Monday, June 29, 2015

An Imperfect Science: Diagnosis of CSF Shunt Malfunction

Clinical scenario: Your patient is a 20 yo male with a history of VP shunt placement as a child for obstructive hydrocephalus. He was brought to the emergency department by his family because of decreased responsiveness over the past day. On arrival to the emergency department, he has aniscoria (L greater than R), no verbal response, and withdraws his extremities symmetrically. An emergent non-contrast head CT shows no change in ventricular size from prior CT scan one year prior and a VP shunt series demonstrates no evidence of fracture of the shunt line. Clearly, something is critically wrong with the patient, but is it his VP shunt to blame?

Clinical question: What is the spectrum of shunt complications? What is the sensitivity of clinical exam and various imaging modalities in detecting shunt malfunction?

Literature Review: There are multiple forms of CSF shunts, the most common of which is the Ventriculo-Peritoneal shunt (as opposed to ventriculo-atrial & ventriculo-pleural) which shunts CSF into the peritoneal cavity. A CSF shunt is composed of a proximal catheter, reservoir, valve and distal catheter [1]. The proximal catheter starts in the frontal horn of the lateral ventricle and exits through a burr hole to connect to the reservoir which is located in the subcutaneous tissue (this is what is accessed when neurosurgery taps a shunt). Flow from the reservoir to the distal catheter is regulated by a one way valve. Programmable shunts allow for the setting of a specific pressure above which fluid drains through a valve. This is sometimes adjusted in one direction or another for VP shunt patients who experience headaches, lightheadedness or other symptoms related to the pressure when their evaluation is negative for obstruction, infection etc. For VP shunts, the distal catheter is then tunneled into the peritoneum

Image Source: Cancer Research UK / Wikimedia Commons

As an emergency physician, one must be familiar with the presentation and diagnosis of shunt complications because they are relatively common; incidence of VP shunt failure is close to 40% at one year and 50% at two years from initial shunt placement, at least in the pediatric population where it has been most actively studied[2]. There are multiple types of shunt malfunctions leading to increased intracranial pressure, including but not limited to:

1. Mechanical Obstruction - Most proximally, the catheter can be obstructed by blood, debris or in-growth of the choroid plexus. The catheter position within the lateral ventricle can also migrate. Kinking or fracture along the catheter track at any point will also lead to shunt failure, as will distal obstruction which can occur when the catheter adheres to the omentum or erodes into intra-abdominal organs.

2. Infection - This often presents with shunt failure, and occurs most commonly within 6 months of placement due to intraoperative contamination with skin flora. The overall incidence of shunt infection is common (8-10%).

3. Ventricular Loculations - Loculations within the ventricle can create non-communicating pockets of CSF that are not drained by the VP shunt. If these grow, they can cause symptoms of hydrocephalus.

At least in very young children, depressed level of consciousness, nausea/vomiting, headache, irritability, and fluid tracking along the shunt site are highly predictive of shunt malfunction (see positive LR below). However, none of these clinical signs and symptoms are adequately sensitive to rule out shunt malfunction in their absence [2,3]. Some signs like abdominal pain/peritonitis are less commonly seen, but more highly predictive of shunt infection.

LR, Sensitivity, & Specificity for clinical signs and symptoms associated with shunt failure in two large pediatric studies

In addition to overall clinical exam and picture, radiographic imaging plays a central role in the emergency department evaluation of VP shunt malfunction.

CT scans are the most commonly used imaging modality to evaluate for shunt malfunction. While enlarged ventricles (when compared with prior imaging studies) are the canonical feature of shunt obstruction, other CT findings correlated with increased intracranial pressure include effacement of the cortical sulci, loss of the basal cisterns and periventricular edema due to transependymal CSF absorption [4]. Based on multiple retrospective pediatric studies using surgical shunt revision as a "gold standard", CT has a sensitivity for shunt malfunction of anywhere between 53% to 92% [4,5; see Table below]. In one small retrospective study of 174 adults evaluated for shunt malfunction with both shunt series and head CT, head CT had a sensitivity of only 52%, a specificity of 78% and negative predictive value of 88% for shunt malfunction [6]. This study only included patients who had had shunt series performed, so it may have underestimated the sensitivity of CT by excluding patients who were evaluated with CT alone. While this is a wide range of estimations for sensitivity, the important point is that a negative head CT does not completely rule out a shunt malfunction.

Shunt series radiographs are used to identify mechanical shunt defects such as shunt discontinuity or kinking. Studies in both children [4,7] and adults [6] support the conclusion that although the yield and sensitivity of radiographic shunt series is very low (see Table below), it is not zero. Shunt series rarely (~ 1-2%) detect abnormalities not identified on initial CT that prompt surgical revision. Therefore, shunt series are still indicated in the evaluation of potential shunt malfunction.

Table 2 from Boyle and Nigrovic, 2015. Reference 4.

In some cases, more commonly in pediatric institutions, MRI protocols have been instituted to reduce cranial radiation in children [4,8,9]. This has been made possible in part due to advances in MRI technology that have allowed for development of "ultra-fast" or Rapid MRI protocols that can acquire images in a span of ~ 1-4 minutes. Rapid Cranial MRI has been studied in comparison to CT for detection of ventricular shunt malfunction in the pediatric population, and appears to be comparable at least with respect to specificity and accuracy [8]. When considering using MRI in place of CT, the provider should be aware that some VP shunts have a programmable shunt valves that can be affected by the magnetic force of the MRI machine and may need to be readjusted after the exam. For this reason, it is common practice to obtain coned-down radiographs of a small indicator usually located near the proximal portion of the distal catheter to identify the setting prior to MR and then again after MR. If the programmed setting has changed, the neurosurgeon can use a magnet to reprogram the setting. The radiologist uses an indicator that looks like a clockface to determine the settings. 

Image source:
Take home Points: Malfunction and infection are common complications of CSF shunts. No single clinical exam finding or image study is sufficient to rule out shunt malfunction, and clinical management should take into account patient history, overall clinical picture, diagnostic data and neurological assessment.

Submitted by Maia Dorsett @maiadorsett
Faculty Reviewed by Peter Panagos and Richard Griffey

1. Wallace, A. N., McConathy, J., Menias, C. O., Bhalla, S., & Wippold, F. J. (2014). Imaging Evaluation of CSF Shunts. American Journal of Roentgenology, 202(1), 38-53.
2.Garton, H. J., Kestle, J. R., & Drake, J. M. (2001). Predicting shunt failure on the basis of clinical symptoms and signs in children. Journal of neurosurgery, 94(2), 202-210.
3. Piatt Jr, J. H., & Garton, H. J. (2008). Clinical diagnosis of ventriculoperitoneal shunt failure among children with hydrocephalus. Pediatric emergency care, 24(4), 201-210.
4. Boyle, T. P., & Nigrovic, L. E. (2015). Radiographic Evaluation of Pediatric Cerebrospinal Fluid Shunt Malfunction in the Emergency Setting. Pediatric emergency care, 31(6), 435-440.
5.Lehnert, B. E., Rahbar, H., Relyea-Chew, A., Lewis, D. H., Richardson, M. L., & Fink, J. R. (2011). Detection of ventricular shunt malfunction in the ED: relative utility of radiography, CT, and nuclear imaging. Emergency radiology, 18(4), 299-305.
6. Griffey, R. T., Ledbetter, S., & Khorasani, R. (2007). Yield and utility of radiographic “shunt series” in the evaluation of ventriculo-peritoneal shunt malfunction in adult emergency patients. Emergency radiology, 13(6), 307-311.
7. Desai, K. R., Babb, J. S., & Amodio, J. B. (2007). The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatric radiology, 37(5), 452-456.
8.Boyle, T. P., Paldino, M. J., Kimia, A. A., Fitz, B. M., Madsen, J. R., Monuteaux, M. C., & Nigrovic, L. E. (2014). Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics, 134(1), e47-e54.
9. Koral, K., Blackburn, T., Bailey, A. A., Koral, K. M., & Anderson, J. (2012). Strengthening the argument for rapid brain MR imaging: estimation of reduction in lifetime attributable risk of developing fatal cancer in children with shunted hydrocephalus by instituting a rapid brain MR imaging protocol in lieu of head CT. American Journal of Neuroradiology, 33(10), 1851-1854.10.

Friday, June 26, 2015

Consultant Teachings No. 2: Thoracolumbar Spinal Fractures - A Spine Consult Isn't Always Necessary

Clinical Scenario:  You are working one evening in the emergency department when an intoxicated young female is brought in by EMS after being involved in a reportedly high speed MVC.  She is clinically intoxicated, uncooperative and tachycardic.  She gets a pan-scan CT which identifies some facial fractures and isolated transverse process fractures of the thoracic spine.  As you decide on the next steps to take care of the patient, you debate whether to discuss the patient with a Spine specialist.

Clinical Question: Which spinal fractures should you discuss with a Spine specialist?  Are there some that do not require any intervention at all?

Literature Review:  With the increased availability and increased utilization of CT scanners in the ED, it has become common practice to “pan-scan” patients who present after a trauma, especially those patients who are obtunded/intoxicated or present following a high risk mechanism.  The use of the CT scan to identify thoracic or intrabdominal injuries has concomitantly lead to an increase in diagnosis of fractures of the thoracic and lumbar spine.  As an example, in one retrospective study conducted in the UK of 303 blunt trauma patients who had a Chest/Abdomen/Pelvis CT performed, only six scans (2%) identified thoracic injury and four (1.3%) demonstrated intrabdominal injury while 51 scans (17%) demonstrated an injury to the thoracolumbar spine [1].

With respect to screening for thoracolumbar spinal injuries specifically, the Eastern Association for the Surgery of Trauma practice guideline now recommends CT scan as the primary imaging modality [2]. This is based on a body of evidence that strongly supports that CT scan is more sensitive than X-ray for detection of thoracolumbar spinal injuries.  For example, in one small German study of 107 minor trauma patients, radiographs had a sensitivity of only 49.2% and specificity of 54.7% for thoracolumbar spinal injury compared with CT scan which served as "gold standard" [3].

While CT scan is more sensitive, not all the spinal fractures that are found are clinically significant (i.e. requiring spine precautions or bracing/surgical intervention) [4].  For example, in the small German study cited above X-ray alone missed 16/28 fractures of the the mid thoracic spine, but none of these were considered  unstable [3].  Of the 94 fractures identified in 51 patients by Chest/Abdomen/Pelvis CT in the UK study, 43 (46%) were considered not clinically significant [1].  Thus, the increased sensitivity of our diagnostic evaluation of trauma not only increases our detection of clinically important fractures, but otherwise stable spinal trauma.

Spine consultation for certain types of stable spinal injuries often comes at the expense of increased patient wait times, prolonged spinal precautions,  increased institutional cost, decreased patient satisfaction, and possibly even poorer outcomes if such consultation delays a patient’s transfer to the floor or ICU [4].   Below is a guide to approaching and managing two types of commonly seen fractures in the Emergency Department.

Transverse Process Fractures  

Source: www.

Transverse Processes (TPs) of the vertebrae primarily function as sites of paraspinal muscle and ligament attachments. They are part of the posterior column in the classic Denis “three column” classification, which divides the spinal column into anterior, middle and posterior structural elements. The vertebral body consists of the anterior and middle columns and is the main axial load bearing part of the spinal unit. The posterior column consists of the elements behind the vertebral body, with the most important components being the pedicles, facet joints and ligamentous complex. Stability for the spinal column is maintained through a series of attachments between the various spinal elements (anterior, middle and posterior). An isolated TP fracture is a stable fracture and does not compromise spinal stability. Additionally, isolated TP fractures are not associated with neurologic deficits. The spinal cord and nerve roots are not in proximity to the TPs, nor are they at high risk of displacing in a manner that would put the nerve root or cord at risk.

A small 2008 retrospective study from the University of Missouri looked at a cohort of 84 patients with TP fractures; 47 were isolated and 37 were associated with other spine fractures [5]. In this study, no patients with isolated TP fractures required surgery or bracing for spinal stability. Furthermore, none of these patients had any neurologic deficits. The authors concluded that conservative management of isolated TP fractures was appropriate, without the need for orthopaedic or neurosurgical consultation. However, if the TP fracture is associated with another spinal fracture such as a vertebral body fracture, a specialist consultation is warranted for treatment recommendations regarding the associated injury, but not necessarily the TP fracture itself. Of course, a cervical TP fracture that extends into the transverse foramen also necessitates additonal imaging and likely spinal consultation, as it may warrant a CT angiogram for evaluation of vertebral artery damage.

Compression Fractures

Vertebral compression fractures are the most common fragility fracture, affecting approximately 25% of people over the age of 70. Compression fractures are a result of axial force on the anterior column that results in a wedge deformity of the vertebral body. The vast majority of compression fractures do not require surgical intervention. Moreover, these fractures are often stable due to their impacted nature. No study has proven that bracing vertebral compression fractures prevents further vertebral collapse, decreases pain, or improves patient satisfaction. Treatment of most vertebral body compression fractures can focus on reducing associated pain with appropriate pain medications. A thorough approach to a patient presenting with an acute compression fracture should include the following:

1: Patient factors: What was the mechanism of injury (simple fall or high-energy injury)? Is the patient ambulatory, bed or wheelchair bound? Are there significant medical comorbidities (ie morbid obesity, extensive pulmonary disease) that would make bracing an ineffective or even dangerous treatment option? Is the patient’s pain controlled enough to obtain an accurate neurologic exam? Is the patient tender over the spinal segment in question?

2: Fracture factors: Is the fracture stable or unstable? The best way to evaluate is to use the patient’s own physiologic forces to see if there is further displacement of the fracture. Barring any neurologic deficits, plain supine AND upright radiographs of the affected area should be obtained. The goal is to see if there is any significant height loss or increased kyphosis between the series. If not, it’s a safe bet that the fracture is stable.

Given a stable fracture, the next step is determined primarily by patient comfort level. If the patient is able to tolerate sustained physiologic loads (ie sitting or standing), it is reasonable to send them home with observation only, no bracing required. Follow up could be provided by their primary care provider or PM&R. If they are in too much pain to stand or sit despite appropriate analgesia, an extension orthosis (like an off-shelf TLSO) is sometimes beneficial and can be provided by the spine consultant on call. If the compression deformity is acute and deemed to be unstable, if there are any neurologic deficits or other associated spinal pathologies, certainly a spine consultation is necessary and appropriate at that time.

Take Home Points:  The increased use of CT imaging, especially in trauma, may lead to the identification of injuries that do not necessarily warrant intervention other than pain control.  For neurologically intact patients, it is useful for the emergency physician to be aware of which fractures warrant either bracing or surgical intervention as unnecessary  consultation can lead to prolonged length of stay and increased cost without significant benefit to the patient.

Submitted by Chris Cosgrove, Orthopedic Surgery PGY-2
Faculty Reviewed by : Lukas Zebala, MD, Assistant Professor, Orthopaedic Surgery

Everyday EBM Editor Maia Dorsett (@maiadorsett)

1. Venkatesan, M., Fong, A., & Sell, P. J. (2012). CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. Journal of Bone & Joint Surgery, British Volume, 94(8), 1097-1100.
2. Sixta, S., Moore, F. O., Ditillo, M. F., Fox, A. D., Garcia, A. J., Holena, D., ... & Cotton, B. (2012). Screening for thoracolumbar spinal injuries in blunt trauma: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5), S326-S332.
3. Karul, M., Bannas, P., Schoennagel, B. P., Hoffmann, A., Wedegaertner, U., Adam, G., & Yamamura, J. (2013). Fractures of the thoracic spine in patients with minor trauma: Comparison of diagnostic accuracy and dose of biplane radiography and MDCT. European journal of radiology, 82(8), 1273-1277.
4. Homnick, A., Lavery, R., Nicastro, O., Livingston, D. H., & Hauser, C. J. (2007). Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. Journal of Trauma and Acute Care Surgery, 63(6), 1292-1295.
5. Bradley, L et al. Isolated transverse process fractures: spine service management not needed. J Trauma 2008 Oct; 65(4):832-6.

Wednesday, June 17, 2015

@WUSTL_EM #EMconf: #FOAMed Supplement No.6

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference.  Please e-mail to share additional resources (or just post them as comments below).
Interesting Case Conference: Guillain- Barre Syndrome
- Life in the Fast Lane has this review of clinical presentation, complications of, diagnosis and management of Guillain-Barre syndrome.
- Our own Everyday EBM published this post on acute neuromuscular respiratory failure.

Pain Control in End-Stage Renal Disease
- We discussed the dangers of narcotic pain management (especially with morphine) in patients with ESRD due to decrease clearance of the metabolite (M6G) which leads to respiratory depression.  The renal fellow's network blog discusses the dangers of opiates in advance renal failure (as well as some suggestions) here.  

- We also  discussed trying techniques of regional anesthesia in end-stage renal disease which can lead to excellent pain control without systemic effects such as respiratory depression. Some of these techniques include femoral nerve and intercostal nerve blocks (you tube videos below).

Femoral Nerve Block for Hip Fractures (Larry Mellick):

Ultrasound-Guided Intercostal Nerve Block for rib fractures:

Peds Endocrine
- We discussed the differential diagnosis and management of pediatric hypoglycemia.  Natalie May wrote this practically-minded post and ED management & disposition decisions in hypoglycemic pediatric patients for the St. Emlyn's Blog.
- Life in the Fast Lane published this post on clinical presentation, diagnosis and management of adrenal insufficiency in kids.
- Emergency Medicine Cases published this post reviewing the TREKK (Translating Emergency Knowledge for Kids) consortium recommendations for treatment of pediatric DKA.

ED "Follow-up" Conference - Cellulitis 
- FOAMcast did this Podcast on Skin and Skin Structure Infections
- The Short Coat addresses antibiotic indications, duration and choice for cellulitis in this post.
- Here is a link to the Volz et. al. article on predicting which ED patients will "fail" observation status and require inpatient admission for their cellulitis.
- UMEM has this educational pearl reviewing predictors of failure for outpatient antibiotics in ED cellulitis patients.


Sunday, June 14, 2015

@WUSTL_EM #EMConf: #FOAMed Supplement No. 5

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference.  Please e-mail to share additional resources (or just post them as comments below).
1. Pediatric Cases:  Neonatal HSV
- You can read a brief review of epidemiology & presentation Neonatal HSV from Peds EM Morsels.
- You can review the "normal" levels of CSF pleocytosis as they vary by age here.
- Free Emergency Medicine Talks reviews a case and Management of Pediatric Status Epilepticus in the Seizing Infant.

2. Evaluation of the Pacemaker in the ED
- Connect to the Jacob et. al. (2011) paper describing radiographic identification of pacemakers/AICD via this emcrit post.
- Life in the Fast Lane covers Pacemaker malfunction here.
- Amal Mattu discusses Can you read ischemia with a pacemaker? and Can a pacemaker treat syphilis?

3. Difficult Diagnosis - Pre-eclampsia
-EMCurious provides a very nice review of the symptoms, workup and management of preeclampsia.

4. Musculoskeletal Cases - We reviewed some interesting cases and musculoskeletal anatomy.  Emergency Medicine Ireland has these resources for emergency medicine anatomy, which include some excellent reviews regarding cervical spine injury.   If you are interested in use of musculoskeletal ultrasound for the emergency physician, you can read Sonoguide's introduction to musculoskeletal ultrasound here.


Wednesday, June 3, 2015

@WUSTL_EM #EMConf #FOAMed Supplement No.4

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference.  Please e-mail to share additional resources (or just post them as comments below).

1. Lightning Injuries 
Today as a combination of part of core content series, Dr. Noelker talked about the rare, but important presentations & management of lightning injuries.  
- For interesting videos on how lightning works, check out this video out:
On the medical side,
 - Life In the Fast Lane had this summary of Lightning Injuries
- The Adventure Medicine blog presents these guidelines on treatment & prevention of Lightning Injuries.
- For some cool teaching videos, see the national weather service site on Lightning Safety.

2. CPC/Interesting Case: Psoas Abscess
- Life in the Fast Lane has this summary of Psoas Abscess presentation & workup

- Apart from details of the diagnosis & management of a psoas abscess, this case reinforced the idea that we should reconsider the possibility of a missed diagnosis for patients who return to the emergency department multiple times.  I love the emdocs, "EM Mindset" series, and this week's post by Deborah Diercks touches on this essential learning point:

"With imperturbability and objectivity the EP will make more accurate diagnoses and will not overlook the subtle clues of serious underlying illness. This requires clinical skill, insight, poise, caring, and experience."

3. Updates to Stroke Care at WashUEM - We learned about the current state of stroke care at our institution (hint: very fast) as well as situations where hyperacute MRI may or may not have a role (such as suspected stroke mimic).

For those who want to read a little bit more on "DWI" MRI for diagnosis of acute ischemic stroke, has this article.

.... and keep your eyes & twitter feed open to catch the next WashU EM J Club Podcast on Endovascular therapy for ischemic stroke.

4. Joint Surgery & EM Trauma Case Conference: Airway Management in Trauma
Today in joint case conference, we had an interactive discussion of how complicated airway in management in trauma can actually be.  This is an area where there are lots  of FOAMed resources, so it was a bit hard to take a pick.  To list a few:
- EM Crit's Laryngoscope as a Murder Weapon series discusses Hemodynamic Kills.
- The Skeptics Guide to Emergency Medicine addresses the use of ketamine in TBI
- emdocs argues that our go-to drugs should be ketamine & rocuronium instead of etomidate & Sux in this post.
- Here is a link to the technique for Bougie-aided Cric on the EMCrit website

Enjoy, @maiadorsett

Monday, June 1, 2015

I am Chris Miller, former Party Fowl, and this is How I Turkey Harder

·       Name: Chris Miller, MD
·       Location: Barnes Jewish Hospital, St. Louis Missouri
·       Current job(s): PGY-2, Emergency Medicine, Washington University in St. Louis
·       One word that best describes how you eat: Furiously
·       Current turkey style: Sara Lee, Honey Roasted, 2mm cuts

I like to keep it simple.  I am very old-school when it comes to that.  On most occasions I find myself eating the sandwich as it was originally packaged.  On occasion, if I’m feeling spontaneous, you will catch me mixing it up a little bit (open face, fork & knife, double decker).

Nail down your microwave times.  I can’t tell you how many times I see nurses, techs and even our own interns wasting too much time at the microwave.  It’s either still cold or scorching hot.  Some rookies will even remove the plastic wrap. 
Here’s a pro tip:
1.     Place sandwich on a paper towel (keep in plastic wrap)
2.     Microwave for 27 seconds
3.     Remove plastic wrap
4.     Add condiments & enjoy

Not all sandwiches are created equal.  Most of the time you can spot the differences as you squat in front of the fridge making your selection.  Some sandwiches, I call them “the chosen ones,” seem to have more meat.  Select these at the beginning to save yourself some time and disappointment later.
Supplement your turkey with other healthy alternatives like reconstituted grape juice and pre-scored graham crackers.  If you are looking for extra protein consider dipping in peanut butter.

I realize this is controversial.  I have even heard of people using mustard instead, but that goes against everything I stand for.  This question often depends on departmental availability.  Original mayonnaise tends to be more popular with the patients.  I often find myself reaching for the Light Hellmann’s.  It packs fewer calories, but still provides that powerful, smooth, creamy texture we all crave in a condiment.

I was nearly a full two years into my residency before I received a game-changing piece of advice.  Sam Smith, PGY-3 (The Czar of ED Turkey) told me that for nearly a year he had been doubling up on his meat.  Rather than wasting time to select the ideal sandwich at the fridge, simply grab any two sandwiches, unwrap, steal meat from one and apply to the other.  Then rewrap and microwave like nothing happened.  What to do with the extra bread is your call.  Double decker vs throwing away are two popular options.
Turkey brings people together and we should embrace that.  I think the former president said it best:
I have no desire to crow over anybody or to see anybody eating crow, figuratively or otherwise.  We should all get together and make a country in which everybody can eat turkey whenever he pleases.
                                                                                                       Harry S. Truman, 33rd President of the USA

1.     Sam Smith, MD PGY-3
2.     Chris Holthaus, MD Attending
3.     Emily Garibay, RN