Medicine and Health Sciences Commons^™

An Elusive Diagnosis: Pheochromocytoma Presenting With Hyperglycemia And Hypertensive Crisis, Tucker Ledo

Rowan-Virtua Research Day

Pheochromocytoma is a rare catecholamine-secreting tumor that can present with a wide range of nonspecific symptoms, often mimicking more common medical conditions and making early diagnosis difficult. We report the case of a 40-year-old female with a history of hypertension and prediabetes who presented to the emergency department with hyperglycemia following an episode of lightheadedness. This case highlights the diagnostic challenge of pheochromocytoma in the emergency department, where initial symptoms may be subtle and easily attributed to more common conditions such as hypertension, diabetes, or menopause. Recognition of episodic sympathomimetic symptoms and unexplained hypertensive crises should prompt consideration of pheochromocytoma …

Case Report: Ascending Cholangitis Presenting As Sepsis With Encephalopathy In An Older Adult With Choledocholithiasis, David Marconi, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Acute cholangitis is a potentially life-threatening biliary infection usually precipitated by ductal obstruction. In adults ≥80 years, classic right upper quadrant pain and jaundice may be absent and delirium may predominate, increasing the risk of diagnostic delay.¹

An 82-year-old woman presented with generalized weakness and altered mental status. She was febrile (101.9 °F [38.8 °C]) and tachycardic (113 beats/min) without hypotension. Laboratory testing demonstrated leukocytosis and marked cholestatic liver injury (total bilirubin 2.8 mg/dL, alkaline phosphatase 660 U/L) with hyperbilirubinemia and acute encephalopathy consistent with sepsis-associated organ dysfunction. Computed tomography and ultrasound suggested biliary obstruction and cholelithiasis; magnetic resonance cholangiopancreatography …

A Rare Intervention: Emergency Ultrasound-Guided Pericardiocentesis Using A Central Line Kit, Alec Mirchandani, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Cardiac tamponade is a life-threatening emergency requiring rapid diagnosis and drainage.

Point-of-care ultrasound (POCUS) expedites recognition and guides pericardiocentesis. We report a case of acute large pericardial effusion with hemodynamic collapse in a previously healthy 46-year-old female, managed emergently with ultrasound-guided pericardiocentesis using a central line introducer and subsequent pigtail catheter exchange; the clinical course was complicated by presumed septic pulmonary emboli and death.

Reducing Pharmacy Callbacks And Improving Workflow Efficiency In The Emergency Department: A Quality Improvement Initiative, Philip .. Carhart, Hannah Culleny, Alexis Schuitema, James Espinosa, Robin Lahr, Sergey Medlenov, Gabriel Meister, Alan Lucerna

Rowan-Virtua Research Day

A simple educational intervention combined with structured provider feedback reduced ED pharmacy callbacks by 86%. While individual call duration remained unchanged, the reduction translated into nearly eight hours of provider time saved annually. This study highlights the impact of targeted quality improvement efforts on: • Workflow efficiency • Interprofessional communication • Patient care reliability. Small systems interventions can produce disproportionate operational benefits.

Molten Sugar Burn To The Dorsal Foot: A Case Highlighting Unique Thermal And Adhesive Injury Mechanisms, James Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

This brief case report emphasizes injury mechanism and anatomic vulnerability rather than burn management, as treatment of deep partial-thickness burns is well established. The clinical value of this case lies in recognizing molten sugar as a uniquely hazardous thermal agent capable of producing deceptively deep injury, particularly when contact occurs on the dorsal foot.

Brief Review: Quantifying The Risks Of Snow Shoveling: Cardiac, Musculoskeletal, And Environmental Hazards, James Espinosa, Swet A. Patel, James Lee, Alan Lucerna

Rowan-Virtua Research Day

Snow shoveling is a common winter activity in cold-weather regions, yet it uniquely combines intense physical exertion, cold exposure, and environmental hazards. Emergency Departments routinely observe seasonal increases in snow-shoveling–related musculoskeletal injuries, falls, and acute cardiovascular events. Despite this, the cardiovascular risk of snow shoveling is not well emphasized in medical education or patient counseling. Snow shoveling is associated with quantifiable and clinically significant risks, including musculoskeletal injury, falls, and acute cardiovascular events, which are reviewed here.

Ice Water Immersion–Associated Syncope: A Case Report With Mechanistic Review And Public Safety Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Sudden ice water immersion can provoke syncope in otherwise healthy individuals, particularly during first-time exposure. We present a case of a 56-year-old man with mild hypertension and hyperlipidemia who experienced abrupt syncope during entry into cold water at a charitable group immersion event. Emergency department evaluation, including electrocardiography and cardiac biomarkers, was normal. Observation and cardiology consultation supported a diagnosis of provoked, immersion-related syncope. This case highlights the physiologic mechanisms of cold shock and autonomic conflict, the potential drowning risk associated with loss of consciousness during water entry, and the opportunity for improved discharge counseling and public safety messaging.

Refeeding Syndrome In A Person Experiencing Homelessness: A Case Report, James Espinosa, Jose Gerald Aragon, Md Fateha, Alan Lucerna

Rowan-Virtua Research Day

Refeeding syndrome (RFS) is a potentially life-threatening metabolic disturbance that occurs following nutritional reintroduction in severely malnourished individuals. It is characterized by rapid intracellular shifts of electrolytes—most notably hypophosphatemia—driven by insulin-mediated metabolic changes. Although commonly associated with eating disorders and chronic illness, RFS may also occur in socially vulnerable populations.

We report the case of a 64-year-old male experiencing homelessness who presented to the emergency department with weakness, muscle cramps, and confusion after resuming regular meals at a local shelter following prolonged minimal intake. Laboratory evaluation revealed severe hypophosphatemia (0.7 mg/dL), hypokalemia (3.0 mmol/L), and hypomagnesemia (1.2 mg/dL). Electrocardiogram demonstrated …

Shopping Cart–Related Injuries In Children: Brief Clinical Review And Public Health Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Shopping cart–related injuries represent a common yet underrecognized mechanism of pediatric trauma. National estimates suggest approximately 24,000 children annually are treated in U.S. emergency departments for shopping cart–related injuries, with falls accounting for the majority of cases. Younger children, particularly those under 5 years of age, are disproportionately affected, and head and facial injuries predominate.

Objective:

To provide a concise clinical and public health review of shopping cart–related pediatric injuries, with emphasis on epidemiology, injury patterns, and opportunities for prevention within emergency department practice.

Methods

Narrative review of national injury surveillance data, prior epidemiologic studies, and consumer safety guidance addressing …

High-Intensity Interval Training And Circulating Brain-Derived Neurotrophic Factor In Healthy Young Adults: A Scoping Review, Rikuto Abe, Safe Elhakeem, Mohamed Elhakeem

Rowan-Virtua Research Day

Abstract

Background: Brain-derived neurotrophic factor (BDNF) plays an important role in synaptic plasticity, neuronal survival, and cognitive function (1,2,3). High-intensity interval training (HIIT) has emerged as a time-efficient exercise modality capable of inducing neurotrophic adaptations (4,5). However, the magnitude and consistency of its effects on circulating BDNF remain unclear.

Objective: This scoping review evaluated the current evidence examining the effects of HIIT on circulating BDNF levels measured via enzyme-linked immunosorbent assay (ELISA) in healthy young adults.

Methods: A systematic search of PubMed, Embase, and Scopus was conducted for randomized and controlled clinical trials published between 2020 and 2025. Studies were …

Effect Of Sauna On Cardiovascular Health In Patients With Heart Failure, Rikuto Abe, Piotr Domaszewski, Safe Elhakeem

Rowan-Virtua Research Day

Abstract

Heart failure (HF) is one of the hallmark diseases that represent a decline of cardiovascular function. Heart failure is characterized by a decrease in the ability of the heart to pump blood throughout the body, leading to symptoms such as fatigue, dyspnea, and swelling. HF is shown to decrease quality of life and increase mortality. Traditional treatments include pharmacology, lifestyle modifications, and surgery. Among the treatments, deliberate heat exposure in the form of dry saunas has been highlighted as a potential treatment option for HF. Dry saunas, especially infrared saunas, are shown to increase body temperature which improves circulation …

Impostor Phenomenon In Healthcare: Prevalence, Implications, And Educational Responses, James Espinosa, Robin Lahr, Sergey Medlenov, Swet Patel, Nicholas Tomasello, James Lee, Neel Parikh, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

The impostor phenomenon describes persistent self-doubt and fear of being exposed as a fraud despite objective evidence of competence. The term 'impostor phenomenon' is preferred over the term "imposter syndrome" because it is not a psychiatric diagnosis and avoids pathologizing normal developmental uncertainty. The original authors used the term 'phenomenon' (Clance & Imes, 1978), and contemporary scholarship increasingly adopts this terminology.

First described by Clance and Imes (1978), the construct has since been studied across diverse professional domains, including medicine, nursing, and academic leadership. Subsequent research demonstrates that impostor experiences occur across genders, training levels, and healthcare roles (Bravata et …

Gut Microbiota Dysbiosis In Down Syndrome: Implications For Gastrointestinal And Neurological Health, Ashlyn Mcclelland, Jennifer Lecomte, Wendy Aita, Andrea Iannuzzelli

Rowan-Virtua Research Day

Down syndrome (DS) is the most common autosomal aneuploidy and has strong associations with increased gastrointestinal, neurological, and immune disorders. Emerging evidence suggests that gut microbiota dysbiosis may play a prominent role in disorders of gut-brain interaction, including constipation and irritable bowel syndrome affecting over half of individuals with DS. This review examines how gut microbiota alterations can contribute to chronic systemic inflammation and neurological manifestations in DS. Included articles were published between 2014 and 2025 and evaluated microbiota composition, inflammatory markers, and gastrointestinal or neurological outcomes in human or animal models of DS.

Across seven studies, characteristic microbiome shifts …

Hydration During Emergency Medicine Shifts: An Overlooked Component Of Cognitive Performance, Well-Being, And Systems Design To Fail To Plan For Shift Hydration Is To Plan To Fail With Shift Hydration, James Espinosa, Alan Lucerna, Swet Patel, Robin Lahr, Sergey Medlenov, Adam Kandil, Frank Wheeler, Wayne Tamaska, James Lee, Neel Parikh, Henry Schuitema

Rowan-Virtua Research Day

Emergency Medicine (EM) clinicians work prolonged, cognitively demanding shifts in environments characterized by unpredictability, interruptions, and high decision density. While fatigue, burnout, and circadian disruption have been widely studied, hydration during active clinical shifts has received little focused attention. Evidence from cognitive, military, and sports physiology literature demonstrates that even mild dehydration can impair attention, working memory, mood, and reaction time. Despite these findings, hydration in Emergency Medicine is typically treated as an individual behavior rather than a systems-level design consideration. This review synthesizes relevant physiologic and performance literature, identifies cultural and structural barriers to hydration during EM shifts, and …

Learning From Our Dental Colleagues: A Brief Review Of Counter-Stimulation To Reduce Procedural Pain In Emergency Medicine Mechanisms, Existing Evidence, And A Pragmatic Research Agenda, James Espinosa, Neal Appelstein, Alan Lucerna

Rowan-Virtua Research Day

Counter-stimulation techniques such as tapping, pressure, vibration, and tissue shaking are commonly observed in dental practice during administration of local anesthetic nerve blocks. Although not systematically described in the Emergency Medicine literature, individual clinicians may employ tactile counter-stimulation techniques during needle-based procedures. The practice remains under-theorized and under-studied within the Emergency Medicine literature. This brief review synthesizes mechanistic neurobiology—including segmental gate control theory (Melzack & Wall, 1965), descending inhibitory modulation, and attentional salience models—with evidence from dental and needle-procedure research. We propose a practical taxonomy of counter-stimulation techniques applicable to Emergency Medicine and identify gaps in the current literature. Finally, …

From Confirmation To Guidance: Making The Case For Intraprocedural Pocus As The Next Developmental Step In Ultrasound-Supported Shoulder Reduction A Conceptual Practice Proposal And Research Agenda, James Espinosa

Rowan-Virtua Research Day

Point-of-care ultrasound (POCUS) is well established for the diagnosis of shoulder dislocation and for the confirmation of successful reduction. However, its role during the reduction maneuver itself remains under-described. This conceptual practice proposal argues that intraprocedural POCUS represents the logical next developmental step in ultrasound-supported shoulder reduction. By introducing real-time visualization of humeral head translation during reduction attempts, clinicians may identify ineffective vectors earlier, adjust technique midstream, and potentially reduce repeated attempts or escalation of procedural sedation. This work does not present outcome data but instead proposes a practical framework, workflow model, and research agenda for intraprocedural implementation. Future study …

Rainfall, Air Quality, And Vaso-Occlusive Crisis In Adults With Sickle Cell Disease, James Espinosa

Rowan-Virtua Research Day

.Patients with sickle cell disease (SCD) frequently report that weather changes precipitate vaso-occlusive crises (VOC). While prior investigations have focused primarily on temperature, humidity, and seasonal variation, emerging data suggest that rainfall patterns may represent a more meaningful environmental signal. In a multi-hospital Emergency Department analysis, below-average rainfall days were associated with significantly increased adult VOC presentations (Ahmed et al., 2023). Rainfall may function as an atmospheric clearing mechanism; reduced precipitation may permit accumulation of airborne particulate matter and environmental pollutants, increasing oxidative stress and endothelial activation—mechanisms central to vaso-occlusion. Multiple epidemiologic studies demonstrate associations between particulate exposure and increased …

The Complex World Of Emergency Department Medication Dosing: Weight Scalars, Dose And Area Under The Curve (Auc) In Medication Dosing--Areas For Future Research, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Weight-based dosing is foundational to emergency medicine practice. With modern ED beds capable of automatic patient weighing, inaccuracies in estimated weight have largely diminished. However, medication misalignment persists, particularly in patients at extremes of body weight and in high-stakes clinical contexts such as rapid sequence intubation (RSI), antimicrobial therapy, and anticoagulation. Emerging pharmacokinetic literature emphasizes total drug exposure—represented by the area under the concentration–time curve (AUC)—as a stronger correlate of efficacy and toxicity than single-point serum levels. This review explores where weight precision most likely matters in the ED, examines weight scalars, and reframes dosing decisions through an exposure-centered paradigm. …

Designing For Difference: A Systems Approach To Sensory-Adaptive Care In The Emergency Department, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Children with genetic syndromes and other neurodevelopmental conditions frequently present to the Emergency Department (ED) with sensory vulnerabilities that complicate evaluation and treatment in high-stimulus environments. While experienced clinicians often adapt instinctively to meet these needs, such adaptations may be inconsistently applied and may also be highly individual provider dependent. We present a case involving a child with a genetic syndrome affecting auditory and visual systems to illustrate how small environmental, relational, temporal, and cognitive adjustments can prevent escalation and enable routine care delivery without specialized resources.

We propose reframing sensory-adaptive care not as an exceptional accommodation but as a …

Towards More Effective And Efficient Ite And Board Preparation In Emergency Medicine: A Conceptual Framework Using Personality Preferences (Mbti) To Inform Study And Test-Taking Behaviors, James Espinosa, Robin Lahr, James Lee, Alan Lucerna

Rowan-Virtua Research Day

Background: Preparation for high-stakes examinations in Emergency Medicine (EM) relies heavily on question-bank practice, rapid decision-making, and targeted review. Despite standardized board-preparation resources, trainees demonstrate substantial variability in study behaviors and perceived efficiency. The Myers-Briggs Type Indicator (MBTI), widely used in medical education for communication and self-reflection, may offer a framework for understanding differences in study and test-taking behaviors, though it is not designed as a predictive psychometric tool.

Objective: To review existing literature relating MBTI preferences to learning behaviors and academic performance, and to propose a conceptual framework linking personality preferences to board-style test-taking patterns in EM trainees.

Methods: …

The Case For Intraprocedural Ultrasound Guidance In Lumbar Puncture--From Landmarking To Navigation In Lumbar Puncture. A Conceptual Review And Research Agenda, James Espinosa, Frank Wheeler, Robin Lahr, Sergey Medlenov, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Ultrasound guidance for lumbar puncture (LP) is well established for pre-procedural landmark identification, particularly in patients with difficult anatomy. However, most current approaches discontinue ultrasound prior to needle insertion, returning the operator to a blind technique. Current emergency medicine ultrasound guided intravenous line insertion demonstrate feasibility of real-time needle visualization.  However,  the development and adoption of real-time guidance in the setting of lumbar puncture remains limited. Prior simulation work demonstrated that ergonomics, operator experience, and workflow integration significantly influence performance in ultrasound-assisted LP (Horn, Espinosa et al., 2016).  Here we make the case that LP is not a static targeting …

Listening To The System: Reframing Emergency Department Noise: The Case For Noise As A Real-Time Operational Signal In A Complex Adaptive System (Cas), James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Emergency Department (ED) noise has historically been framed as an occupational and environmental hazard requiring mitigation. And this is still true—but not complete. Early work focused on exposure reduction and spike identification. Subsequent mapping studies demonstrated spatial and temporal differentiation in ED acoustic load. We propose an expanded conceptual model: acoustic variability may function not only as a hazard, but also as a real-time signal of operational turbulence within the ED as a complex adaptive system (CAS). Drawing on human factors, alarm fatigue, resilience engineering, and complexity science, we synthesize existing literature and institutional experience to identify a critical gap—noise …

When The Clock Stands Still: Clock Time Vs. Experienced Time In The Emergency Department Brief Review: Neurobiology Of Time Perceptiontemporal Distortion As A Marker Of Cognitive Load And Operational Turbulence, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Emergency clinicians frequently report that time during ED shifts can feel unusually slow or unusually fast. This shared observation has rarely been examined formally in emergency medicine. Altered time perception has also been described in high demand professions such as aviation, sports, military operations, and emergency response. Individuals often report time dilation during critical events and time compression during highly coordinated performance. These findings suggest that temporal perception reflects underlying neurocognitive responses to environmental demands. Emergency departments share many characteristics with these environments, including rapid decision making, task switching, and intermittent high stakes events.

Objective:  Brief narrative review concerning …

From Lists To Landscapes And Locations: Spatial Memory And Schema Formation (Memory Palace Adaptation) As A Neurobiologically Informed Strategy For Teaching Environmental And Toxicology Emergencies Ite And Board Review In Emergency Medicine Residency, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background:

Most emergency medicine board domains inherit spatial scaffolding from foundational anatomy education (e.g., neuroanatomy, gastrointestinal tract, cardiopulmonary structures). Environmental emergencies lack an inherent anatomic anchor and are frequently taught as disconnected lists, increasing cognitive load and impairing schema formation. Similarly, toxicology crosses age, and specialty without an inherent anatomic structural anchor.

Objective:

To describe a scene-based, learner-generated landscape model designed to reintroduce spatial structure into environmental emergency education and to situate the model within contemporary neurobiology and learning science.

Educational Innovation:

Residents construct a large-format landscape diagram (sun–water–mountain schema) during live instruction. Environmental conditions are spatially anchored in ecologically …

Olfaction And Clinical Cognition In Medicine: An Under-Theorized Sensory Modality In Healthcare, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Olfaction is the most evolutionarily ancient sensory modality and retains privileged neuroanatomical connections to limbic and threat-detection systems. Despite its biological significance, olfactory perception is under-discussed in contemporary medical education and academic literature, particularly in healthcare environments.

Objective: To examine olfaction as a low-bandwidth, high-salience diagnostic signal in medicine; to explore its neurobiological foundations; and to analyze its ethical, social, and professional implications within Emergency Medicine and other clinical settings.

Methods: Narrative synthesis of neuroscience, evolutionary biology, volatile organic compound (VOC) research, and clinical observational practice.

Discussion: Olfactory pathways bypass primary thalamic relay and project directly to limbic structures …

The Physics And Biology Of High-Risk Falls: Biomechanical Analysis And Physics Assists In Understanding Why The Threshold For High-Risk Was Lowered To 10 Feet, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Recent revisions to the National Guideline for the Field Triage of Injured Patients lowered the high-risk fall threshold from >20 feet  to >10 feet for all ages. Guideline changes are multifactorial and typically reflect epidemiologic registry data, injury severity trends, and systems-level performance feedback. However, biomechanical analysis assists in understanding the importance of the change.

Objective: To demonstrate that a 10-foot fall generates sufficient kinetic energy and deceleration forces to exceed structural tolerance thresholds in multiple human tissues, and to show that fundamental physics independently supports the recent trauma protocol change.

Methods: Application of gravitational motion equations (v = …

The Ones That Got Away:Shared Misses, Shared Mastery — A Proposal For Leveraging Spaced Retrieval, Variable Reinforcement, And Collective Learning In Emergency Medicine Residency, James Espinosa D, Robin Lahr, James Lee, Swet M. Patel, Alan Lucerna

Rowan-Virtua Research Day

Background

Residents frequently engage in individual question-bank study for board preparation; however, missed questions are typically processed in isolation. Educational psychology demonstrates that spaced retrieval and variable reinforcement enhance durable learning. Psychological safety further supports collective sense-making in professional education . The addition of a periodic, structured, collective shared-review process model may leverage these principles within residency training.

Objective

To propose a resident-driven educational initiative that transforms individually missed board-style questions into a shared, psychologically safe learning stream that promotes durable knowledge retention and community-based mastery.  The movement of this stream could be a chief resident responsibility, or could be …

Detecting Early Operational Turbulence In The Emergency Department Using Fourier And Wavelet Analysis: A Conceptual Framework For Signal-Informed Anticipation And Prediction In The Ed Complex Adaptive System, James Espinosa, David Ho, Alan Lucerna

Rowan-Virtua Research Day

Background:

We theorize that Emergency Departments (EDs) function as complex adaptive systems characterized by nonlinear interactions, oscillatory demand patterns, and abrupt phase transitions from stable flow to turbulent states. Traditional dashboards rely on threshold metrics that detect instability after degradation becomes visible. Many ED data streams are significantly retrospective as well as compression-averaged into temporal systems such as days, months, quarters or even years. Signal processing methods—particularly Fourier and wavelet analysis—offer the  framework for detecting latent oscillatory shifts preceding overt operational change from laminar to transitional to turbulent flow states. This could lead to better methods of adaptation.

Conceptual Framework: …

Beyond Traditional Emergency Medicine Residency Match Interviews: Behavioral Questions As Stress Tests For Resident Selection A Theory-Driven Micro-Assessment Framework For Detecting High-Value Traits, Alan Lucerna, James Lee, Robin Lahr, James Espinosa

Rowan-Virtua Research Day

Background: Traditional residency selection metrics incompletely capture behavioral traits essential for emergency medicine (EM) performance.

Objective: To propose a theory-driven framework using structured behavioral questions as stress tests to detect high-value traits.

Methods: Conceptual analysis of three standardized behavioral prompts assessing execution, systems thinking, and team orientation.

Results: Distinct response patterns align with observable domains associated with reliability, performance, and leadership.

Conclusion: Behavioral stress test questions offer a scalable, low-cost method to enhance residency selection processes.

When Individual Implicit Bias Meets Ed System Turbulence: Expanding The Implicit Bias And Cultural Bias Conceptual Frame To Support Reflective Decision Making Through Both Individual Bias Reduction Strategies As Well As System-Level Design Approaches, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background

Cultural and implicit bias have been widely studied as contributors to disparities in healthcare delivery. Prior literature has largely conceptualized bias as an individual-level cognitive phenomenon occurring within clinician–patient interactions. However, emergency departments (EDs) function as complex adaptive systems (CAS), characterized by time pressure, uncertainty, cognitive load, and environmental noise. These conditions may contribute to the expression of implicit bias in clinical care.

Objective

To reframe cultural and implicit bias in the ED as both an individual cognitive property as well as a system-dependent and modulated  phenomenon and to propose that the operational state of the ED influences the …