P E R I G E ED U K E E M E R G E N C Y M E D I C I N E F A L L 2 0 1 8

W E L C O M E

C H A R L E S G E R A R D O , M DM e s s a g e f r o m t h e C h i e f

On September 12, 1962, President John F. Kennedy delivered a memorable

speech to thousands in Houston, Texas, where he presented the case for a national effort to land a man on the Moon.

Half a century later, in 2012, Dr. Joshua Broder, Duke Emergency Medicine Residency Program Director, chose Kennedy’s moonshot speech as an inspiration and metaphor for our residency. Subsequently, that metaphor has spread to all Duke Emergency Medicine efforts, and guides our priorities and activities. As President Kennedy said, “We choose to go to the moon…not because [it is] easy, but because [it is] hard.”

With this serving as our backdrop, we present to you the first issue of our newsletter PERIGEE, named for the point of the Moon’s orbit at which it is nearest to Earth. We feel that this newsletter highlights some of the best of Duke Emergency Medicine.

In this inaugural issue, we will introduce you to the latest additions to our mission, share a glimpse

into the cutting edge of our clinical practice and research, discuss the latest developments in our training programs, and more. You will learn about our newest faculty members, some familiar and some new to Duke. Though I risk extending the Moon metaphor too far, I must point out that one is not only an emergency physician, but also a literal rocket scientist.

I hope you enjoy learning about the diverse global health research programs we have developed in recent years, and the role we play in National Institutes of Health-funded research networks in the United States. In this issue we also highlight some of our most exciting recent innovations in ultrasound imaging and the unique applications of existing technology such as telehealth.

You will see how we have recently strengthened the tie between our educational programs and research programs by developing a resident research fellowship. I am sure you will be impressed with the academic productivity and promising trajectory exhibited by these trainees. In order

to describe the depth and breadth of our educational programs, we explain the development and success of our Physician Assistant Emergency Medicine Residency Program.

Finally, we take the opportunity to visit with one of our residency graduates, Dr. Chris Johnson. We catch up on the career of this former chief resident and check out his impressive photography.

We hope you appreciate reading about our recent accomplishments and looming ambitions, as we continue to set our sights on a metaphorical lunar horizon. Though we have not reached “the Moon,” this newsletter seeks to represent our most recent, closest approximation of it. Because we believe that, although the Apollo program accomplished its goal, we never fully attain our metaphorical Moon. It remains high, amidst our lofty aspirations, always in our sights but beyond our current reach. There, it serves to challenge and inspire us, organizing our plans and activities, calling us to reach and soar ever higher.

Sincerely,

Charles J. Gerardo, MD, MHSChief, Division of Emergency MedicineDuke University Hospital

D U K E E M 03

per· i·gee (n . )the point in the Moon’s orbit at which it is nearest to Earth

C O N T E N T S

We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”

- President John F. Kennedy September 12, 1962

“ 02 Chief’s Message

04 Serving the Global Community

08 Seeing Deeper: Developments in Ultrasound Research

09 New Faculty

10 NIH Network Partners: SIREN and PETAL

12 Duke EM Tests Telemedicine

14 Resident Research Spotlight

15 Resident Research Publications

16 Alumni Update: Chris Johnson

18 PA EM Residency

20 Mission and Contributors

Traumatic injury is a leading cause of death and disability globally, with approximately 10

million cases annually. It has been estimated that 21% (52.3 million disability-adjusted life years) of the injury burden in low- and middle- income countries (LMIC) could be averted through basic surgical and emergency care.

In their efforts to combat this global injury epidemic, for the last decade the Duke EM Global Health Section has extensively studied traumatic injury in collaboration with our partners at Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania. Partnerships like this exemplify Duke’s commitment to “Knowledge in the Service of Society.”

The research team’s methods run the gamut from clinical intervention trials to geospatial information systems analyses and epidemiologic studies.

Dr. Catherine Staton is the Director of both the Duke Section of Emergency Medicine Global Health and the Hubert Yeargan Emergency Medicine Global Health Fellowship Program. In September 2015, Dr. Staton received a K01 grant from the NIH Fogarty International Center to establish an intervention for alcohol use in the Tanzanian setting. As part of that work, Dr. Staton enrolled over 1,000 patients, conducting surveys and focus groups of patients, family members, healthcare practitioners, and the community advisory board on the

S e r v i n g t h e G L O B A L

C O M M U N I T Y

E M N E W S

In Tanzania, Duke EM fulfills Duke’s commitment

to Knowledge in the Service of Society

View of Mount Kilimanjaro from Dr. Catherine Staton’s residence in Moshi, Tanzania.

D U K E E M 05

use of alcohol in Tanzanian society. She validated the tools for an upcoming trial of a brief intervention for alcohol use.

Such work requires truly embedding in local culture—Dr. Staton not only had to develop the intervention but also had to adapt it to both the Swahili language and Tanzanian culture. This included ensuring research nurses used Tanzanian-specific data, chose the most appropriate Swahili words, and avoided words with negative connotations. Dr. Staton’s R01 application will implement her next step, which is a novel adaptive clinical trial in Tanzania. In part due to this work, Dr. Staton has received the Duke Global Health

E M N E W S

Furthermore, Dr. Vissoci has rounded out the team’s work by contributing his expertise to systematic reviews, such as in their analysis of road traffic injury preventions in LMICs published in 2016. He has also contributed a summary of observational studies, and the quality of traumatic brain injury clinical practice guidelines. Dr. Vissoci has also provided his expertise in the ability to perform built environment analysis and hotspotting epidemiological studies of areas at high risk for traffic injuries.

After analyzing traumatic brain injury data from Tanzania, Dr. Vissoci created and developed an app using machine learning to predict mortality, which can help with clinical decision-making in limited-resource settings. In May, Dr. Vissoci was one of a handful of applicants invited to present an idea at the SAEM’s Annual “Lion’s Den.” In this session,

researchers “pitch” their idea to experienced researcher “lions,” who then comment or critique, offering “deals” for mentorship. Dr. Vissoci presented his proposal for an app that predicts mortality from traumatic brain injury with and without surgery.

The Global Health Section also provides a team for mentorship of many students and trainees. In February 2018, Dr. Julian Hertz was selected to receive funding from the Vanderbilt-Emory-Cornell-Duke (VECD) Global Health Fellows Consortium for his research. Sponsored by the US NIH Fogarty International Center, VECD institutions and faculty have a long history of excellence in global health research, leading to several high-impact global health discoveries by VECD trainees. During his prior training, Dr. Hertz spent two years living and working at KCMC and has noticed a sparsity of patients with chest pain or acute coronary syndrome (ACS). During his 11 months living in Tanzania for this grant, Dr. Hertz will describe the prevalence of ACS at KCMC. This grant will be an excellent stepping stone for Dr. Hertz’s next steps in obtaining further NIH funding to conduct research in this setting.

One of the Section of Global Health’s successful trainees, Dr. Sophie Wolfe Galson, is finishing her fellowship and is thrilled to be joining us this year as an Assistant Professor in the Division of Emergency Medicine (EM). Dr. Galson completed a Master of Science in Global Health during

Institute Faculty Travel Grant Award, was nominated for the Society for Academic Emergency Medicine (SAEM) Academy for Women in Emergency Medicine Outstanding Early Career Award, and last year received the SAEM Global Emergency Medicine Academy Academic Achievement Award.

Dr. Joao Vissoci has been an integral partner in this work, adding innovative methods to solve unique global health challenges. Together, Drs. Staton and Vissoci have qualitatively and quantitatively described the culture of alcohol use in Tanzania and validated a tool to diagnose alcohol use disorders (Alcohol Use Disorder Identification Test) in Swahili-speaking patients. They are currently validating the international cut off by comparing it to the Diagnostic and Statistical Manual (DSM) and the Drinker Inventory of Consequences.

Dr. Staton and staff of KCMC. Above right, KCMC entrance.

her fellowship and conducted research looking at the prevalence of untreated hypertension among patients presenting to the emergency department. She recently returned to the United States after completing 7 months of fieldwork in Moshi, Tanzania, where she was studying non-communicable diseases in the emergency department under the mentorship of Dr. Catherine Staton and Dr. John Stanifer. Dr. Galson and her colleagues published “Epidemiology of hypertension in Northern Tanzania: A community-based mixed-methods study” in BMJ OPEN earlier this year.

In April, she presented her work at the European Cardiology Congress (Europrevent) conference in Ljubljana, Slovenia, and was awarded best oral poster presentation. Most recently, Dr. Galson defended her master’s thesis at the Duke Global Health Institute on the burden of hypertension in the emergency department and linkage to care in Moshi. She is currently working on publishing the results.

Also rejoining the Duke team in July 2018, this time as faculty, is Dr. Anjni (Patel) Joiner, who completed her residency at Duke and EMS/Disaster Fellowship as well as a Masters of Public Health at Emory University. Dr. Joiner brings with her quantitative and qualitative skills as well as ongoing collaborations with the Ministry of Health of Malawi. She will continue to focus her research on access-to-care challenges in the global health setting and potential public health–minded interventions that can be administered by a prehospital care system in low-resourced settings.

One of Duke EM’s former ultrasound fellows and current ultrasound faculty, Dr. Elias Jaffa, also collaborated with the Global Health section to initiate a point-of-care ultrasound program and create a ultrasound fellowship program for trained EM physicians at KCMC.

The Duke–KCMC collaboration has culminated in significant capacity building for KCMC, with the latter now being able to host 2 residents

trained specifically in EM (Noel Makundi, 2nd year, and Frida Shayo, 1st year) through sponsorship from Duke University.

The presence of these pioneering Tanzanian EM specialists will only increase the already explosive academic output from this international collaboration.

Catherine Staton, MD Joao Vissoci, PhD

Julian Hertz, MD Sophie Wolfe Galson, MD

D U K E E M 07

E M N E W S

Duke Emergency Medicine (EM)’s ultrasound program has been growing steadily

over the past few years.

Program director Dr. Erica Peethumnongsin took over leadership from Dr. Bri Steele in July 2017 and has overseen a number of important projects. These efforts include: EM resident education (intern rotations, senior electives, and simulation days); interdepartmental education programs (involving internal medicine, pediatrics, critical care, and surgery trainees); a popular annual medical student elective; workflow improvement with the

QPath archiving system; and faculty ultrasound workshops.

January 2017 marked the beginning of the Duke emergency ultrasound fellowship, when Dr. Elias Jaffa, a Duke EM residency graduate, became the first faculty fellow. He was joined 6 months later by the program’s second fellow, Dr. Kevin Gurysh, also a Duke EM graduate. Both Drs. Jaffa and Gurysh joined the Duke EM faculty group upon graduation.

The fellowship recently welcomed its third fellow, Dr. Rebecca Theopanous, chief resident from the 2018 graduating class. This year, the fellowship has already received

multiple applications from strong candidates, and Dr. Peethumnongsin is looking forward to possibly matching its first external candidate in the fall.

Ultrasound research has been a significant component of the program, led primarily by Dr. Josh Broder, who won the General Electric/Emergency Medicine Foundation Point of Care Challenge Grand Prize for his work using low-cost 3D ultrasound to evaluate patients with hemorrhagic shock. His work has spawned multiple 3D ultrasound projects that are already being published, with articles expected in the coming year on the use of 3D ultrasound to evaluate infant hydrocephalus, transplant kidneys, appendicitis, biliary pathology, and early pregnancy.

The program is embarking on an EMS educational research project to determine the feasibility of training Durham EMS providers to perform focused cardiac and pulmonary ultrasound to assist with field management.

Drs. Peethumnongsin and Jaffa have partnered with Dr. Catherine Staton, director of the Global Health Fellowship, to develop a longitudinal point-of-care ultrasound educational curriculum in Tanzania at Kilimanjaro Christian Medical Center (KCMC). Dr. Jaffa traveled to Moshi, Tanzania, earlier this year to meet Dr. Francis Sakita, the first EM-trained faculty working at KCMC, and learned of the immediate and long-term needs

D e v e l o p m e n t s i n U l t r a s o u n d R e s e a r c h

S E E I N G D E E P E R :

Dr. Broder demonstrates the 3D ultrasound device.

Erica Peethumnongsin, MD, PhD

Elias Jaffa, MD

Rebecca Theopanous, MD

of the program. He then created a device that can livestream images from the ultrasound machines at KCMC to computers across the globe, which will allow real-time quality assurance of KCMC scans by faculty at Duke or other collaborating institutions. Dr. Peethumnongsin traveled to Moshi later in the year and implemented Dr. Jaffa’s technology during her visit.

The program looks forward to more exciting collaborations both here at Duke and across the globe.

D U K E E M 09

N E W F A C U L T Y

Cathleen Bury, MD

i n E m e r g e n c y M e d i c i n e

Daniel Buckland, MD,PhD

Brendan Flanagan, MD

Sophie Wolfe Galson, MD

Haromol S. Gill, MD Kevin Gurysh, MD

Kevin Gurysh, MD

Anjni Joiner, DO Timothy E. Snow, MD

E M N E W S

NATIONAL PARTNERS THROUGH SIREN AND PETAL

SIREN PETALEmory UniversityMassachusetts General HospitalMedical College of WisconsinOregon Health and Science UniversityTemple UniversityUniversity of California, Los AngelesUniversity of CincinnatiUniversity of MinnesotaUniversity of PittsburghUniversity of WashingtonWayne State University

Baystate Medical Center Beth Israel Medical CenterUniversity of California, San Francisco University of Colorado HospitalUniversity of Michigan Medical CenterMontefiore MosesCleveland Clinic FoundationHarborview Medical CenterUPMC Presbyterian Wake Forest Baptist HealthIntermountain Medical CenterVanderbilt University Medical Center

When most people think about emergency medicine, they consider medical

conditions such as myocardial infarction, cardiac arrest, traumatic injury including brain and spinal cord injury, and seizures.

To establish better care for patients with these conditions, the Strategies to Innovate Emergency Care Clinical Trials Network (SIREN) (NIH Project Number: 1U24NS100659-01) seeks to improve the outcomes of patients with such neurologic, cardiac, respiratory, or hematologic emergencies by identifying effective treatments administered in the earliest stages of care.

The National Heart, Lung, and Blood Institute (NHLBI) and National Institute of Neurological Disorders and Stroke (NINDS) support the network. It comprises over 50 hospitals across the nation, each

hosting a multi-disciplinary team of researchers. Since research has demonstrated that there is a narrow window of opportunity to intervene in such emergency conditions, conducting clinical trials in the emergency setting presents unique challenges to researchers.

Emergency physicians, neurologists, cardiologists, intensivists, neurosurgeons, trauma surgeons, cardiac surgeons, biostatisticians, paramedics, rehabilitation doctors, and other experts will partner in making projects work. Duke Emergency Medicine has a long history of conducting such trials and thus is poised to play an important role in the network.

Duke has previously collaborated on the NIH-funded ProCESS trial, in which patients in septic shock were randomized to one of three protocols of care.

N I H N e t w o r k P A R T N E R S

S I R E N :S T R A T E G I E S T O I N N O V A T E E M E R G E N C Y C A R E C L I N I C A L T R I A L S N E T W O R K

Duke Emergency Medicine is excited to be a partner in two NIH-funded emergency care research networks.

Similarly, the Prevention and Early Treatment of Acute Lung Injury (PETAL) network is funded

by NHLBI to develop and conduct randomized controlled clinical trials to prevent or treat Acute Respiratory Distress Syndrome (ARDS).

Building on the strengths and accomplishments of the Acute Respiratory Distress Syndrome Clinical Trial Network (ARDSNet), PETAL forges new partnerships by bringing emergency and acute care

Like its predecessors, the Neurological Emergencies Treatment Trials Network (NETT) and the Resuscitation Outcomes Consortium (ROC), SIREN is tasked with performing pragmatic trials that focus on meaningful outcomes for patients, with readily applicable results that can immediately impact patient care.

Furthermore, SIREN seeks to utilize modern clinical trial designs including adaptive methods, registry-based randomized trial methods, platform trials, and other cutting edge designs.

Several trials are being planned for the network, the first a study of hyperbaric oxygen treatments for patients with traumatic brain injury.

Given Duke’s nation-leading hyperbaric program, we anticipate having a significant impact on this trial.

P E T A L :P R E V E N T I O N A N D E A R L Y T R E A T M E N T O F A C U T E L U N G I N J U R Y

medicine research groups from different areas to work together to focus on prevention and earlier intervention of ARDS.

Duke has already enrolled patients in two of the trials, ROSE and VIOLET. ROSE is a randomized trial of muscle blocking medication for patients who require a ventilator for their critical illness. VIOLET is a trial of vitamin D supplementation in critically ill patients.

D U K E E M 11

E M N E W S Duke EM Tests T E L E M E D I C I N E

As the volume of patients seeking medical care continues to grow, finding

creative ways to care for patients is ongoing. In many instances, the care needed is specialized and, at times, urgently needed. Telehealth is an innovative way to help close the gap between patient needs and provider availability. Some current initiatives utilizing telehealth are for mental health patients in emergency departments (EDs), patients needing intensive care–level expertise, post-operative visits, and acute stroke management.

In emergency medicine, there is continued pressure to see more patients in a finite space, and the Duke Emergency Department is no different in having to deal with these issues. On a daily basis, the Duke ED sees an average of 220 patients per day, which is just over 80,000 patients per year. In many instances, patients have to wait to be placed in a treatment space. Telehealth is an opportunity to initiate patient care as they wait for bed space, and do so in a meaningful manner while maintaining a positive patient experience.

A pilot was completed using telehealth, in which a Duke provider would see patients after their initial triage and initiate care as the patient waited for a room to come available. The provider was located remotely and called in to a telehealth cart, which allowed the provider to speak with and examine the patient.

To begin the process after triage, a nurse would approach the patient and ask if they would be willing to be seen by the telehealth provider. The provider would speak with the patient as well as perform a physical exam. With the assistance of the nurse, the provider would be able to auscultate the heart and lungs with a stethoscope specialized to transmit the sounds through the cart. Additionally, the nurse would be able to assist the provider with other physical exam maneuvers, such as the abdominal exam, pupillary exam, or evaluation for edema. After the assessment, the provider completed the medical screening exam, ordered labs and imaging, and initiated symptom management.

Five providers (4 physicians, 1 advanced practice provider) were identified to be involved in the pilot, in hopes of limiting provider variability when implementing a new technology. For patients, the inclusion criteria were individuals more than 21 years old with a non-psychiatric complaint. On average, the individual provider saw 4 patients per hour. During follow-up phone calls, patients were asked to rate their overall experience and

220

80,000

Duke EM sees an average of

PATIENTS PER DAY,

PATIENTS PER YEAR.

likelihood of repeat utilization, and were asked to provide open-ended feedback of the experience. Patients rated their overall experience as 4.5 out of 5, with everyone being willing to go through the experience again. The providers were also surveyed and provided their thoughts on telehealth and their overall experience.

The future plans for telehealth in Duke ED include an expanded coverage model for more days of the week and more hours per day, which would require increasing the provider cohort, as well as increased nursing staff and tech coverage to support patient needs. Additionally, the technology could be scaled to offer provider coverage to rural EDs where there is a lack of board-

certified ED providers. There is also opportunity to use telehealth in the initiation of care for patients who are sent to the ED from urgent care, even prior to the arrival of the patient to the hospital.

The telehealth pilot sheds light on the impact this technology can have on ED throughput, as well as its positive impact on patient satisfaction and experience.

PROVIDER FEEDBACK

“Easier to use than expected.”

“Able to easily assess patient and see all that I needed.”

“Accessories work really well.”

PATIENT FEEDBACK

“It felt like a normal experience. Like I had a real doctor.”

“I was amazed. I didn’t even think that was possible. Thought it was innovative way to get things started.”

D U K E E M 13

E D U C A T I O N

As Duke Emergency Medicine

(EM) continues to expand its research footprint, John Eppensteiner, MD, took this previous

academic year away from traditional residency training to complete the inaugural Graduate Research Fellowship.

This year was built under the guidance of Alex Limkakeng, MD, MHS, Vice Chair of Research in the Division of Emergency Medicine, and Charles Gerardo, MD, Chief of the

Division of Emergency Medicine, in collaboration with the laboratory of Bruce Sullenger, PhD, of the Surgical Sciences Division. Dr. Eppensteiner’s interests are primarily focused in the area of acute inflammation and the immune response following traumatic injury.

With funding support from the Surgical Critical Care Initiative (Sc2i) as well as the Division of Emergency Medicine, Dr. Eppensteiner has split his time over the course of the fellowship between developing the fundamentals of a career in emergency medicine research and collaborating with Dr. Sullenger’s lab to start his own primary research projects.

The fellowship year included participation in SAEM’s Advanced Research Methodology Evaluation

Resident R E S E A R C H Spotl ight

J O H N E P P E N S T E I N E R , M D

International emergency medicine is an

exciting and diverse field. For Jinny Ye, MD, a second-year Emergency Medicine resident,

the broader field of global health has often been an academic area to which she’s been drawn. As the child of immigrant parents and frequently visiting relatives in China, she developed an identity of being

connected not to one nation but to the world.

During medical school, Dr. Ye conducted a project on initiation of antiretroviral therapy in HIV in Mozambique, a low-income country with a long history of Portuguese colonization. Her experiences implementing the project gave her a glimpse of issues surrounding limited resources and access to care.

Under the Duke Brazil Initiative Grant, Dr. Ye had the unique opportunity to visit Maringá in southern Brazil in December 2017 to study access to antivenin in the

J I N N Y Y E , M D

and Design course, a graduate Immunology course as part of Duke’s Clinical Research Training Program, grant writing workshops, and lab-based training in several biological assay techniques. Furthermore, this is now an established track within the residency program. Duke EM residents who wish to pursue a special interest in research will now have this specialty training path available in the future.

Within the Sullenger Lab, Dr. Eppensteiner has worked primarily in collaboration with Jaewoo Lee, MS, PhD, an expert in the field of sterile inflammation and the innate immune response who has worked previously in the development of novel approaches to control trauma-induced inflammation. Together, they published a paper reviewing the

treatment of snake envenomations. She spent two weeks learning about the unique nationalized Brazilian health system, Sistema Único de Saúde, working with collaborators at Universidade Estadual de Maringá, and meeting a real-life South American rattlesnake, crotalus durissus.

The collaborators she met shared their unparallelled enthusiasm and excitement in learning from and about others, and no less important, their love for churrasco, Brazilian barbecue. Their culture of generous hospitality allowed Dr. Ye

RES IDENT RESEARCH PUBL ICAT IONS

role of damage-associated molecular patterns and extracellular vesicles in sterile inflammatory states like trauma, including the possibility of using both as diagnostic and therapeutic targets.

This year has provided a unique opportunity to leverage a collaboration between basic scientists and EM clinicians. The unique opportunity of emergency physicians to be bedside at “time-zero” of a patient’s clinical course has spurred Dr. Eppensteiner’s curiosity into early and effective interventions to improve or prevent downstream problems.

In the future, he hopes to continue this work in the development of a biomarker-based approach to better predict complications in critically ill and injured patients.

to build on her previous Portuguese language skills she learned while in Mozambique.

Dr. Ye will continue building a foundation in international emergency medicine by taking a research year in 2018–2019, when she will spend the majority of her time learning the principles of clinical research and basics of linear regression while implementing a project on out-of-hospital cardiac arrest in Brazil. The projects resulting from this research year will serve as a foundation for an International Emergency Medicine fellowship in 2020–2022.

D U K E E M 15

Are non-pharmacologic pain interventions effective at reducing pain in adult patients visiting the emergency department? A systematic review and meta-analysis. Sakamoto JT, Ward HB, Vissoci JR, Eucker SA. Acad Emerg Med. 2018 Mar 15. doi: 10.1111/acem.13411

Transvenous pacemaker placement: Left lateral decubitus position and wireless digital radiography. Broder JS, Silver JM, Fischetti CE. Am J Emerg Med. 2018;36(3):467-469.

Immunothrombotic activity of damage-associated molecular patterns and extracellular vesicles in secondary organ failure induced by trauma and sterile insults. Eppensteiner J, Davis RP, Barbas AS, Kwun J, Lee J. Front Immunol. 2018;9:190.

Built environment analysis for road traffic hotspot locations in Moshi, Tanzania. Waldon M, Ibingira TJ, Andrade L, Mmbaga BT, Vissoci JRN, Mvungi M, Staton C. Int J Inj Contr Saf Promot. 2018;8:1-7. doi: 10.1080/17457300.2018.1431941

Male with progressive bilateral lower extremity edema. Gill H. Visual Journal of Emergency Medicine. 2018 Jan;10:108-109.

Bedside ultrasound used to diagnose infective endocarditis in undifferentiated shock. Wessel A, Stemple S, Broder J. Visual Journal of Emergency Medicine. 2018;10:32-4.

Viridans streptococci Intracranial Abscess Masquerading as Metastatic Disease. Ruderman B, Thoureen T, Broder J. Journal of Education and Teaching in Emergency Medicine. 2018;3(1).

Qualitative evaluation of trauma delays in road traffic injury patients in Maringá, Brazil. Patel A, Vissoci JR, Hocker M, Molina E, Gil NM, Staton C. BMC Health Serv Res. 2017 Dec;(1):804.

Exploring older adult ED fall patients’ understanding of their fall: A qualitative study. Shankar KN, Taylor D, Rizzo CT, Liu SW. Geriatr Orthop Surg Rahabil. 2017;8(4):231-237.

Road traffic injury in sub-Saharan African countries: A systematic review and summary of observational studies. Vissoci JR, Shogilev DJ, Krebs E, Andrade LD, Vieira IF, Toomey N, Portero Batilana A, Haglund M, Staton CA. Traffic Inj Prev. 2017;18(7):767-773.

A three year-old male with abdominal pain. Nelson B, Broder J. Visual Journal of Emergency Medicine. 2017;9:21-24.

Boy with fever and cough. Zhang K, Broder J. Ann Emerg Med. 2017;70(3):e33-e34.

E D U C A T I O N Alumni U P D A T E

Currently, I work for a private, democratic emergency medicine group, the Richmond

Emergency Medicine Physicians, Inc., or REPI for short.

We staff emergency departments in the Bon Secours Health System in the Richmond, VA, area, including the Adult and Pediatric EDs at St. Mary’s Hospital, the ED at St. Francis Medical Center, and the free-standing ED at Westchester Emergency Center. In a few months, we will staff another free-standing ED at the Short Pump Emergency Center.

After completing residency in 2008, I went on to complete my Pediatric Emergency Medicine fellowship at the UNC / WakeMed program. I graduated from fellowship in 2010, then stayed on a year working with the ED group at WakeMed while my wife finished her NICU fellowship at UNC.

I joined REPI in 2011, and currently serve as the Assistant Medical Director of the Pediatric Emergency Department, and I am also the chair of recruitment for the group.

I love working as part of a democratic group—there is definitely extra work outside of the clinical shifts, but it allows us to be in control of our practice.

I split my time about 50 / 50 between the Peds ED and the rest of our departments. Each of our EDs has a different feel and different patient population, and I really like the variety it affords—it keeps work from stagnating, and I think it helps avoid burnout.

C HRI S JO HNSO N, MD

Duke Emergency Med ic ine Ch ie f Res ident , C lass o f 2008

Dr. Johnson shares highlights from his life, family, and career in the ten years since his residency at Duke.

DEMOCRATIC MEDIC INE & D IVERSE PAT IENTS

CHRIS JOHNSON, MD

When I’m not working clinically, I’m often out somewhere in Richmond (usually on the James River) taking photos or having fun adventures with my two sons, who are 7 and 4. Photography has interested me since high school, and I officially made a business out of it a few years ago. I post my work to social media on Instagram (@vintage_rva, @cpjRVA, and @cpjohnso) and Facebook (CPJ RVA photography).

OUTS IDE OF CL IN IC

Last year, I was in downtown Richmond when I came across a homeless man who asked if I had any spare money he could use to buy lunch. I felt badly as I didn’t have any cash, and I kept walking.

When I was finished, I went back and found the man in the same spot and told him that I still didn’t have any cash but would take him to a nearby cart or restaurant to buy him lunch with my credit card. His eyes lit up, and we walked a few blocks to a local lunch spot that served hot dogs and sodas. We sat outside while he ate and chatted a bit—his name was Lloyd and he had fallen on some hard times. Nonetheless, he had a warm smile and was extremely grateful for the meal.

At work in the ED, we often see people who are down on their luck, and it’s the little things we do that can go a long way, both in and out of work.

L ITTLE THINGS GO A LONG WAY

D U K E E M 17

E D U C A T I O N

P A E M R E S I D E N C YContinues to be a Resounding Success

The utilization of Advanced Practice Providers (APPs) in the field of emergency medicine

has continued to increase over the past decade. In 2005, 13 percent of all US emergency department (ED) visits were seen by an APP, up from only 4 percent in 1993. From 2006 through 2009, 64% of EDs utilized APPs.

It is clear that APPs have the real and anticipated potential to increase the efficiency of the ED by offloading some of the burden of patient care while still providing excellent care. EDs have become increasingly overburdened, and access to health care delivery systems continues to be a national concern. The APP concept in emergency medicine illustrates a well-proven solution to the problem of diminishing health care access and rising health care costs.

Duke Emergency Medicine continues to receive a high proportion of critically ill patients. This requires practitioners who are highly skilled and experienced in all aspects. One of the limiting factors of physician assistant (PA) recruitment has

been the availability of experienced practitioners.

To address this challenge, we implemented a residency in Emergency Medicine for Physician Assistants in 2016. The residency program teaches our PA residents the advanced skills, medical knowledge, and humanistic qualities that contribute to a foundation of a successful career in emergency medicine. Presently, the United States has 26 PA residency programs in emergency medicine.

The program is a 12-month intensive clinical training and educational program, enabling our PA residents to be exposed to both adult and pediatric patients in all aspects of emergency medicine. What makes Duke’s program unique is that the PA residents are embedded with the MD residents. The PA residents

become valued members of the emergency medicine team. They work closely with and learn from our distinguished faculty, Emergency Medicine residents, and our APPs.

This close collaboration gives the PA resident the hands-on experience that is needed to become a competent clinician as well as a PA leader in the demanding field of emergency medicine.

The residency has a strong emphasis on both clinical and didactic training. In addition to learning the evaluation and management of a diverse emergency medicine patient population, PA residents attend a weekly didactic lecture series. They also attend educational seminars, journal club, simulation lab, ultrasound training, and clinical skills labs. This intense training program has been designed to provide a

The residency was a fantastic opportunity that allowed me to learn from some of the best in the field and at a level one trauma center. It was a challenging, humbling, and rewarding experience that I would recommend to anyone passionate about emergency medicine.“

Melissa Radcliff, MHS, PAC

comprehensive understanding of the pathophysiology and treatment of disease and traumatic injuries.

Requirements for acceptance into the PA Residency Program are completion of an approved PA training program and successful completion of the National Certification Council for Activity Professionals certification. Passion for emergency medicine and a personal interview with the admission committee is essential. Upon completion of the residency, a certificate of completion is awarded by the Division of Emergency Medicine. The graduate resident is then eligible to take the specialty board exam in emergency medicine.

An indicator of the success of the program is that all of our graduate residents have become permanent

members of our Emergency Medicine family. Additionally, there has been a 20-fold increase in our application rate. The ultimate goal is for the PA residency program to become the number-one program in the country and serve as a national model for excellence.

We have had 4 graduates of our residency program to date:

• 2016: Andrew McGraw, MHS, PAC, and Gaea McCaig, MS, ATc, MHS, PAC.

• 2017: Kati Schmutz, MHS, PAC, and Melissa Radliff, MHS, PAC.

The present residents are Lindsey Rowe, MHS, PAC, and Katie Sloter, MHS, PAC.

“

The Duke Emergency Medicine PA Residency was the best decision I have made regarding my medical education. The PA and MD leadership here at Duke is second to none. I was provided with the tools and knowledge to start my career working in a position that is not offered to new grads and feel that I was very well prepared for my current position as a PA at the Duke Emergency Department. It would have taken me several years to learn what I was able to learn in 12 short months of residency.”

Andrew McGraw, MHS, PAC

“

D U K E E M 19

O U R M I S S I O NTo provide expert care for patients, to train the next generation of emergency medicine physicians to be leaders in the field of EM, and to conduct innovative research that improves patient care.

Duke South, White Zone, Room 1571-ADUMC 3707 Durham, NC 27710

First Class MailU.S. PostagePAIDDurham, NCPermit No. 60

Cl ick. L ike. Fol low. Watch.

surgery.duke.edu/ emergency-medicine

Duke Surgery @DukeEmergency Duke Surgery

© Copyright 2018 Duke Surgery

P E R I G E E C O N T R I B U T O R S Editor in Chief Alexander Limkakeng, MD

Layout and Design Scott Behm

Cover Artist Megan Llewellyn

EM Contributors John Eppensteiner, MD

Dean Harrison, MPAS

Charles Gerardo, MD

Chris Johnson, MD

Neel Kapadia, MD

Erica Peethumnongsin, MD, PhD

Ashley Phillips

Catherine Staton, MD

Jinny Ye, MD