Modern Resident - The newsletter of AAEM/RSA
June/July 2012
Volume 4: Issue 1  |  FacebookTwitter


Your 2012-2013 Leaders:

President
Leana S. Wen, MD MSc

Vice President
Stephanie Gardner, MD

Secretary-Treasurer
Taylor McCormick, MD

Immediate Past President
Teresa M. Ross, MD

At-Large Board Members
Rachael Engle, DO
Ali Farzad, MD
Megan Healy, MD
Sarah Terez Malka, MD
Meaghan Mercer, DO

Medical Student Council President
Mary Calderone

Publications Advisor - Ex-Officio Board Member
Joel Schofer, MD RDMS FAAEM

Modern Resident Contributors

Copy Editor: Rachael Engle, DO
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this issue's contributors:
Leana S. Wen, MD MSc; Megan Healy, MD; Veronica Tucci, MD JD; Kevin Farquharson, MD; Jeff Scott, MD; Jessica Baxley, MD; Rachael Engle, DO; Joe Lex, MD MAAEM FAAEM; Catherine Carrubba, MD FACEP; Steven McGuire, DO; Manuel Penton, MSIII; Aditya Ancha, MSIV; and Eric Schott, MSIII

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by July 15th for the August/September edition.

Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.


President's Update

Leana S. Wen, MD MSc
AAEM/RSA President
Brigham & Women's Hospital/Massachusetts General Hospital

I'm very excited to lead our dynamic and nimble organization through another year of advocacy: for residents and students, for our specialty, and for our patients. RSA had our first board meeting of 2012-2013 at SAEM, and your new board members have a lot of new projects planned for this year. Check out RSA's new website at www.aaemrsa.org – it offers tons of resources including the new FREE EM:RAP; our FREE publications; our next Call for Committees to get involved with national leadership; and updates from our committees, including our newest committee: the International Committee!


Mark your calendars for the AAEM/RSA Advocacy Day, September 12, 2012, in Washington, DC! More information coming soon! Check Facebook for more updates.


Advocacy Committee Update

Megan Healy, MD
Advocacy Committee Chair
Temple University Hospital

The AAEM/RSA Advocacy Committee has exciting news to report! Just a few weeks ago, the Senate voted an astounding 96-1 to pass the FDA user fee reauthorization bill, which also strengthens the FDA’s ability to respond to the critical drug shortages that have affected our patients. In the past few months, emergency physicians nationwide have been forced to make tough choices when important drugs like Ativan, Dilaudid and RSI medications have been found in short supply, if available at all. Along with our colleagues in other specialties, we have all seen that these challenges compromise our ability to care for patients.

The AAEM/RSA board members and Advocacy Committee from this year and last provided input to the FDA user fee reauthorization bill and worked on ensuring that emergency medical drugs were specifically addressed in the legislation. Our resident and student members sent letters to our legislators and joined with other professional organizations in a coalition mode to advocate for the drug shortages provisions contained in the reauthorization bill. The grassroots effort from AAEM/RSA helped convince Senators to vote with our interests in mind and led to this rare showing of bipartisanship.

Other portions of the Senate version of the reauthorization bill-S. 3187- renew two user fee programs and create two more, ensuring that the FDA has the necessary resources to review and approve new medical products. It also contains provisions that improve the submission process for medical device manufacturers and expedite the review of drugs targeting serious diseases. Most importantly to EPs, the bill enhances the ability of the FDA and drug manufacturers to anticipate and respond to potential drug shortages.

On July 9th, President Obama took the final step of signing the Food and Drug Administration Safety and Innovation Act, a piece of legislation which combined the key portions of both the Senate and House Bills.

Thank you to all the members who took the time to contact their Senators. It is great to see the activism of our member base and to know we can make a difference on such an important issue. Want to become involved in the issues that impact emergency physicians and the welfare of our patients? We encourage all members to sign up to receive AAEM’s legislative alerts. These concise emails let you know when action is needed most and will link you to a pre-formatted letter or email which will then be sent on your behalf to your members of Congress. This efficient process ensures that your voice is heard!

Sign up here: http://www.capwiz.com/aaem/home/ (scroll to bottom left).


AAEM/RSA Video and PowerPoint Presentation Now Online!

The American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) has just released two promotional online resources. The AAEM/RSA video and PowerPoint presentation both illustrate what AAEM/RSA is all about – advocating for our patients, our specialty and YOU!!

Go to http://www.aaemrsa.org/resources/presentations to view the video and PowerPoint presentation. Please feel free to use these resources in your residency program, your EMIG, or any other way you choose to reference AAEM/RSA and all of its many membership benefits and opportunities.

Remember, along your journey, AAEM/RSA is with you all the way!


Photo of the Month #1

Manuel Penton, MSIII
Veronica Tucci, MD JD
Kevin Farquharson, MD
University of South Florida College of Medicine


Click to enlarge

Which of the following is the most likely etiology for the picture above?

  1. A 7-year-old Caucasian male was brought to the ED by his parents with numerous staples lodged diffusely on his anterior trunk after being found crying in his parent's garage. The parents believe the child was playing with his father's staple gun before they arrived.
  2. A 6-year-old Caucasian male was brought to the ED by his babysitter with numerous lacerations on his anterior trunk and right upper extremity. The babysitter reports that she found the child in the bathroom playing with his father's disposable shaver. In an effort to stop the bleeding, an emergency medicine intern used staples to temporarily close the lacerations.
  3. A 6-year-old Caucasian male brought to the ED by EMS with flash flame burns to the posterior trunk, anterior trunk, face and right upper extremity. The patient was reportedly playing with a cigarette lighter when he accidentally lit his shirt on fire. After being transferred to the pediatric ICU, the patient eventually received operative excision and skin grafting to treat his full-thickness burn wounds.

Answer: C
The image above is an AP chest X-ray taken of a 6-year-old male status-post operative excision and skin grafting for full thickness burn wounds to his posterior trunk, anterior trunk, face and right upper extremity. An unmeshed autograft was cut to size and secured in place over this wound using surgical staples and Histoacryl. Upon presenting to the ED, the patient had vital signs within normal limits and a negative review of symptoms. The physical exam found no soot in the mouth, normal speech, and discomfort due to pain. Examination of the skin in the ED revealed a patient with 3rd degree burns to the back that wrapped around the right flank to the right side of the abdomen, 1st degree burns to most of back and chest, 2nd degree burn to upper right shoulder, 2nd and 3rd degree burns to right anterior hand and palm, 1st degree burn to right side of head and right ear and singed eyebrow hairs and hairs to top of head. Emergent treatment of the patient included sedation with morphine, midazolam and the administration of ketamine. The TBSA was about 30-35%. The following photos were taken in the ED at the time of presentation.

Click to enlarge

Choices A & B are not correct. Although the chest X-ray demonstrates staples in place, the distribution and number make it highly unlikely that it was caused by a traumatic event with a staple gun or the result of medical repair of simple lacerations.


Toxicology Board Review Question
Jeff Scott, MD
St. Louis University School of Medicine

Q: A 45-year-old male complains of fatigue, joint and muscle aches, finger numbness, dysuria and painful ejaculation. He and his wife have just recovered from severe food poisoning during their Caribbean vacation. Which diagnosis is most likely?

A. Guillain Barre
B. Ciguatera Poisoning
C. Viral Illness
D. Chlamydia
E. E. Coli

Answer: B
Tropical reef and predatory fish may contain large amounts of ciguatoxin or similar toxins produced by dinoflagellates eaten by their prey.

Toxins which are tasteless, odorless and heat resistant affect cellular sodium and calcium channels. Toxicity first produces severe GI and sometimes fatal cardiac symptoms such as hypotension and bradycardia that typically resolve within four days. This is followed by neurological symptoms such as fatigue, malaise, peripheral and oral parasthesias, blurry vision, myalgia and arthralgia, cold allodynia, dysuria, dyspareunia, and painful ejaculation. If diagnosed within 72 hours of consumption, IV mannitol is found to prevent or lessen neurological symptoms. Otherwise treatment is supportive.

Neurological symptoms may persist for months to years and may be lessened by gabapentin, nifedipine and antidepressants. Patients should be instructed to avoid fish as well as other foods that may precipitate symptom recurrence (i.e., alcohol, caffeine and nuts). Sexual partners of symptomatic patients have reported genital pain and parasthesia. Women should be informed that chronic ciguatera is associated with spontaneous abortion and premature labor.

References:

  1. Friedman M, Fleming L, Fernandez M, et al. Ciguatera fish poisoning: treatment, prevention, and management. Mar Drugs. 2008; 6(3); 456-79.
  2. Chateau-Degat M, Beuter A, Vauterin G, et al. Neurologic signs of ciguatera disease: evidence of their persistence. Am J Trop Med Hyg. 2007; 77(6):1170-5.
  3. Dickey R, Plakas S. Ciguatera: a public health perspective. Toxicon. 2010; 56 (2):123-36.

Abdominal Pain Board Review
Jessica Baxley, MD

A 58-year-old male with a history of chronic myelogenous leukemia and diverticulosis presents to the emergency department with persistent left lower quadrant pain for two days. His vital signs are within normal limits. Which of the following is true of this disease process?

  1. Negative CT findings rule out a diagnosis of complicated diverticulitis.
  2. Diffuse, persistent abdominal pain is common with uncomplicated diverticulitis and should not warrant additional work.
  3. If CT is unable to delineate between diverticulitis and an alternate diagnosis, a water-soluble contrast enema may be used to make the diagnosis.
  4. Presentation of this disease in immunocompromised patients is often more pronounced, though their clinical course is similar to non-immuncompromised patients.

Answer: C
Though CT is the ideal initial imaging modality, it is not always 100% sensitive and specific, and enemas may be used to make the diagnosis. However, the contrast material must be water-soluble in case perforation is present; barium enemas are contraindicated.1

A is false. Though the sensitivity and specificity of abdominal CT for the diagnosis of complicated diverticulitis are high, small diverticula and abscess formation can be missed. Additionally, colon cancer (which can present similarly) may be difficult to distinguish from the bowel wall thickening seen with diverticulitis.2

B is false. Although diverticulosis can be associated with bloating and cramping pain, uncomplicated diverticulitis is usually associated with localized discomfort. Diffuse persistent tenderness could suggest complicated diverticulitis and should be further worked up to evaluate for the presence of perforation, abscess, fistula or obstruction.2

D is false. Elderly individuals and immunocomprised patients often have less noticeable symptoms of diverticulitis but have a higher incidence of complications and a higher mortality rate.3

References:

  1. Miller FH, Rosen MP, Lalani T, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria Left Lower Quadrant Pain - suspected diverticulitis. [online publication]. Reston (VA): American College of Radiology (ACR); 2011.
  2. Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.
  3. Ferzoco LB, Raptopoulos V, Silen W: Acute Diverticulitis. New England Journal of Medicine. 1998; 338:1521.

Photo of the Month #2
Rachael Engle, DO
Joe Lex, MD MAAEM FAAEM
Temple University Hospital

HISTORY OF PRESENT ILLNESS
74-year-old male complained of severe headache for one week. It came on rather suddenly as he was carrying laundry up the steps from his basement. It was only partially relieved by over-the-counter analgesics and did not seem to be going away.

PHYSICAL EXAM
HR 74, R 14, BP 138/74, T 98.4 SpO2 97% on RA.
General: The patient is awake, alert but looks uncomfortable.
Neuro: Cranial Nerves II-XII intact, no cerebellar signs, gait steady and walks without difficulty.
HEENT: PERRL, mild photophobia, EOMI, no visual field cuts. No scalp or sinus tenderness to palpation/percussion.
Skin: No rashes
CV/Pulmonary/Abdomen and Back: Nonfocal
Labs: CBC and BMP both WNL

Noncontrast CT Head: Cerebrospinal Fluid:

Click to enlarge

QUESTIONS

  1. The CT head was read negative by neuroradiologist. What is the diagnosis?
  2. What is the pertinent finding from the lumbar puncture?

ANSWER:

CSF Xanothochromia from Subarachnoid Hemorrhage

CT scans have a 98% sensitivity for detecting subarachnoid hemorrhages within the first 12 hours of symptom onset. After the initial 12 hours after symptom onset, CT scans become less sensitive secondary to the reabsorption of blood.1

CT scan followed by lumbar puncture is necessary to accurately diagnose subarachnoid hemorrhage, especially if it has been greater than 12 hours since onset of symptoms. When the CT scan is negative, lumbar puncture is done to look for CSF Xanthrochromia or red blood cells.

CSF Xanthrochromia occurs because of the breakdown of red blood cells into bilirubin, causing the yellow appearance of the CSF. This takes place 12 hours after symptom onset and can be evident up to three weeks after onset. If xanthochromia is not visualized, it is recommended to send the sample for spectrophotometry to detect bilirubin.2,3

When there is clinical suspicion of a subarachnoid hemorrhage and symptoms have been present for more then 12 hours, it is imperative to perform a LP with a negative head CT.

References:

  1. Edlow JA, Caplan LR: Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 342: 29, 2000.
  2. Al-Shahi R, White PM, et al: Subarachnoid hemorrhage. BMJ 333: 235, 2006.
  3. Chalmers AH, Kiley M: Detection of xanthochromia in cerebrospinal fluid. Clin Chem 44: 1740, 1998.

Neurology Board Review Questions
Aditya Ancha, MSIV
Veronica Tucci, MD JD
Catherine Carrubba, MD FACEP
University of South Florida School of Medicine

BOARD REVIEW: STROKE NEUROLOGY

Q1. A 65-year-old male presents with dizziness and generalized weakness early this afternoon while shopping shortly after dinner. The patient recently underwent open heart surgery to have a prosthetic heart valve placed. His current medications include simvastatin, metoprolol and coumadin. He describes the dizziness as occurring gradually over the past few days and not succumbing to losing his balance and having a traumatic fall. He describes the dizziness as being bearable with a constant level of intensity, while also denying any nausea, vomiting or ringing in his ears. On physical exam, the patient exhibits vertical nystagmus but no horizontal or rotatory nystagmus. A Dix-Hallpike maneuver was performed, which proved to be negative. A pneumatic otoscope was also used to insufflate air into both his ear canals, which also failed to provoke an episode of vertigo with nystagmus. Which of the following is the correct diagnosis?

A. Physiologic vertigo
B. Central vertigo due to stroke
C. Benign positional vertigo (BPV)
D. Perilymph fistula
E. Meniere’s Disease

Answer: B
The patient’s gradual onset of vertigo, low-intensity dizziness, presence of only a vertical nystagmus, and lack of nausea, vomiting and tinnitus are all more indicative of a pathology reflecting central vertigo, and a high index of suspicion should be maintained. On the other hand, peripheral vertigo is described as having sudden onset, intense dizziness, frequent nausea and vomiting, tinnitus and a rotatory-vertical or horizontal nystagmus, although all these symptoms may not be present at once. Nystagmus with only a vertical component generally represents a brainstem abnormality, helping to support pathology reflective of central vertigo here. The patient also has many risk factors for a stroke given his recent cardiac surgery and use of warfarin. In any patient taking warfarin, central vertigo should always be evaluated to rule out pathology. During the physical exam, the physician should look for other signs of a central pathology, such as neurological deficits like diplopia, dysarthria or visual abnormalities. This also includes loss of a corneal or gag reflex. All the other answer choices are incorrect since they represent pathologies that reflect a peripheral vertigo. The Dix-Hallpike test evaluates for BPV, which it is 50 to 80% sensitive for, while the insufflation of air with the pneumatic otoscope tests for a perilymph fistula, an opening in the oval or round window creating an abnormal communication between the middle ear and vestibular apparatus.

References:

  1. Goldman, B. "Chapter 164. Vertigo and Dizziness" (Chapter). Tintinalli, JE, et al: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e: http://www.accessmedicine.com.ezproxy.hsc.usf.edu/content.aspx?aID=6365889

Q2: A 60-year-old male with a history of diabetes and hypertension presents with weakness, dizziness and abnormal speech for the past 24 hours. The patient’s spouse states that he recently started acting “funny,” and his symptoms have been worsening. Upon examination, the patient appears confused but is able to follow your commands. During the cardiac examination, a left carotid bruit is auscultated. During the neurological examination, a sensory and motor loss is noted in the right lower leg. The patient’s speech sounds halting and effortful, but he is able to repeat words back to you. The patient does not have evidence of cranial nerve abnormalities on exam. What syndrome describes the ischemic stroke this patient suffers from?

A. Anterior Cerebral Artery Infarction
B. Middle Cerebral Artery Infarction
C. Posterior Cerebral Artery Infarction
D. Vertebrobasilar Infarction
E. Cerebellar Infarction

Answer: A
Patients with an anterior cerebral artery infarction suffer from contralateral sensory and motor loss in the lower extremities sparing the face and upper extremities. A left-sided lesion is associated with mutism and transcortical motor aphasia - with repetition retained, while a right-sided lesion is associated with motor hemineglect. A middle cerebral artery infarction (choice B) is incorrect, because an infarction here affects the face and upper extremities. Choice C is incorrect, since the patient presents with no visual field deficits. Choice D is incorrect, since the patient does not present with simultaneous signs and symptoms of vertigo, headache, nausea, visual disturbances, oculomotor palsies, limb weakness or oropharyngeal dysfunction. Finally, choice E is incorrect since the patient does not have vertigo, ataxia, headache, dysarthria, nausea, vomiting, or cranial nerve abnormalities.

References:

  1. Go, S, et al. "Chapter 161. Stroke, Transient Ischemic Stroke, and Cervical Artery Dissection." Tintinalli, JE, et al: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e: http://www.accessmedicine.com.ezproxy.hsc.usf.edu/content.aspx?aID=6356350

Q3: A 75-year-old female patient presents with headache, nausea and vomiting for the past 48 hours. Her past medical history is significant for an aortic valve replacement 15 years ago. The patient is alert, and she tells you she suffered from no recent trauma. Upon examining her, you note the patient’s visual acuity is 20/20 in both eyes, but her speech is abnormal. During the neurological examination, the patient is able to understand your questions, respond appropriately, and repeat words back to you, but her words are poorly articulated. In addition, you ask the patient to walk across the room, and she nearly falls. As the physician, you suspect the patient may be suffering from a cerebellar infarction. What is your next step in the management of this patient?

A. Emergent surgical decompression
B. Administer unfractionated heparin
C. Administer recombinant tissue plasminogen activator (rtPA)
D. Emergent MRI or MRA
E. Infuse hypertonic saline

Answer: D
The patient's signs: dysarthria from her poorly articulated words and gait ataxia from her inability to walk, and symptoms: headache, nausea and vomiting, are all consistent with a cerebellar infarction. Due to the obscuration by a posterior fossa bone artifact, an emergent MRI or MRA is preferred after a noncontrast brain CT may be used to rule out a hemorrhagic infarction. Choices A and E are incorrect, because they involve therapeutic interventions for the development of cerebellar edema. The development of an obstructing hydrocephalus is a possible complication of a cerebellar infarction that can result in poor outcomes. Choices B and C are therapeutic interventions that may be utilized in an ischemic stroke, but diagnosis should always precede treatment.

References:

  1. Go, S, et al. "Chapter 161. Stroke, Transient Ischemic Stroke, and Cervical Artery Dissection." Tintinalli, JE, et al: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e: http://www.accessmedicine.com.ezproxy.hsc.usf.edu/content.aspx?aID=6356350

DO in EM
Steven McGuire, DO
Jacobi/Montefiore

Part 1 (wait for part 2 for the EM Match Game and your Doggy Bag):

After the last bite of Lasagna Classico, I asked for the check. I was relieved. I had made a very difficult choice for the future of my family and me. Like many 4th year medical students, I made a lot of tough decisions – before and during medical school. I had to make all the difficult decisions other EM bound students make, including where to rotate, where to apply, where to interview, and how to rank the programs. I was like everybody else – at times confident, at times insecure, at times obsessed, at times resigned to my fate, at times anxious, and at times relaxed.

While I may not be unique, I think I am different in a few respects from my colleagues that matched into EM this March 16th. I am a DO student. I am turning 40 this year. I am married with a 2-year-old son and 9-month-old daughter. There can’t be more than a handful of applicants like me in any given year, can there?

I don’t worry "too much” about "too much." I rarely get stressed over tests, or rotations, or Boards, or even public speaking. I’m “even Steven." Whatever it is, it will generally be ok.

But...I started having anxiety dreams around July. I am not the top of my class. I haven’t invented anything that made your life better. I am not even the most interesting man in the world, and I never drink Dos Equis. I am not the best EM applicant on paper. One of the great things about EM is that it’s a field where you have to be smart and hard working but where everybody will give you a chance to be smart and hard working. If medicine is populated by "nerds," which I think is a given, then perhaps EM is filled with “cool nerds." We are allowed to be slightly more interested in surfing than T1-weighted MRI images. If you pass the “2am test” and are willing to learn with your colleagues, you can probably make it in EM.

Enough about you, back to me. One thing I do worry "too much" about is my family. My wife gave up as much as I did when I started med school. She dropped me off at my Boston to NYC BoltBus or MegaBus. She stayed home alone, worked, and paid the mortgage in Boston. She was pregnant with our son, while I studied three states away. She was a “single mother” three days a week when I went back for labs and exams. She was pregnant with our daughter during my 3rd year, when I commuted 55 miles each way to RI for core rotations. As hard as I worked to be a good husband, father and med student, she worked at least as hard to pick up the slack and keep teaching 6th grade math. So I worry about making life even harder for her, for them. I was scared. What would residency mean for them?

The NRMP scares everybody – especially as both MD and DO schools are increasing class sizes without corresponding increases in residency spots. DO students have data that makes it a bit scarier. Historically, DO’s have filled a little over 10% of ACGME program spots. But EM has been getting more competitive – in both matches. This year was the first time in many years that there were no unfilled EM spots in the NRMP match. In 2008, 77% of EM was filled by seniors at U.S. MD schools. This year, 80% were filled that way. There is also the unverified statistic I’ve been told by several people: only 40% of DO’s match into their top three choices in the NRMP. Like I said, the match is scary.

Stay tuned, the second part of this article will be continued to the August/September issue of Modern Resident.


Echelons of Care Part 2
2nd Lt. Eric Schott, MS III
Uniformed Services University of the Health Sciences

The following series is composed of two parts, outlining the path of a soldier from battlefield injury to definitive care in the U.S. Part one outlined the path of care within the combat zone; from point of injury in the field to larger hospitals with more extensive resources. This comprised echelons (levels) I - III. Part two will now summarize care following evacuation through that given at military hospitals in the U.S.

Once evacuated from the combat zone, patients enter echelon four care, including all definitive medical and surgical care outside the combat zone, yet within the communication zone of the theater of operations. The focus here is on treating patients requiring more intensive rehabilitation or special needs, prior to further evacuation to the U.S. Landstuhl Army Regional Medical Center in Germany now provides this capability in our current operations in the Middle East. This is a semi-permanent or permanent facility with OR and ICU capability, general, orthopedic, gynecologic, urologic and oral surgery, dental and optometry services, as well as outpatient specialty and primary care services. Larger facilities can provide support for up to 476 patients.

The final level of care, echelon five, is provided in the continental United States. They provide the ultimate treatment capability for patients generated within the combat zone. Department of Defense (DoD) hospitals (military hospitals) and Department of Veterans Affairs (DVA) hospitals are specifically designated to provide the soldier with maximum ability to return to function through medical, surgical, rehabilitative and convalescent care. If DoD resources are unable to satisfy this task, civilian hospitals may be used. Prominent examples include Walter Reed Army Medical Center in Washington, DC, Brook Army Hospital and San Antonio Medical Center in San Antonio, TX, and David Grant Medical Center in California. Here, the remainder of care is provided on both inpatient and outpatient (with appropriate lodging facilities) status for as long as needed.

As current and future conflicts and missions continue, the Department of Defense continues its ongoing process of data collection from all stages of care with research ongoing at all points between. Of final note, it should be realized that a considerable amount of care takes place between each level on aero-medical transports to and from each stage. This incorporates another field of specialty care somewhat unique to the military. Regardless of the circumstances, military medicine stands ready to provide the care necessary to support our most important and specialized resource: its personnel.

References:

  1. Folio, L. R. (2010). Combat Radiology: Diagnostic Imaging of Blast and Ballistic Injuries. New York: Springer.
  2. Silva, K. (2010). Medical Care in Theater. 3rd Annual Trauma Spectrum Conference (pp. 10-11). Bethesda, MD: Defense Centers of Excellence.
  3. U.S. Dept of the Army. (2004). Emergency War Surgery. Washington, DC: Borden Institute, Walter Reed Army Medical Center.
  4. U.S. Joint Chiefs of Staff. (1995). Joint Publication 4-02: Doctrine for Health Services Support in Joint Operations. Washington, DC: US Department of Defense.