Loma Linda University

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T. Kent Denmark, MD
Director, Center for Interprofessional Education, Director Center for Interprofessional Education
Loma Linda University
Professor, Emergency Medicine
School of Medicine
Professor, Basic Sciences
School of Medicine
Professor, Medical Education
School of Medicine
Professor, Pediatrics
School of Medicine
Publications    Scholarly Journals--Published
  • Hasty M, Kness S, Klasner A, Denmark TK, Herman MI, Brown L. "Cutaneous Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) Infections in Two Geographically Distant Pediatric EDs." Academic Emergency Medicine 14.1 (2007): 35-40. ( 1/2007 ) Link...
    OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0?686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA?positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.
  • Denmark TK, Crane HA, Brown L. "Ketamine to avoid mechanical ventilation in severe pediatric asthma." Journal of Emergency Medicine 30.2 (2006): 163-166. ( 3/2006 )
    Children experiencing severe asthma exacerbations may deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation is often life saving in this setting, but also exposes the asthmatic child to substantial iatrogenic risk. We present two cases of severe asthma exacerbations in prepubertal children for whom the administration of a bolus of intravenous ketamine followed by a continuous infusion of a relatively large dose of ketamine led to prompt improvement, obviating the need for mechanical ventilation. These cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing these children to the risks associated with mechanical ventilation.
  • Kim TY, Denmark TK. "Intraabdominal abscess masquerading as a properly placed GT." Clinical Pediatrics 44. (2005): 539-541-. ( 5/2005 )
  • Denmark TK, Thorp A. "Hair tourniquet masquerading as an STD." Cal/ACEP newsletter . (2004): 9-9. ( 12/2004 ) Link...
  • Vargas EJ, Mody AP, Kim TY, Denmark TK, et al.. "Pediatric upper esophageal coin removal by emergency physicians: A pilot study." CJEM 6.6 (2004): 431-433. ( 11/2004 ) Link...
  • Brown L, Shaw T, Moynihan JA, Denmark TK, et al. "Investigation of afebrile neonates with a history of fever." CJEM 6.5 (2004): 343-348. ( 9/2004 ) Link...
  • Brown L, Denmark TK, et al. "Procedural sedation use in the emergency department managment of pediatric ear and nose foreign bodies." AJEM 22.4 (2004): 310-314. ( 7/2004 )
  • Denmark TK, Hargrove J, Brown L. "Utility of intramuscular ketamine for obtaining central venous access." CJEM 6.4 (2004): 259-262. ( 7/2004 ) Link...
  • Eppich W J, Nypaver M M, Mahajan P, Denmark K T, Kennedy C, Joseph M M, & Kim I. (2013). The Role of High-Fidelity Simulation in Training Pediatric Emergency Medicine Fellows in the United States and Canada. Pediatr Emerg Care, 29(1), 1-7. ( 1/2013 - Present ) Link...
    Objectives: The American Academy of Pediatrics Section on Emergency Medicine's Simulation Interest Group developed a survey targeting pediatric emergency medicine (PEM) fellowship program directors to assess the use of high-fidelity simulation (HFS) in PEM fellow training. Methods: Content experts in simulation and in PEM developed a 38-item Internet-based questionnaire that was distributed to PEM program directors via e-mail though www.surveymonkey.com. Results: Seventy-seven percent (51/66) of PEM program directors in the United States and Canada responded to the survey. Sixty-three percent of programs incorporate HFS in PEM fellowship training. For programs with HFS, the most frequent uses of HFS include (1) decision making for trauma resuscitations (97%, 31/32) and medical emergencies (91%, 29/32), and for the application of advanced life support (84%, 27/32); (2) technical skills: intubation (100%, 31/31), bag-mask ventilation (94%, 29/31), cardioversion/defibrillation (90%, 28/31), and difficult airway management (84%, 26/31). Of program directors without simulation, a majority valued simulation for PEM fellow training, and 59% (11/19) plan on expanding efforts. Perceived barriers to an active simulation program exist: lack of financial support (79%, 15/19), lack of simulator equipment (74%, 14/19), lack of a dedicated physical space (68%, 13/19), and insufficiently experienced simulation faculty (58% 11/19). Conclusions: Sixty-three percent of PEM fellowship programs integrate HFS-based activities. The majority of PEM fellowship program directors value the role of HFS in augmenting clinical experience and documenting procedural skills. Regional simulation centers are one possible solution to offer HFS training to fellowships with limited financial support and/or lack of experienced simulation faculty.
  • Schubert C C, Denmark T K, Crandall B, Grome A, & Pappas J. (2013). Characterizing Novice-Expert Differences in Macrocognition: An Exploratory Study of Cognitive Work in the Emergency Department. Ann Emerg Med, 61(1), 96-109. ( 1/2013 - Present ) Link...
    Study objective: The objectives of this study are to elicit and document descriptions of emergency physician expertise, to characterize cognitive differences between novice and expert physicians, and to identify areas in which novices' skill and knowledge gaps are most pronounced. The nature of the differences between novices and experts needs to be explored to develop effective instructional modalities that accelerate the learning curve of inexperienced physicians who work in high-complexity environments. Methods: We interviewed novice emergency physicians (first-year residents) and attending physicians with significant expertise, working in an academic Level I trauma center in Southern California. With cognitive task analysis, we used task diagrams to capture nonroutine critical incidents that required the use of complex cognitive skills. Timelines were constructed to develop a detailed understanding of challenging incidents and the decisions involved as the incident unfolded, followed by progressive deepening to tease out situation-specific cues, knowledge, and information that experts and novices used. A thematic analysis of the interview transcripts was conducted to identify key categories. Using classification techniques for data reduction, we identified a smaller set of key themes, which composed the core findings of the study. Results: Five interns and 6 attending physicians participated in the interviews. Novice physicians reported having difficulties representing the patient's story to attending physicians and other health care providers. Overrelying on objective data, novice physicians use linear thinking to move to diagnosis quickly and are likely to discount and explain away data that do not "fit" the frame. Experienced physicians draw on expertise to recognize cues and patterns while leaving room for altering or even changing their initial diagnosis. Whereas experts maintain high levels of spatial, temporal, and organizational systems awareness when overseeing treatment modalities of multiple patients, novices have difficulty seeing and maintaining the "big picture." Conclusion: Novice physicians use sense-making styles that differ from those of experts. Training novices to respond to the high cognitive demand of complex environments early in their careers requires instructional modalities that not only increase their knowledge base but also accelerate the integration of knowledge and practice. Simulation and custom-designed avatar-mediated virtual worlds are a promising new technology that may facilitate such training. Future research should expand on the results of this study through the use of larger sample sizes and interviews conducted at multiple sites to increase generalizability. [Ann Emerg Med. 2013;61:96-109.]
  • Kim T Y, Barcega B B, & Denmark T K. (2012). Pediatric Emergency Department Census During Major Sporting Events. Pediatric Emergency Care, 28(11), 1158-1161. ( 11/2012 - Present ) Link...
    Objectives: Our study attempted to evaluate the effects of major sporting events on the census of a pediatric emergency department (ED) in the United States specifically related to the National Football League Super Bowl, National Basketball Association (NBA) Finals, and Major League Baseball World Series. Methods: We performed a retrospective data analysis of our pediatric ED census on the number of visits during major sporting events over a 5-year period. Data during the same period 1 week after the major sporting event were collected for comparison as the control. We evaluated the medians of 2-hour increments around the event start time. Subgroup analysis was performed for games involving the local sporting teams. Results: Our results showed no significant difference in ED census during the sporting events, except in the post 6 to 8 hours of the NBA finals. Subgroup analysis of the Los Angeles Lakers showed the same significant findings in the post 6 to 8 hours of the NBA finals. Conclusions: No major difference in pediatric ED census is observed during the most major sporting events in the United States.
  • Festekjian A, Ashwal S, Obenaus A, Angeles D M, & Denmark T K. (2011). The Role of Morphine in a Rat Model of Hypoxic-ischemic Injury. Pediatric Neurology, 45(2), 77-82. ( 8/2011 - Present ) Link...
    We investigated whether morphine plays a neuroprotective role in a neonatal rat pup model of bilateral carotid artery occlusion with hypoxia. At postnatal day 10, rats received either morphine (n = 7), naloxone (n = 7), or saline placebo (n = 15) after hypoxic-ischemic injury. Survival (days), weight gain and animal testing (negative geotaxis, surface righting, and rotarod) were compared between treatment groups. Lesion volume was delineated with magnetic resonance imaging at days 7 and 28-57 after injury. Survival in rats treated with morphine, naloxone, or saline was, respectively, 14, 29, and 73%. Median number of days of survival after bilateral carotid artery occlusion with hypoxia treated with morphine was 4 (95% confidence interval 4 to 22), with naloxone was 3 (95% confidence interval -1.4 to 21), and with placebo was 28 (95% confidence interval 18 to 28). There were no statistically significant differences in magnetic resonance imaging-derived ischemic lesion volumes, weight gain, or behavioral testing measures between the groups. Morphine was ineffective as a neuroprotectant in rat pups with severe hypoxic-ischemic injury and may have contributed to their decreased survival. Published by Elsevier Inc.
  • Nguyen H B, Daniel-Underwood L, Van Ginkel C, Wong M, Lee D, . . . Clem K. (2009). An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: An evaluation for medical student training. Resuscitation, 80(6), 674-679. ( 6/2009 - Present ) Link...
    Objective: Widespread application of early goal-directed therapy (EGDT) and the severe sepsis resuscitation bundle is limited by clinician knowledge, skills and experience. This study evaluated use of simulation-based teaching during medical training to increase future clinician knowledge in the above therapies for severe sepsis and septic shock. Methods: A prospective cohort study was performed with medical students at all levels of training. A 5-h course including didactic lectures, skill workshops, and a simulated case scenario of septic shock were administered to the participants. A checklist including 21 tasks was completed during the patient simulation. An 18-question pre-test, post-test and 2-week post-test were given. The participants completed a survey at the end of the course. Results: Sixty-three students were enrolled. There was statistical difference between the pre-test and each of the post-test scores: 57.5 +/- 13.0, 85.6 +/- 8.8, and 80.9 +/- 10.9%, respectively. 20.6% of participants thought the pre-test was too difficult, whereas all participants thought the post-test was either appropriate or too easy. The task performance during the simulated septic shock patient was 94.1 +/- 6.0%. The participants noted improvements in their confidence levels at managing severe sepsis and septic shock, and agreed that the course should be a requirement during medical school training. Conclusions: Medical simulation is an effective method of educating EGDT and the severe sepsis resuscitation bundle to medical students with limited experience in patient care. The results suggest that our course may be of further benefit at increasing clinical experience with this intensive protocol for the management of severe sepsis and septic shock. (C) 2009 Elsevier Ireland Ltd. All rights reserved.
  • Inoue N, Kim T Y, Birkbeck-Garcia A M, Givner A, & Denmark T K. (2009). Incidence of Serious Bacterial Infections in Ex-premature Infants with a Postconceptional Age Less Than 48 Weeks Presenting to a Pediatric Emergency Department. West J Emerg Med, 10(1), 37-40. ( 2/2009 - Present )
    OBJECTIVES: Premature infants are at higher risk of developing serious bacterial infections (SBI). However, the incidence of SBI in ex-premature infants presenting to the emergency department (ED) remains undetermined. The objective of this study is to examine the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks presenting to a pediatric ED. METHODS: A retrospective medical record review was conducted on 141 ex-premature infants with a postconceptional age of less than 48 weeks who had a full or partial septic work up completed in a pediatric ED between January 1, 1998 and March 31, 2005. RESULTS: The overall median gestational age at birth was 35 weeks (IQR 33-36 week) and the overall median postconceptional age at ED presentation was 40 weeks (IQR 37-42 weeks). Thirteen (9.2%) infants were found to have a SBI. Five subjects had pneumonia, four with bacteremia, two with pyelonephritis, and two with a concomitant infection of meningitis/pneumonia and bacteremia/pyelonephritis. CONCLUSION: The results of this study reveal that the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks is similar to in-term infants (9.2%) and is consistent with previously published incidence rates in-term infants (10%).
  Books and Chapters
  • Denmark TK, Roger SC. Drowning and submersion injuries. Pediatric Emergency Medicine: Elsevier 2008: 987-991 ( 10/2004 - 2/2005 )
     
  • Denmark TK. Inborn errors of metabolism. Pediatric Emergency Medicine: Elsevier 2008: 273-276 ( 9/2004 - 2/2005 )