-    tion/ management of
braced double coverage on overnights, which         patients experiencing
was begun in July. Nights are much more toler-      poisoning from cardiac toxins. Strategies were
able, and occasionally even pleasant now.           also discussed to decrease the door to needle
                                                    time when our prehospital
Fundraising and development efforts for the         colleagues identify a patient
new ED continue. This has included presenta-        experiencing a STEMI. Dr.         Strategies were
tions by TMHED leadership to potential donors       Savitt moderated a question         discussed to
in the community.                                   and answer period, which            decrease the
On October 14th The Miriam hosted a special         was crucial in identifying EMS    door to needle
CME event for the Rhode Island EMS commu-           concerns. The event was very      time when our
nity. The meeting was a combination of a con-       well received. A similar ses-        prehospital
                                                    sion is being planned for next
tinuing medical education event and a discus-                                        colleagues iden-
sion regarding current relations between TMH        year and is being built around
                                                    the evaluations provided from       tify a patient
and the EMS community. UEMF physicians Jo-                                            experiencing a
seph Lauro and Daniel Savitt, Medical Director      the attendees.
of the TMHED, and TMH interventional cardi-         TMHED’s Stroke Center re-
ologists Paul Gordon and Doug Burtt pre-            mains very busy as
sented at the CME event. Topics included 12                                             (continued on page 15)

                                                                            EMERGENCY MEDICINE
  PAGE 4

                                                                                                            Bill Lewander, MD -
        Pediatric Emergency Medicine—HCH                                      Associate Chair of Pediatric Emergency Medicine

               The long anticipated       in the Hasbro Children’s Hospital We are presently in the process of
               H1N1 flu epidemic is       Emergency Department. For the interviewing for an academic at-
               upon us,         Many      first time ever our                       tending and two new
               thanks to Dr. Susan        annual patient cen-                       fellowship positions.
               Duffy, our clinical        sus      exceeded
                                                                                    PEM faculty members
               director, and our          53,000 visits while
                                                                                    have authored or co-
               staff for helping us       the number of pa-
                                                                                    authored a number of
   plan for and meet the present          tients who left with-
                                                                                    publications over the
   challenge of caring for the record     out being seen re-
   number of patients we are seeing       mained below 3%.                                (continued on page 20)

                                                                                                    Sue Duffy, MD - Medical Director,
    Hasbro Children’s Hospital Emergency Department                                                   Hasbro Children’s Hospital ED

                     An outbreak of       with flu like symptoms. For ap-            practitioners, fellows,
                     Flu     surprised    proximately 4 weeks the Hasbro             nursing staff and sec-
                     Rhode Island in      ED averaged 100+ excess patients           retaries worked exces-
                     the spring of ’09    per day and on multiple occasions          sive hours to assure
                     and the pediatric    doubled its typical daily census.          that the PED func-
                     emergency de-        The PED staff rose to the occasion         tioned at full capacity.
                     partment experi-     and effectively cared for many             With the help of col-
  enced uncharacteristically high         children with varying severity of          leagues and resources from the
  volumes of young patients with          flu like symptoms and reassured            “adult” emergency department,
  flu like illnesses lasting into early   their often-anxious families. The          the division of ambulatory pediat-
  summer. As the news emerged                          Hasbro ED managed             rics that loaned space and rear-
  about the spread of H1N1 Influ-                      this excess volume            ranged their practice to help care
  enza throughout the world, plan-                     while continuing to           for flu patients, and multiple hospi-
  ning began for its expected re-                      function as the terti-        tal departments, the PED demon-
  turn. By late October it became                      ary care pediatric            strated its ability to handle a po-
  apparent that the preparations                       emergency depart-             tential pandemic surge of patients.
  were worthwhile as the PED,                          ment and trauma
  along with pediatrician offices                      center for the re-            In addition to managing flu, the
  across the region experienced           gion. Many of the pediatric emer-          Hasbro ED continued to strive to
  unprecedented surges of patients        gency medicine faculty, nurse              provide
                                                                                                            (continued on page (20)

    UEMF Sponsored Pediatric Golf Tournament
  University Emergency Medicine Foundation was the plati-
  num sponsor for the 3rd Annual Rhode Island Chapter of
  the American Academy of Pediatrics Golf Tournament
  that was held on Monday, September 28, 2009 at the
  Swansea Country Club. There were 80 golfers who partici-
  pated. The tournament raised over $20,000 for The To-
  morrow Fund Cancer Center; The Palliative Care Program;
  and The Adolescent Leadership Council (TALC). Awards
  were given for the Straightest Drive to Greg Lockhart and
  for the Longest Drive to his son Brad Lockhart. EM resi-
  dents Lindsay MacConaghy and Matt Siket were on the              Sponsored in part by University Emergency Medicine Foundation

  team that finished in 3rd place in the tournament.
  Next year’s tournament will be held on Monday, August 9,
  2010 at the Exeter Country Club.
     Thanks to all those who participated this year!

D E P A R T M E N T       O F
                                                                                                     PAGE 5

                   Rhode Island Hospital—Chest Pain Center
                                                        patient in-     our processes to look at qual-
                                                        formation,      ity of care measures in ED tri-
                                  We are expanding patient out-         age and management of this
                                   our processes to
                                   look at quality of   comes, care     patient population.
                                   care measures in     provider        We are pleased to announce
                                       ED triage &      v a r i a -     that Allison Jackson, PA-C has
                                    management of       tions,  and     been named Coordinator of
                                       this patient     offer feed-     the Rhode Island
                                      population.       back    and     Hospital     Chest
Over the last several months                            education to    Pain Center. She
we have been working to                                 both patient    will work to en-
improve a number of acute            and provider. Besides the re-      hance the quality
cardiac care services for our        cent expansion of admission        of care processes
patient population. We have          criteria, we now have the oc-      of our chest pain
now implemented the chest            casional capacity to offer an      patients in-
pain unit registry/treatment         accelerated risk stratification    stitutionally Anthony Napoli, MD
                                                                                           Medical Director
database. This database will         protocol in low risk pa-           and within
allow us to accurately track         tients . We are also expanding     the chest pain unit.

      More Department of                                  Gary Bubly—RIMS President
    EM Faculty Offices at Coro
                                                              Please join us in congratulating Dr. Gary
With the growing emergency medicine fac-                      Bubly as the president elect of the
ulty at Rhode Island and The Miriam Hospi-                    Rhode Island Medical Society.
tals and Brown University, we have an addi-                    Dr. Bubly is the Assistant Medical Direc-
tional satellite administrative office now in                  tor of The Miriam Hospital’s Emergency
the Coro Building on the first floor. The                      Department. Dr. Bubly has been an ac-
new location includes administrative offices                   tive member of University Emergency
for emergency medical services including          Medicine Foundation serving on the board of direc-
Drs. Ken Williams, Francis Sullivan, and Joe      tors for several terms as well as being the Treasurer
Lauro; disaster medicine with Dr. Selim Su-       and Chair of the Finance and Negotiation Commit-
ner; neuroscientists Adam Chodobski and           tees.
Joanna Chodobska ; Dr. Jay Baruch, medi-
cal ethics; and Dr. Thom Meredith, palliative     Dr Bubly received UEMF’s inaugural Exemplary Ser-
care.                                             vice Award to recognize his outstanding service
                                                  leadership, and citizenship.

                 DEM Blood Drive                                Merchant Keynote Speaker
                                                              Lifespan Research Celebration
Special thanks to those who rolled up
their sleeves for the Department of Emer-                                 Dr. Roland Clay Merchant
gency Medicine Blood Drive held on                                        gave the keynote address at
September 1, 2009. The blood drive was                                    this year’s 17th Annual Life-
very successful. We donated 34 units of                                   span Research Celebration.
blood to the Rhode Island Blood Center                                    Dr. Merchant was last year’s
which can help save 102 lives. Our next                                   Bruce Selya Award winner.
blood drive is Tuesday, January 5. 2010.                                  His lecture was entitled, “HIV
January is Blood Donor Appreciation Month.                                Screening and Diagnostic
Everyone who donates blood will get a free                    Testing in US Emergency Departments:
1 pound bag of Dunkin Donuts coffee.                          What Have We Learned So Far?”

                                                                           EMERGENCY MEDICINE
  PAGE 6

                                                                                                   Michael J. Mello, MD
                    Injury Prevention Center                                 Medical Director, Injury Prevention Center

                 The Injury Prevention Center at Rhode       recreational centers, PTA groups, DCYF agencies,
                 Island Hospital (IPC) has been keeping      and local universities.
                 busy this summer and throughout the         Through the help of Safe Kids Worldwide, we have
                 fall season with 1) large-scale car seat    also been addressing child pedestrian safety. We
                 check events, where parents and care-       were awarded two $500 grants towards pedes-
                 givers receive education and hands-on       trian safety for two programs this October. We
                 assistance with the proper use of child     held an event on International Walk to School Day
                 restraint systems and safety belts; 2)      event in Middletown, RI and another at Roger Wil-
   certification trainings, where local law officers, par-
   ents, and other local organizations become certi-
   fied child passenger safety technicians; and 3) par-
   ent/caregiver workshops, where the IPC staff teach
   parents and caregivers about injury prevention
   There have been more than 15 car seat check
   events throughout the region, including Provi-
   dence, Warwick, Central Falls, East Providence,
   Johnston, Newport, South Kingstown, Smithfield,
   and Fall River, MA. There were large numbers of
   participants at several of the events including our
   biggest event on September 12, 2009 at the Kohl’s
   department store located in Warwick. The IPC has          liams Zoo on keeping your children safe on Hallow-
   recently gained new corporate partners, including         een.
   Texas Roadhouse, Lowe’s, and Burlington Coat Fac-                      IPC Awarded CDC Grant
   tory. Our efforts have helped more than 876 fami-
   lies! Thanks to the Kohl’s Cares for Kids Car Seat        The Injury Prevention Center at Rhode Island Hos-
   Check Program, we were able to supply brand new           pital has been awarded a grant from the Centers
   car seats to qualifying families. Kohl’s Cares foun-      for Disease Control and Prevention for a three-year
   dation support also provided for the IPC to engage        translational research project studying alcohol
                     multiple media activities during        screening and brief intervention services for injured
                     National Child Passenger Safety         adolescent patients. Michael Mello, MD, MPH will
                     week in September. Highway bill-        be the Principal Investigator and Julie Bromberg,
                     boards, bus placards, newspaper         MPH, CCRA project manager are joined by Co-
                     ads, and radio messages were util-      Investigators Ted Nirenberg, PhD, Janette Baird,
                     ized to draw attention to child         PhD, Jim Linakis, MD, PhD, Tom Chun, MD, and
                     passenger safety and Rhode Is-          Christina Lee, PhD. They will examine the adoption,
                     land’s new booster seat law.            implementation and maintenance of alcohol
                                                             screening and brief intervention and referral to
                      The IPC also recently hosted a         treatment (SBIRT) services for injured adolescent
   child passenger safety certification course. This 32-     patients at seven pediatric level 1 trauma centers.
   hour National Child Passenger Safety Certification        SBIRT is a comprehensive effective approach to pro-
   Training Program certifies individuals as child pas-      viding early intervention and treatment to those
   senger safety technicians and instructors. This fall      with risky alcohol use through universal alcohol
   we have also held a CPS Renewal Course, which is          screening. However, limited research has been
   an 8-hour course where technicians can renew              conducted on the dissemination of SBIRT and this is
   their certification. There are approximately 100          especially true within pediatric trauma centers. The
   certified technicians and instructors in the state of     project will involve workshops at the 2009 and
   Rhode Island that put their knowledge to work             2010 Injury Free Coalition for Kids annual meet-
   through a variety of activities, including child safety   ings, creating and utilizing a website of resources,
   seat checks, and this course keeps them updated.          as well as participating in monthly conference calls.
   We have held many child passenger safety informa-         One of the final project outcomes will be a manual
   tional trainings throughout Rhode Island during           of best practices for implementing SBIRT within the
   this summer and fall including at daycare centers,        care of the injured adolescent.

D E P A R T M E N T       O F
                                                                                                                      PAGE 7

                                                       Ultrasound                               Otto Liebmann, MD
                                                                                      Emergency Medicine Ultrasound

                            The Division of Emergency Ultra-
                            sound is growing. Dr. Sachita
                            Shah joins us in November after
                            completing her Emergency Ultra-
                            sound (EUS) fellowship at High-
                            land Hospital in Oakland, Califor-
                 nia. Dr. Shah visited Rwanda and imple-
                 mented a sustainable international EUS cur-
                 riculum. Drs, Liebmann and Shah will be start-
                 ing the Brown EUS Fellowship in July .
                 EUS research is also growing within the divi-
                 sion and there are now two ongoing random-
                 ized trials along with several smaller research
                 studies. Several of these studies involve col-
                 laborative efforts with outside departments
                 such as neurology.
 The division has formed strong bonds with
 other departments and hospitals. Residents,
 ICU, fellows, and Hasbro pediatric EM fellows
 continue to rotate through the monthly EUS
 elective at Rhode Island Hospital. We have
Gr and Ro unds

 offered emergency and critical care ultrasound
 courses at
This past year Rhode Island Hospital, The Miriam
 Hospital, Women & Infants Hospital, and New-
 port Hospital training nurses, mid-level practic-                 our patients. From ultrasound-guided foreign
 tioners as well as physicians.                                    body removal to reduced pain through re-
                 Most importantly, the development of the EUS      gional anesthesia to life-saving procedures in
                 Division has directly lead to improved care for   sick and dying patients the growth of emer-
                                                                   gency ultrasound is making a difference.

                                                      Sports Medicine
                         The Sports Medicine Pro-                  to help with reducing patient costs
                         gram has been very busy                   for testing.
                         in the second half of                     Our community efforts have also
                         2009 as we contribute to                  been very active. Dr. Feden and Dr.
                         our mission to reduce                     Raukar have been staffing football
                         injury in Rhode Island                    games and have been providing
through education, and community programs.                         training room clinics once or Neha Raukar, MD
Our goal to have all students involved in contact                  twice a week.
sports have baseline neuro-psychologic testing is
gaining momentum. Dr. Jacobs and Dr. Raukar                        Sports Medicine is gearing up to
spoke with BlueCross RI to help explain what con-                  submit the fellowship application
cussions are and how they are diagnosed for their                  to the GME committee. The devel-
patient newsletter. Dr. Raukar also did a news                     opment of this ACGME accredited
conference on concussion for Channel 12 that                       fellowship in Primary Care Sports
aired in November. Meetings have been set up                       Medicine is our next mission.
with the major insurance carriers in Rhode Island

                                                                                E M E R G E N C Y         M E D I C I N E

                                      Emergency Medicine Research
   Michael Mello, MD, MPH was awarded a 3-year $599,994 R01 grant from the Centers for Disease Control
   for his project entitled “Translation of Alcohol Screening and Brief Intervention Guidelines to Pediatric
   Trauma Centers.” Dr. Mello’s study aims to increase the use of SBIRT among injured adolescents treated
   at pediatric level 1 trauma centers.
   Dr. Mello was also awarded a $3,290 subcontract on a 1-year ARRA administrative supplement from
   Brown University for a project entitled “Enhanced MI with Alcohol Positive Trauma Patients.”
   Roland C. Merchant, MD, MPH, ScD and Ted Nirenberg, PhD were awarded a 1-year ARRA administrative
   supplement from NIH for their project entitled “Brief Intervention for Drug Misuse in the Emergency De-
   partment.” This supplement will provide unique research opportunities and summer employment to four
   Brown University students and one faculty member from Rhode Island College.
                  UEMF has funded three Junior Faculty Research Development Grants in FY10:
   Aris Garro, MD, MPH was awarded $31,478 for his project entitled “Diagnosing Asthma in Young Chil-
   dren with Wheezing: Parents’ Perception of Barriers.” Dr. Garro will identify and explore the variables that
   are associated with delays in the diagnosis of asthma in order to develop a theoretical model to explain
   the diagnostic process and begin to determine ways to improve the recognition of asthma in young chil-
   Leo Kobayashi, MD was awarded $20,000 for his project entitled “Simulation Learning Initiative in Proce-
   dural Sedation Training for Routine Engagement of Anticipatory Maneuvers.” Dr. Kobayashi will use so-
   phisticated medical simulation to study Emergency Department procedural sedation and its operators in
   order to better understand and improve sedation training and practice, and enhancing staff prepared-
   ness and vigilance for significant complications.
   Alyson McGregor, MD, MA was awarded $25,000 for her project entitled “Gender Disparities on Time-to-
   ECG: Does Sex Matter?” Dr. McGregor will develop a mathematical model to explain delays in time-to-
     Chest Pain the results to create a focused
   ECG and will useUnit Medical Director educational intervention aimed at changing Emergency
   Medicine health care workers behavior to decrease the TECG for patients.

                    Lifespan Research Celebration 2009—Poster Presentations
        In Situ intermediate-fidelity medical simulation for comparison of in-hospital first responder sudden cardiac arrest re-
              suscitation with semi-automated defibrillators and with automated external defibrilators . Dunbar-Viverios JA,
              Kobayashi L, Sheahan BB, Rezendes MH, Devine J, Cooper MR, Martin PB, Jay GD
            Emergency department prescriptions for long-term inhaled corticosteroids for children with asthma: Are we fol-
           lowing recommendations? Garro A, Asnis L, Merchant RC, McQuaid E
           Intra-articular injection (tribosupplementation) with native and recombinant lubricin (PRG4) prevents cartilage de-
             generation in the rat ACL injury model Jay GD, et al
             Teaching neonatal resuscitation to emergency medicine residents: Does a simulation-enhanced intervention
    improve knowledge and skills? Lee M, Brown L, Overly F
    Assessment of severe dehydration in children with diarrhea using ultrasound and clinical exam. Levine AC, Shah S, et al
    Can computer-based feedback improve emergency department patient uptake of HIV screening? Merchant RC, et al
    Predictors of being unsafe to answer intimate partner violence screening questions: Findings from the behavioral risk fac-
    tor surveillance system 2006. Ranney M, Gjelsvik A
    Do clinicians prefer the 2006 or 2001 CDC HIV testing recommendations? Waxman MJ, Merchant RC, et al
    Young children with wheezing are a prime target for public health interventions in the pediatric emergency department
    Yoon J, Garro AC
    Medical Education/Medical Simulation
    Medical simulation scenario visualization with a graphic diagram representation system Kobayashi L, Overly FL, Jay GJ

D E P A R T M E N T          O F
                                                                                                                                                                 PAGE 9

          Department of Emergency Medicine - Faculty Publications June 2009—present
Mello MJ, Baird J, Nirenberg T, Smith J, Woolard R, Dinwoodie R: Project Integrate: Translating Screening and Brief Interventions for Alcohol Problems to a Community
Hospital Emergency Department. Substance Abuse 2009, 30:223-229
Stein L, Minugh A, Longabaugh D, Wirtz P, Baird J, Woolard R, Lee C, Mello MJ, Nirenberg T, Becker B, Carty K, Goginen A: Readiness to change as a mediator of the
effect of a brief Motivational Intervention on post-treatment alcohol related consequences of injured Emergency Department hazardous drinkers. Psychology of Addictive
Behaviors. 2009, 23:2, 185-195
Woolard R, Degutis L, Mello M, Rothman R, Cherpitel C, Post L, Hirshon JM, Haukoos J: Public Health in the ED: Surveillance, Screening, and Intervention Funding and
Sustainability. Academic Emergency Medicine. 2009,16:1138-1142
Merchant RC, Nettleton JE, Mayer KH, Becker BM: Blood or body fluid exposures and HIV PEP utilization among first responders. Prehospital Emergency Care. 2009;13:6-13
Merchant RC, Lau TC, Liu T, Mayer KH, Becker BM: Adult sexual assault evaluations at Rhode Island emergency departments, 1995-2001. Journal of Urban Health. 2009; 86
(1): 43-53
Lyons MS, Lindsell CJ, Haukoos JS, Brown J, Calderon Y, Couture E, Merchant RC, White DAE, Rothman RE on behalf of the National Emergency Department HIV Testing
Consortium: Nomenclature and definitions for emergency department human immunodeficiency virus (HIV) testing: report from the 2007 conference of the National
Emergency Department HIV Testing Consortium. Academic Emergency Medicine. 2009; 16(2):168-77
Merchant RC, Clark MA, Mayer KH, Seage III GR, DeGruttola VG, Becker BM: Video as an effective method of delivering pretest information for rapid human immunodefi-
ciency virus testing. Academic Emergency Medicine. 2009;16:124-35
Milzman D, Napoli AM, Hogan C: Emergency Department Use of Thoracic Impedance Compared to Chest Radiograph to Diagnose Acute Pulmonary Edema. American
Journal of Emergency Medicine 2009; 27(7): 770-775
Overly F, Sudikoff S, Duffy S, Anderson A, Kobayashi L: “Three scenarios to teach difficult discussions in pediatric emergency medicine- 1) sudden infant death, 2) child
abuse with domestic violence, and 3) medication error.” Sim Healthcare 2009; 4(2):114-130
Ranney M, Odero W, Mello M, Waxman M, Fife R: Injuries from interpersonal violence presenting to a rural health center in Western Kenya: Characteristics and Correlates.
Inj. Prev. 2009; 15;36-40
Tubbs R, Partridge R, Rotter T, Valente JH: Outcomes in patients with Congestive Heart Failure treated with Bi-Level Positive Airway Pressure: Safer than previously
thought? Turkish Journal of Emergency Medicine 2009; 9(2):53-58
Carpenter CR, Valente JH, Breyer M: 2009 SAEM Review: 20 Potentially Practice-Changing Abstracts. Emergency Physicians Monthly 2009; 16(7):1, 14-15
Lee M, Mello MJ: The Costs of Evaluating Minimally Injured Alcohol Impaired Drivers in the Emergency Department. Annals of Emergency Medicine July 2009; 54:593-599
Salz T, Wilson S, Liebmann O, Price D: An initial description of a sonographic sign that verifies intrathoracic chest tube placement. American Journal of Emergency Medi-
cine. on line July 2009 DOI: 10.1016/j.ajem.2009.04.010.
Linakis JG, Chun TH, Mello MJ, Baird J: Alcohol related visits to the emergency department by injured adolescents: A national perspective. Journal of Adolescent Health,
2009; Jul;45(1):84-90.
Weiss-Laxer N, Mello MJ, Nolan P: Evaluating the educational component of a hospital-based child passenger safety program. Journal of Trauma July 2009; 67(1): S30-3
Merchant RC, Catanzaro BM, Seage III GR, Mayer KH, Clark MA, DeGruttola VG, Becker BM: Demographic variations in HIV testing history among emergency department
patients: implications for HIV screening in US emergency departments. J Medical Screening July 2009, 16 (2):60-66
Merchant RC, DePalo DM, Stein MD, Rich JD: Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible Chlamydia
and/or gonorrhea urethritis. Int J STD and AIDS, July 2009; 20:534-539
Goldlust E, Walton E, Stanley R Yard E, Garst B, Comstock D, Ebner Erceg L, Cunningham R: Injury Patterns at U.S. and Canadian Overnight Summer Camps: First Year of
the Healthy Camp Study. Injury Prevention, Aug 2009
Drewniak E., Jay G., Fleming B., Crisco J: Comparison of two methods for calculating the frictional properties of articular cartilage using a simple pendulum and intact
mouse knee joints. J Biomech 2009:Aug25;(42)12:1996 – 1999.
Nirenberg TD, Baird J, Harrington M, Mello MJ, et al: A cross-sectional study of the self-report of stress among emergency department patients. Journal of Emergencies,
Trauma, and Shock. Aug 2009; 2:155-8
Elsaid KA, Machan JT, Waller K, Fleming BC, Jay GD: The impact of anterior cruciate ligament injury on lubricin metabolism and the effect of inhibiting TNF-a on chondro-
protection in an animal model, Arthritis Rheum, Sep 2009;60(10) 2997-3006.
Taguchi, M., Zhao C, Sun YL, Jay GD, An KN, Amadio PC: The Effect of Surface Treatment Using Hyaluronic Acid and Lubricin on the Gliding Resistance of Human Extra-
synovial Tendons In Vitro. J Hand Surg AM 2009 Sept;34(7):1276-81.
Merchant RC, Catanzaro BM: HIV testing in US EDs, 1993-2004. American Journal of Emergency Medicine, September 2009; 27:868-874
Sudikoff S, Overly F, Shapiro M: "High-fidelity medical simulation as a technique to improve pediatric residents' emergency airway management and teamwork: a pilot
study." Pediatr Emerg Care, October 2009
Garro AC, Fearon F, Koinis-Mitchell D, McQuaid EL: Does Pre-Hospital Telephone Communication with a Clinician Result in More Appropriate Medication Administration by
Parents during Childhood Asthma Exacerbations? Journal of Asthma, 1532-4303, Volume 46, Issue 9, Nov 2009, Pages 916 – 920.
Chang D, Abu-Lail N, Coles J, Guilak F, Jay G, Zauscher S: Friction force microscopy of Lubricin and hyaluronic acid between hydrophobic and hydrophilic surfaces. Soft
Matter Nov 2009, 5: 3438 – 3445.
Vaca F, Mello MJ, Hargarten S. Historical Parallel Evolution of Injury Prevention and Control Science and Emergency Medicine. Academic Emergency Medicine. Nov 2009,
Merchant RC, Clark MA, Langan TJ, Seage III GR, Mayer KH, and DeGruttola VG: Effectiveness of increasing emergency department patients’ self-perceived risk for being
HIV infected through audio-computer self-interview (ACASI)-based feedback about reported HIV risk behaviors. Academic Emergency Medicine, November 2009
                                                                                 Book Chapters:
Becker BM, Cahill J, Gibler B: Parasites. in Rosen’s Emergency Medicine 7th Edition. Eds: John Marx, MD, Robert Hockberger, MD and Ron Walls, MD. 2010. Elsevier
Zink BJ, Raukar N: Bone and Joint Infections, in Rosen’s Emergency Medicine 7th Edition. Eds: John Marx, MD, Robert Hockberger, MD and Ron Walls, MD. 2010. Elsevier

                                 Midlevel Providers
  The UEMF Midlevel group welcomes 6 new members to
  reach a current staffing of 23 Emergency Medicine Midlevels.
  We welcome:Mary Kate Donleavy, PA-C; Lamia Laloui, PA-C;
  Rebecca Hassel, PA-C; Marcie Pasanen, PA-C; Christopher
  Ferreira, PA-C; Fiona Craft, FNP; and Sharon Cotter, FNP.
  The whole Midlevel group enjoyed its first annual MLP Re-
  treat Day. The group worked on team building skills and
  drills while Rock Climbing at a local Rock Climbing Gym.

                                                                                                             E M E R G E N C Y                     M E D I C I N E

                  The Resident Scholarly Development Fund                             (continued from page 1)

   am happy to announce the creation of the             deal of time and effort in making the Brown
   Brown Department of Emergency Medicine               Emergency Medicine residency one of the pre-
   Resident Scholarly Development Fund. This            mier EM residencies in the nation. Now you
   fund will provide scholarships for Brown emer-       have the chance to make a financial investment
   gency medicine residents to carry out projects       to advance the scholarly development of our
   or training in the research or education realms.     exceptional residents. In order to jump start the
   For example, the scholarships could be used to       Fund, the Department of Emergency Medicine
   support a clinical research project in the ED, or    and UEMF will contribute $5,000. Our goal will
   the development of a new training module in          be to get to $10,000 by the start of the 2010
   medical simulation, or an advanced training ex-      academic year in July.
   perience in medical ethics.
                                                        Your contribution is tax deductible. Please con-
   We are now asking Brown EM faculty members           sider sending a check as follows:
   and alumni to help build the Resident Scholarly
                                                        UEMF – Resident Scholarly Development Fund
   Development Fund through donations of what-
                                                        Department of Emergency Medicine
   ever amount is practical and comfortable. The
                                                        593 Eddy Street, Claverick 2
   strength of any fund raising effort is not just in
                                                        Providence, RI 02903
   the amount of contributions, but also in the
                                                        Attention: Michelle Costa
   level of participation of those who care about
   the cause. Many of you have invested a great
                                                        Thank You for Your Support!

                                                                                 UEMF Annual
     Chest Pain Unit Medical Director                                       The annual review of UEMF
                                                                            business and financials for
                                                                            2009 will be held on Decem-
          The Department of Emergency Medicine                              ber 11, 2009 from 11am-
                                                                            1pm in the Claverick first
             University Emergency Medicine Founda-                          floor conference room. All
                                                                            UEMF members are wel-
                                    tion                                    come. Election results for
                                                                            the board of directors will be
                               Holiday Party                                announced.
                      Friday, December 18, 2009
              Cocktails: 6:30-7:30pm Dinner: 7:30pm                           5th Anniversary for
                                                                               Coding & Billing
                        Alpine Country Club
                                                                             The UEMF Coding & Billing
              251 Pippin Orchard Road, Cranston, RI                          Department celebrated their
                                        5th anniversary for in-house
                                                                             coding and billing opera-
                      Featuring an elegant dinner buffet                     tions. There was a continen-
                                                                             tal breakfast held on Thurs-
                                & entertainment                              day, November 19th at their
                                                                             125 Whipple Street office.
                          Semi-formal attire                                 Congratulations and special
                                                                             thanks for all their hard
          Charity Event for Crossroads Women’s Shelter                       work!

D E P A R T M E N T      O F
                                                                                               PAGE 11

                   Brown Department of EM—National Scene
                                                                                   Matt Kopp, MD
                                                                                   was appointed
                                                                                   to the national
                                                                                   ACEP Reim-
       ACEP Research Forum Posters                                                 Committee.
               Assessing Inter-Rater Reliability & Agreement
               Between Two Methods of Non-invasive
               Hemodynamic Monitoring in Clinically Stable
               ED Patients—Drs. Napoli, Forcada-Lowrie,
               Corl, & Machan                                     The Alpert Medical School of
               Value of Non-invasive Measurement of Con-          Brown University’s Department
               tractibility to Predict Morality in ED Patients    of Emergency Medicine hosted
               Undergoing Early Goal-Directed Therapy for         a reception for faculty, residents,
               Severe Sepsis—Drs. Napoli, Corl, Forcada-
                                                                  and Alumni on October 6, 2009
               Lowrie, and Gardiner
                                                                  in the Hyannis Room at the Mar-
 ED Prescriptions for Long-Term Inhaled Corticosteriods for       riott Copley Place. Over 50 peo-
 Children with Asthma: Are We Following Recommenda-               ple were in attendance. Thanks
 tions? - Drs. Garro, Asnis, Merchant, & McQuaid
                                                                  to all those who participated.

                                                                                   E l i z a b e t h
                                                                                   Sutton, MD was
                                                                                   awarded a Cer-
                                                                                   tificate of Appre-
                                                                                   ciation by the
      Chairs &                                                                     Emergency
Department Challenge                                                               Medicine Resi-
                                                                                   dent      Associa-
Please consider a donation to the
                                                                                   tion. She was
SAEM Research Foundation!                                                          nominated      by
                                                                                   the       Brown
                                      The next New England
                                                                   Emergency Medicine Interest
                                      Regional SAEM Meeting        Group (EMIG) for her significant
                                      will April 14, 2010. Ab-     impact on education of medical
                                      stracts are due: December    students in EM.
                                      2, 2009.
                                                                   Janette Baird, PhD presented at
                                     The next SAEM Annual          the Research Society of Alcoholism
                                     Meeting is June 3-6, 2010.    conference in June, as part of a
                                     Abstracts are due: Decem-     symposium on Brief Interventions
                                     ber 2, 2009.                  for Alcohol Misuse in Trauma Cen-
                                                                   ters & Emergency Departments.
                              Dr Joshua Jauregui, a PGY1 EM        Daniel Tsze, MD was awarded Best
                              resident, works at the Medical       Research Abstract for his INK ab-
                              Simulation Center during confer-     stract at the Society for Pediatric
                              ence.                                Sedation Conference.

                                                                  E M E R G E N C Y     M E D I C I N E

                                Grand Rounds 2009-2010
   September 23, 2009                                                           Upcoming Dates
   Timothy Flanigan, MD                                                           2009-2010
   “HIV and Other Infectious Dis-
   eases in Jails and Prisons:                                                  December 16, 2009
   Scaling the Walls with the Help             DEPARTMENT OF                   “History of EM—Part III”
   of Academic Medicine”                   Emergency Medicine                     Brian J. Zink, MD
   Brown University                                                               Brown University

                                                                                 January 20, 2010
                                                                               Alcohol Withdrawal &
                            October 21, 2009                                   Observation Medicine
                   The Future of Emergency Medicine                           Sandra Schneider, MD
        Dr. Brian Zink with a panel discussion by Drs Brian Clyne,            University of Rochester
             Gregory Jay, James Linakis, and Lisa Schweigler.
                            Brown University                                    January 27, 2010
                                                                                   Trauma Care
                                                                                Henry Wang, MD
                                                                               University of Alabama

                                                                                 February 3, 2009
                                                                               Pulmonary Embolism
                                                                                Mara McErlean, MD
                                                                              Albany Medical College
           November 4, 2009
          “Tobacco SBIRT in the                                                   March 17, 2010
        Emergency Department”                                                         Disaster
        Steven L. Bernstein, MD                                            Pediatric Emergency Medicine
                                                                              Thomas Terndrup, MD
        Yale University School of
                                                                               Penn State—Hershey
                                                                                College of Medicine

                                                                                  March 24, 2010
           Recent Faculty Development Sessions                             Cardiac Resuscitation Research
                                                                               Tom Aufderheide, MD
 Dr. Michele Cyr, the Associate Dean for Academic Affairs presented        Medical College of Wisconsin
 Brown Faculty Appointments, Reappointments, & Promotions in Octo-
 ber 2009. This session featured a question and answer segment.                  April 28, 2010
                                                                              Women’s Health Issues
 In September 2009, Dr. Richard Besdine, Director of the Brown Univer-
                                                                                Joanna Cain, MD
 sity Center for Gerontology and Health Care Research, gave a presen-
                                                                                Brown University
 tation on the educational and research activities in his Center and the
 opportunities available for collaborative work with his faculty and re-
                                                                                  May 26, 2010
                                                                                   Public Health
                                                                                Adrian Tyndall, MD
                          Join Us for                                           University of Florida
                Faculty Development Sessions!                                     June 16, 2010
  The next faculty development session is Tuesday, December 1st from            Diagnostic Health
  10:30am to 1:30. Dr. David Cone will be presenting a workshop                Andrew Perron, MD
  called “Publish & Flourish—How to Get from Idea to Manuscript”. The         Maine Medical Center—
  workshop will discuss publishing scholarly work. Dr. David Cone is              Tuft University
  the editor of Academic Emergency Medicine.

D E P A R T M E N T      O F
                                                                                                  PAGE 13

          Welcome New Emergency Medicine Attendings!
Esther Choo, MD
Dr Choo graduated in 2001 from the Yale University School of Medicine. She com-
pleted her EM Residency at the Boston Medical Center in 2005. Dr. Choo completed a
2-year research fellowship at the Center for Policy and Research at the Oregon Health
& Science University in 2009. Her research interests include child abuse, intimate part-
ner violence and medical education.

Sarah Gaines, MD
Dr. Gaines received her MD from Georgetown University School of Medicine in 2003.
 She is a graduate of the University of Pittsburgh EM Residency and was Chief Resident
in 2006. Most recently, she completed a Fellowship in EM Education at Oregon Health
& Science University. Her primary focus will be in medical education and medical hu-
Joseph Lauro, MD
Dr. Lauro received his MD in 2006 from St. George’s University School of Medicine. He
completed his EM Residency at SUNY Upstate University in 2009. Dr. Lauro is a former
New York City paramedic and is focusing on EMS education. Dr. Lauro is working pri-
marily at The Miriam Hospital ED.

Adam Levine, MD
Dr. Levine completed his MD and Masters of Public Health in 2004 at the University of
California at San Francisco. He is a graduate of the Harvard University School of Medi-
cine EM Residency in 2009. Dr. Levine is interested in clinical research and interna-
tional emergency medicine/ global health.

  Ahteri Forcada-Lowrie, MD
  Dr. Forcada-Lowrie received his MD in 2005 from Uni-
  versity of Wisconsin School of Medicine & Public
  Health. He graduated from the Brown University
  Emergency Medicine Residency Program in 2009. His
  academic interests are in cardiovascular disease &
  monitoring. Dr. Forcada-Lowrie is working primarily
  at The Miriam Hospital ED.

  Laura McPeake, MD
                                                                        Dr Anand Shah working a shift at
  Dr. McPeake received her MD at State University of                    TMHED.
  New York at Downstate in 2003. She is a 2007 gradu-
  ate of the Alpert Medical School of Brown University’s
  EM Residency Program. Most recently, Dr. McPeake
  practiced EM at Provena Covenant Medical Center in
  Illinois. Dr. McPeake is working primarily at The
  Miriam Hospital ED.

  Thom Meredith, MD
  Dr. Meredith received his MD from the University of
  Massachusetts Medical School in 2005. He completed
  the Yale University School of Medicine EM Residency                   Drs Neha Raukar & Laura are hap-
  in 2009. He has an interest in end-of-life and pallia-                pily working a shift at TMHED.
  tive care, as it applies to emergency medicine.
                                                           More new EM attendings page 19

                                                                  E M E R G E N C Y        M E D I C I N E
         PAGE 14

                         EMERGENCY MEDICINE RESIDENCY
                    The continuous life      recently selected as reviewers for       tain compliance with ACGME re-
                    cycle of residency       the International Emergency Medi-        quirements and improve resident
                    education was on         cine Literature Review. Jared Blum       education. As Associate PD, she
                    full display this sum-   has a forthcoming publication in         will continue her major roles in
                    mer when, one day        JAMA. Mike Lee’s recent first-           resident recruitment and career
                    after honoring sen-      author publication in Annals of EM       development. She will also be es-
                    iors at graduation,      was picked up by all the national        tablishing new clinical electives,
    Brian Clyne, MD         we welcomed      media outlets. Matt Zuckerman            overseeing the growth of our web-
    Director EM Residency a fresh group      helped establish a new community         site, helping to expand our alumni
                            of enthusias-    service experience for residents at      network, and serving as chair of
  tic interns for their first day of ori-    the Rhode Island Free Clinic where       the Wellness Committee. Undoubt-
  entation. At the risk of sounding          residents care for the homeless          edly, she will also continue to dem-
  cliché, one can’t help but marvel at       and uninsured. Jamie Cohn, John          onstrate the exceptional clinical
  the transformation that occurs be-         Haran, Tobi Kummer and several           leadership we have come to ad-
  tween these two milestones. In             others are serving as mentors for        mire.
  many ways, what occurs in be-              medical students in the Brown
                                                                                      The residency recently established
  tween is deeply personal. The ad-          “Doctoring” course. Tami Thome
                                                                                      three Scholarly Tracks as a supple-
  age “you get out what you put in”          continues her spectacular leader-
                                                                                      ment to our conference series. Resi-
  applies well to residency educa-           ship of the Wellness Committee
                                                                                      dents will have a chance to partici-
  tion. In other ways, residency is          which recently provided the resi-
                                                                                      pate in an Education, Research, or
  prescripted by strongly worded             dents with new monogrammed
                                                                                      Leadership track during their third
  requirements set forth by the              scrubs. This list is by no means
                                                                                      and fourth years. The goals are to
  ACGME. Every program must find             complete for it would be impossi-
                                                                                      help residents refine their career
  a way to balance its residents’            ble to capture all the energy re-
                                                                                      interests, foster mentorship, and
  needs with the ACGME rules based           lated to scholarship, education,
                                                                                      complete projects that will contrib-
  on local resources. Fortunately, we        and volunteerism within the pro-
                                                                                      ute to their professional develop-
  have a wealth of resources to help         gram.
  residents cross that bridge from
                                             Our seniors are actively seeking
  orientation to graduation. What                                                     We are innovating weekly confer-
                                             jobs and the program sponsored
  follows are updates, announce-                                                      ence by providing more interac-
                                             another successful “Career Night”
  ments and initiatives undertaken in                                                 tive, case-based, small group ses-
                                             in September. A panel of experts
  our pursuit of program excellence.                                                  sions that satisfy the needs of adult
                                             including some Brown EM alumni
                                                                                      learners. To that end, Dr. Bob
  Just as the interns have settled in,       from a range of practice settings
                                                                                      Tubbs was recently appointed to
  interview season is here again and         convened to offer advice on the
                                                                                      the position of Assistant Program
  for the fourth consecutive year the        job search process. Dr. Jessica
                                                                                      Director with the main responsibil-
  program has received a record              Smith gave a presentation on inter-
                                                                                      ity of ensuring the quality of con-
  number of applications. A select           viewing skills and seniors had a
                                                                                      ference. Bob was a member of the
  group will be interviewed for what         chance to ask questions over an
                                                                                      Brown residency class of 2006,
  we hope results in another great           informal dinner. This annual event
                                                                                      serving as chief in his senior year
  class. Our goal in the recruitment         is part of a series of career counsel-
                                                                                      and has distinguished himself as
  process is to identify bright people       ing workshops the program has
                                                                                      an educator since joining the fac-
  with core values of self-motivation,       organized. It’s a great opportunity
                                                                                      ulty. Last year, he was recognized
  a strong work ethic and great in-          for alumni to get involved, so
                                                                                      for his efforts with an Outstanding
  terpersonal skills. If we continue to      please send us your contact infor-
                                                                                      Physician Award and the coveted
  attract people with these traits, the      mation to participate. The current
                                                                                      Faculty Teaching Award.
  program will undoubtedly con-              seniors are looking for jobs and
  tinue to thrive.                           fellowships all over the country         Other exciting new developments
                                             and it would be helpful to connect       include the arrival many enthusias-
  It’s no secret that residents, current
                                             with alumni to get your perspec-         tic young faculty with a gift for
  and past, are our most effective
                                             tive and locate the best opportuni-      bedside teaching, the decision to
  recruiting tool. When applicants
                                             ties in your area.                       expand elective time to the PGY-2
  see their accomplishments, the
                                                                                      year, and a monthly dedicated
  quality of the program speaks for          Speaking of Dr. Jessica Smith, she
                                                                                      Toxicology lecture series. I wish
  itself. For example, consider the          recently accepted a new position,
                                                                                      there were time and space for
  activities of just a few current resi-     that of Associate Program Director.
                                                                                      more, but until next time...
  dents. Liz Goldberg, Joshua                For two years Jessica has worked
  Jauregui, and Kimmie Pringle were          tirelessly to help the program main-

D E P A R T M E N T          O F
                                                                                                    PAGE 15

Anderson Emergency Center                                 The Miriam Hospital ED
                           Continued from page 3                            Continued from page 3

We continue to make important strides in           well. In July, Ilse Jenouri, MD, MBA assumed the
advancing patient service in the depart-           role of Co-Director of the TMH’s Stroke Center.
ment. Through the contributions of Lynn            She gave a presentation entitled, “ A View from
Sweeney, MD and Linda Dykstra, RN, a               the Emergency Room,” at The Fifth Annual Nor-
didactic program on patient service has            man M. Fain Memorial Stroke Lecture, held at the
been implemented in the department.                Providence Marriot, on October 19. At this lecture
This program is expected to reintroduce            program TMH was awarded the Get-With-The-
all staff to the fundamentals of patient ser-      Guidelines-Stroke Gold Achievement Award from
vice, and reinforce                                the AHA for adherence to at least 2 years of
a shared vision of                                 >85% of all GWTG-Stroke quality indicators. The
our practice while
                           ...our staff is         Miriam Hospital was the only hospital in RI to
diminishing barri-        participating &          achieve this award.
ers between the           implementing
                                                   TMHED will be launching the newest MedHost
various       divisions projects through
                                                   upgrade in late October. In addition, Logicare
that work in the              our 5S &             has been modified to enable faxing to pcp’s on
emergency center. Flow & Function
                                                   admitted patients. TMH administration has
This program will
also serve as an           committees              agreed to purchase a universal license for Logi-
                                                   care to enable the faxing from all computers
orientation          in-
                                                   within the department.
service to all new staff.
                                                   TMHED has also added the EZ-IO device. Nurses
Our team continues to grow. The new
                                                   and physicians have been in-
nurses, physicians, physician assistants,
                                                   serviced on its use, so it is ready TMHED will
nurse practitioners, and medical assistants
                                                   for prime time.
that have joined us continue to get accli-                                              be launch-
mated to the department, and have suc-             In order to prepare for an an- ing the new-
cessfully joined our team.                         ticipated H1N1 volume surge, est MedHost
                                                   TMHED set up a triage tent in
                                                   the ED parking lot in early Oc- upgrade in
                                                   tober, to debug logistic issues. late October.
                                                   We remain involved in plan-
                                                   ning the hospital’s response to this new threat.
                                                   Matt Kopp was elected Vice President of the
                                                   Rhode Island Chapter of ACEP. Neha Raukar and
                                                   Jessica Smith were elected Councilors for RIACEP
                                                   as well. Gary Bubly was elected President-elect of
   EM’s Out & About Socials                        the Rhode Island Medical Society, the first emer-
                                                   gency physician to hold that post.
The Department of Emergency Medicine
and UEMF is sponsoring these are casual            Finally, the 2009 TMHED Holiday Party is sched-
opportunities for the faculty and staff to         uled for December 11 at Via Roma. We hope to
socialize and celebrate various events:            see you there!
birthdays, promotions, recognitions, etc.
at a local establishment. We have had 2
very fun outings, one in September At
Rick’s Roadhouse and one in October at
Ardeo’s. Our next Out & About Social will
be in January 2010. An announcement
will be sent for a date and location.

                                                                  E M E R G E N C Y         M E D I C I N E

                                         In the Spotlight—Media
                                                                                      HCHED in the Media
 Dr Greg Jay was named in USA Today’s
 Most Influential Doctors database for his
          work on Osteoarthritis

                                     Gregory Jay, MD, PhD

                                                                                In October, with the flu season in
 Other newsworthy stories:                                                      full swing, Dr William Lewander
 Dr Selim Suner was on WJAR Channel 10 discussing pan-                          was interviewed by local media. Dr.
 demic flu planning and H1N1 on August 11, 2009.                                Lewander discussed the signs and
                                                                                symptoms for parents to look for to
 Dr Dave Lindquist spoke to WPRI Channel 12 about heat ill-
                                                                                know if they need to bring their
 ness prevention tips, warning signs, & reminders for best prac-
                                                                                children to the ED. The interviews
 tices during the hottest days of the summer on August 18,
                                                                                appeared on the air and online on
 2009.                                                                          the and
 Adam Chodobski & Joanna Szmydyner-Chodobska were                     
 quoted in the Boston Globe & on regarding their
 blood brain barrier research. “Seeking a pathway into the

                                                    Dr Neha Raukar
                                                    gave an interview
                                                    to WPRI Channel
                                                    12 regarding con-
                                                    cussions     which
                                                    was included in a
                                                    story on high
                                                    school sports and
                                                    head injuries.

                                                                                On October 29, 2009, Dr Susan
 A study led by EM 2nd year resident Michael                                    Duffy, Medical Director of the Has-
 Lee, MD, of the Injury Prevention Center finds                                 bro ED was on WLNE-TV Channel 6
 that injured alcohol-impaired drivers who are                                  taking answering viewers questions
 in motor vehicle accidents and are discharged                                  about 2009 H1N1.
 to home after being treated have higher ED
 charges than patients who are not alcohol-
 impaired. Michael Lee is quoted. Media cover-              Lubris, Biomodels Report on Potential New Therapy for
 age includes Armenian Medical Network;                     Osteoarthritis: The discovery by scientists at Biomodels, a (Australia); National Post                 Mass-based start-up company, led by Gregory Jay, MD,
 (Canada); Medical News Today; Science Co-                  PhD an emergency medicine physician at RIH, report
 dex; First Science; News Spider; Science Cen-              that injecting the protein lubricin into knee joints can
 tric; Red Orbit; Science Daily; Join Together;             dramatically reduce cartilage degeneration. Dr Jay pre-
 Genetic Engineering News;;                 sented the findings at the American College of Rheuma-
 WBRU-FM; Providence Business News; Phy-                    tology conference.

                                                                                               PAGE 17

                           EMERGENCY MEDICINE FACULTY
                                                                    Assistant Professor (Clinical)
                                 Assistant Professor                Charles Callahan, MD, MPH
                                 Thomas Chun, MD                    Laura Chapman, MD
                                 Brian Clyne, MD                    Deirdre Fearon, MD
                                 Jeffrey Feden, MD                  John Foggle, MD
                                 Aris Garro, MD
                                                                    Ahteri Forcada-Lowrie, MD
                                 Frantz Gibbs, MD
                                                                    Sarah Gaines, MD
                                 Eric Goldlust, MD, PhD
Professor                                                           Elizabeth Jacobs, MD
                                 Leo Kobayashi, MD
Bruce Becker, MD                                                    Joseph Lauro, MD
                                 Adam Levine, MD
Gregory Jay, MD, PhD                                                Laura McPeake, MD
                                 Otto Liebmann, MD
William Lewander, MD                                                Thom Meredith, MD
                                 Alyson McGregor, MD
Brian Zink, MD                                                      Lynne Palmisciano, MD
                                 R. Clayton Merchant, MD, MPH
                                 Anthony Napoli, MD                 Paul Porter, MD
Associate Professor                                                 Todd Seigel, MD
Angela Anderson, MD              Frank Overly, MD
                                 Neha Raukar, MD                    Anand Shah, MD
Adam Chodobski, PhD
                                 Lisa Schweigler, MD                Jessica Smith, MD
                                 Sachita Shah, MD                   Lynn Sweeney, MD
Susan Duffy, MD
Jason Hack, MD                   Robert Tubbs, MD                   Otis Warren, MD
James Linakis, MD, PhD           Jonathan Valente, MD
                                                                     Clinical Instructor
Michael Mello, MD                Michael Waxman, MD
                                                                     Amir Bernaba, MD
Ted Nirenberg, PhD                                                   Sonya Daria, MD
(Secondary)                      Clinical
                                                                     Laura Forman, MD
Daniel Savitt, MD                 Assistant Professor
                                                                     Megan McNamara, MD
Dale Steele, MD                  Erica Constantine, MD
Andrew Sucov, MD                 Catherine Cummings, MD
Selim Suner, MD                  Michelle Daniel, MD                 Teaching Associate
                                 Kathleen Doobinin, MD               Christine Garro, PA
Clinical Associate               Thomas Germano, MD                  Allison Jackson, PA
Professor                        Kirstin Gregg, MD                   Lisa Murphy, FNP
Gary Bubly, MD                   Andrew Griscom, MD                  John Pliakas, MSN
Ali Kazim, MD                    Thomas Haronian, MD
Andrew Nathanson, MD             Ilse Jenouri, MD                    Research Associate
Elizabeth Nestor, MD             Mihir Kamat, MD                     Julie Bromberg, MPH
David Portelli, MD
                                 David Kaplan, MD
Lawrence Proano, MD                                                  Teaching Fellows
                                 Matthew Kopp, MD
Francis Sullivan, MD                                                 Harmon Arora, MD
                                 John LaFleur, MD
                                 David Lindquist, MD                 Ryan Carter, MD
Associate Professor (Clinical)   James Monti, MD                     Rachel Fowler, MD
Gregory Lockhart, MD             James Rayner, MD                    Megan Ranney, MD
Kenneth Williams, MD             John Riedel, MD
                                 Marcia Robitaille, MD              Dr. Michael Mello was pro-
Assistant Professor              Nathan Siegel, MD
Siraj Amanullah, MD, MPH                                            moted to Associate Professor
                                 Elizabeth Sutton, MD               in July 2009.
Kavita Babu, MD                  Brian Wiley, DO
Janette Baird, PhD (Research)
Jay Baruch, MD                                                        In order from left to right: Drs
Linda Brown, MD                                                       Deidre Fearon, Ken Williams,
Joanna Szmydynger-                                                    Greg Lockhart, Ilse Jenouri,
Chodobska, PhD (Research)                                             Dave Portelli , Beth Sutton,
Esther Choo, MD                                                       Mihir Kamat, Matt Kopp and
                                                                      Dave Lindquist were honored
                                                                      by Brown University over the
                                                                      summer for their medical

                                                                E M E R G E N C Y      M E D I C I N E

                   Rhode Island Hospital Medical Simulation Center
                                  Faculty from the       through January 2010. Dr. Lindquist recently had
                                  Department        of   two invitations as a guest speaker:
                                  Emergency Medi-        Invited participant and presenter for round table
                                  cine continue to       forum: Improving Healthcare Quality and Safety.
                                  lead the way for       Director: Dr. David Nash
                                  simulation     pro-    Jefferson University, Philadelphia, PA
                                  grams, both educa-     Invited as Master Trainer assisting Team Perform-
                                  tional and research.   ance Plus for Train-the-Trainers seminar of Catholic
 Notably, the RIHMSC has been selected by the So-        Health System Long Island (CHSLI). Representa-
 ciety for Simulation in Healthcare (SSiH) out of        tives from emergency departments of 4 different
 hundreds of centers worldwide as the initial proto-     hospitals were trained over 2 days.
 type center to trial their newly developed creden-      Melville, NY.
 tialing process. This will take place in December       Dr. Ivona Sediva (Pediatric Critical Care) and Dr.
 2009 and is a credit to the hard work of Dr. Leo        Frank Overly successfully obtained funding
 Kobayashi, Emily Hinchey and everyone who has           through a Lifespan Risk Management grant to de-
 helped RIHMSC reach its current position as a lead-     velop a simulation-enhanced procedural training
 ing academic simulation facility.                       program for the insertion of central lines using ul-
 Dr. Linda Brown and Jeff Devine have started to         trasound. This grant will also provide resources to
 expand the sim center’s programs to offer more          be shared by Emergency Medicine, Pediatrics, In-
 frequent PALS, ACLS and their respective instruc-       ternal Medicine and Surgery.
 tor trainer courses. These programs will be a great     A new member to our simulation family arrived in
 resource for the region and healthcare providers        October. His name is HAL, and he is a 5 year old
 looking for training and certification for caring for   human patient simulator. He comes with many
 acutely ill pediatric and adult patients.               new features including blinking eyes, pupils that
 Our program with high school students titled “ A        react to light and seizure activity on command.
 Sim day in the Life of an Emergency Medicine Phy-       He is also wireless and tetherless which will be
 sician” continues to grow. The program, led by          very useful for Dr. Linda Brown’s portable pediat-
 Frank Overly, had 300 students from the National        ric code program. HAL was purchased with funds
 Youth Leadership Forum experience a simulation          from another Risk Management Grant.
 enhanced interactive experience. Feedback from          Finally, we would like to acknowledge the contin-
 these students was excellent; many saying this          ued efforts from Dr. Elizabeth Sutton and Dr. John
 was the highlight of their weeklong program.            Foggle who continue to lead the simulation pro-
 Faculty from Emergency Medicine are working             grams for EM medical student elective and EM
 with Ximedica, a medical product research, devel-       resident simulation conference. Many hours go
 opment and design company based out of Rhode            into both of these programs which benefit our
 Island. A shared interest in improving medical          residents and possibly future residents in emer-
 care through human factors and simulation-              gency medicine. Last, but certainly not least, we’d
 enhanced projects has led to a working relation-        like to recognize Jenn Taveira for coordinating the
 ship with this innovative company. The first pro-       multitude of courses, collecting invaluable data for
 ject looking at a new device design for the preven-     our center, and keeping everything on track.
 tion of DVT’s has been a success and other pro-
 jects are in the pipeline. Mark Jones has been in-      Dr David Lindquist fa-
 strumental in the success by ensuring that Xi-          cilitated a nationally
 medica receives high quality audio visuals and          broadcasted       audio
 showing them how to take advantage of all the           conference on medical
 benefits the sim center has to offer.                   simulation       called
 Dr. David Lindquist continues to work with several      Teaching Multidicipline
 prominent departments to develop and execute            CRM via Medical Simu-
 multidisciplinary teamwork training. His most re-       lation for the American
 cent project is working with the Pediatric sur-         College of Medical
 geons, Pediatric Critical Care intensivists and the     Quality (ACMQ) on
                                                                                       Dr. Devin Sokolowski a PGY3
 staff in the Pediatric Intensive Care Unit. This pro-   November 19. 2009.          resident at the Sim Center work-
 gram is scheduled to run from November 2009                                                 ing on Sim Baby.

                                                                                               PAGE 19

                 New Emergency Medicine Attendings
                                        For more new EM attendings see page 13
Paul Porter, MD
Dr. Porter received his MD and MBA in 1996 from the University of Pennsylvania School of
Medicine. He completed his EM residency at Morristown Memorial Hospital in 2009 as a
Chief Resident. He also completed an Internal Medicine Residency in 2006. Dr Porter is a
Major in the military. He has previously worked as a health care consultant. Dr. Porter will
be working primarily at TMH ED.

Lisa Schweigler, MD, MPH, MS
Dr. Schweigler received a MPH from the University of North Carolina at Chapel Hill School
of Public Health. She received her MD in 2003 at Duke University School of Medicine. Dr.
Schweigler completed the Robert Wood Johnson Clinical Scholars Program in 2009 at the
University of Michigan where she also completed her EM residency and was a Chief Resi-
dent in 2007. Dr. Schweigler is interested in health policy and health services research.

Todd Seigel, MD
Dr Seigel received his from MD the University of Minnesota Medical Center in 2005. He com-
pleted his EM residency at Harvard affiliated Beth Israel Deaconess Medical Center in 2008.
Most recently, Dr. Seigel completed a Critical Care Fellowship at Massachusetts General Hos-
pital. His academic interests are in resuscitation and critical care.

Anand Shah, MD
Dr Shah received his MD at the Medical College of Wisconsin in 2005. He is a 2009 EM
graduate from our RIH/Alpert Medical School EM Residency Program and has served as a
Chief Resident. Dr Shah is interested in public health and was accepted to the Robert Wood
Johnson Clinical Scholars Program in 2010.

Sachita Shah, MD
Dr Shah graduated from the University of Washington School of Medicine in 2004. She com-
pleted her EM Residency at the Harvard Affiliated Brigham & Women’s & Massachusetts Gen-
eral Hospitals Program in 2008. Dr Shah completed an Ultrasound Fellowship in 2009 at Ala-
meda County Medical Center. Her area of interest is research and education in emergency

Otis Warren, MD
Dr Warren graduated from the University of Pennsylvania School of Medicine in 2005. He
completed his EM residency in 2009 at Alameda County Medical Center. His area of interest
is clinical research.

New EMS Fellow—Ryan Carter,
MD                                                                 Results of the
Dr Carter completed his EM Residency at
Boston Medical Center in 2009. He re-
                                                              Annual CPC Competition—
ceived his MD from Boston University in                          Congratulations!
2005. Dr. Carter is doing a 2-year EMS Fel-
lowship under the supervision of Dr. Ken Williams.     Winners of the Brown University EM CPC Com-
                                                       petition will compete in the finals ACEP.
                                                       Residents:              Attendings:
                                                       1. Ellen Hsu            1. Eric Goldlust
             Recent Grant Submittals:                  2. Gareth Biegun        2. Tom Germano
    We had 6 applications for The Rhode Island         3. Katherine Kimbrell 3. Kavita Babu
    Foundation Medical Grants.

                                                                   E M E R G E N C Y     M E D I C I N E

      EMS & Critical Care Transport                                     Women & Infants
                                                                       Emergency Medicine
                                 Recent national
                                 meetings include                         Partnership
                                 N A S E M S O ,
                                 AMTC, and EMS                      The Department of Emergency Medicine
                                 Eagles        at                   and UEMF have been in discussion with
                                 ACEP.       Ryan                   W&I on a collaborative relationship for
                                 Carter, our EMS                    clinical care, education, and research
                                 Fellow, attended                   Many positive changes are already in
                                 AMTC and EMS
                                                                    place due to the dialogue between
                                 Eagles. Hot top-
ics include airway management alternatives, regu-         Alyson    UEMF Emergency Physicians and the
                                                       McGregor, MD W&I Triage Unit throughout the past
lation of air ambulances, and H1N1.
                                                                    two years. UEMF Emergency Physicians
RI DOH EMS is hard at work completing an EMS
Pandemic Response Plan. Likely that there will be      will provide Women & Infants Hospital a combined
some triage of calls and transport to alternative      mission which includes consultative and clinical ef-
care sites if the system is stressed.                  forts with the goal of achieving the best overall care
                                                       for women. This collaboration affords boundless
LifePACT is busier than ever with interesting
calls. Volume should be well over 1000 transports      opportunity for research partnering endeavors. This
this year. Full integration with the Express Care      is a unique relationship with opportunity for many
Transfer and Access Center is almost complete, and     residents and faculty to create interdisciplinary, multi-
we are sharing call room, storage, and work space      center research collaborations in fields related to
there. The second ambulance, designed specifi-         women’s health, ultrasound, domestic violence and
cally by and for pediatric transport, is coming late   many more! If you need assistance in becoming
winter/early spring!
                                                       matched with someone at W&I who may be inter-
                                                       ested in your research focus, please contact me.

Pediatric EM         (continued from page 4)
                                                                     HCH ED                  (continued from page 4)
past few months on the risk of brain
injury after head trauma; alcohol re-
lated visits to the emergency depart-                      the region’s children with state of the art care. The
ment by injured adolescents; high fidel-                   children’s acute psychiatric unit has successfully
ity medical simulation for resident edu-                   decreased admissions of patients to Hasbro Hospi-
cation; hypertensive emergencies in                        tal as staff members provide acute psychiatric ser-
children; and the use of bedside ultra-                    vices 24 hours per day. New modalities for seda-
sound for soft-tissue infections.                          tion and anxiolysis including nitrous oxide have
                                                           been successfully incorporated into PED care.
Congratulations to Aris Garro who re-                      Video Fibre optic laryngoscopic equipment is now
ceived a UEMF Junior Faculty Research                      available to facilitate the intubation of even the
Development Grant for Project CLEAR                        youngest patients. Efforts are underway to incor-
(Caregiver Lessons on Early Asthma                         porate teamwork training and simulation educa-
Recognition) and Dr. Susan Duffy who                       tion into the care of critically ill patients. New pa-
received a Risk Management training                        tient education resources are available to our pa-
grant for physician and nurse leader-                      tients. In addition, focused educational resources
ship and team training during critical                     related to ongoing departmental research projects
care. Finally, Drs. Tom Chun and Jim                       are now available for patients with asthma, con-
Linakis are co-investigators on Dr. Mi-                    cussive injuries and teens exposed to alcohol.
chael Mello’s Center for Disease Con-
trol’s R01grant Translation of Alcohol                     Overall, it has been a busy but rewarding fall for
Screening and Brief Intervention Guide-                    the PED that demonstrated its potential to success-
lines to Pediatric Trauma Centers.                         fully respond to the acute health needs of the pe-
                                                           diatric community in the region.

VOLUME         3, ISSUE         2                                                                                                                   PAGE 21

 Department of Emergency Medicine
 593 Eddy Street, Claverick 2
 Providence, RI 02903
 Phone: 401-444-5141
 Fax: 401-444-5118

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             Please consider the environment before printing this newsletter.

 Department of Emergency Medicine
 Affiliated entity of
 Lifespan Partners 

 Dept of EM Physicians’ photographs professionally done by Phillipi Photographi—

                                          Upcoming Events
 12/1/09—Faculty meeting, 8am
                                                 9/28-9/30/10—ACEP Scientific                          Faculty Meetings— 8am
 12/3/09—UEMF Informational                      Assembly, Mandalay Bay, Las                       Anderson Emergency Center—
 Board of Directors Meeting,                     Vegas, NV                                                     9:30am
 10am                                                                                            January 5, 2010
                                                 11/5-10/10—AAMC Annual
                                                                                                 February 2, 2010
 12/11/09—UEMF Annual Mem-                       Meeting, Washington, DC
                                                                                                 March 2, 2010
 bers’ Meeting, 11am
                                                                                                 April 6, 2010
 12/17/09– UEMF Voting Board                                                                     May 4, 2010
 of Directors Meeting, 10am                                                                      June 1, 2010
                                                                                                 July 13, 2010*
 New England Regional SAEM                                                                       August 3, 2010
 (NERDS) Meeting—4/14/10                                                                         September 14, 2010*
                                                                                                 October 5, 2010
 6/3-6/6/10—SAEM Annual
 Meeting, Marriott Desert Ridge,                                                                 November 2, 2010
 Phoenix, AZ                                                                                     December 7, 2010
                                                                                                 * Normally the faculty meetings fall on the first Tuesday
                                                                                                 of the month. These fall on the second Tuesday.
 6/17/10 Brown University EM
 Residency Graduation Banquet

 7/14/10—Brown University
 EM Welcome Party

                                                                                                 E M E R G E N C Y                         M E D I C I N E

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