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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Thursday, February 4, 2016

Dr. James R. Roberts & Martha Roberts, CEN, ACNP, bring you tips, tricks, and pearls for how to diagnose and treat a mallet finger. Everything you need to know is in this video. 
PP Mallet Splint.JPG
Click here to watch the video.​


Monday, February 1, 2016

Every new advanced nurse practitioner, physician assistant, or resident gets his fair share of complex emergency department procedures during training. Seasoned providers, however, are just as excited to place a central line in a septic patient, LP a "rule-out meningitis," or swiftly fix a nursemaid's elbow.

This month we hope to remind you of a few sweet and satisfying procedures that take only moments to do. Your skill in completing these procedures is imperative. Not only will you amaze your patient, but you'll shorten your door to dispo-time.



The Stye

The stye is a nefarious character with an agenda. It starts off by slowly enlarging over the patient's lid, and it can consume other portions of the face if not treated appropriately. Patients may present to the ED on the fifth day or later when the enlarged lid starts to impair their vision. Occasionally, patients have associated facial swelling, tenderness, or even a preseptal cellulitis. Distinguishing the signs of these complications is imperative for proper treatment. It may be difficult to discern the emergent eye from the urgent eye from the "it-can-wait" eye. You will feel confident about draining an eye lid abscess after reading this post, and you can add one more magic ace to your deck.

 

The Approach

  • Identification of stye (or hordeolum)
  • Evert the lid to look for the pus collection
  • If pus is readily seen, incision and drainage of stye
  • Correct outpatient treatments and aides
  • Ophthalmology follow-up

The Pause

A stye, or hordeolum, is an eyelid abscess that is internal or external. They are erythematous, tender, and swollen collections of pus that are also typically bacterial infections. Styes usually point externally and progress in size over time, and touch and blinking can exacerbate the pain.

Styes usually occur when a hair follicle or gland becomes blocked or irritated. Patients with chronic blepharitis may also experience more frequent occurrences of styes. Just like any other abscess, the treatment of a pus-containing stye is incision and drainage (I&D). Don't attempt I&D if no pus can be seen. Rather, advise warm soaks for a few days to see how it progresses. We also urge patients to do warm water (not scalding) washcloth soaks five or six times a day for 15 to 20 minutes each for several days after I&D. The best way to do this is to fill a sink with hot water, place two washcloths into the water, wringing one out and applying it to the eyelid. When it cools, change the cooled cloth for the hot one in the sink. Alternate the cloths so one of the hot compresses is on the eyelid for about 20 minutes.

Health care professionals will often ask patients to apply topical ointments, such as erythromycin or triple antibiotic ointment ophthalmic ointments. New studies and evidence-based practicing ophthalmologists, however, suggest using neomycin instead because of the resistance to erythromycin.

Some people are sensitive to neomycin, so a generic (and inexpensive) alternative is polysporin ointment such as bacitracin-polymyxin. Other ointments such as tobramycin and gentamicin [HL2] aminoglycosides are bactericidal antibiotics that will inhibit bacterial protein synthesis, but they do not work as well as they used to. These drugs used to be very effective, but certain bugs such as Pseudomonas aeruginosa and some Staphylococcus aureus have formed a strong resistance. UpToDate suggests that most styes are caused by S. aureus. Randomized controlled trials regarding antibiotic ointment treatment are lacking. UpToDate does suggest that topicals "do not aid in promoting healing," although most clinicians will still prescribe antibiotic ointments. (http://bit.ly/1K2Khoz.) Clinicians may occasionally need to prescribe treatment for styes with antibiotic ointments for patients with chronic blepharitis.

It is important to talk to patients about the risks and benefits and the cost for treating straightforward styes in an otherwise healthy, well-appearing patient without a preseptal cellulitis. Patients should first attempt warm soaks prior to an ointment regime or just prior to application. Furthermore, you need to leave the corticosteroid drops to the professionals and refer patients to be seen in two to three days for a full exam in the office with a working slit lamp.

One More Pause

Knowing the language when it comes to eye diseases and issues is really sexy. It feels good when I can tell an ophthalmologist I see no cell and flare and no Seidel sign[HL3] . We want to make sure you can talk shop about eyelid abscesses. The difference between the stye and the chalazion is that styes can turn into a chalazion, and these need to be excised and drained by an ophthalmologist. For a great video of this very procedure, we urge you to watch Dr. Mel Herbert get his eyelid treated for chronic stye turned to chalazion here: http://bit.ly/1RdLAsC.Dr. Herbert reminds us that chalazions are inflammatory, sterile, chronic lesions (more than two weeks) of eyelid gland. He advises to try warm compresses and seek the ophthalmologist if all else fails.​

The Procedure

  • Gather equipment, including 4X4 gauze, basin filled with warm water, tetracaine ophthalmic drops, and a 25 g needle. No eye patch is needed.
  • Place the patient in a supine or upright sitting position.
  • Take out any contact lenses and tell the patient to refrain from wearing them for at least two weeks.
  • Drop two to three drops of tetracaine into the patient's affected eye. Let him hold a tissue under his eye after you place the drops. This gives him something to do, and it helps him blot his eye as it tears from the medication.
  • Examine the eye thoroughly. Evert both lids. Check for foreign body with staining and the Wood's lamp. Examine the pupil reaction and light sensitivity.
  • Put the 25 g needle onto a 3 mL syringe. This will allow for greater stability and control of the fine needlepoint.
  • Place the warm compress over the eye for approximately 30 seconds to clean the eye and prime the abscess for drainage.
  • Use the 25 g needle on the 3 mL syringe by entering the stye horizontally (not vertically) over the area of maximum tenting.
  • Gently squeeze the lid to extract all pus.
  • Promptly apply another warm 4x4.
  • Allow the patient to hold the 4x4 on his eye while you complete paperwork.
  • Have him follow up with ophthalmology in two to three days.
  • One last trick for the more anxious patient: Prescribe a single Valium 5 mg tablet at bedtime [KA4] to ensure a restful night's sleep and eye rest. This is also helpful for those who present with corneal abrasion.

Do not blindly incise the swollen area of the eyelid if no pointing pus pocket is identified. Drainage of the superficial pointing abscess is usually very easy and curative, but not all swollen eyelids contain a simple stye.

See our video here. 


Cautions/Pearls

  • Evert the eyelid to identify the area when pus has accumulated and where the abscess is pointing. It's usually on the lid margin.
  • Do not be afraid to get blood or pus in the eye. Use tetracaine to numb the eye to avoid the foreign body sensation during the procedure. Irrigate the eye with gentle normal saline or other eye wash post-procedure.
  • Immediately apply a warm compress post-procedure.
  • Consider suggesting artificial tears for daily use to help with dry eye complaints.
  • Do not give ointments or antibiotics to patients with simple, straightforward styes. Consider reserving oral antibiotics for those who have a facial cellulitis or if you are concerned about preseptal cellulitis.
  • Doing a CT of the orbits is highly recommended if preseptal or septal cellulitis is on your differential.
  • Consider other diagnoses if the eye appears red and inflamed and the abscess is not that impressive. Are you missing shingles? Is there a Hutchinson's sign[HL5] ? Did you look for dendritic lesions?
  • Is the patient HIV positive or have a transplanted organ, hepatitis, diabetes, or a previous nonhealing infection? Consider ophthalmic ointments and oral antibiotics.
  • What about pain control? Acetaminophen and ibuprofen are fine choices if there are no contraindications.
  • Lower lid styes over the lacrimal gland should not be drained in the ED and need immediate ophthalmic follow-up. These typically will need oral antibiotics; consider doxycycline or cephalexin.
  • Are styes contagious? Generally not, but we must encourage patients not to rub their eyes because this can cause corneal abrasion and worsening infection.
  • If you consider the abscess to be a chalazion and it has already been drained in the past month, do not drain it again. It will only cause the patient more pain and it will reaccumulate. It may also cause worsening scarring. Refer these patients to ophthalmology in the morning. The 2 am wake-up call is not necessary.

Tip of the Week

Eye drops and ointments are among the worst offenders when it comes to cost. Erythromycin and triple antibiotic ointment are roughly $15-$20 per gram, but others can truly break the bank. Vigamox is about $150,) and TobraDex is $200, and they may prevent patients from filling the prescription. These big guns aren't typically indicated for a simple stye. It is imperative that you understand the treatment and antibiotic course for all ophthalmic conditions. The ocular stye may be one of your most frequent offenders, so keep in mind that triple antibiotic ointment is affordable and most likely an effective treatment. The true treatment remains: I&D, possible antibiotic ointment, and wound check in 48 hours if not better.

 

Read the other Procedural Pause posts on abscesses:



Monday, January 4, 2016

Part Three in a Three-Part Series

 

This is the third and final part of our series on foreign bodies and fluoroscopy. Click here for part one and here for part two.

 

This month, we walk you through a step-by-step guide with bonus video footage to aid in your technique. This progressive procedure is absolutely significant to your practice, and we hope you all get a chance to try it.

 

 

The Approach

n        Identification of foreign body on plain film or ultrasound

n         Saphenous or posterior tibial nerve block

n         Enlargement of the wound or entrance site using incision or skin cutting

n         Blunt or sharp dissection of the associated tissue

n         Foreign body removal using fluoroscopy

n         Copious irrigation

n         Close follow-up with podiatry

n         Infection risk considerations, antibiotic coverage, and proper dressing

 

The Pause

Are you prepared to get leaded up? You need to wear lead protection while doing this procedure. Be sure to remove any excess clothing or equipment before starting, and wear upper and lower lead in the radiology testing area (or even if you are using the portable C-arm). A thyroid protector is always suggested. If you are pregnant, we suggest opting out of performing the procedure, although studies have shown it is safe as long as you are properly covered. The guidelines for lead wear are standard per your facility. Most lead coats range from seven to 15 pounds, depending on the type and the amount of surface area requiring coverage.

 

The Procedure

n         Obtain radiographs of the affected area. The plantar portion of the foot was involved in this case so we obtained initial lateral and AP films of the foot. (NOTE: If the foreign body is known to be plastic or wood, fluoroscopy may not be a suitable choice for removal.)

n        Contact the radiology tech post-identification of the foreign body and inquire about the C-arm. Occasionally, this can be taken to the bedside, and other times it must be used in the radiology treatment area. (NOTE: You will have already checked your department policy. Do not try to sort this out in real time.)

n         Order continuous fluoroscopy in your EMR. For those of you still using paper, an order is required either way. You also need to document indications and alternatives for billing purposes.

n         Obtain warm water bath with soap and water, antiseptic, suture tray or kit (curved hemostat, forceps), sterile gloves, sterile towels, marking pen, 11 blade scalpel, 27 g needle, 18 g needle, 10 mL syringe, lidocaine 1% with bupivicane 0.5%, and sodium bicarbonate.

n        Combine 5 mL of lidocaine with 4 mL of bupivacaine with 1 mL of sodium bicarbonate for nerve block.

n       Soak the foot in a warm soap water bath for five to 10 minutes to loosen skin and clean area. Then use an antiseptic like chlorhexidine to copiously clean the area.

n        Use the pen to mark your site.

n       Perform posterior tibial nerve or saphenous nerve block. (Nerve blocks will be covered in future blog series.)

n         A local injection can be used, but often may not as effective as a full block.

 

It is important to know the approximate (if not exact) location of the foreign body because lower extremity blocks have specific areas of innervation. The nerve block is highly favored with additional anesthesia added to the site if needed.

n       Consider using LET in the affected area for additional anesthesia. This can be applied in triage or prior to going to the treatment area.

n         Wrap a sterile towel around the ankle. This will help you move and reposition the ankle and foot while you are involved in the sterile procedure.

n         Position the patient in a supine position. As stressed in the past, positioning is half the battle and can make or break your procedure. Provide comfort for the patient with pillows or padding, use adequate lighting and height of your workspace, and have the nurse administer pain medication as needed. This allows for proper visualization, inspection, and timely management. (Emerg Med Clin North Am 2003;21[1]:205.)

n         Shield your patient with proper lead attire.

n         Position the C-arm appropriately over the affected area. (See video for actual positioning techniques.) The technician can help guide you and start your “exposure clock.” They are excellent resources during the procedure, and we suggest you check in with them often by asking how much time you have left.

n         Use the same pen to act as an identifier for placement when using the scout shots to locate the FB. Mark the area on the foot.

n         Make an incision over the area of interest with an 11-blade scalpel. Directly visualize the area without any probing to see if the object is visible and removable.

n         If not visualized, shoot another scout shot to determine depth of the foreign body while inserting your hemostat or forceps. This is when the continuous fluoroscopy may be of most help. As you approach the object, you will be able to see it in real time and localize it.

n         Once localized, remove the foreign body with hemostat or forceps. Tweezers should NOT be used because they do not close fully around most metal or glass objects.

n         Irrigate the area. Large volumes should be considered, 300-500 mL. You must remove all foreign body material to avoid infection. Consider using a 10 mL syringe with splashguard to forcefully inject irrigation fluid. With that being said, application of “povidone-iodine solution, hydrogen peroxide, or detergents to irritant solutions should be avoided because of their cytotoxic properties and lack of significant bactericidal action.” (Ann Emerg Med 1999;34[3]:356.)

n         We also suggest using tap water because it is cheaper and creates less waste. It is also just as effective. (See tip below.)

n         Depending on the incision you have made, you may want to consider closing the area with loosely approximated sutures. This approach is controversial and should be discussed with a podiatrist. If it is a small incision, no closure is needed, and a bulky dressing, cast shoe, and crutch should be used for a week to 10 days. Crutch or walker use is important because it will help relieve the pressure on the site. It is also important to encourage the patient to rest the extremity.

n         Antibiotics: Yes for diabetics. We suggest staph and strep coverage with a cephalosporin such as Keflex. If the patient has a history of MRSA, you may want to consider culturing the site if it is an old, infected foreign body. One dose of IV Invanz or Ancef may also be considered. You must also consider coverage for Pseudomonas, so adding Cipro may be a solid choice.

n         Update the tetanus shot if indicated.

 

Please see our video for exact technique by clicking here.

 

Cautions and Pearls

n         Consider the indications for foreign body removal first. Is there neurovascular compromise? Evidence of infection? Is it causing a cosmetic deformity? If it is causing a functional impairment or chronic pain or if the patient requests it, you should be gearing up to go to fluoro.

n         If the patient has none of the above and would prefer the specialist, consider referral at that time. Also consider signs of sepsis or bacteremia if the site appears cellulitic or more extensively compromised.

n         Consider patients with diabetes, HIV, PVD, or other immunocompromised disorders to be delicate, and treat them with prophylactic antibiotics.

n         Contraindications include deep embedding, neurovascular compromise, poor or inadequate information about the foreign body, and risks for severe bleeding (i.e., bleeding disorders, medications). These issues should be considered high-risk, and the foreign body may best treated in the operating room or by podiatry directly. (Emerg Med Australas 2013;25[6]:603.)

n         Set the patient up for success at the start. Many patients have expectations that the foreign body can easily be removed without much damage or complication. This might be the case, but sometimes it is not reasonable. Discuss risks and benefits with the patient upfront and why or why not the procedure should be completed.

n         Have the patient sign a consent form with the risk-benefit discussion documented, and send a copy of that form home with them. Your paperwork should also include names of follow-up personnel, expected recovery course, signs and symptoms of infection, and the potential for retained foreign body. Nerve damage is also a concern, and should be discussed with the patient every time. Proper dressings, wound care technique, and extremity care should also be discussed ad nauseum.

The American College of Radiology recommends that your consent form state:

“Before the proposed procedure is performed, the following will be explained to the patient or, if the patient is unable to provide consent, to the patient’s legal representative:

“a. The purpose and nature of the procedure or treatment.

“b. The method by which the procedure or treatment will be performed.

“c. The risks, complications, and expected benefits or effects of such procedure or treatment.

“d. The risk of not accepting the procedure or treatment.

“e. Any reasonable alternatives to the procedure or treatment and their most likely risks and benefits.

“f. The right to refuse the procedure or treatment.” (American College of Radiology. ACR-SIR Practice Parameter on Informed Consent for Image-Guided Procedures. Resolution 39, 2014; http://bit.ly/1II3ror).

n        Make appointments in real time for patients whenever possible.

n        Caution (even possible contraindication) the use of this procedure in children. The risk of a “stochastic injury later in life is elevated for pediatric patients who have a longer projected life span and are more radiosensitive in the first decade of life than are adults.” (Pediatr Radiol 2002;32[10]:700.)

 

Possible Limitations

Not all procedures are perfect, and many times there are simply not enough data to support their everyday use. Two physicians used a mini C-arm to image foreign bodies in small blinded, randomized control in-vitro study. The physicians used five types of foreign bodies of different densities: metal, gravel, glass, wood, and plastic. The foreign bodies were placed into 50 of the 100 chicken legs. The blinded investigators imaged the legs and determined the presence or absence of foreign bodies. The results showed that although radiographic “imaging located 100 percent of metal, gravel, and glass, plastic and wood could not be consistently detected (sensitivity 0.4, specificity 0.6).” (Pediatric Emerg Care 1997;13[4]:247.) This may conclude that the mini C-arm can detect some foreign bodies but not all. Further clinical trials would help determine whether the procedure is truly necessary.

 

Foreign body of the foot removed. (Photo by Martha Roberts)

 

Additional Clinical Pearls

n         Unprotected individuals working “24 inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, while those working 36 inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation” (J Ortho Trauma 1997;11[6]:392.)

n         Hand and wrist radiation exposure is an identifiable concern because they are uncovered during the procedure. There is little information available on this specific area, but typically the hands do not eagerly absorb radiation.

n         Procedures that have been associated with substantial radiation dose: transjugular intrahepatic portosystemic shunt creation, embolization (any location, any lesion), stroke therapy, biliary drainage, visceral angioplasty, stent placement, stent graft placement, chemoembolization, angiography and intervention for gastrointestinal hemorrhage, carotid stent placement, vertebroplasty, radiofrequency cardiac ablation, complex placement of cardiac electrophysiology devices, and percutaneous coronary intervention. (J Vasc Interv Radiol 2003;14[8]:977; J Vasc Interv Radiol 2003;14[6]:711.)

 

Selfie of the foreign body removal team: Caitlin, RN, Jamie, RN and Martha Roberts, NP. Not pictured: Dr. Kim, and Carol, RN. (Photo by Martha Roberts)

 

 

The Final Thought

Jim weighs in: The use of fluoroscopy is an individual choice. Some practitioners are unfamiliar with it, and some hospitals have strict requirements regarding users. The best way to get introduced to the procedure is to watch an orthopedic surgeon or podiatrist do it first. Then, see one, do one, and teach one.

 

Martha weighs in: Without a doubt, there will be initial push back from your facility concerning your capability to perform this procedure. Talk it out. Your scope of practice allows you to complete this type of intervention with assistance from your radiology team. You have the skills to read and interpret radiographs and remove foreign bodies. The problem is that you need a radiologist and technician to be your ally. Some of the radiology technicians require a radiologist to be at the bedside shooting the continuous fluoroscopy while you do the procedure, and that is just a protocol you need to follow. If this is your house procedure, then do it. There is no reason the radiologist cannot pop over for a five-minute procedure, and help you get set up.

 

Just have an open and frank conversation about the procedure and why it will be the best for the patient. When you put the patient first, it leaves little room for argument and muscle-flexing. Then again, if your in-house radiology chief flat-out states you cannot perform the procedure, then consider calling podiatry. Finally, if you are pregnant or simply do not want any more radiation exposure than you have already had in this lifetime, consider ultrasound or referral. We can’t all be Superwoman (or man)!


Tuesday, December 1, 2015

Part Two in a Three-Part Series

 

Welcome back to our series on foreign body and fluoroscopy. If you’re new to the series, catch up on part one at http://emn.online/1lb0SAI.

 

Why is fluoroscopy worth investigating? A group of Chinese interventional radiologists looked at eight years’ worth of data using percutaneous fluoroscopically guided removal (PFGR) of foreign bodies in soft tissues. The 2009 study looked at foreign bodies in the skin from one week to 10 years. Ninety-four percent of the 346 foreign bodies were removed without any serious complications. The removal time ranged from 30 seconds to 20 minutes, but the mean was one to six minutes. Set up, transport, and communication with specialists can add more time to your procedure. The technique is very effective and important to consider. The savvy practitioner may well conclude PGFR of foreign bodies in the soft tissue under fluoroscope is safe and effective. (J South Med Univ 2009;29[12]:2504.)

 

Another recent study analyzed the amount of radiation received by orthopedic surgeons during fluoroscopy procedures. (J Clin Diagn Res 2015;9[3]:RC01; http://bit.ly/1WKNIYG.) The authors looked at 12 right-handed male orthopedic surgeons in a three-month prospective study and their radiation exposure measurement (with adequate protection measures in all procedures) using C-arm fluoroscopy. Each surgeon used five thermoluminescent dosimeter (TLD) badges, which were tagged at the neck, chest, gonads, and wrists. The procedural and operative time was recorded, and researchers obtained the exposure dose of each badge. Mean radiation exposure to all the parts of the badges were within permissible limits, and a significantly positive correlation between exposure time and dose was seen for the left and right wrists. The authors concluded that the total amount of radiation exposure during fluoroscopy did not exceed the recommended levels.

 

Watch the video here.

 

Tip of the Month: Sterile Isotonic Saline vs. Good, ol Tap Water

We know you are hungry for evidence-based data so let’s get rid of this sacred cow once and for all. Sterile isotonic saline can be used as the choice for irrigation of wounds and soft tissue. Tap water, however, is completely acceptable. Numerous studies comparing the two show no significant increase in the incidence of infection. (J Accid Emerg Med 1997;14[3]:165; Ann Emerg Med 1990;19[6]704; Acad Emerg Med 1998;5[11]:1076; Am J Emerg Med 2002;20[5]:469.)

 

Many providers prefer an ultrasound-guided technique for most or all of their procedures. Many types of foreign bodies could be easily detected using US, according to a study by Gooding, et al. (J Ultrasound Med 1987;6[8]:441.) Some of these materials include but are not limited to glass, metal, wire, and wood. The US-guided approach, according to the authors, also “pinpointed the surface beneath which the foreign bodies lay and localized all precisely as to depth from the surface.” Simple detection of the foreign body is important, but precision is even more poignant. Misguided views of the object could lead to increased tissue damage, blood loss, and an increased risk of complications.

 

Fluoroscopy is simultaneously a useful and dangerous tool. If not used properly, this radiographic expedition will do harm to you and your patient. We are not trying to turn you all into radiologists or force you to do an interventional radiology rotation; we simply want to broaden your horizons. Plain radiographs reveal many things including broken bones, calcifications, and our topic of interest, foreign bodies. Fluoroscopy is the art of using serial x-rays to obtain a real-time view of a structure, dislocation, or object. It is a useful tool in the field of medicine, but if there is any doubt that the procedure is not appropriate, then don’t do it. Consider calling your radiologist and ask him to be present if he has the time.

 

Join us next month (and next year!) when we present the final part of this series with a step-by-step video and guided approach.


Tuesday, November 24, 2015
This new bonus feature from James R. Roberts, MD, & Martha Roberts, CEN, ACNP, brings you tips, tricks, and pearls to make your emergency medicine practice easier.
 
This month, their first Clinical Pearl features the JR Knot, invented by its namesake James Roberts. This easy pearl will show you how to secure a central line.
 
About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

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