30 JUN 2015 Waterfront Meeting - PowerPoint Presentation

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30 JUN 2015 Waterfront Meeting

SpeakerTopicTimeLecture Pretests10MRD-SD LT HightowerOpening Remarks10NMCSD EDDr. CarstairsPoisoned Patient45FST Dr. ClappAllergies and Anaphylaxis45University of SDCDR BuechelHPV Study5Fleet DentalCAPT RonconeDental Updates5MRD-SDLT HightowerUpdates5Lecture Posttests10Total135Slide2

Pre Test

Please start on the quizzes as soon as you find a seat! Put your name on the quiz and pass to the end of the row (left) when you are done.JanuaryChest Pain- Dr. OakleyTriage- LT FeroliFebruaryShock- Dr. MecklenburgPulmonary Emergencies- Dr. PowersMarchAcute Pain- Dr. VoogdSurgical Abdomen- Dr. IgnacioAprilAirway Management- Dr. Hauff MayDental- LT Meadows (IDC’s)Ultrasound- Dr. Hurst (MO’s)Slide3

Medical Readiness Division

MRD_SD_GMO@navy.mil(619) 556-5191Bldg 116San Diego, CA 92136Clinic (619) 556-8114Slide4

Management of the Poisoned Patient

Shaun D. Carstairs, M.D. FACMT FACEPCDR MC USN30 June 2015Slide5

Introduction

Poisoning emergencies common in the ED2.5 million toxic exposures reported in 20091544 deathsClinical effects dependent upon many variablesDoseLength of exposure timePre-existing health of patientClin Toxicol (Phila) 2010; 48:979-1178Slide6

Objective

To provide basic concepts for evaluation and appropriate management of the poisoned patientSlide7

Topics

Resuscitation/initial managementDiagnostic approachHistory/physical examToxidromesElectrocardiogramLaboratory analysisTreatment approachDecontaminationAntidotesEnhancement of clearanceSlide8

Resuscitation and Initial ManagementSlide9

Initial Management

Thorough assessmentAppropriate stabilizationSupportive careConsider a broad differential diagnosisSlide10

MISTAKE #1

Assuming a patient’s presenting symptoms are due to a toxicologic cause without excluding potentially serious conditionsSlide11

Case #1

25 year old male with history of drug abuse found “altered” at home by parentsVS: T 100.3, R 20, P 130, BP 100/60Confused, dry skin/mucous membranesLooks antimuscarinic…. or is he?Lumbar puncture  590 WBCSlide12

Case #2

21 year old Marine, found downStrong smell of EtOHPlaced in the front hallway to “sleep it off”… only he doesn’t wake up in the morningHead CT shows intracranial hemorrhageSlide13

Initial Management

Same as the non-poisoned patientABC’sIV, O2, cardiac monitoringDepressed mental statusCheck blood glucoseConsider naloxone and/or thiamine as indicatedSlide14

Circulatory Status

Large-bore IV’sStrongly consider central venous access, esp. if hypotensiveIn hypotensive patients, mechanism of toxicity can guide vasopressor choiceDirect vasopressors preferredDopamine not an ideal agent in poisoned patientsSlide15

History & Physical ExaminationSlide16

History

Name and amount of agent(s)Time of ingestion/exposureRoute of exposureCo-ingestantsReason for exposure (i.e., suicidal, accidental)Search exposure environment for pill bottles, drug paraphernalia, suicide note, chemical containers, etc.Slide17

Vital Signs

Blood pressureHeart rateRespiratory rate/depthIncreased: salicylates, toxic alcoholsDecreased: opioidsTemperatureHigh: salicylates, sympathomimetics, antimuscarinics, serotonin toxicity, NMSLow: opioids, sedative-hypnoticsSlide18

Physical Examination

Pupillary size/reactivityLarge: sympathomimetics, antimuscarinicsSmall: opioids, cholinergicsNystagmusEthanol, phenytoin, PCP, DXM, ketamineDysconjugate gazeSlide19

Physical ExaminationSlide20

Physical Examination

Mental statusAgitationConfusionObtundationSkinWarm: sympathomimetics, antimuscarinicsMoist: sympathomimetics, cholinergicsDry: antimuscarinicsSlide21

Physical Examination

Lungs – bronchorrhea, wheezingBowel soundsNeurologic examinationUrination/defecationOdorsSlide22

Toxidromes

Toxicologic syndromesConstellation of signs and symptoms suggestive of a specific receptor effectHelpful in establishing diagnosis when exposure is unclearMany have overlapping featuresWarning: not all patients will have a “classic” toxidromeSlide23

Case

21 year old maleFound unresponsive with needle in armVS: T 97.0, R 4, P 60, BP 90/60Pupils 1mm bilaterallySkin cool/clammySlide24

Opioid

SedationMiosisDecreased respirationsDecreased bowel soundsSlide25

Case

18 year old male presents combative, mumbling, and incoherentVS: T 102.0, R 20, P 122, BP 138/78Pupils 6mm bilaterallySkin red, warm, and drySlide26

Antimuscarinic

Agitation/sedationHallucinationsMydriasisDry skin/MM’sDecreased bowel soundsUrinary retentionSlide27

Antimuscarinic

Agitation/sedationHallucinationsMydriasisDry skin/MM’sDecreased bowel soundsUrinary retentionSlide28

Case

Date: 3/20/199535 year old female presents with tonic-clonic seizuresVS: T 99.0, R 5, P 45, BP 90/40Pupils 2 mm bilaterallyHEENT: Secretions/vomit in mouth & noseLungs: Rales & wheezingSkin: diaphoreticSlide29

Cholinergic

DiarrheaUrinationMiosisBradycardiaEmesisLacrimationSalivationSlide30

Case

23 year old male brought to ED by ambulanceFound unresponsive outside rave partyVS: T 97.0, R 8, P 55, BP 107/55Pupils 5 mm bilaterallyGCS 5Slide31

Sedative-Hypnotic

SedationNormal pupilsDecreased respirationsSlide32

Case

45 year old male found screaming outside his hotelAgitatedVS: T 103.5, R 20, P 140, BP 190/110Pupils 6 mm bilaterallySkin: diaphoreticSlide33

Sympathomimetic

AgitationMydriasisTachycardiaHypertensionHyperthermiaDiaphoresis© Warner Bros. PicturesSlide34

ElectrocardiogramSlide35

Electrocardiogram

ECG abnormalities common in poisoned patients (up to 70% in one study*)Most findings nonspecificRecognition of specific changes can guide therapy*Homer et al. (abstract), Mediterranean Emergency Medicine Congress, 2005Slide36

Case

20 year old female arrives seizing and unresponsive s/p unknown ingestionVS: T 98.9, R 12, P 160 BP 80/45Slide37

ElectrocardiogramSlide38

Sodium Channel Blockade

Wide QRS (>120 ms)Tall R wave in aVRTCA’sDiphenhydramineIA/IC antidysrhythmicsCocainePropranololThe list goes on…Slide39

Sodium Channel Blockade

TreatmentSodium bicarbonate bolusHyperventilationHypertonic salineSlide40

ElectrocardiogramSlide41

ElectrocardiogramSlide42

Case

68 year old female arrives after unknown overdoseDrowsy but arousableVS: T 98.0, R 12, P 35, BP 60/PSlide43

ElectrocardiogramSlide44

Bradycardia

Sinus bradycardiaJunctional rhythmVentricular escape rhythmAtrial tachycardia with blockSlide45

Bradycardia

Calcium channel blockersBeta blockersClonidine & imidazolinesDigoxinSlide46

ElectrocardiogramSlide47

QTc

ProlongationMany medications can cause prolonged QTcRarely causes problemsBe concerned if patient is bradycardicSlide48

QTc

ProlongationSlide49

Laboratory AnalysisSlide50

Labs

Not a substitute for a thorough history and physical exam!Recommended labs:Metabolic panel (everyone)Acetaminophen level (everyone)Salicylate level (if exam/VS suggestive)Osmol gap (maybe)Slide51

Labs

Specific drugs (as indicated):EthanolValproic acidCarbamazepinePhenytoinLithiumDigoxinSlide52

The Urine “

Tox Screen”Commonly orderedRarely helpfulDoes not imply causality, only exposureLots of false positives/negativesDon’t rely on it to guide management decisionsSlide53

Treatment of the Poisoned PatientSlide54

Decontamination

Providers tend to overestimate potential benefitsLittle data showing improvement in outcomesShould only be considered after consideration of risks and benefitsSlide55

Syrup of Ipecac

Derived from roots of ipecacuanha plantDirect chemoreceptor zone actionMay cause prolonged emesis and sedationNo proven benefitNot recommendedSlide56

Activated Charcoal

Large surface areaAdsorbs many ingested xenobioticsShown to reduce AUC for many substancesNo improvement in outcomesSlide57

Activated Charcoal

Doesn’t work withMetalsIonsAlcoholsDon’t use withCausticsVomiting patientDepressed mental statusSlide58

Activated Charcoal

ComplicationsEmesisAspirationBowel perforation/obstruction with MDACMay consider if patient presents <1 hour s/p ingestion of worrisome substanceSlide59

Gastric

LavageLarge bore tube placed into stomach (NGT if liquid ingestion)Gastric cavity irrigated & aspirated to remove materialSlide60

Gastric

LavageSlide61

Gastric

LavageSlide62

Gastric

LavageSlide63

Gastric

LavageSlide64

Gastric

LavageSlide65

Gastric

LavageComplicationsHypoxiaAspirationLaryngospasmDysrhythmiasPerforationNot routinely recommendedSlide66

Whole Bowel Irrigation

Polyethylene glycolPhysically “flush” the GI tract of unabsorbed xenobioticsLimited dataConsider in:Iron & other metalsSustained-release medicationsEnteric coated productsBody packers (mules)Slide67

Whole Bowel Irrigation

ContraindicationsIleusBowel obstruction/perforationHemodynamic instabilitySlide68

Antidotes

Not necessary in most poisoningsCan be lifesaving in selected patientsConsider expected side effects and contraindications before useSlide69

N-

AcetylcysteineUsed primarily in acetaminophen poisoningFully protective if given up to 8 hours post-ingestionDetoxifies NAPQI (toxic metabolite)Can give with charcoalCons: smells bad, can cause vomiting, hypotension/rash (IV)Slide70

Naloxone

Opioid poisoningIV is preferred route but can give IM/SCGoal is reversal of respiratory depression, not awakening patient!Can precipitate opioid withdrawalShorter-acting than many opioidsSlide71

Flumazenil

Benzodiazepine receptor antagonistUseful in carefully selected patientsMay precipitate life-threatening withdrawal in chronic benzo usersDo not use in patients who may have ingested seizure-inducing medicationsSlide72

Fomepizole

4-methylpyrazolePotent inhibitor of alcohol dehydrogenasePreferred over ethanol for toxic alcohol poisoningDoes not cause sedation or hypoglycemiaSlide73

Antibody Fragments (

Fab)Rattlesnake envenomationBlack widow envenomationDigoxin poisoningSlide74

Antibody Fragments (

Fab)Most sheep-derivedExpensiveAnaphylactoid reactions (uncommon)ContraindicationsAllergy to horse or sheep serumPapaya allergySlide75

Hydroxocobalamin

Vitamin B12 precursorBinds cyanide irreversibly to form cyanocobalaminTurns body fluids redCan interfere with lab testingHas largely supplanted use of cyanide antidote kitSlide76

Methylene

BlueUsed to treat methemoglobinemiaCofactor for NADPH-methemoglobin reductase enzymeAvoid in G6PD deficiencySlide77

Enhancement of ClearanceSlide78

Alkalinization

May enhance excretion of weak acids“Ion-trapping”IV sodium bicarbonate (bolus)Consider in poisoning with:SalicylatesPhenobarbitalChlorpropamideMethotrexateAvoid over-alkalinizationSlide79

Dialysis

Useful in xenobiotics with:Small molecular weight (<500 Daltons)Low Vd (usu. <1 L/kg)Low protein bindingClears xenobioticCorrects acid-base abnormalitiesSlide80

Dialysis

Consider in:SalicylatesToxic alcoholsLithiumTheophyllineValproic acid (severe poisoning)Slide81

Other Methods

Urinary acidification – not recommendedForced diuresis – not recommendedCharcoal hemoperfusion – not widely availableMulti-dose activated charcoalTheophyllinePhenobarbitalDapsoneCarbamazepineQuinineSlide82

Shipboard Treatment

ABC’s are paramountConsider charcoal if <1 h and no contraindicationsNo ipecac, gastric lavage, or induced emesis!Antidotes helpful in select patients (esp. bicarb, NAC)If concerned, transfer to MTF ASAP or call Poison Control Center (800-222-1222)Slide83

Shipboard Treatment

Most patients will recover with careful supportive careHistory and physical exam can provide important cluesLook for toxidromesAntidotes helpful in select patientsConsider decontamination & elimination enhancementSlide84

Question #1

A patient presents to you after having ingested ten 800-mg ibuprofen tablets 4 hours ago. Which of the following treatments is indicated?A. Whole bowel irrigationB. Gastric lavageC. Activated charcoalD. Syrup of ipecacE. None of the aboveSlide85

Question #1

A patient presents to you after having ingested ten 800-mg ibuprofen tablets 4 hours ago. Which of the following treatments is indicated?A. Whole bowel irrigationB. Gastric lavageC. Activated charcoalD. Syrup of ipecacE. None of the aboveSlide86

Question #2

A patient is brought to the medical department comatose. Vital signs are as follows: T 97.9, P 60, R 4, BP 105/70. Pupils are 1 mm diameter bilaterally. Which of the following treatments would be most helpful?A. N-acetylcysteineB. Activated charcoalC. NaloxoneD. Sodium bicarbonateE. Methylene blueSlide87

Question #2

A patient is brought to the medical department comatose. Vital signs are as follows: T 97.9, P 60, R 4, BP 105/70. Pupils are 1 mm diameter bilaterally. Which of the following treatments would be most helpful?A. N-acetylcysteineB. Activated charcoalC. NaloxoneD. Sodium bicarbonateE. Methylene blueSlide88

Question #3

A 22-year old male is brought in by shipmates for strange behavior. He is confused, has dry warm skin, pupils are 6 mm bilaterally, and vital signs are as follows: T 100.6, R 12, P 130, BP 126/72. Which of the following did he most likely ingest?A. Jimson weedB. CocaineC. MethamphetamineD. HeroinE. AlcoholSlide89

Question #3

A 22-year old male is brought in by shipmates for strange behavior. He is confused, has dry warm skin, pupils are 6 mm bilaterally, and vital signs are as follows: T 100.6, R 12, P 130, BP 126/72. Which of the following did he most likely ingest?A. Jimson weedB. CocaineC. MethamphetamineD. HeroinE. AlcoholSlide90

Question #4

Which of the following interventions should always be performed on a potentially poisoned patient?A. Assess and secure airway as neededB. Obtain intravenous accessC. Provide supportive careD. Call Poison Control CenterE. All of the aboveSlide91

Question #4

Which of the following interventions should always be performed on a potentially poisoned patient?A. Assess and secure airway as neededB. Obtain intravenous accessC. Provide supportive careD. Call Poison Control CenterE. All of the aboveSlide92

Questions?Slide93

Acute Allergic Reactions and Anaphylaxis

LCDR Nate Clapp MD, MSFamily medicine/Flight surgeryFleet surgical team threeSlide94

Disclosure

I have no financial or other interests involving any products or companies that will be discussed in this lectureSlide95

Objectives

Define allergic reactions and anaphylaxisUnderstand the mechanisms through which these reactions occurTreat acute allergic reactions and anaphylaxisManage patients appropriately after an allergic or anaphylactic reactionSlide96

Anaphylaxis: How Common Is It?

Approximately 1,500 deaths per year in USNumber of non-fatal reactions is not known presumed to be around 100,00066% are new casesParenteral and topical agents>oralCondition poorly defined until 20042005 definition agreed upon by:National Institute of Allergy and Infectious Disease (NIAID)Food Allergy and Anaphylaxis Network symposiumSlide97

Definitions

Allergy – acquired potential to develop immunologically-mediated adverse reactions to normally innocuous substancesAnaphylaxis“A serious allergic reaction that is rapid in onset and may cause death”.Has clinical criteriaSlide98

Anaphylaxis Criteria

Acute onset of illness (minutes to hours) with involvement of skin, mucosa or both, and at least one of the following:Respiratory compromiseReduced blood pressure (SBP <90) or symptoms of end-organ dysfunctionOr Two or more of the following:Skin-mucosal involvementRespiratory compromise (Reduced blood pressure/end-organ compromisePersistent GI symptoms (Nausea, vomiting,OrReduced BP after exposure to known allergen (PCN, peanuts, etc…)Slide99

Same Thing/Different LookSlide100

Allergy Terms

Urticaria (hives)Blood vessel dilation and edema of the dermisCutaneous elevations (wheals)PruriticSuperficialPolymorphicAngioedemaAnaphylaxisSlide101

A Picture Is Worth 1000 Words

AngioedemaUrticariaSlide102

PruritisSlide103

Pathophysiology of Allergic Reactions

Type I (Immediate hypersensitivy): IgE drivenTwo step processStep 1: Sensitization (First time immune system decides the antigen is not its friend)Step 2: Re-exposure to antigen>>activation of mast cells and basophils>>degranulation and release of mediatorsSlide104

Mediators of Anaphylaxis

Histamine (most important)Increased vascular permeability (H1 and H2). Vasodilation, shock, angioedema, urticarialSmooth muscle contraction (H1)Brochoconstriction, GI effects (vomiting/diarrhea), uterine contractionCardiacCoronary artery spasm (H1)Increased heart rate (H2)Increased glandular secretion (H1 and H2) (mucus/saliva)GI: Increased gastric acid secretion (H2)Leukotrienes and prostaglandinsCytokinesSlide105

Target Organs

CardiovascularHypotension (30%), syncope,arrhythmia, anginaRespiratory (50% of cases)Upper – pharyngeal or laryngeal edemaLower – bronchospasm GI (30% of cases)Nausea, vomiting, diarrhea, crampingSkin (88% of cases)Flushing, erythema, pruritus, urticarial, angioedemaCentral nervous systemHeadache, confusion, altered mental statusSlide106

Clinical Spectrum and Time Course

Clinical ManifestationsNasal congestionUrticariaAngioedemaPresyncope/bronchospasmCardiovascular collapse and respiratory failure**Skin involvement occurs in 88% of all reactions **Must look out for the other 12%Time Course of PresentationImmediate/early onset5-30 min after parenteral2 hours after oralMost fatalities occur within 30 minBiphasic anaphylaxisSecond wave reactionOccurs in 1-20% of cases of anaphylaxis1-72 hours later, most within 8 hoursSeverity of initial reaction not predictiveSlide107

Etiologic Agents

Anaphylactic (IgE-mediated)FoodMedicationsInsect VenomLatexExerciseAnaphylactoid: NOT IgE-mediatedOpioidsAspirin and NSAIDSRadiocontrast mediaMimics anaphylaxis (treatment is the same)Immediate systemic reactionMay occur on first exposureLevel of reaction depends on degree of exposureSlide108

Treatment of Allergic Reaction

IVOxygenMonitorBenedryl (diphenhydramine) 50 mg IV (H1 blocker)Zantac (ranitidine)50 mg IVAlbuterol (wheezing/SOB)Steroids (take 4-6 hours to take effect)Decadron 10 mg IVSolumedrol 125 mg IVSlide109

H2 Blockers are important

Diphenhydramine 50 mg IV + ranitidine 50 mg IVDiphenhydramine 50 mg IV + PlaceboUrticaria at 2 hours8%26%Need for additionalAnti-histamines4%23%Slide110

Treatment of Anaphylaxis

IVOxygen and Prepare for difficult airway (Bougie or glidescope)MonitorEpinphrine 1:1000 0.3-0.5 mL SC or IM q5 min OREpinephrine drip (1 mg in 1 L NS. Start 1 cc/min titrate every minute) OREpinephrine 1:10,000 1-5 cc IV (0.1 mg/ml)“Epinephrine is the drug of choice for anaphylaxis” (World Allergy Organization) Bronchodilator, chronotrope and inotropeGlucagon 1-5 mg IV if patient on Beta BlockerSlide111

Airway ManagementSlide112

Management

Monitor for 8 hours (cover the second wave)Admit if:Severe presenting symptoms even if resolvedHistory of severe, protracted or recurrent anaphylaxisComorbidities (asthma, CHF, Renal disease)Concurrent beta blocker useSlide113

Medications at Discharge

Epipen (0.3 mg) IM and teach how to use itH1 blocker (3-7 days)H2 blocker (3-7 days)Corticosteroids (3-7 days)Slide114

Question 1

Allergic reactions commonly involve the skin and mucosa. What percentage of cases do not involve skin or mucosa?A. 1%B. 6%C. 12%D. 21%Slide115

Question 2

Which of the following statement(s) meet the definition of anaphylaxis?A. Acute onset of illness (minutes to hours) with involvement of skin or mucosa AND respiratory compromiseB. Reduced blood pressure after exposure to a known allergenC. Skin or mucosal involvement AND persistent GI symptomsD. All of the aboveE. A and B onlyF. A and C onlySlide116

Question 3

You are underway and a 50-year old Master Chief weighing 70 kg presents to Medical complaining of throat swelling, difficulty breathing and pruritic hives. Which of the following is an inappropriate dose/route of epinephrine administration combination to treat his anaphylactic reaction?A. Epinephrine 1:1000 1-5 mL IVB. EpiPen 0.3 mg IMC. Epinephrine 1:1000 0.2-0.5 mL IMD. Epinephrine 1:1000 0.2-0.5 mL SCSlide117

Question 4

You find out the Master Chief is on Toprol (metoprolol) XL 50 mg daily for hypertension. Which of the following aduncts is MOST LIKELY to improve his treatment?A. Diphenhydramine (Benadryl) 50 mg IVB. Ranitidine (Zantac) 50 mg IVC. Glucagon 5 mg IVD. Solumedrol 125 mg IVSlide118

Pearls and Pitfalls

Give epinephrine to everyone with respiratory or cardiovascular symptoms (Don’t wait for them to get bad)Remember to give an H2 blocker in addition to the H1 blockerLow threshold for admission/observationMost second wave phases occur within 8 hoursDon’t forget Glucagon if patient on a beta blockerKnow your epinephrine doses/routes of administration.Make it simple and teach your CorpsmenSlide119

QuestionsSlide120

Fleet Dental

Sara A. Chilcutt LT DC USNFleet Division Officer/ Fleet Liaison OfficerNBHC Naval Base San DiegoFleet Office: (619) 556-4797Front Desk: (619) 556-8239/40sara.a.chilcutt.mil@mail.milSlide121

HPV Knowledge and HPV Vaccine Uptake Among U.S. Navy Personnel 18 to 26 Years of Age

Jennifer Buechel, CDR, NC, USNSlide122

Introduction

PhD Candidate at the University of San Diego, CaliforniaObtained NMCSD and USD IRB approvalsFederally funded grant under the Tri-Service Nursing Research Program Obtained research setting approval from the Commander, U.S. Navy Forces PacificAll COs and XOs (SURFPAC) are aware Study recruitment phase began late May 2015 Slide123

Study Purpose Slide124

Study Methods

Inclusion Criteria:Active duty (or reserve on active status) in the U.S. Navy between 18 and 26 years old Goal of 250 participants Electronic survey using Max Survey softwareRecruitment Strategies: First: Batch emailsSecond: Advertisements Third: In person Slide125

Study Update

Only 30 eligible participants have completed the survey If you have not sent out the batch emails, please do so Create ways for recruiting: Safety Stand Downs, Health and Wellness Fairs PHAs/Well Woman ExamsLearning tools for junior medical personnelPODs, ship papers Post and hand out recruitment toolsTraining and Safety Officers, “Fun Bosses” Slide126

Special Thanks

All the Medical Readiness Division (MRD) personnel Site visits with DDG-73, DDG-110, LSD-49USS Makin Island’s medical department personnel are the bomb!! Big thanks!!Individual providers Welcome suggestions and ideas, research among the fleet is a team effort!If you are within the age range, please come see me to complete the survey (medical personnel not exempt) Slide127

Contact Information

CDR BuechelEmail: jbuechel@sandiego.eduPrimary #: 734-250-4190Secondary #: 619-825-7385 Slide128

Medical Readiness Division

MRD_SD_GMO@navy.mil(619) 556-5191Bldg 116San Diego, CA 92136Slide129

Active Duty Clinic-Gen Surgery

Director, MRD CDR Hoang has volunteered to see common general surgery pathology on Fridays at Dept of Surgery, NMCSD to fast track fleet referrals, including:Soft tissue (lipoma, epidermal inclusion cyst, pilonidal cyst); Anal disease (hemorrhoid, anal/rectal abscess); Screening colonoscopySymptomatic cholelithiasisHernia (ventral, incisional, inguinal, umbilical)Gen surg matrix referral rules still apply. Conditions requiring long term follow up will not be included in active duty clinic, unless discussed with MRD Physician Supervisors.Include “forward to Dr. Hoang” in body of the referral.Slide130

Upcoming Meetings

July 29th @ 1000-1200TraumaPsych EmergenciesAugust 27th @1000-1200X-ray interpretation (GMOs)Pelvic/speculum exam (IDCs)September 30th @1000-1200Ortho emergencies + Splint/Cast basicsPrev MedOctober 28th @1000-1200EKG InterpretationOptho EmergenciesACRSlide131

CME – how toSlide132

CME – how toSlide133

CME – how toSlide134

CME – how toSlide135

Post Tests

Please put your name on the quiz!Slide136

CME Information

CME Code (To claim credit online): 7888Closing Date (To claim credit online): 07 JUN 2015To complete CME Log onto the MRD IDC website and click on the CME credit linkorGo to NMCSD SEAT SharePoint site (via citrix or NMCSD/BMC computer) and click on MRDSD Waterfront Meeting http://nmcsd-as-spfe05/sites/dpe/setd/Lists/cmesurvey/Item/newifs.aspx?List=be0f840e%2D0489%2D4b5a%2Db8de%2D9c4cd1a323e5&Web=0901130e%2Dd444%2D45b8%2D8bc7%2D5b9ec10dca77