Concussions: A Hard-Hitting Problem


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Concussions: A Hard-Hitting Problem

  1. 1. CONCUSSIONS:<br />A Hard Hitting Problem<br />Zohar Shamash, M.D.<br />Columbia University Medical Center - Pediatrics<br />
  2. 2. Andy<br />1/2<br />17-y.o. male, no significant past medical history<br />Hit in head by a line drive while playing short stop on his high school baseball team<br />Lost consciousness for ~1 minute and had some retrograde amnesia<br />No vomiting or difficulty walking<br />Now with 7/10 dull headache<br />Normal vitals, physical exam significant for 3x4cm boggy hematoma on R forehead, TTP<br />Normal neurologic exam<br />
  3. 3. Andy<br />2/2<br />What happened?<br />How to manage this patient acutely?<br />What are his discharge instructions?<br />What to expect when he goes home?<br />What about returning to play?<br />When to follow-up?<br />
  4. 4. OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to play<br />Sequelae<br />Prevention<br />
  5. 5. Definition<br />a complex pathophysiological process that affects the brain, induced by traumatic biomechanical forces<br />International Multidisciplinary Conference on Concussion<br />a trauma-induced alteration in mental status that may or may not involve loss of consciousness<br />American Academy of Neurology<br />bell-ringer<br />ding<br />knock-out<br />
  6. 6. My Child Doesn't Have a Brain Injury, He Only Has a Concussion –DeMatteo, et. al.<br />MILD TRAUMATIC BRAIN INJURY=CONCUSSION<br />“Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.”<br />“…the concussion label is strongly predictive of earlier discharge from the hospital and earlier return to school, independent of GCS and the presence of other associated injuries.”<br />
  7. 7. features<br />direct blow or impulsive force<br />short-lived impairment<br />resolves spontaneously<br />functional rather than structural injury<br />may involve loss of consciousness<br />normal structural neuroimaging studies<br />
  8. 8. Grading scales<br />>25 different published grading systems<br />developed through expert opinion <br />rely heavily on LOC <br />Prague, 2004, 2nd CIS symposium: classified into simple and complex groups<br />simple concussion sxs lasting <10 days<br />complex concussions sxs lasting >10 days or involving prolonged LOC, seizures, prolonged cognitive impairment or a history of multiple concussions.<br />Zurich, 2008, 3rd CIS symposium: groups abandoned<br />2010 recommendation: use symptom based approach for determination of return to play<br />
  9. 9. Deprecated grading systems<br />
  10. 10. OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to play<br />Sequelae<br />Prevention<br />
  11. 11. A public-health problem<br />CDC estimates 300,000 sports related concussions occur each year<br />Only includes LOC (~10%) so underestimation<br />Children and young adults at increased risk. Possible reasons:<br />Less force required for same injury in child<br />Children more engaged in sports<br />Developing brain more susceptible to disruption<br />
  12. 12. …even bigger than we know<br />Under-recognition:> 1/3 athletes do not recognize their symptoms as a result of concussions<br />Under-reporting: athletes do not regularly report their symptoms to trained personnel<br />28% of athletes report continuing to play after a blow to the head that results in dizziness<br />61% of football players stay in the game after a hit in the head resulting in headache<br />
  13. 13. Youth Sport injury rate<br />*<br /><ul><li>Football has highest incidence of all youth sport
  14. 14. Girls have higher rate of concussion than boys in similar sports</li></ul>*per 1,000 athlete exposures<br />
  15. 15. pathophysiology<br />Functional disturbance without gross structural injury<br />Mild head injury may result in cortical contusions due to coup and contrecoup injuries<br />
  16. 16. lactate<br /> cerebral blood flow<br />pathophysiology<br />K+ efflux to extracellular space<br /> ATP consumption and glucose utilization<br />Energy crisis<br />Disruption of cell membrane<br /> Na+/K+ pump activity<br />Release of glutamate<br />Cell death<br />Further K+ efflux<br />Depolarization/ suppression neuronal activity<br />Hypometabolic state<br />
  17. 17. pathophysiology<br />
  18. 18. OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to play<br />Sequelae<br />Prevention<br />
  19. 19. Acute evaluation and management<br />ABCs and stabilization of the c-spine, especially if LOC<br />Can be done by a health professional on the sidelines of a game<br />Neurological assessment and mental status testing<br />MANUAL STABILIZATION OF THE PEDIATRIC C-SPINE<br />
  20. 20. S.A.C.<br /><ul><li>Example of standardized tool for the sideline evaluation of athletes who suffer a head injury
  21. 21. “AAOx3” found to NOT be reliable method of screening</li></li></ul><li>Signs and Symptoms<br /><ul><li>hallmarks are confusion, amnesia often without preceding LOC
  22. 22. LOC occurs <10% but important sign that may herald need for further imaging/intervention</li></ul>Physical<br />Headache<br />Nausea<br />Vomiting<br />Balance problems<br />Visual problems<br />Fatigue<br />Photosensitivity<br />Phonosensitivity<br />“Dazed”<br />“Stunned”<br />Cognitive<br /><ul><li>Mental “fogginess”
  23. 23. Feeling slowed down
  24. 24. Difficulty concentrating
  25. 25. Difficulty remembering
  26. 26. Amnesia
  27. 27. Repeats questions
  28. 28. Speaks slowly</li></ul>Emotional<br />Irritability<br />Sadness<br />More “emotional”<br />Anxiety<br />Sleep<br />Drowsiness<br />Altered sleep patterns<br />Difficulty falling asleep<br />
  29. 29. Westmead post-traumatic amnesia scale<br />□ What is your name?<br />□ What is the name of this place?<br />□ Why are you here?<br />□ What month are we in?<br />□ What year are we in?<br />□ In what town/suburb are you in?<br />□ How old are you?<br />□ What is your date of birth?<br />□ What time of day is it?<br />□ Three pictures are presented for recall<br />Measures post-traumatic amnesia and other cognitive deficits associated with mild TBI<br />Takes<1 minute, useful in ED<br />correlates with findings in more detailed neuropsychologic testing<br />incorrect response to one question is test for cognitive impairment after head injury<br />
  30. 30. to image or not to image<br />CT typically normal in concussive injury, should be considered whenever suspicion of intracranial structural injury exists<br />Concussion rarely associated with a c-spine injury, skull fracture, or intracranial hemorrhage<br />Other imaging:<br />MRI and SPECT (gamma radiation)<br />Post-concussion syndromeabnlSPECT and PET scans.<br />
  31. 31. Warning signs<br />severe headache<br />seizures<br />focal neurologic findings on examination<br />Repeated, prolonged emesis<br />significant drowsiness or difficulty awakening<br />slurred speech<br />poor orientation to person, place, or time<br />neck pain<br />significant irritability <br />LOC for > 30 seconds<br />GCS <15 at 2 hours or <14 at any time<br />
  32. 32. Vol 374 No 9696 October 3, 2009<br />Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Kupperman et al<br />Looking for who TO NOT scan<br />The prediction rule for children aged 2 years and older had a negative predictive value of 99.95% and a sensitivity of 96.8%<br />normal mental status<br />no loss of consciousness<br />no vomiting<br />non-severe injury mechanism*<br />no signs of basilar skull fracture **<br />no severe headache<br />BATTLE’S SIGN<br /><ul><li>severe= motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 5 feet or head struck by a high-impact object
  33. 33. ** haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign</li></li></ul><li>Vol 357 No 9266 May 5, 2001<br />The Canadian CT Head Rule for patients with minor head injury Stiell et al<br />Minor head injury is defined as witnessed LOC, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15<br />Looking for who TO scan<br />High risk (for neurological intervention)<br />GCS score <15 at 2 h after injury<br />Suspected open or depressed skull fracture<br />Any sign of basal skull fracture <br />Vomiting ≥two episodes<br />Age ≥65 years<br />Medium risk (for brain injury on CT)<br />Amnesia before impact >30 min<br />Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)<br />
  34. 34. Glasgow coma scale<br />
  35. 35. disposition<br />Observation (for 2-4 hours) in ED for patients with normal neurologic exam<br />Discharge with a responsible person—give excellent discharge instructions<br />Is it necessary to wake patient up every 2 hours at home?<br />No data, but if you’re worried enough you should probably admit<br />Might make patient worse because treatment for concussion is sleep/relaxation<br />Hospital admission is recommended for patients at risk for immediate complications from head injury , patients with:<br />GCS <15<br />Abnormal CT scan: intracranial bleeding, cerebral edema<br />Seizures<br />Bleeding risk<br />
  36. 36. Treatment: physical/cognitive rest<br />Physical rest<br />Increased symptoms with cognitive activities after concussion, so cognitive rest encouraged. May include:<br />Temporary leave of absence from school<br />Shortening of school day<br />Reduction in workload<br />Increased time to complete assignments/test<br />“cocoon therapy”<br />Medication?<br />
  37. 37. OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to play<br />Sequelae<br />Prevention<br />
  38. 38. So, when can I return to play?<br />Many "return to play" guidelines, but little scientific evidence to support them <br />No athlete should return to play when symptomatic at rest or with exertion<br />In fact, it is illegal in 11 states<br />Most will be asymptomatic within one week, but conservative management recommended in children<br />Wait 7-10 days longer<br />
  39. 39. Step-wise Return to play<br />Graduate to following step after >24 hours without symptoms<br />Return to previous step if symptoms recur<br />Return to play!<br />
  40. 40. Neuropsychological testing<br />Provides objective measure of brain function in athlete with concussion—validated for test retest reliability<br />Computerized tests: ANAM, CogState,HeadMinder, and ImPACT<br />Vast majority of studies conducted by developers of test<br />Ideally compared to baseline/preinjury test<br />
  41. 41. Impact test clinical report <br />
  42. 42. <ul><li>Run by Department of Neuropsychology
  43. 43. Departments of
  44. 44. Neurology
  45. 45. Neuropsychiatry
  46. 46. Sports Medicine
  47. 47. Physical Therapy
  48. 48. Uses ImPACT testing</li></li></ul><li>OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to play<br />Sequelae<br />Prevention<br />
  49. 49. sequelae<br />second impact syndrome<br />post concussion syndrome<br />cumulative neuropsychologic impairment<br />post-traumatic epilepsy<br />post-traumatic headaches<br />post-traumatic vertigo<br />other cranial nerve injuries<br />
  50. 50. Second impact syndrome<br />Occurs when an athlete who has sustained an initial head injury sustains a second head injury before the symptoms associated with the first have fully cleared<br />Can cause severe brain injury or even death<br />Cause is hypothesized to be disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased ICP<br />All reported cases in athletes younger than 20 years old<br />
  51. 51. VIDEO<br />
  52. 52. legislation<br />In 2006, a 13 year old named ZackeryLystedt suffered a concussion while playing football but went back into the game. <br />He collapsed after the game and had a brain bleed, and suffered severe brain damage.<br />On May 14th 2009, Gov. Christine Gregoire of Washington state signed the “ZackeryLystedt Law,” the nation's toughest youth athlete return-to-play law.<br />It requires medical clearance of youth athletes suspected of sustaining a concussion, before sending them back in the game, practice or training<br />
  53. 53. Post concussion syndrome (PCS)<br />Constellation of physical, cognitive, emotional, and behavioral symptoms<br />DSM IV requires presence of symptoms in at least 3 of 6 categories for at least 3 months after injury and evidence of neuropsychological dysfunction.<br />Prevalence in adults between 11-64%<br />Limited studies done on children<br />
  54. 54. p.C.S. symptoms<br />
  55. 55. Epidemiology of Postconcussion Syndrome in Pediatric Mild Traumatic Brain Injury -Barlow, et. al.<br />Prospective cohort study of epidemiology and natural history of PCS children with mild TBI compared with children with extracranial injury<br />Among school-aged children with mTBI, 13.7% were symptomatic  3 months after injury compared with <br />2.3% symptomatic after 1 year<br />Finding could not be explained by trauma, family dysfunction, or maternal psychological adjustment.<br />
  56. 56. Seizures and concussions<br />3 different types of events:<br />“impact seizure” <br />immediately following a concussive injury (w/in 2 secs)<br />Not associated with epilepsy, underlying brain injury, similar to convulsive syncope<br />Manage similar to concussions<br />Early post-traumatic epilepsy<br />Within one week following injury<br />Late post-traumatic epilepsy<br />After one week following injury<br />
  57. 57. Cumulative neuropsych impairment<br />Repeated concussions can cause cognitive impairment  <br />“Dementia pugilistica" has been long recognized as sequelae of boxing (20% of professional boxers)<br />Neuropsychological symptoms<br />Behavior<br />Personality changes<br />Depression<br />Suicidality<br />Parkinsonism <br />Other speech/gait abnormalities<br />Higher incidence of dementia than in general population among NFL players with history of multiple concussions—called “chronic traumatic encephalopathy” <br />Neuropathological study of boxers with chronic TBI demonstrates some features of AD incudingneurofibrillary tangles, amyloid plaques<br />ApoE genotype and tau isoforms also may play a role<br />
  58. 58. OvervieW<br />Concussion fundamentals<br />Epidemiology and pathophysiology<br />Management<br />Return to Play<br />Sequelae<br />Prevention<br />
  59. 59. Prevention<br />Mouthguards<br />Helmets<br />Shown to reduce concussion in skiing and snowboarding<br />In football, developed to reduce severe head trauma but not concussions<br />In soccer, protect against soft tissue injuries<br />Concussions usually from head-to-head or head-to-elbow contact<br />Heading the ball safe if done properly<br />Education!<br />
  60. 60. As Injuries Rise, Scant Oversight of Helmet Safety<br />Football helmets not formally tested against the forces believed to cause concussions, only to withstand high forces that would otherwise fracture skulls<br />NOCSAE standard hasn't changed since written in 1973<br />While bicycle helmets are designed to withstand only one large impact before being replaced, football helmets can encounter potentially concussive forces hundreds of times a season<br />Helmet companies now developing helmets to specifically reduce concussion<br />
  61. 61. Resources/education<br /><br />Tons of educational resources<br />Handouts<br />Facebook page<br />iphone app “Cognit” <br /> concussion section<br />The most important mainstay of prevention is education of coaches, athletes, parents<br />
  62. 62. Andy<br />1/2<br />17-y.o. male, no significant past medical history<br />Hit in head by a line drive while playing short stop on his high school baseball team<br />Lost consciousness for ~1 minute and had some retrograde amnesia<br />No vomiting or difficulty walking<br />Now with 7/10 dull headache<br />Normal vitals, physical exam significant for 3x4cm boggy hematoma on R forehead, TTP<br />Normal neurologic exam<br />
  63. 63. Andy<br />2/2<br />What happened?<br />How to manage this patient acutely?<br />What are his discharge instructions?<br />What to expect when he goes home?<br />What about returning to play?<br />When to follow-up?<br />
  64. 64. references<br />1/2<br />Canadian Paediatric Society. Identification and management of children with sport-related concussion. Paediatr Child Health. 2006;11(7):420–428<br />Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503<br />McKeag DB. Understanding sports-related concussion: coming into focus but still fuzzy. JAMA.2003;290 (19):2604 –2605<br />Shores, EA, Lammél, A, Hullick, C, et al. The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early  identification of cognitive impairment in patients with mild traumatic brain injury. J NeurolNeurosurg Psychiatry 2008; 79:1100.<br />Levin, HS, O'Donnell, VM, Grossman, RG. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J NervMentDis 1979; 167:675.<br />Ponsford, J, Willmott, C, Rothwell, A, et al. Use of the Westmead PTA scale to monitor recovery of memory after mild head injury. Brain Inj 2004; 18:603.<br />Kennard MA. Age and other factors in motor recovery from precentral lesions in monkeys. Am J Physiol. 1936;115 :138 –146<br />Anderson V, Moore C. Age at injury as a predictor of outcome following pediatric head injury: a longitudinal perspective. Child Neuropsychol. 1995;1 :187 –202<br />Cantu RC. Work-up of the athlete with concussion. Am J Med Sports. 2002;4 :152 –154<br />Randolph C, McCrea M, Barr WB. Is neuropsychological testing useful in the management of sport-related concussion? J Athl Train. 2005;40 :139 –152<br />Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108 :1297 –1303<br />Kraus JF. Epidemiological features of brain injury in children: occurrence, children at risk, causes and manner of injury, severity, and outcomes. In: Broman SH, Michel ME, eds. Traumatic Head Injury in Children. New York, NY: Oxford University Press; 1995<br />Gordon KE, Dooley JM, Wood EP (2006). "Descriptive epidemiology of concussion". Pediatric Neurology 34 (5): 376–8.  <br />Christopher C. Giza and David A. Hovd, J Athl Train. 2001 Jul–Sep; 36(3): 228–235.The Neurometabolic Cascade of Concussion<br />Kelly, JP, Rosenberg, JH. Diagnosis and management of concussion in sports. Neurology 1997; 48:575.<br />Paniak, C, Reynolds, S, Phillips, K, et al. Patient complaints within 1 month of mild traumatic brain injury: a controlled study. Arch ClinNeuropsychol 2002; 17:319. <br />Lawler, KA, Terregino, CA. Guidelines for evaluation and education of adult patients with mild traumatic brain injuries in an acute care hospital setting. J Head Trauma Rehabil 1996; 11:18.<br />Atzema, C, Mower, WR, Hoffman, JR, et al. Defining "therapeutically inconsequential" head computed tomographic findings in patients with blunt head trauma. Ann Emerg Med 2004; 44:47.<br />Bee, TK, Magnotti, LJ, Croce, MA, et al. Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury. J Trauma 2009; 66:1015.<br />Norlund, A, Marké, LA, afGeijerstam, JL, et al. Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial. BMJ 2006; 333:469.<br />Jagoda, AS, Cantrill, SV, Wears, RL, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2002; 40:231.<br />Evans, RW. The postconcussion syndrome and the sequelae of mild head injury. In: Neurology and Trauma, 2nd ed, Evans, RW (Ed), Oxford, New York 2006. p.95.<br />Kushner, D. Mild traumatic brain injury: toward understanding manifestations and treatment. Arch Intern Med 1998; 158:1617.<br />Bruce, DA. Delayed deterioration of consciousness after trivial head injury in childhood. Br Med J (Clin Res Ed) 1984; 289:715.<br />Kors, EE, Terwindt, GM, Vermeulen, FL, et al. Delayed cerebral edema and fatal coma after minor head trauma: role of the CACNA1A calcium channel subunit gene and relationship with familial hemiplegic migraine. Ann Neurol 2001; 49:753.<br />McQuillen, JB, McQuillen, EN, Morrow, P. Trauma, sport, and malignant cerebral edema. Am J Forensic Med Pathol 1988; 9:12.<br />Saunders, RL, Harbaugh, RE. The second impact in catastrophic contact-sports head trauma. JAMA 1984; 252:538.<br />Collins, MW, Lovell, MR, Mckeag, DB. Current issues in managing sports-related concussion. JAMA 1999; 282:2283.<br />Cantu, RC, Voy, R. Second impact syndrome: a risk in any sport. Physician Sports Med 1995; 23:27.<br />
  65. 65. References<br />2/2<br />Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury.. Pediatrics. 2010 Aug;126(2):e374-81.<br />McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185–200<br />Canadian Paediatric Society. Identification and management of children with sport-related concussion. Paediatr Child Health. 2006;11(7):420–428<br />Dematteo CA, Hanna SE, Mahoney WJ, et al. "My child doesn't have a brain injury, he only has a concussion". Pediatrics. 2010;125(2):327–334<br />Denny-Brown D, Russell WR. Experimental cerebral concussion. Brain. 1941;64(2–3):93–164<br />Ommaya AK, Gennareli TA. Cerebral concussion and traumatic unconsciousness: correlation of experimental and clinical observations of blunt head injuries. Brain. 1974;97(4):633–654<br />Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 2002;16(3):220–242<br />Muñoz-Sánchez MA, Murrilo-Cabezas F, Cayuela A, et al. The significance of skull fracture in mild head trauma differs between children and adults. Childs Nerv Syst. 2005;21(2):128–132<br />Katayama Y, Becker DP, Tamura T, Hovda DA. Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg. 1990;73(6):889–900<br />Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228–235<br />Yoshino A, Hovda DA, Kawamata T, Katayama Y, Becker DP. Dynamic changes in local cerebral glucose utilization following cerebral concussion in rats: evidence of a hyper- and subsequent hypometabolic state. Brain Res. 1991;561(1):106–119<br />Sunami K, Nakamura T, Ozawa Y, Kubota M, Namba H, Yamaura A. Hypermetabolic state following experimental head injury. Neurosurg Rev. 1989;12(suppl 1):400–411<br />McCrory P, Johnston KM, Mohtadi NG, Meeuwisse W. Evidence-based review of sport-related concussion: basic science. Clin J Sport Med. 2001;11(3):160–165<br />Johnston KM, McCrory P, Mohtadi N, Meeuwisse W. Evidence-based review of sport-related concussion: clinical science. Clin J Sport Med. 2001;11(3):150–159<br />American Academy of Neurology. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1997;48(3):581–585<br />Colorado Medical Society. Report of the Sports Medicine Committee: Guidelines for the Management of Concussions in Sport (Revised). Denver, CO: Colorado Medical Society; 1991<br />Cantu RC. Guidelines for return to contact sports after cerebral concussion. Phys Sportsmed. 1986;14(10):75–83<br />Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36(3):244–248<br />Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375–378<br />Thurman DJ, Branche CM, Sniezek JE. The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. J Head Trauma Rehabil. 1998;13(2):1–8<br />
  66. 66. The end!<br />
  67. 67. Thank you!<br />The chiefs: Tom, Mithila, Yaffa<br />Dr. Maria Kwok and CHONY ED faculty<br />My family: Joey and Noa<br />Dr. Stanberry, Dr. Wedemeyer, Dr. Hametz<br />Tuesday Audubon Clinic: Christine, Annika, Omalara, Jillian, Ronny, Jason, Alanna, Josh<br />My class—CHONY 2011<br />