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Our Instructors

Chief Executive Officer - Teaching Faculty

Robert Beatty, MD FACEP

Founder

Dr. Beatty received his Bachelor’s of Science in Biological Sciences from Clemson University and earned his Doctorate in Medicine from the University of South Carolina School of Medicine.   He completed his residency training in Emergency Medicine at the Johns Hopkins Hospital in Baltimore, Maryland.   Dr. Beatty has extensive experience as a clinician, medical leader, department chairman, medical director, regional medical director, and Chief Medical Officer.   In addition to his clinical and administrative roles, Dr. Beatty is a regular speaker at several national conferences and is an active expert medical witness. He is an avid teacher, and regularly supervises Physician Assistants, Nurse Practitioners, and fellow physicians.   He has served as a physician mentor to his medical staff, and as a member of hospital credentialing, medical executive and peer review committees.   Having extensively recruited, interviewed, hired, and reviewed countless numbers of healthcare providers, his expertise in team building, recruitment, and the hiring process allows us to deliver the message of our programs in a way that other courses can’t match.   In addition, having established an Advanced Practice Provider residency program in multiple hospitals, Dr. Beatty understands the key concepts needed to prepare Nurse Practitioners and Physician Assistants for their transition to independent clinical practice.  Dr. Beatty works as a full time emergency physician and medical director, and is a valuable resource to our program!

Clinical Skill and Procedure Workshop
airway course for Nurse practitioners
ultrasound course for PA's and NP's
Chief operating officer- nursing supervisor

Rachel Beatty, MSN, FNP-BC, AG-ACNP-BC

Founder

Mrs. Beatty received her Bachelor’s of Science in Nursing from Adventist University in Orlando, Florida.  She Earned her Master of Science in Nursing from the University of South Alabama, graduating in the top 10% of her class.   She is a member of the Phi Kappa Phi Honor Society and has an extensive background in clinical nursing education.   She has earned dual board certification as a family nurse practitioner and an adult/geriatric acute care nurse practitioner from the American Nurses Credentialing Center (ANCC).   As a former nurse in emergency medicine, she earned her certification as an emergency nurse (CEN), and has successfully transitioned her broad-based clinical knowledge to the private practice setting as a family practice nurse practitioner and an urgent care nurse practitioner.   With experience in both the outpatient and acute care settings, She educates nurse practitioners and physician assistants about current topics in clinical management and the expectations of modern care delivery.  Rachel oversees all of the day-to-day operations of Provider Practice Essentials, and her clinical knowledge, experience, and teamwork allow for full collaboration of our teaching faculty to maximize your educational experience and provide engaging clinical topics for your practice!

 

Clinical Skill and Procedure Workshop

Teaching Faculty

Physicians

Ali Farzad, MD, FAAEM

Dr. Farzad is an emergency physician with great interest in cardiovascular emergencies and electrocardiography. He trained in emergency medicine at the University of Maryland Medical Center, where he also completed a cardiovascular emergencies fellowship under the mentorship of Dr. Amal Mattu. He currently works clinically at Baylor University Medical Center in Dallas, serving as an Assistant ED Medical Director and Observation Unit Medical Director.  Dr. Farzad is currently a Clinical Assistant Professor at Texas A&M College of Medicine, and an educational blog editor at ECGWeekly.com.

airway course for Nurse practitioners
Teaching Faculty

Paul Banerjee, DO, FACOEP

Dr. Banerjee received his Bachelor’s of Science in Psychology with a minors in Biology and Chemistry from the University of Pittsburgh.  He earned his Medical degree from the Philadelphia College of Osteopathic Medicine in Pennsylvania.  Dr.  Banerjee completed his residency training in Emergency Medicine and is board certified.  He has been practicing for over 20 years, and has served as a regional medical director and site medical director of several community Emergency Departments.  He currently serves on Faculty with the University of Central Florida, and is a clinical professor of Emergency Medicine.  In addition, he is the EMS medical director for Polk County Fire and Rescue.

 

Clinical Skill and Procedure Workshop

Kevin Freels, MD

Dr. Freels earned his medical degree from Saint Eustatius School of Medicine. He is an emergency medicine physician that graduated from an emergency medicine fellowship at Oklahoma State University. He also completed his residency in family medicine with an emphasis in emergency medicine from the University of Alabama at Birmingham, where he was assistant chief resident. Dr. Freels received extensive training in ultrasound during his fellowship and residency training. He is currently a medical director in a growing emergency department and has interest in providing up-to-date, evidence based medicine. He has also previously worked/volunteered as a physician mentor, medical outreach programs and tutored for the USMLE boards.

 

Clinical Skill and Procedure Workshop
Teaching Faculty

David Harbour, DO

Dr. Harbour earned his medical degree from NOVA-Southeastern University and has practiced emergency medicine and urgent care for over 19 years.  He is the owner of multiple urgent care centers and is an expert in practice management, provider development, billing, and coding.  He serves as an assistant professor at NOVA-Southeastern University, the Univerity of Central Florida College of Medicine, and Lake Erie College of Osteopathic Medicine.

 

Clinical Skill and Procedure Workshop
Teaching Faculty

Rory Hession, MD

Dr. Hession received his Bachelor of Arts degree in Biology from The University of Hawaii at Hilo.  He earned a Master Degree in Molecular Biology, followed by a Doctorate of Medicine from the Medical University of South Carolina in Charleston, South Carolina.  He completed his residency training in Emergency Medicine from the Orlando Regional Medical Center in Orlando, Florida.  He has been practicing for over 14 years in both Community and 

 

Clinical Skill and Procedure Workshop
Teaching Faculty

Chris Hill, DO, FAAEM

Dr. Hill received his Medical degree from NOVA-Southeastern University (NSU).  He completed his residency training in Emergency Medicine and is board certified.  He continues to practice emergency medicine, as he has done for over 19 years.  He has served as an assistant clinical professor of Emergency Medicine with NSU, co-owner of an urgent care center, medical director, EMS educator, and urgent care physician.

Clinical Skill and Procedure Workshop

Camilo Mohar, DO

Dr. Mohar obtained a bachelor’s degree in Biology at Florida International University. He went on to acquire his Doctorate’s degree at Lake Erie College of Osteopathic Medicine. After completing emergency medicine training at University Hospitals in Ohio, he is now an emergency department attending at AdventHealth Orlando, Florida. Dr. Mohar enjoys teaching and has extensive experience working with different providers both at bedside and in conference. His special interests within emergency medicine include critical care.

Clinical Skill and Procedure Workshop
ultrasound course for PA's and NP's

Neil Pothraj, MD

Dr. Pothraj attended the Drexel University College of Medicine and completed his emergency medicine residency at Medstar Georgetown University Hospital/Washington Hospital Center.  He currently works as an attending physician at Washington Hospital Center and lives locally in Washington, DC.
Clinical Skill and Procedure Workshop

Daryl Reese, MD

Dr. Reese is a board-certified Emergency Physician from Rochester, NY.  He graduated from the University of Virginia with a Bachelor of Arts in Psychology.  Dr. Reese finished a Post-Baccalaureate program at the historical Howard University and matriculated into Howard University’s College of Medicine.  He completed his Emergency Medicine Residency at Emory University School of Medicine.  After residency, Dr. Reese moved to Dallas, where he has been practicing for over 15 years.  He has served on various medical advisory committees and has been a partner in emergency medicine and urgent care groups.  Currently, he is the owner of and Medical Director for Breio Health Center, and occupational medicine clinic.

 

Clinical Skill and Procedure Workshop

Trent Stephenson, DO

Dr. Stephenson completed his undergraduate degree from Southern Methodist University and went on to earn his Doctor of Osteopathic Medicine from Kansas City University. He completed his Emergency Medicine Residency at UTSW in Dallas, Texas and now has over 12 years of experience. He currently works as an emergency physician in the Dallas-Fort Worth area. When he is not working, he is pumping iron, telling dad jokes and spending time with his wife and two children.

Clinical Skill and Procedure Workshop

Sandi Thomas, DO

Dr. Thomas earned her Bachelor of Arts degree in Biochemistry from Boston University.  She earned her medical degree from the NSU college of medicine.  She has completed her residency training in Emergency Medicine and is board certified.  She has been practicing as an emergency physician for over 15 years in both community and academic settings.

 

Clinical Skill and Procedure Workshop

Neal Zeigler, MD FACEP

Dr. Zeigler, MD, FACEP, grew up in suburban Chicago and attended college at University of Illinois and Xavier University of Louisiana. He earned his medical degree at Chicago Medical School, and completed his residency at Wayne State University in Detroit, Michigan, where he was honored as Emergency Medicine Resident of the Year in 2005. He has been practicing emergency medicine in the Dallas-Fort Worth metroplex since 2005. He has been a leader in multiple busy emergency departments, including roles as Chief Medical Officer and Medical Director. He also is a founding member of MPACT For Mankind, which is a nonprofit that provides health services and resources to communities both locally and abroad.  

His personal interests and activities include golfing, traveling, spending time with his family (and puppies), and actively participating in his fraternity (Kappa Alpha Psi Fraternity, Inc.)

Clinical Skill and Procedure Workshop

Adrienne Caiado, MD

Faculty

Hi! My name is Adrienne Caiado and I am an Emergency Physician currently working at Charles Regional Medical Center in La Plata, MD. I am originally from Cape Cod, Massachusetts. I studied Behavioral Neuroscience at Northeastern University in Boston before deciding I wanted to pursue medicine. I moved to Hershey, Pennsylvania (yes, it really does small like chocolate on certain days of the week) in 2015 to attend Penn State College of Medicine. From there, I completed by residency in Emergency Medicine at Georgetown University and Washington Hospital Center in Washington, DC. I graduated as chief resident in my final year. In my free time I love cheering on Boston Sports teams, taking my dog Denny on long walks along the Potomac River, skiing wherever we can with my husband, and sailing in warmer weather.

Clinical Skill and Procedure Workshop

Advanced Practice Providers

Russell Wilson, PA-C, ATC

Russell Wilson began his medical career as an EMT in 1994 and finished his Paramedic licensure in 1997 while attending Angelo State University in San Angelo, Texas. He graduated from ASU in 1997 with his Bachelors of Science degree in Kinesiology. Afterward, he continued working part-time as a Paramedic while obtaining his Master’s Degree in Sports Health from Texas Tech University in 2000. Russell worked for several years as an athletic trainer, serving high schools throughout Texas along with Division III and Division II collegiate athletic programs. In 2010, he graduated from the University of North Dakota School of Medicine Physician Assistant program.  Prior to PA school, he worked as a Paramedic throughout various locations in Texas and in the Gulf of Mexico onboard an offshore oil-drilling rig. As a PA-C, he has worked in an outpatient VA clinic, urgent care facilities, a general orthopedic clinic, a level I hospital trauma service, and a physical medicine & rehab clinic. He is also part of the ancillary staff for the USA Taekwondo Olympic teams. He is a certified Physician Assistant, certified Athletic Trainer, and continues to maintain his Paramedic license. He is a retired Firefighter/Captain from the Runaway Bay Volunteer Fire Department. Russell and his lovely wife Caryn enjoy camping, traveling, and visiting museums.

Clinical Skill and Procedure Workshop
Teaching Faculty

Melissa Cody, ARNP

Melissa has been practicing as an Acute Care NP since 2010 after graduating from Marquette University in Milwaukee, WI.  She has extensive experience in cardiothoracic surgery, advanced heart failure management and general ICU patient management.  She is currently practicing as an ICU nocturnist and is the Coordinator of the Critical Care Advanced Practitioner Program.  In her spare time, she enjoys competing in Triathlons and spending time with her family.

Clinical Skill and Procedure Workshop

Morgan Bestenlehner, PA-C

Morgan earned a Bachelor of Science degree in Kinesiology-Athletic Training from the University of Wisconsin-Madison. She then advanced her skills by obtaining a Master of Science in Kinesiology from Illinois State University. After a few years of caring for injured athletes of all levels, she pursued her Master of Science in Physician Assistant Studies at Elon University in North Carolina. Since graduating Elon, she has been working in the Emergency Department at Medstar Washington Hospital Center. She spends her free time traveling, trying new restaurants, spending time with friends and family, and watching sports (Go Badgers)!

Clinical Skill and Procedure Workshop

Melanie Jones, PA-C

Melanie has previously worked in Neurological Surgery and Orthopedic Spine, with a specialty in complex spine and deformity cases.  She currently continues to work in surgical specialities as a first assist, and also practices interventional pain management and urgent care.  In her spare time, Melanie loves spending time with her daughter, reading and learning new hobbies such as photography, acoustic guitar, and most recently, cycling.

Clinical Skill and Procedure Workshop

Marsena Collins, FNP-C, ENP-C

Marsena earned her Bachelors of Science in Nursing from the University of Southern Mississippi in 2006. She completed her Master of Science Nurse Practitioner in 2012. She has a Dual Certification as a Family and Emergency Nurse Practitioner through the American Academy of Nurse Practitioners. She is currently the Lead Advanced Provider in the Emergency Room at a community hospital in Dallas, Texas. In her spare time she’s quite the foodie and loves enjoying every aspect of life with her spouse and toddler.

Clinical Skill and Procedure Workshop

Lindsay Portz, PA-C

Lindsay Portz, is a physician assistant and practices in orthopedic surgery. She attended LSU for undergraduate studies, and attended Nova Southeastern University in Jacksonville, FL for her master’s as a physician assistant. Lindsay enjoys running, playing tennis, and group workout classes.

Clinical Skill and Procedure Workshop

Kristina Reardon, MSN, ANP-BC, AGACNP-BC

Ms. Reardon has been a neurosurgical nurse practitioner since 2009. She completed her Bachelor of Nursing and Master of Nursing degrees at University of Pennsylvania. She is certified as an Adult Nurse Practitioner (ANP) and Adult Geriatric Acute Care Nurse Practitioner (AGACNP) through the American Nurses Credentialing Center. She is an avid runner and is on a journey to run a marathon in each state.

Clinical Skill and Procedure Workshop

Vanessa Rogers, MSN, ANP-BC, AGACNP-BC

Vanessa graduated from University of Texas at El Paso with a Masters Degree in Adult Gerontology Acute Care. She works in the ICU locally in Dallas, Texas.  In her free time she enjoys spending time with her family, reading, and traveling.  An avid learner, Vanessa enjoys sharing her skills with others who are interested in medical education.

Clinical Skill and Procedure Workshop

Laura Hanna, PA-C

Laura Hanna is a Physician Assistant with more than 20 years of experience as an emergency room consultant. She earned her Bachelor of Science in Biomedical Science from Texas A&M University and a Master of Science in Physician Assistant Studies from Baylor College of Medicine. She began her career in a large private practice orthopedic group before transitioning to the plastics and craniofacial surgery service at a Level I Trauma Center in Dallas, TX. Laura has served as a mentor for APP students and enjoys lecturing at local and national conventions. She is passionate about providing practical, evidence-based medicine. To that effort, she has completed TCU’s evidence-based research fellowship, along with her current Master’s studies at University of Oklahoma Law with a focus in Healthcare Law. She spends her off time hanging out with her kids, fishing, and listening to live music.

Clinical Skill and Procedure Workshop
Teaching Faculty, Lead Instructor

Scott Biggs, PA-C – Team Leader

Scott earned a Bachelor of Science degree in Biology from James Madison University.  He completed his Master of Science degree in Clinical Medical Science and Physician Assistant Studies at Barry University in Miami Shores, Florida.  He is board certified.  He currently serves as the lead PA in a community emergency department that sees over 45,000 patients per year.  In addition to his extensive experience in emergency medicine, he has worked as a member of a large transplant team and also clinically in both interventional radiology and vascular surgery.  Scott has been practicing emergency medicine for over 11 years.

Clinical Skill and Procedure Workshop

Brandon Geer, APRN

Brandon Geer is a board certified Family Nurse Practitioner working primarily in urgent care and emergency medicine. He has a masters degree in both Public Health and Nursing, and is currently working on his Doctorate of Nursing practice. He has previously worked as a nurse in Emergency, Intensive Care, and Flight Nursing. Brandon has a passion for education, and thus teaches as an adjunct professor of nursing while also teaching ACLS, BLS, PALS, and Point of Care Ultrasound. He also volunteers as a Firefighter and EMT. In his spare time, he enjoys spending time with his Wife and animal family, and is currently training for an Ironman Triathlon.

ultrasound course for PA's and NP's
Teaching Faculty

Rich Greene, EMPA-C, RDMS

Rich earned a Bachelor of Science from the US Air Force Academy prior to completing a 23 year career in the military. During this time, he attended the military’s Intraservice Physician Assistant Program where he received a Bachelor of Science and Masters of Physician Assistant Studies from University of Nebraska Medical Center. He is board certified and has worked in emergency medicine for the last 10 years obtaining additional specialty certifications in Emergency Medicine from NCCPA, ultrasound, trauma, and critical care.  Rich has worked in emergency medicine in settings spanning from Level I trauma centers to community regional hospitals. His teaching experience includes training combat medics in pre-hospital and trauma care and as an adjunct clinical instructor for Campbell University, teaching clinical skills to Physician Assistant, medical students, and residents.  He currently works in a community emergency department that sees approximately 45,000 patients per year.

Clinical Skill and Procedure Workshop
ultrasound course for PA's and NP's

Lucas Marlatt, ARNP

Luke earned his Masters of Science degree in Advanced Practice Nursing (FNP) from the University of Florida and is board certified by the American Nurses Credentialing Center.  He has experience as an Emergency Department nurse and nurse practitioner, and is currently in his 8th year of clinical practice.  In addition to his clinical duties, he enjoys teaching nursing and APP students.

Clinical Skill and Procedure Workshop

Ivan Mustafa, APRN

Ivan is an Advanced Practice Registered Nurse in Emergency Medicine. He has worked in and led Emergency Services since 1985 where he started in the fire service and worked through the ranks to EMS Chief of two different fire agencies. He serves in a number of committees throughout Florida and is a consultant for the Florida Department of Health. He has been a registered nurse since 1996 and an APRN since 2003.  He holds instructor certifications in ACLS, PALS and holds a State of Florida Instructor III certification, among others. Ivan is a  speaker in a variety of conferences and seminars and actively teaches continuing education programs throughout the country and internationally. He remains involved in a number of Fire and EMS projects and provides consultation services to agencies in the areas of Fire Services, EMS, accreditation and professional development.  Ivan and his wife have been involved with pet rescue and fostering since 2010 and have fostered and adopted out hundreds of dogs.

Clinical Skill and Procedure Workshop

John Rothwell, III DNP, ARNP

Dr. Rothwell earned his Doctorate of Nursing Practice, Masters of Science degree in Advanced Practice Nursing (FNP), and Bachelor degree in Nursing Science from the University of Central Florida in Orlando, Florida.  He is board certified by the American Nurses Credentialing Center.  Previously, Dr. Rothwell served in the US Army as a combat and flight medic and provided emergent medical services and training to medical and non-medical personnel.  He has a Critical Care and Emergency Medicine background and is currently a faculty member of the University of Central Florida.  He has worked in community emergency department and urgent care centers for several years.

 

Clinical Skill and Procedure Workshop

Amy Patel, PA-C

Amy double majored in Biology and Exercise and Sport Science at the University of North Carolina at Chapel Hill. She completed her Master of Science in Physician Assistant Studies at LMU – Debusk College of Osteopathic Medicine. She has been working as an emergency medicine PA since 2012 serving multiple states including the Carolinas, Texas, and now in Washington, DC at at Medstar Washington Hospital Center. She enjoys traveling, reading, and spending time with her husband, family, and friends.

Clinical Skill and Procedure Workshop

Kathryn Rodgers, PA-C

Kathryn earned a Bachelor of Science degree in Biological Sciences from Virginia Polytechnic Institute.  She completed her Master of Science in Physician Assistant Studies at Lake Erie College in Ohio.  She has worked in primary care and geriatric settings, and currently works in a busy Emergency Department in Washington, DC, where she currently lives.  She is originally from the Washington DC/Northern Virginia metropolitan area and enjoys hiking, traveling, wineries, and spending her time with friends and family.

 

Clinical Skill and Procedure Workshop
Teaching Faculty

Payal Shah, PA-C

Payal received her Bachelor of Science in Biology and Bachelor of Arts in Anthropology from the University of Florida. She then proceeded to attend Nova Southeastern University in Fort Lauderdale, FL and completed her Master’s in Physician Assistant Studies. While on rotations, she realized she wanted to practice Emergency Medicine and moved to Illinois after she graduated to work as an ER PA-C at a level II trauma center for over 2 years. She has also worked as a locums provider at other emergency departments. She has now accepted a position to move to DC to work as a physician assistant at Medstar Washington Hospital Center’s Emergency Department.

Clinical Skill and Procedure Workshop

Sara Thompson, PA-C

Sara earned her Bachelor of Science degree in Biotechnology from the University of Nebraska-Omaha and then completed her Master of Physician Assistant Studies at University of Nebraska Medical Center. She started her career in orthopedic surgery in 2011. In 2012 she started in Emergency Medicine in Omaha, Nebraska – a specialty she continued to practice full time until 2022. She then transitioned to Orthopedic Surgery full time where she specializes in total joint replacement and works as a first assist in the operating room. She continues to work part time in Emergency Medicine.

Clinical Skill and Procedure Workshop

Virginia Tran, PA-C

Virginia earned her Bachelor of Science Degree in Neuroscience from George Mason University and completed her Master of Physician Assistant Studies at Philadelphia University, now Thomas Jefferson University. In 2015, she began her career in Emergency Medicine at a Level I Trauma Center in Washington, D.C. Since then, she has transitioned to Orthopedic Surgery specializing in spine and total joints where she now works full-time and part time in Emergency Medicine and Urgent Care. In her free time, she enjoys rock climbing, traveling, eating new foods, and spending quality time with family and friends.

Clinical Skill and Procedure Workshop

Margaret Schifano, PA-C

A native of Minnesota, Margaret completed her undergraduate degree in Biology and Hispanic Studies at Pepperdine University in California. She later went on to Harding University in Arkansas for her degree in Physician Assistant Studies. She completed the General Emergency Medicine Physician Assistant Fellowship at Columbia in 2021 and stayed on full-time after that for a year until recently moving to DC with her husband and daughter. She now works full time at George Washington University Hospital in the Emergency Department where she serves as the APP New Graduate Program Onboarding & Education Coordinator as well as Assistant Clinical Professor of Emergency Medicine. She continues to work per-diem for the department. Her interests in Emergency Medicine include education and ultrasound. She is currently pursuing a Doctorate degree in Leadership in Clinical Practice and Education.

Clinical Skill and Procedure Workshop

Grace McConville, PA-C

Grace earned her Bachelor of Science in Human Nutrition, Foods and Exercise from Virginia Tech. After graduating from undergrad she practiced as a Registered Dietitian in Charleston, SC until she returned to PA school at the University of Alabama Birmingham. After graduating from PA school with her Masters in Physician Assistant Studies she worked as a physician assistant in the Thoracic Cardiovascular ICU at UVA Hospital. She transitioned to Orthopedic Surgery in Washington, DC where she specializes in hand and upper extremity. Outside of work she enjoys spending time with her chocolate lab, hiking, traveling, trying new foods and spending time outdoors.

Clinical Skill and Procedure Workshop

Sonographers

Liza Gonzalez, RDMS, RVT

Liza Gonzalez, RDMS, RVS has been a sonographer for 23 years. She is originally from Philadelphia and wanted to explore something new, so she moved to Florida and now works for the Orlando VA Medical Center in Lake Nona. Helping and caring for her fellow veterans and local communities has always been her passion! Being an ultrasound technologist has given
her a skill that she enjoys doing everyday!

Clinical Skill and Procedure Workshop

Lisa Haro, RDMS, RVT

Lisa is a Registered Diagnostic Medical Sonographer (RDMS) and a Registered Vascular Technologist (RVT) in central Florida. She received a degree in Diagnostic Medical Sonography from Palm Beach State College and has been working in the field since 2012. She always wants to learn more, loves teaching ultrasound, and has worked with students in the field for many years. In her free time, she enjoys spending time with her family and friends, and going on vacations.

Clinical Skill and Procedure Workshop

Contributors

Kelsey Bates, APRN, FNP-C

Kelsey earned her Master of Science degree as a Family Nurse Practitioner from Texas Woman’s University in 2017.  She earned her ASN from Collin College in 2013 and her Bachelor of Science Nursing from Texas Tech Univerity in 2014.  She is certified by the AANP.  Kelsey works in physical medicine focusing on musculoskeletal and neurological conditions.  She also helps patients manage and control various chronic cardio metabolic diseases.  Her passion as an NP is to help patients function act their highest level possible.  Kelsey lives in Farmersville, TX with her husband and two dogs.  In her spare time, she loves to be outdoors, exercise, travel, and spend time with her family and friends.

Lindee Abe, APRN, FNP-C, ENP-C

Lindee earned her Associate of Science Health Science Laboratory Technology from George Washington University in 2006. She earned a Bachelor of Science and Masters of Science in Nursing from the College of Saint Mary in 2009 and 2011, respectively. She was awarded her Post Masters Certificate as a Family Nurse Practitioner from Clarkson College in 2015. She is dual certified as a Family and Emergency Nurse Practitioner through the American Academy of Nurse Practitioners. She serves as the Nebraska state representative for the American Academy of Emergency Nurse Practitioners. She has worked as a contractor for the VA, urgent care, and emergency medicine. She has served in the Army Reserves for 19 years in varying capacities, including lab tech, emergency room nurse, case manager, and nurse practitioner.

The Advanced and Difficult Airway Course

The Ultrasound Course

The Clinical Skills & Procedure Workshop

The Clinical Skills & Procedure Workshop + The Airway Course

The Clinical Skills & Procedure Workshop + The Ultrasound Course

Dermatology Overview

Dermatology Essentials

Definition

Cellulitis: infection of dermis and subcutaneous fat

Impetigo: superficial purulent lesions, esp. on face and extremities. Commonly with bullae and/or golden crust

Erysipelas: raised erythematous lesion with clear borders

Folliculitis: hair follicle inflammation. Superficial and limited to the epidermis.

Furunculosis: hair follicle infection that extend to dermis. Multiple = carbuncle

Necrotizing Infection: Deeper SSTI that involve fascial and/or muscle compartments

Etiology

Microbiology

  • Cellulitis: primarily Staph and Strep, incl. MRSA. In immunocomp./diabetics, GNRs also
    • Other etiologies: cat/dog bite P. moltocida; gardening Sporothrix; salt water Vibrio vulnificus; puncture wound → Pseudomonas
  • Impetigo: Strep or Staph
  • Erysipelas: group A Strep usu.
  • Folliculitis/furunculosis: S. aureus, Pseudomonas
  • Necrotizing Infections: Polymicrobial (eg strep and GNRs in Type I, Fournier’s), Group A Strep, S. aureus, Aeromonas hydrophila, Vibrio vulnificus

At risk: athletic teams, military, prison, MSM, communities with MRSA infxn, Diabetic

High risk for more aggressive infection: splenectomy, immunocompromised

Differential Diagnosis

  • Cellulitis
  • Impetigo
  • Erysipelas
  • Folliculitis
  • Furunculosis
  • Necrotizing fasciitis
  • Myonecrosis
  • Calciphylaxis
  • Cutaneous metastasis from neoplasms (especially adenocarcinoma)
  • Graft-versus-host disease (in appropriate population)
  • Sweet syndrome

Patient History

  • Recent trauma to the affected area?
  • Any recent surgeries (hip replacement is risk factor)?
  • Ask about the presence of HIV, diabetes, liver disease, or kidney disease.
  • History of IV drug abuse or subcutaneous injection.
  • Recurrent Cellulitis: Assess for predisposing conditions such as edema, obesity, eczema, venous stasis, and toe web abnormalities.
  • Recurrent Abscesses: Search for local causes such as pilonidal cyst, HS, or foreign body. Consider 5-day decolonization (intranasal mupirosin, daily chlorhexidine). Consider neutrophil disorder if abscesses began in childhood.

Physical Exam

  • Evaluate affected area for erythema, edema, warmth, and pain on palpation.
  • Look for lymphangiitis (erythematous tracks under the skin marking an inflamed lymphatic system), palpate for lymphadenopathy.
  • Assess for evidence of necrotizing infection: systemic toxicity with high temperature, hypotension, disorientation, lethargy, skin discoloration or bullous lesions, anesthesia, firm skin with wooden-hard induration, pain extending beyond cutaneous erythema, pain out of proportion to exam

Work Up

Note: Diagnosis is largely clinical

Laboratory:

  • CBC with diff, ESR/CRP if concern for osteo, CK if concern for necrotizing infection or pyomyositis.
  • Furuncle/pustule can be aspirated for gram stain and culture.
  • For cellulitis, blood cultures are generally low yield, but should be obtained in patients undergoing chemo, neutropenic patients, and those who suffered animal bites.

Imaging:

  • If concern for osteo, xray; consider MRI
  • If concern for necrotizing infection can look for gas in fascial planes on x-ray or CT, but this is highly insensitive

Triage

More serious presentations of skin and soft tissue infections:

  • Toxic shock syndrome: fever, HA, vomiting, myalgias, pharyngitis, diarrhea, diffuse rash with desquamation. Hypotension and shock.
  • Osteomyelitis: infection of bone due to hematogenous seeding or direct spread from overlying focus.
  • Necrotizing fasciitis: infection and necrosis of superficial fascia, subq fat, and deep fascia. Clues: rapidly spreading cellulitis, systemic toxicity (inc TSS), pain out of proportion to exam, bullae formation, gangrene, crepitus. Surgical and medical emergency.
  • Gas gangrene: Clostridial myonecrosis, a fulminant skeletal muscle infection. C. perfringins usually in the setting of trauma; C. septicum in setting of cancer. Surgical and medical emergency.

Treatment

Purulent (furuncle/carbuncle/abscess):

  • Mild: I & D
  • Moderate: I & D, send for culture and sensitives
    • Empiric treatment: Bactrim 1-2 DS tab BID or Doxycycline 100mg BID
    • Defined treatment: MRSA: Bactrim 1-2 DS tab BID, MSSA: Dicloxacillin 250 Q6H or Cephalexin 500 Q6H or Cefadroxil 500mg po q12.
  • Severe: I & D, send for culture and sensitiivies
    • Empiric treatment: Vancomycin or Daptomycin or Linezolid or Ceftaroline
    • Defined treatment: MRSA: similar to empiric, MSSA: Nafcillin or Cefazolin or Clindamycin (if Susceptible)

Nonpurulent (necrotizing infection/cellulitis/erysipelas):

  • Mild: impetigo: topical mupirocin; oral treatment: Penicillin VK or Cephalosporin (eg Cephalexin 500mg PO Q6H) or Dicloxacillin 500mg PO Q6H or Clindamycin 300mg PO Q8H
  • Moderate: IV therapy: penicillin or Cefriaxone or Cefazolin or Clindamycin 300mg PO Q8H or 600mg IV Q8H
  • Severe: emergency surgical evaluation/debridement to rule out necrotizing process
    • Empiric treatment: Vancomycin PLUS Piperacillin/Tazobactam
    • Defined treatment for necrotizing infections:
      • Strep. pyogenes:Penicillin PLUS Clindamycin
      • Vibrio vulnificus:Doxycycline PLUS Ceftazidime
      • Aeromonas hydrophila:Doxycycline PLUS Ciprofloxacin
      • Polymicrobial: Vancomycin PLUS Piperacillin/Tazobactam

Duration of Therapy: 5-7 Days

Treatment Notes:

Erythema may initially worsen with antibiotics 2/2 local bacterial killing.

– For cellulitis, elevation of the affected extremity is essential to treatment.

– For Staph aureus infections (eg suppurative cellulitis) in 2014 at Hopkins susceptibilities were: TMP-SMX 87-88%, Tetracycline 89-91%, and Clindamycin 46-60%.

– For Beta-hemolytic Strep infections (eg non-suppurative cellulitis) all strains are susceptible to penicillin. At Hopkins there are high rates of resistance to TMP-SMX and tetracyclines and variable rates of resistance to Clindamycin.

– If you are concerned for a necrotizing infection, CONSULT SURGERY. Empiric antibiotic treatment with vancomycin (or linezolid) PLUS zosyn (or carbapenem) should be initiated. Clindamycin can be added to inhibit toxin production.

References

  1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52. [PMID:24973422]
  2. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-12. [PMID:14985488]

Resources

Heart Failure

Cardiology Essentials

Definition

Syndrome characterized by impaired myocardial performance and progressive maladaptive neurohormonal activation of the cardiovascular system leading to circulatory insufficiency to meet the body’s demands.

Systolic heart failure or heart failure with reduced ejection fraction (HFrEF): Clinical diagnosis of heart failure and an EF of less than 50%.

Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF): Clinical signs and symptoms of heart failure with evidence of normal or preserved EF and evidence of abnormal LV diastolic function by Doppler echocardiography or cardiac catheterization

Right heart failure: Majority of cases are a result of left heart failure, although isolated pulmonary diseases can also cause this syndrome.

Etiology

  • Non-ischemic dilated cardiomyopathy (familial or idiopathic)
  • Hypertrophic cardiomyopathy
  • Restrictive cardiomyopathy
  • Cardiomyopathy as a result of fibroelastosis
  • Mitochondrial disease
  • Left ventricular non-compaction
  • Ischemic cardiomyopathy
  • Stress induced cardiomyopathy
  • Valvular obstruction or insufficiency
  • Hypertensive cardiomyopathy
  • Inflammatory (lymphocytic, eosinophilic, giant cell myocarditis)
  • Infectious (Chagas, Lyme disease, HIV, viral, bacterial, or fungal infections)
  • Endocrine disorders (thyroid disease, adrenal insufficiency, pheochromocytoma, acromegaly)
  • Familial storage disease (hemochromatosis, glycogen storage disease, Hurler syndrome, Anderson-Fabry disease)
  • Amyloidosis
  • Connective tissue disease (SLE, polyarteritis nodosa, scleroderma, myositis, sarcoidosis)
  • Muscular dystrophies
  • Neuromuscular disease (Friedreich ataxia, Noonan disease)
  • Toxins (alcohol, anthracyclines, radiation)
  • Tachyarrhythmia

Pathophysiology

Progressive disorder initiated by a form of myocardial injury either sudden (MI or myocarditis) or chronic insults (familial, metabolic, HTN, valve disease, shunting) that result in maladaptive compensatory mechanisms.

These mechanisms include activation of the sympathetic nervous system and activation of the RAS system which overtime lead to pump dysfunction and circulatory collapse.

Differential Diagnosis

Other entities that may look like acute decompensated heart failure:

  • Acute coronary syndrome
  • Interstitial lung disease
  • Pneumonia
  • ARDS
  • Other sources of volume overload such as CKD/ESRD vs cirrhosis, pulmonary hypertension, PE, cardiac tamponade, constrictive or restrictive pericarditis

Patient History

Ask about the signs and symptoms:

  • Worsening dyspnea at rest or exertion?
  • Fatigue?
  • Orthopnea?
  • PND?
  • Weight gain?
  • Increased edema?
  • Lightheadedness?
  • indigestion?
  • Chest heaviness?
  • Fever?
  • Chest pain?
  • Timing of symptom onset?

Ask about triggers of acute decompensation:

  • dietary indiscretion? foods high in Na like lunch meats, chips, canned foods, fast foods?
  • missed medication doses (diuretic)?
  • are they weighing themself daily? adjusting diuretics?
  • any signs or symptoms that an ischemic event has occurred?
  • do they consume alcohol excessively?

Physical Exam

  • Weight gain (if possible look at previous discharge weights)
  • Elevated jugular venous pulsations (Key!), hepatojugular reflux
  • Orthopnea
  • Pulmonary rales
  • Third and/or fourth heart sound
  • Pedal edema
  • Sacral edema in patients who are mostly in bed

Work Up

Laboratory

  • Renal function panel, liver function panel (CMP): Patients who are volume overloaded due to acute decompensated heart failure often have an acute kidney injury and hepatic congestion.
  • Potassium, calcium (CMP), magnesium. May need to check more frequently (e.g. bid) especially if pt will be diuresed.
  • CBC: Anemia is present in up to 40% of patient with heart failure.
  • Consider pro-BNP if volume exam not helpful; compare to prior.
  • If patient is presenting newly with HF and/or etiology is unclear:
    • troponin and lipid profile, especially if HFrEF the pt may need further work up for ischemic disease
    • TSH
    • in the right patient, consider iron studies (hemochromatosis), serum ceruloplasmin (Wilson’s), trypanosoma cruzi IgG (chagas), blood alcohol level or CDT etc.

Imaging

  • ECG, chest x-ray, echocardiography

Other imaging and diagnostic modalities that can be considered based on the patient’s history:

  • Cardiac MR
  • Nuclear imaging
  • Right heart catheterization
  • Left heart catheterization
  • CT angiogram.
  • Endomyocardial biopsy

 

Triage

Strongly consider step-down or ICU if evidence of decompensation with hypoperfusion (cold and wet):

Altered mental status, Cold extremities, evidence of organ hypoperfusion: increasing lactate or rising creatine, narrow pulse pressures

Risk Stratification

The American College of Cardiology/American Heart Association (ACC/AHA) Heart Failure Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment.

The four stages of heart failure in the ACC/AHA classification are:

  1. Stage A: At high risk of developing heart failure due to underlying conditions or risk factors such as hypertension, diabetes, or coronary artery disease.

  2. Stage B: Structural heart disease is present, but there are no symptoms of heart failure. This stage includes patients with a history of myocardial infarction (heart attack) or left ventricular remodeling after a cardiac injury.

  3. Stage C: Structural heart disease is present, and there are symptoms of heart failure such as fatigue, shortness of breath, and decreased exercise tolerance. This stage includes patients with past or current symptoms of heart failure who are responding to treatment.

  4. Stage D: Advanced heart failure that is refractory to standard treatments. This stage includes patients with severe symptoms of heart failure at rest, despite maximal medical therapy. Patients in this stage may require advanced interventions such as heart transplant or mechanical circulatory support.

The ACC/AHA Heart Failure Classification is based on a combination of factors, including clinical symptoms, physical examination findings, imaging studies, and laboratory tests. This classification system is useful for guiding treatment decisions and predicting outcomes in patients with heart failure. It can also help clinicians identify patients at high risk for developing heart failure and initiate preventive interventions to improve outcomes.

The New York Heart Association (NYHA) Functional Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment. The classification system was developed in 1928 and is still widely used today.

New York Heart Association functional classification

The NYHA Functional Classification is based on the patient’s subjective symptoms and limitations related to physical activity. It is often used in clinical practice to assess the severity of heart failure, guide treatment decisions, and predict outcomes. Patients with more severe symptoms are more likely to have poorer outcomes, and may require more aggressive treatment or consideration of advanced interventions, such as heart transplantation or mechanical circulatory support.

It’s important to note that the NYHA Functional Classification is just one aspect of the overall assessment of heart failure and should be used in conjunction with other clinical and diagnostic findings.

The Seattle Heart Failure Model (SHFM) is a clinical prediction model that provides an estimate of the probability of death and other adverse outcomes in patients with heart failure. It was developed to help clinicians make more informed decisions about treatment and to assist in risk stratification of patients with heart failure. The SHFM incorporates a wide range of patient characteristics, including demographics, clinical symptoms, laboratory values, and medication use, to predict the likelihood of various outcomes, such as mortality, hospitalization, and quality of life. The model is based on data from over 11,000 patients with heart failure and has been validated in several independent cohorts. To use the SHFM, a clinician inputs data on the patient’s age, sex, symptoms, medical history, laboratory values, and medication use into a web-based calculator. The model then generates a personalized estimate of the patient’s probability of death and other outcomes at 1 year and 5 years. The SHFM also provides a range of other information, such as the estimated survival time, probability of hospitalization, and predicted quality of life. The SHFM has been shown to have good accuracy in predicting outcomes in patients with heart failure, and it can be useful in guiding treatment decisions and in risk stratification of patients. However, it is important to note that the SHFM is just one tool among many that can be used in the management of heart failure, and it should be used in conjunction with clinical judgment and other diagnostic and prognostic tools.  

The MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) risk score is a prognostic model that is used to predict mortality in patients with chronic heart failure. It was developed using a large international database of over 39,000 patients with heart failure from 30 different studies.

The MAGGIC risk score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of mortality in heart failure, including age, sex, systolic blood pressure, NYHA functional class, heart rate, serum sodium, serum creatinine, ejection fraction, etiology of heart failure, and use of certain medications such as ACE inhibitors, beta blockers, and diuretics.

The MAGGIC risk score assigns points to each of these variables based on their estimated contribution to mortality risk. The total number of points is then used to estimate the patient’s probability of mortality at 1 year and up to 5 years. The MAGGIC risk score has been shown to have good discrimination and calibration in predicting mortality in patients with heart failure.

The MAGGIC risk score is useful for identifying high-risk patients who may benefit from closer monitoring and more aggressive treatment, as well as for guiding clinical decision-making and communication with patients and families about prognosis. However, it is important to note that the MAGGIC risk score is just one tool among many that can be used in the management of heart failure, and it should be used in conjunction with clinical judgment and other diagnostic and prognostic tools.

CHA2DS2-VASc score: The CHA2DS2-VASc score is a tool used to estimate the risk of stroke in patients with atrial fibrillation. Since atrial fibrillation is a common comorbidity in heart failure, this score can be useful in managing heart failure patients with concurrent atrial fibrillation.

The CHA2DS2-VASc score is a clinical prediction rule that is primarily used to estimate the risk of stroke in patients with non-valvular atrial fibrillation. It is not specifically used in the management of heart failure, but rather in the management of comorbidities that may be present in patients with heart failure.

Patients with heart failure are at an increased risk of developing atrial fibrillation and other cardiovascular diseases, such as stroke, myocardial infarction, and peripheral vascular disease. As such, the CHA2DS2-VASc score can be used in the management of heart failure as a tool to identify patients who are at an increased risk of developing these conditions, and to guide clinical decision-making regarding the use of prophylactic therapies such as anticoagulation.

The CHA2DS2-VASc score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of stroke and other cardiovascular events, including age, sex, history of stroke or transient ischemic attack, hypertension, diabetes, heart failure, and vascular disease. The score assigns points to each variable based on its estimated contribution to the risk of stroke or other cardiovascular events.

While the CHA2DS2-VASc score is not specifically designed for use in heart failure, it is an important tool that can be used to guide clinical decision-making in the management of patients with heart failure and comorbidities. It can help identify patients who may benefit from prophylactic therapies and other interventions aimed at reducing the risk of stroke and other cardiovascular events.

 

Heart failure with reduced ejection fraction (HFrEF) is a condition where the heart muscle weakens and can’t pump blood effectively. Treatment for HFrEF usually involves a combination of lifestyle changes, medication, and other interventions.

The HFrEF therapy calculator is a tool that can help healthcare professionals determine the most appropriate treatment plan for patients with HFrEF. The calculator takes into account the patient’s age, sex, blood pressure, kidney function, and other factors, and recommends medications and doses that have been shown to be effective in treating HFrEF.

The calculator is based on guidelines developed by the American College of Cardiology, American Heart Association, and Heart Failure Society of America. These guidelines recommend a combination of medications that target different aspects of heart failure, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, and aldosterone antagonists.

The HFrEF therapy calculator takes into account the patient’s current medications and adjusts the recommendations accordingly. It also provides guidance on when to start or stop certain medications, and how to titrate the doses to achieve the maximum benefit while minimizing side effects.

The Renal Risk Score is a tool that helps predict the risk of developing acute kidney injury in patients with heart failure who are undergoing intravenous diuretic therapy.

The renal risk score is a tool that is primarily used to estimate a patient’s risk of developing acute kidney injury (AKI) after undergoing cardiac surgery. However, the risk of AKI is also a concern in patients with heart failure, particularly those who are hospitalized or receiving treatment with certain medications.

In patients with heart failure, the risk of AKI is often related to factors such as low cardiac output, fluid overload, and the use of medications that can affect kidney function. Some of these medications include diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), and nonsteroidal anti-inflammatory drugs (NSAIDs).

Several studies have looked at the use of the renal risk score in patients with heart failure. One study, published in the journal Circulation Heart Failure in 2014, found that the renal risk score was able to predict the risk of AKI in patients hospitalized with heart failure. The study also found that patients with higher renal risk scores were more likely to require dialysis or have a longer hospital stay.

Another study, published in the Journal of Cardiac Failure in 2018, evaluated the use of the renal risk score in patients with heart failure who were receiving treatment with sacubitril/valsartan, a medication used to treat heart failure with reduced ejection fraction. The study found that the renal risk score was able to predict the risk of AKI in these patients and could be used to guide dosing of the medication to minimize the risk of kidney injury.

Overall, while the renal risk score was developed for use in patients undergoing cardiac surgery, it may also be a useful tool for predicting the risk of AKI in patients with heart failure. By identifying patients at higher risk of AKI, healthcare providers can take steps to minimize the risk of kidney injury and improve outcomes for these patients.

Treatment

Acute Decompensated Heart Failure

IV diuresis:

Determine home regimen and try to give an increased dose. Patients with anasarca DO NOT ABSORB ORAL MEDS. Remember patients who are naïve to diuretics may not require high doses for good urine output. As a rule of thumb, the furosemide dose can be initially calculated at 40 (mg) X serum creatinine. Titration will be performed according to initial response. Common diuretics include furosemide, torsemide, metolazone, and Chlorothiazide. For ESRD patients who no longer make urine, volume removal will be via ultrafiltration and may need to be done more aggressively as tolerated by BP. Be sure to check electrolytes twice a day and aggressively supplement (keep K around 4 and magnesium around 2.4. Check daily weights (standing if possible) and monitor Ins and Outs.

Afterload reduction in systolic heart failure:

If no kidney injury is detected you can consider an ACE-Inhibitor, otherwise hydralazine with/or without nitrates. In more severe cases, one may consider sodium nitroprusside

Inotropy: Usually in severe cases or if effective diuresis is not achieved despite other efforts.

Dobutamine or milrinone

Remember to hold beta blockers in acute decompensated heart failure

Chronic Heart Failure Therapies

Mortality reducing agents:

  • ACE inhibitors/ARBs
    • start in all pt’s with current or prior sx’s of HFrEF unless contraindicated; try ACEi first and then try ARB if not tolerated
    • caution in pts with ↓SBP, renal insufficiency, or ↑serum potassium (>5.0 mEq/L). Angioedema occurs in < 1% of pts with ACE inhibitors.
  • ANRIs (angiotensin receptor–neprilysin inhibitor: valsartan/sacubitril)
    • start in pt’s with NYHA class II-III HFrEF who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality. Harmful if started concomitantly with ACEi/ARB – wait 36 hrs after stopping ACEi/ARB to inititate
  • Beta blockers (metoprolol succinate, bisoprolol, and carvedilol)
    • start in all pt’s with current or prior sx’s of HFrEF unless contraindicated
  • ISDN + Hydralazine
    • clear benifit in African American pt’s with NYHA class III-IV HFrEF
    • likely beneficial for all pt’s with HFrEF, though utility somewhat limited by TID dosing
  • Aldosterone receptor blockers (eplerenone, spironolactone)
    • recommended in patients with NYHA class II–IV HF and who have LVEF of 35% or less

HF Hospitalization Reducing Agents

  • Digoxin
  • Ivabradine (inhibits the If current in the SA node, ↓HR)
    • can use in NYHA class II-III stable chronic HFrEF (LVEF ≤35%) who tolerate maximum BB in NSR with HR of 70 bpm or more at rest[2]

Advanced Therapies

  • Left ventricular assist device (right heart must be able to tolerate this)
  • Heart transplantation

References

  1. Khot UN, Jia G, Moliterno DJ, et al. Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification. JAMA. 2003;290(16):2174-81. [PMID:14570953]
  2. Yancy CW, et al: 2016 ACC/AHA/HFSA Focused Update on NewPharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for theManagement of Heart Failure, Journal of the American College of Cardiology (2016), doi: 10.1016/j.jacc.2016.05.011.
  3. Griffin BP, Callahan TD, Menon V, et al. Manual of Cardiovascular Medicine. Lippincott Williams & Wilkins. 2013 4th edition; Heart Failure and Transplant 125-159
  4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-239. [PMID:23747642]

Resources

Advanced and Difficult Airway Course Content

Airway Anatomy and Assessment

  • Overview of airway anatomy
  • Indications of normal airway
  • Identification of difficult airway characteristics
  • Application of assessment for anticipation

Indications for Airway Management

  • Predictors of airway failure
  • Identification of clinical risk factors
  • When to intervene

Non-Invasive Airway Interventions

  • Progressive Oxygenation
  • Pulmonary Mechanics
  • Measured oxygenation techniques
  • CPAP and BIPAP

Invasive Airway Management

  • Rescue airway interventions
  • Laryngeal mask airway
  • Posterior pharyngeal airway adjuncts
  • Endotracheal intubation

Airway Options

  • Identification and selection of the correct airway device
  • Discussion of equipment options and their uses
  • Preparation for induction and intubation

Intubation Drugs

  • A pharmacology review of induction agents
  • Selection of the best drug combinations for induction
  • Safe decision-making

Induction and Intubation

  • Application of each prior learning topic to provide safe intubation
  • Stepwise, thorough discussion about safe airway induction and intubation
  • Correct techniques for endotracheal tube insertion

Confirming Tube Placement

  • Processes to ensure an endotracheal tube is correctly placed
  • Discussion about reintubation and confirmation
  • Application to difficult airway management

Difficult Airway Equipment

  • Intubating LMA, Lighted Stylet, Light Wand, Video Laryngoscope and more
  • Learn how to select the correct equipment for the situation
  • Double set-up indications

The Difficult Airway 

  • Application of difficult airway algorithms to fit the correct clinical conditions
  • A stepwise process discussion to maximize airway success
  • Indications and procedure for emergent cricothyrotomy

Ultrasound Course Content

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity

Biliary Ultrasound

  • Liver and Gall Bladder
  • Identification of anatomy
  • Abnormal Findings and Diagnostic Criteria
  • Interpretation of findings and Management

DVT Ultrasound

  • Lower extremity venous anatomy and scanning technique
  • Expected normal and abnormal findings
  • Interpretation of doppler and compressibility images
  • Clinical decision-making and follow-up

eFAST Ultrasound

  • Trauma-focused exam 
  • Includes abdomen, bladder, cardiac, and pulmonary imaging
  • Diagnostic criteria and decision-making
  • Includes common and subtle findings

Ocular Ultrasound

  • Technique and probe placement
  • Retinal detachment, foreign bodies, lens dislocation, vitreous hemorrhage, retrobulbar hematoma, and papilledema
  • Next clinical steps

Pelvic Ultrasound

  • Probe placement and scanning technique
  • Uterine, ovarian, and adnexal pathology
  • Next clinical steps

Pulmonary Ultrasound

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

Renal Ultrasound

  • Anatomy and probe placement
  • Ultrasonic anatomy and expected findings
  • Clinical correlation and management

Soft Tissue Ultrasound

  • Probe selection and settings
  • Foreign body, cellulitis, abscess, and cyst identification
  • Next clinical steps

Ultrasound for Vascular Access

  • Anatomy of peripheral and central veins
  • Application of Ultrasound to assist with line placement
  • Visualization of landmarks and expected clinical findings

Abdominal Aorta Ultrasound

  • Anatomy and ultrasound placement
  • Expected normal and abnormal findings
  • Next clinical steps and application

3-Day Clinical Skills & Procedure Workshop + The Airway Course

Day 1 Morning

Airway Anatomy and Assessment

  • How to assess an airway
  • Identification of landmarks
  • Predicting a difficult airway
  • Special scenarios
  • Airway classification and grading

Indications for Airway Management

  • Clinical conditions
  • Respiratory status
  • Anatomy
  • Predictors of airway need
  • Common approaches

Non-Invasive and Invasive Airway Management

  • Escalation of intervention
  • Sequential oxygenation
  • BIPAP
  • CPAP
  • Endotracheal Intubation
  • Airway Adjuncts (LMA, OPA)

Airway Options and Medications

  • Types of airway devices
  • Airway equipment
  • Laryngoscopes
  • Fiberoptic and Video Scopes
  • Induction agents and dosing

Induction and Intubation

  • Procedure organization and setup
  • Stepwise airway protocols
  • Anatomy
  • Endotracheal Intubation
  • Hands-On Procedure Practice

Tube Confirmation and Difficult Airway Management

  • Confirmatory tests
  • Defining an intact airway
  • How to manage a failed airway
  • Difficult airway algorithm and management
  • Fiberoptic laryngoscopy
  • Laryngeal mask airway
  • Video laryngoscope

Day 1 Afternoon

procedure

Difficult Airway Algorithm and Simulation

  • Application of the difficult airway algorithm
  • Simulated patient scenarios
  • Intubation with video laryngoscopy
  • Hands-On airway procedure lab
  • Individual review with instructor
  • Certification Examination

Day 2 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 2 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 3 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 3 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and Decisions Rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

3-Day Clinical Skills & Procedure Workshop + The Ultrasound Course

Day 1 Morning

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity
ultrasound

Abdominal Ultrasound

  • Aorta (all views, normal anatomy, pathology)
  • Biliary Quadrant (gallbladder, stones, techniques)
  • Kidney (hydronephrosis, pyelonephritis)
  • Trans-abdominal Pelvis
procedure

Trauma Ultrasound

  • eFAST exam
  • Right upper quadrant imaging
  • Left upper quadrant imaging
  • Bladder Imaging
  • Cardiac Imaging
  • Lung Imaging
procedure

Free Scan with Live Models

  • Small groups, team led with hands-on guidance and findings

Day 1 Afternoon

Specialty Ultrasound

  • Ocular Ultrasound (retinal detachment, foreign bodies)
  • Foreign body imaging
  • Ultrasound-Guided IV and Central access technique
  • Lower Extremity Vascular Ultrasound
procedure

Afternoon Free Scan

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

Day 2 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 2 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 3 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 3 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and Decisions Rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

1-Day Advanced and Difficult Airway Course Schedule

Day 1 Morning

Airway Anatomy and Assessment

  • How to assess an airway
  • Identification of landmarks
  • Predicting a difficult airway
  • Special scenarios
  • Airway classification and grading

Indications for Airway Management

  • Clinical conditions
  • Respiratory status
  • Anatomy
  • Predictors of airway need
  • Common approaches

Non-Invasive and Invasive Airway Management

  • Escalation of intervention
  • Sequential oxygenation
  • BIPAP
  • CPAP
  • Endotracheal Intubation
  • Airway Adjuncts (LMA, OPA)

Airway Options and Medications

  • Types of airway devices
  • Airway equipment
  • Laryngoscopes
  • Fiberoptic and Video Scopes
  • Induction agents and dosing

Induction and Intubation

  • Procedure organization and setup
  • Stepwise airway protocols
  • Anatomy
  • Endotracheal Intubation
  • Hands-On Procedure Practice

Tube Confirmation and Difficult Airway Management

  • Confirmatory tests
  • Defining an intact airway
  • How to manage a failed airway
  • Difficult airway algorithm and management
  • Fiberoptic laryngoscopy
  • Laryngeal mask airway
  • Video laryngoscope

Day 1 Afternoon

procedure

Difficult Airway Algorithm and Simulation

  • Application of the difficult airway algorithm
  • Simulated patient scenarios
  • Intubation with video laryngoscopy
  • Hands-On airway procedure lab
  • Individual review with instructor
  • Certification Examination

1-Day Ultrasound Course Schedule

Day 1 Morning

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity
ultrasound

Abdominal Ultrasound

  • Aorta (all views, normal anatomy, pathology)
  • Biliary Quadrant (gallbladder, stones, techniques)
  • Kidney (hydronephrosis, pyelonephritis)
  • Trans-abdominal Pelvis
procedure

Trauma Ultrasound

  • eFAST exam
  • Right upper quadrant imaging
  • Left upper quadrant imaging
  • Bladder Imaging
  • Cardiac Imaging
  • Lung Imaging
procedure

Free Scan with Live Models

  • Small groups, team led with hands-on guidance and findings

Day 1 Afternoon

Specialty Ultrasound

  • Ocular Ultrasound (retinal detachment, foreign bodies)
  • Foreign body imaging
  • Ultrasound-Guided IV and Central access technique
  • Lower Extremity Vascular Ultrasound
procedure

Afternoon Free Scan

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

The APP Clinical Skills and Procedure Workshop Schedule

Day 1 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 1 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 2 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 2 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and decision rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

The Clinical Skills & Procedure Workshop + The Ultrasound Course

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Offer Expires July 7. Excludes hotels and custom group programs.