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July 2017 – Journal CME Page 1
Continuing Medical Education - News & Information July, 2017 - Volume 22, Issue 5 Multi-Agency Edition
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Inside this issue:
From the Editor 1
Cert & CME info 2
FDNY contacts 3
OLMC physicians 3
CME Article/Quiz 4
Citywide CME
Exam Calendar
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Journal CME Newsletter
FDNY - Office of Medical Affairs
9 Metrotech Center 4th fl Brooklyn, NY 11201
718-999-2671
Joshua.Bucklan @fdny.nyc.gov
From the Editor
The FDNY welcomes EMS Fellows Dr. Albert Arslan and Dr. Matthew
Melamed. This year, both of our EMS Fellows did their Emergency Medicine
Residencies locally, Dr. Arslan at NYC Health + Hospitals/Lincoln and Dr.
Melamed at New York-Presbyterian Brooklyn Methodist. Both EMS Fellows
will be active in REMAC committee’s and Continuing Medical Education.
Joshua Bucklan, RN, EMT-P REMAC Liaison Office of Medical Affairs, FDNY
** All candidates must now meet CME requirements ** All REMAC paramedics and candidates should review Certification &
CME Information on page 3 journal and plan accordingly.
All upcoming exam candidates, see registration instructions at the bottom of the last page of this journal.
Candidates who will not have a CME letter at the time of their REMAC exam must email [email protected] ASAP.
July 2017 – Journal CME Page 2
REMAC Exam Study Tips REMAC candidates have difficulty with: REMAC Written exams are approximately:
* Epinephrine use for peds patients 12% GOP * 12-lead EKG interpretation 60% Treatment Protocols * ventilation rates for peds & neonates 12% Appendices 16% Scenarios
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Certification & CME Information
By the day of their exam, all REMAC paramedics and candidates must present a letter from their Medical Director verifying fulfillment of CME requirements.
Upcoming candidates without a CME letter ASAP must email [email protected]
FDNY paramedics, see your ALS coordinator or Division Medical Director for CME letters.
CME letters must indicate the proper number of hours, per REMAC Advisory # 2007-11: 36 hours - Physician Directed Call Review
- ACR Review - QA/I Session - Emergency Department Teaching Rounds - Maximum of 18 hours
36 hours - Alternative Source CME - Maximum of 12 hours per venue - Online CME (see examples below) - Clinical rotations - Lectures / Symposiums / Conferences - Associated Certifications – 4 hours each: - Journal CME BCLS / ACLS / PALS / NALS / PHTLS
Failure to maintain a valid NYS EMT-P card will suspend your NYC REMAC certification until NYS is recertified.
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REMAC certification exams are held monthly for new and expired candidates, and for currently certified paramedics who may attend up to 6 months before their expiration date.
REMAC CME and Protocol information is available and suggestions or questions about the newsletter are welcome. Call 718-999-2671 or email [email protected]
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REMSCO: www.NYCREMSCO.org Online CME: www.EMS-CE.com www.MedicEd.com www.EMCert.com www.WebCME.com NYS/DOH: www.Health.State.NY.US www.EMINET.com statenislandem.com
July 2017 – Journal CME Page 3
FDNY ALS Division Coordinators
Lt. Telina Lloyd 718-999-0836 Mike Romps 718-380-0108 Citywide ALS Division 4
Anthony Kendall 212-964-4518 Krista O’Dea 718-979-7175 Division 1 Division 5
Michael Sullivan 718-665-5167 Hector Arroyo 718-281-8325 Division 2 Bureau of Training
Gary Simmonds 718-968-9750 Nicole Nehwadowich 718-383-1732 Division 3 EMS Pharmacy
FDNY EMS Medical Directors
Dr. Glenn Asaeda 718-999-2790 Dr. David Ben-Eli 718-999-2790 Chief Medical Director of Office of Medical Affairs Medical Director Division 4 Medical Director Haz-Tac
Director of Resident and Medical Student Education Dr. Bradley Kaufman 718-999-1872 Dr. Nathan Reisman 718-999-2790 First Deputy Medical Director Medical Director Division 5 Medical Director of Training & EMD Medical Director CFR Dr. Doug Isaacs 718-999-2790 Dr. Pamela Lai 718-999-2790 Medical Director Division 1 Medical Director ALS QA/QI EMS Fellowship Program & Rescue Paramedic Program Director Associate Medical Director Rescue Paramedic Program Dr. Dario Gonzalez 718-665-5167 Dr. Benjamin Zabar 718-999-2790 Medical Director Division 2 Medical Director BLS QA/QI & PASU USAR/FEMA Director & OEM Liaison Associate Medical Director of Training Dr. Nikolaos Alexandrou 718-999-0124 Medical Director Division 3 Medical Director OLMC FDNY SEMAC and SEMSCO NYS Representative
EMS Fellows
Dr. Albert Arslan 718-999-0364 Dr. Matthew Melamed 718-999-0351
FDNY OLMC Physicians and ID Numbers Alexandrou, Nikolaos 80282 Hegde, Hradaya 80262 Rotkowitz, Louis 80317 Asaeda, Glenn 80276 Hew, Phillip 80267 Schenker, Josef 80296 Barbara, Paul 80306 Huie, Frederick 80300 Schneitzer, Leila 80241 Bayley, Ryan 80314 Isaacs, Doug 80299 Silverman, Lewis 80249 Ben-Eli, David 80298 Jacobowitz, Susan 80297 Soloff, Lewis 80302 Freese, John 80293 Kaufman, Bradley 80289 Van Voorhees, Jessica 80310 Friedman, Matt 80313 Lai, Pamela 80311 Williams, Alan 80316 Giordano, Lorraine 80243 Munjal, Kevin 80308 Zabar, Benjamin 80323 Gonzalez, Dario 80256 Redlener, Michael 80312 Zimmerman, Jason 80324 Hansard, Paul 80226 Reisman, Nathan 80326
July 2017 – Journal CME Page 4
FDNY–EMS CME JOURNAL 2017 JULY
“Why does the threat of violent death alter some of us, even if subtly, forever? Why does it make us unusually numb or calm when we ought to feel terrified? Why do scents or sounds trigger in some of us a feeling of terror or unbearable dread, even in situations where we know, at least, intellectually, that we are perfectly safe?”
– Jessica Stern, Denial: A Memoir of Terror 1,2
Introduction
This month’s topic will cover Part 1 of Post-traumatic Stress Disorder (PTSD). This installment will describe the onset and symptoms in adults and children, and the underlying disease process. Part 2 will layout the treatment, resources, and prevention strategies for PTSD.
Walking down the street, or sitting on the train, do we see what post-traumatic stress looks like? It's everywhere and nowhere. If we could read peoples' thoughts, we would know that thoughts can cause paralysis of an invisible kind, controlling our next move or decision. Our rational mind knows that we are safe, but the emotional mind believes differently. People who have endured horrible events suffer predictable psychological harm. Adverse health problems are also found with PTSD. These include elevated risk for depression, risk for diabetes and heart disease, and risk for substance abuse.3
The Centers for Disease Control and Prevention tells us that most everyone has been through a stressful event in his or her life. When the event, or series of events, causes a lot of stress, it is called a traumatic event. Traumatic events are marked by a sense of horror, helplessness, serious injury, or the threat of serious injury or death. Traumatic events affect survivors, their friends and relatives, and people who have seen the event either firsthand or on television.4 People differ inhow they react to traumatic events, and the different types of trauma. A prior history of trauma may make some people more susceptible to later traumatic events, while others become more resilient. The majority of people who have experienced a traumatic event will get better with time.
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When the emotional and physical response to the threat continues well after the event has ended, the result is post-traumatic stress disorder (PTSD). From recorded history, observations of veterans returning from war, gave illustrations of the symptoms of post-traumatic stress disorder. Even so, it was not until 1980 when a group of Vietnam veterans lobbied for official recognition of the diagnosis by the American Psychiatric Association that it was officially named. This designation created an explosion of research and efforts to find successful treatments.5 New techniques in brain imaging (functional MRI, single-photon emission CT, and PET) have helped bring a better understanding of the actual changes that occur in the brain with PTSD. This new information has improved treatment options yielding better results. PTSD is a chronic and debilitating condition that can have profound effects on functioning (workplace, family and social), and severely compromise quality of life. Studies show that at least 50% of adults will encounter a traumatic event in the course of their lifetime,6 with rates of PTSD around 8% in the general population. Higher rates have been documented among military personnel, police officers, firefighters, and EMS responders to disasters and mass trauma. For veterans who served during the Vietnam era, the rate is about 30%, for the Gulf War Veteran population about 12%, and Operation Enduring Freedom and Operation Iraqi Freedom (Afghanistan and Iraq) service members’ current PTSD has been measured at 11-20%. Only about half of those who need treatment for PTSD and depression actually seek it, and slightly more than half who receive treatment get care that meets minimum clinical standards, according to a 2008 study. 7,8,9 The combination of PTSD, traumatic brain injury, and chronic pain puts military personnel at high risk for alcohol and substance abuse. Substance abuse, depression, physical injuries with associated pain, unemployment, and homelessness are all associated with PTSD. Many states are developing action plans to prevent such deteriorations in PTSD patients, with a particular focus on veterans.9 In general, women are twice as likely as men to be diagnosed with post-traumatic stress disorder. Refugees are at higher risk for post-traumatic stress disorder because of the stressful events that forced them to flee their homeland and the difficulties involved in moving to a new country.10 All totaled, PTSD is a large public health challenge. Findings from the FDNY World Trade Center Health Program After 9/11, the FDNY World Trade Center Health Program asked FDNY rescue/recovery workers (Fire and EMS) about their emotional well-being. Members reported issues with anger, irritability
and anxiety; memory and concentration; changes in eating, sleeping and exercise patterns; and, increases in alcohol and tobacco use. Findings show the persistent impact of the 9/11 tragedy, with the greatest effects reported by FDNY rescue/recovery workers who either were at the WTC site during the morning of the collapses or who lost loved ones (family, coworkers and friends) on 9/11. There was also substantial overlap in health conditions, as most of those with PTSD also developed anxiety and depression and many had physical health problems as well. This overlap of conditions is called comorbidity.
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The most common WTC-related mental health observed illnesses were PTSD and depression. As shown in the adjacent diagram, more than 90% of FDNY members with probable PTSD also have symptoms consistent with depression. Similarly, more than 40% of members with probable depression also have symptoms consistent with PTSD.11 Researchers at Mount Sinai Icahn School of Medicine have found that those responders with PTSD also had elevated biomarkers for increased cardiovascular disease risk including high sensitivity C-reactive protein (hsCRP), a key biomarker of inflammation indicative of increased cardiovascular risk.12 Comorbid PTSD, gastroesophageal reflux disease (GERD) and lower respiratory disease (chronic bronchitis, emphysema, and asthma) also "walk hand in hand." In 1997, Dr. Michael Blumenfield, professor of psychiatry at New York Medical College, evaluated the risk factors for development of PTSD in New York City EMS members. The results showed that 9.3% of those surveyed met the full criteria for PTSD. An additional 10% met the full criteria with the exception that symptoms had not been present for a month at the time the questionnaire was completed. The total percentage of those suffering from PTSD at that time was 19.3%. Work-related factors showed a cumulative effect for the presence of PTSD. Those divorced, with military war zone experience, or prior emergency service experience were more likely to have PTSD. He observed that EMTs and paramedics were not only exposed to major traumatic events, but also to chronic stress.13
Risk Factors for PTSD Percent employees with PTSD by
total number of work-related risk
factors:
1) 9-1-1 NYC EMS experience,
2) > 4 years with NYC EMS,
3) > 7 years in any emergency work,
4) Rank higher than EMT,
5) Ave. of more than 40 hrs/week.
July 2017 – Journal CME Page 7
Exposure to Traumatic Events
In the wake of the 9/11 attacks, researchers reported a wide range of mental and physical health conditions, with PTSD the one most commonly studied. For many New Yorkers, the trauma of the event triggered or exacerbated depression, PTSD, anxiety, or substance use disorders. Among those in lower Manhattan, many witnessed horrific events such as the deaths of friends and co-workers. Others fled the towers only to be engulfed by a dust cloud. Thousands of New York-area residents lost family members in the attacks. During the
morning of the attacks, 911 operators received over 3,000 calls. Some callers were assisting others; some were calling for themselves, making pleas for help. Over time, residents, office workers, and students in downtown Manhattan, as well as rescue and recovery workers and volunteers, were subjected to daily stress for months.16 In addition to PTSD, research also found that the risk of job loss increases if the responder has a chronic medical illness. More recently, the health care environment has been identified as a source of traumatic stress. Medical trauma is experienced because of medical procedures, illnesses, and hospital stays. Waking during a medical procedure, known as “anesthesia awareness,” has been reported in about two of every 1,000 patients. Those who experience it report a traumatizing experience.17 The Intensive Care Unit environment has been shown to create traumatic stress for patients. Mechanically ventilated patients can feel restrained and unable to move while not fully understanding why. Researchers at Johns Hopkins University School of Medicine recently found that PTSD symptoms occurred in 20% of critical illness survivors at 1-year follow-up, with a higher prevalence in those who had comorbid psychopathology, received benzodiazepines, or had early memories of frightening ICU experiences.18,19,20 Imagine a patient from a major accident waking up in an ambulance with severe pain and not knowing why the pain exists and how to control it. Now if that should be repeated routinely on an intensive care unit, it makes sense that the brain would become hyperreactive and that "fight-or-flight" becomes a conditioned response, or even a habitual state. This creates physical stress on all the body systems causing fatigue and malfunction, resulting in a weakened immune system, digestive problems, insomnia, neck and back pain, cardiovascular problems, headaches, and other conditions of chronic stress. Life-threatening medical conditions can cause or exacerbate PTSD. In one study, one-third of patients with traumatic injuries suffered from PTSD at six months after hospital discharge.15 Michelle Flaum Hall, a mental health counselor and PTSD sufferer, shared her own experience following a placental abruption and emergency C-section. During this event, she was unable to advocate for herself, she was vulnerable and had to rely heavily on her caregivers to attend to her needs. “I needed my providers to maintain a caring and professional focus on me, which means not allowing one’s own “stuff” to get in the way of sensitive and respectful communication,” referring to one of her low moments when two nurses engaged in personal conversation at her bedside. She adds, “Experiencing medical trauma can be dehumanizing; treating patients as competent, resilient people restores their humanity.” Her hope is for mental and emotional health to be fully integrated so that the whole patient can receive care. 21
July 2017 – Journal CME Page 8
Sexual violence affects women and men. The long-term effects of sexual assault include high rates of depression and post-traumatic stress disorder. Rape victims are also 13 times more likely to abuse alcohol and four times more likely to contemplate suicide.2 Emotional recovery and cooperation with the judicial process are vastly improved when positive social services and emotional support are provided as early as possible following the traumatic event.4 Prostitution and the use of illicit drugs make individuals more susceptible to
violence. To avoid disrupting the criminal investigation, only ask pertinent questions related to their emergency medical care, but should the patient choose to share their story with you, listen attentively and respectfully. 22 The Stress Response
The body’s stress response can affect how we experience fear and how those memories are stored. The limbic system of the brain contains structures responsible for how we feel emotion. It combines higher mental functions and primitive emotion into a single system often referred to as the emotional nervous system. The amygdala is a "threat-detector." It helps the brain recognize potential threats, and signals to the hypothalamus and the brainstem to prepare the body for fight-or-flight reactions by increasing
heart and breathing rate. Connections from the amygdala extend to areas of the prefrontal cortex (PFC) as well as sensory areas throughout the brain. Your PFC recognizes danger and tells the rest of your body how to respond. The brain’s hippocampus helps form new memories, while the PFC helps with "fear extinguishing," which is the ability to learn that a signal previously linked with an imminent threat is no longer linked with the threat. This is very important to knowing when we are safe and shutting off the alarm. PTSD affects how the brain interprets and stores the events that we experience. Following an experience that is extremely terrifying, your brain may overestimate the degree of danger and your stress system overrespond. Instead of returning to normal over time, your body stays on high alert and keeps releasing stress hormones. 23
Studies of the brain have shown that the three areas involved in learning and memory—the hippocampus, amygdala and prefrontal cortex—undergo distinct structural and functional changes in individuals with PTSD. Chronic stress increases the size, activity level and number of neural connections in the amygdala, making you more fearful. It also reduces levels of critical neurotransmitters, especially serotonin and dopamine. Too little serotonin will make you prone to depression, anxiety, and binge eating. Too little dopamine can leave you unfocused, unmotivated, and lethargic. Decrease in the size of the PFC will make it hard to make plans or decisions, limit your working memory, and affect impulse control. 24
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On a positive note, nervous system connections are not hard-wired. The brain can create new connections and multiple pathways (“circuits”). Based on sensory input, it can generate or prune synaptic connections in response to experience. Neuroplasticity is the term that describes the modifiability of the brain by experience and practice. This permits one area of the brain to take over for an area that is damaged from injury. In the process called neurogenesis, new neurons develop in the hippocampus, improving learning, long-term memory, and regulating emotions.25
The illustration below shows the two primary structures that affect the stress response. Below the illustration is a chart that highlights important parts of the brain involved in PTSD and contrasts their function under normal circumstances as opposed to when someone has PTSD.26
July 2017 – Journal CME Page 10
Symptoms of PTSD
The emotions and sensations that were imprinted during the trauma are experienced not as memories but as disruptive physical reactions in the present. There are four main symptoms that develop and that must last at least one month or more for a diagnosis of PTSD: re-living the event: repeatedly re-experiencing the trauma in the form of nightmares or
upsetting dreams, flashbacks, and uncontrollable thoughts. When this happens, the body often reacts by activating the fight-or-flight response.
avoidance: person avoids anything related to trauma. This includes avoiding situations that could trigger flashbacks or uncontrollable thoughts, avoiding places, people, and activities that remind them of what happened to them, and suppressing feelings or thoughts about the trauma. Some survivors may use alcohol or other substances as a way to avoid and numb feelings and thoughts related to the trauma; others may escape in work, or mental or physical challenges.
hyperarousal: heightened sensitivity and response to stress and trauma. People with hyperarousal may be jittery and are startled easily. They often have problems with concentration because they are constantly alert and looking for danger. Hyperarousal often leads to irritability, outbursts of anger, and trouble sleeping. Overprotectiveness or overcontrolling of loved ones may occur.
changes in thoughts, feelings and beliefs, like:
feeling sad, anxious, or afraid most of the time becoming emotionally numb losing interest in activities and relationships thinking of themselves as bad or feeling guilty believing that the world is a scary, dangerous place and people can’t be
trusted
Normal function Post traumatic stress disorder Amygdala
Emotional brain sets off fight-or-flight in response to danger
Sets off fight-or-flight in response to memories or thoughts about danger
Hippocampus Transfers and stores information into memories
Stores fragmented memories with traces of images, sounds and physical sensations, that are easily triggered
Prefrontal
cortex Rational brain creates complex thinking, decision making and appropriate behavior
Dysfunctional thought processes and decision making; inappropriate responses to situations, overreaction, warped sense of time
Hypothalamus-
pituitary-
adrenal (HPA)
axis
Releases hormones like cortisol, epinephrine (adrenaline), and norepinephrine in response to a threat
Overactive, which leads to imbalances in hormone levels and increases stress and anxiety
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The TRAUMA mnemonic is used to help remember the various aspects of PTSD:
Survivors’ immediate reactions following a trauma are quite complicated and are affected by their own experiences, the accessibility of support, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. In the past, particularly regarding group or mass traumas, the assumption was that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual’s style of coping and not valuing one type over another. Acute stress disorder (ASD) represents a normal response to stress. Symptoms are the same as PTSD and last at least three days and up to one month. Acute stress disorder happens more often with one specific trauma than with repeated exposure to traumatic events. Most individuals who have acute stress reactions never develop PTSD. Getting medical treatment within a few hours of experiencing a traumatic event may reduce the likelihood that you will develop acute stress disorder. The symptoms of PTSD usually occur within the first six months, but may develop months or years later. Symptoms often interfere with the person’s ability to work, go to school, and have meaningful relationships. Communication with others is disrupted by numbing, avoiding people and social situations, or by hostility and anger. When traumatic memories cannot be processed and verbally expressed, the pain is often expressed physically. This could be in various forms, including chronic pain, hypertension, allergies, autoimmune conditions, gastrointestinal disturbances, or chronic fatigue. PTSD symptoms left untreated, can become so severe that the person attempts suicide. 27
Dissociation
There are two defensive states that occur when encountering trauma: dissociation or immobilization (freeze) and sympathetic hyperarousal (fight-or-flight). Dissociation, generated in the primitive brain, occurs in highly traumatized patients. It is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These patients, instead of struggling to escape, they separate from their negative emotions and their bodies and lose their ability to perceive fear. Patients with acute stress disorder and post-traumatic stress disorder may develop dissociative symptoms. Recent studies of trauma indicate that the human brain stores traumatic memories in a different way than normal
memories. Instead
July 2017 – Journal CME Page 12
they are dissociated, or "split off," and may erupt into consciousness from time to time without warning. The affected person cannot control or "edit" these memories. They may resurface spontaneously or be triggered by objects or events in the person's environment. Dissociation can range from daydreaming to total amnesia. Over a period of time, these two sets of memories, the normal and the traumatic, may coexist as parallel sets without being combined or blended. In extreme cases, different sets of dissociated memories may cause people to develop separate personalities for these memories— a disorder known as dissociative identity disorder (formerly called multiple personality disorder). 28 People who experience a traumatic event will often have some degree of dissociation during the event itself or in the following hours, days or weeks. In most cases, the dissociation resolves without the need for treatment. The goal of treatment is association: reconnecting the fragments of trauma, so that the brain can recognize that "that was then and this is now." 29 A PTSD trigger is anything - a person, place, situation, or thought - that reminds the person of the trauma and sets off a PTSD symptom, like a flashback.
You’re driving down the highway, the road is wet and cars keep racing past
you, splashing water on to your windshield. Suddenly you lose control of the car and feel the car plummeting down an embankment. You hear glass breaking, metal screeching and feel searing pain all over your body. You open your eyes and realize that you’re sitting on your couch at home watching TV. You’ve just relived the car accident you were in two months ago for the hundredth time since it happened. Watching rain on the TV triggered the flashback. This is one illustration of a trigger producing a flashback.
PTSD in Children More than one in four children experiences a significant traumatic event before reaching adulthood. The impact of traumatic events on children is often more far reaching than trauma on adults, because the child's development is adversely affected. The development of important neural pathways depends on the child’s early experience. The first three years of life are particularly important for laying down healthy, robust neural pathways for connection. Neuronal plasticity enables the child to adapt to environmental change and is important to brain development and children’s healing. The strength and survival of these neural connections are based on their use. The more a connection is used, the stronger it becomes.30, 31, 32
MRI of child who survived 2008 China earthquake show changes in the network of neural connections in the brain34
Early traumatic experiences can alter the organization of the brain and later brain functioning. Traumatized children may appear almost autistic and may experience great difficulties with learning. Children who have experienced trauma may exhibit sleep difficulties, attention deficit disorders, aggressive and defiant behavior, anxiety symptoms, phobias, and social avoidance, as well as depression. Trauma exposure during childhood is also associated with increased risk for suicide, alcoholism and IV drug use.
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Panic symptoms in the immediate aftermath of trauma exposure are predictive of subsequent PTSD in children. Children also present with physical symptoms such as headaches and abdominal complaints.27, 30
SYMPTOMS ASSOCIATED WITH PTSD IN CHILDREN
Bedwetting Being easily startled
Being unable to talk or forgetting how to talk
Feeling tense or “on edge”
Acting out the scary event during playtime
Having difficulty sleeping
Being unusually clingy with a parent or other adults
Losing interest in activities that once brought happiness
Crying Isolation from friends
Conclusion
PTSD is a large public health challenge. Unfortunately, because the wound is invisible, it remains below the water line, out of sight. The majority of people who experience a traumatic event will get better with time. However, for many, a traumatic event will cause major changes in one’s emotional life. We know that certain populations are more at risk, including children and those whose work exposes them to traumatic events. We also know that in addition to a previous exposure to trauma, some circumstances can contribute to worsening symptoms and progression to PTSD. Advances in neuroscience, and related fields, have revealed that trauma produces actual physiological changes in the brain. In PTSD, the brain’s alarm system has been hijacked, stress hormone secretion is overactive, and the signal that the threat is gone is faulty, creating the state of hyperarousal. New treatments are
proving successful in restoring ownership of the body and mind back to the individual by repairing the faulty “alarm system” that has hijacked the emotional brain. The sooner that this connection is restored the sooner that quality day-to-day life experiences can resume. How this recovery process works will be the subject of next month’s CME Journal.
Dedicated to the EMTs and Paramedics who have struggled in the battle against PTSD.
July 2017 – Journal CME Page 14
Contributed by: Lt. Joan Hillgardner, EMTP Office of Medical Affairs
References
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University, The President and Fellows of Harvard College, developingchild.harvard.edu/resources/three-core-concepts-in-early-development.
33. Lubit, Roy H , MD. "Posttraumatic Stress Disorder in Children Clinical Presentation." Posttraumatic Stress Disorder in Children Clinical Presentation: History, Physical Examination, Complications. WebMD LLC, 22 Sept. 2016. Web.
34. “Brain Structure Alterations Observed in Children With PTSD.” Psychiatry Advisor, Haymarket Media, Inc., 26 Oct. 2016, www.psychiatryadvisor.com/traumastress/brain-structure-alterations-observed-in-children-with-ptsd/article/568296/.
35. Karam, E. G., Friedman, M. J., Hill, E. D., et al. Cumulative traumas and risk thresholds: 12-month PTSD in the world mental health (WMH) surveys. Depress. Anxiety, 2014;31: 130–142.
July 2017 – Journal CME Page 16
July 2017 Journal CME Quiz POST-TRAUMATIC STRESS DISORDER – PART 1 1. How likely is it that someone in the general population will suffer from PTSD at some point
in their life?
a. Very common because most people will suffer from it at some point in their lives (75% or more)
b. Somewhat common because the majority of people will suffer from it at some point in their lives (50–75%)
c. Not too common, but a sizable minority of people will suffer from it at some point in their lives (10–50%)
d. Not very common because less than 10% of people will suffer from it at some point in their lives
2. How common is PTSD in emergency responders?
a. PTSD is much more common in the general population than in emergency responders
b. PTSD rates are about the same between the general population and emergency responders
c. PTSD is more common in emergency responders than in the general population d. PTSD is rare in emergency responders.
3. What does comorbid mean?
a. Two or more disorders or illnesses occurring in the same person b. A type of traumatic event when two people die c. A way of treating psychological disorders d. A type of condition that is permanent
4. What is the most common comorbid condition with PTSD?
a. Obesity b. Heart conditions c. Depression d. Alcohol abuse
5. Children and teens that have experienced traumatic events and are showing signs of post-traumatic stress disorder may experience which of the following symptoms:
a. Loss of speech or difficulty with speech b. Acting out a scary event in play c. Impulsive and aggressive behaviors d. All of the above
July 2017 – Journal CME Page 17
6. Which of the following is an example of an avoidance symptom?
a. Keep forgetting where you put your keys b. Taking a longer route to work to bypass the street of a call location c. Remembering everything about an upsetting call d. Talking to one’s spouse about an upsetting call
7. Which of the following is an example of a re-experiencing symptom?
a. Having a recurring nightmare about an upsetting call b. Having a sudden vivid memory of an upsetting call while driving c. Feeling nauseated or angry if someone brings up the details of an upsetting call d. All of the above
8. Which of the following is an example of a hyperarousal symptom?
a. Getting upset at loud noises b. Not wanting to ride a rollercoaster c. Sleeping more than you should d. Feeling especially motivated to respond to calls
9. Dissociation means to become separated from painful memories, thoughts, and feelings.
a. True b. False
10. During early childhood, the development of important neural pathways depends on the
child’s early experience. Early traumatic experiences can alter the organization of the brain and later brain functioning.
a. True b. False
July 2017 – Journal CME Page 18
Based on the CME article, place your answers to the quiz on this answer sheet. Respondents with a minimum grade of 80% will receive 1 hour of Online/Journal CME.
--------------------------------------------------------------------------------------------------------------------- Please submit this page only once, by one of the following methods:
• FAX to 718-999-0119 or • MAIL to FDNY OMA, 9 MetroTech Center 4th flr, Brooklyn, NY 11201
--------------------------------------------------------------------------------------------------------------------- Contact the Journal CME Coordinator at 718-999-2790:
• three months before REMAC expiration for a report of your CME hours. • for all other inquiries [email protected].
Monthly receipts are not issued. You are strongly advised to keep a copy for your records. ---------------------------------------------------------------------------------------------------------------------
Note: if your information is illegible, incorrect or omitted you will not receive CME credit.
check one: EMT Paramedic
other
Name
NY State / REMAC # or “n/a” (not applicable)
Work Location
Phone number
Email address Submit answer sheet by the last day of July 2017
July 2017
CME Quiz
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Questions 1-10 for all providers
Call Review
Regional CME – Sessions are subject to change. Please confirm through the listed contact.
See other opportunities at www.nycremsco.org under News & Announcements
Note: A potential source of is E.D. Teaching Rounds (maximum of 18 hours) See any hospital E.D. Administrator for availability (especially HHC hospitals)
Boro Facility Topic Location Contact
BK Kingsbrook contact to inquire → ED Conference Room Aaron Scharf 718-363-6644
Lutheran contact to inquire → Call Review Inquire → Dale Garcia 718-630-7230
MN Lenox Hill & Health Plex
contact to inquire → Call Review, Lecture Inquire → Mike Skovira
[email protected] Mt Sinai
Hosp contact to inquire →
Call Review Inquire → Eunice Wright [email protected]
NY Presbyterian contact to inquire → Inquire → Steven M. Samuels
212-746-0596 NYU School
of Medicine contact to inquire →
Call Review, Lecture Inquire → [email protected] http://cme.med.nyu.edu/course
QN Elmhurst Hosp
Call Review: Trauma Rounds
A1-22 Auditorium 3rd Wednesdays, 0830-0930
Anju Galer RN 718-334-5724 [email protected]
Mt Sinai Qns Call Review, Lecture 25-10 30 Ave, conf room
last Tuesdays, 1800-2100 Donna Smith-Jordon 718-267-4390
NYH Queens contact to inquire → East bldg, courtyard flr Mary Ellen Zimmermann RN 718-670-2929
Queens Hosp Call Review Emergency Dept 2nd & 4th Thurs 1615-1815
Maria Jones or Julia Fuzailov 718-883-3070
St John’s University
contact to inquire → Call Review 175-05 Horace Harding Expwy 718-990-8436
www.stjohns.edu/ems/cme St John’s
Episcopal contact to inquire →
Lecture 1st floor Board Room Michelle Scarlett [email protected]
SI RUMC contact to inquire → Call Review, Lecture Inquire → Tony McKay NRP
[email protected] SIUH North
& South contact to inquire →
Call Review Inquire → Holly Acierno RN [email protected]
2017 NYC REMAC Examination Schedule updated 04/04/2017
Month
Registration
Deadline
Refresher exams1 – no fee for exam Basic exams2
all at 18:00
NYS/DOH Writte
3
n 10:00 exams 18:00 exams
January 1/1/17 1/18/17 1/18/17 1/20/17 1/23/17 1/25/17 1/19/17
February 2/1/17 2/20/17 2/13/17 2/16/17 2/20/17 2/22/17 2/16/17
March 3/1/17 3/14/17 3/10/17 3/14/17 3/16/17 3/23/17 3/16/17
April 4/1/17 4/20/17 4/14/17 4/18/17 4/20/17 4/21/17 4/20/17
May 5/1/17 5/17/17 5/15/17 5/17/17 5/19/17 5/24/17 5/18/17
June 6/1/17 6/20/17 6/16/17 6/20/17 6/22/17 6/23/17 6/15/17
July 7/1/17 7/19/17 7/17/17 7/19/17 7/21/17 7/24/17 7/20/17
August 8/1/17 8/17/17 8/17/17 8/21/17 8/24/17 8/22/17 8/17/17
September 9/1/17 9/13/17 9/13/17 9/18/17 9/21/17 9/20/17 9/14/17
October 10/1/17 10/17/17 10/17/17 10/19/17 10/23/17 10/25/17 10/19/17
November 11/1/17 11/16/17 11/10/17 11/14/17 11/16/17 11/22/17 11/16/17
December 12/1/17 12/20/17 12/12/17 12/15/17 12/20/17 12/22/17 12/21/17
1 REMAC Refresher examination is offered for paramedics who meet CME requirements and whose REMAC certifications are either current or expired less than 30 days. To enroll, go to the REGISTER link under “News & Announcements” at nycremsco.org before the registration deadline above. Candidates may attend an exam no more than 6 months prior to expiration.
2 REMAC Basic examination is for initial certification, or inadequate CME, or certifications expired more than 30 days. Seating is limited. Registrations must be postmarked by the deadline above. Exam fee by $100 money order to NYC REMSCO is required. All Basic candidates must meet new education requirements. Email [email protected] for instructions.
3 NYS/DOH exam dates are listed for information purposes only. Scheduling is through your paramedic program or contact NYS DOH for more information.