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Winter 2013 TM

LEVEL 1

/ COVER STORY /

Time-Critical Diagnosis Paves the Way for Better Outcomes / F E AT U R E /

Trauma Services Q & A: The Definition of a Trauma Center

A L S O IN TH IS ISS UE :

• Preventing secondary brain injury in the battlefield • Building a no text zone •P  rofiles: new to the Trauma Services team • Continuing education


WINTER 2013

CONTENTS FEATURES

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TIME-CRITICAL DIAGNOSIS PAVES THE WAY FOR BETTER OUTCOMES Missouri is the first state in the nation to comprehensively integrate the common processes involved in the medical treatment of time-critical conditions.

TRAUMA SERVICES Q & A Douglas Schuerer, MD, director of Trauma Services at Barnes-Jewish Hospital, defines the differences between a trauma center and an emergency department.

Time-critical diagnosis paves the way for better outcomes, page 4

PROFILES IN THE NEWS

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BUILDING A NO TEXT ZONE Distracted driving is defined as any activity that can divert a person’s attention from the primary task of driving.

CALENDAR

9 PREVENTING SECONDARY BRAIN INJURY IN THE BATTLEFIELD A tried-and-true oral medication prescribed to treat type 2 diabetes may one day save soldiers from dying of secondary, blast-related brain injuries sustained in armed combat.

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ADDITIONS TO THE TRAUMA SERVICES TEAM

2013 CONTINUING EDUCATION OPPORTUNITIES

BARNES-JEWISH HOSPITAL AND WASHINGTON UNIVERSITY PHYSICIANS


B A R N E S - J E W I S H H O S P I TA L ,

a nonprofit academic institution, is the largest hospital in Missouri and is consistently ranked among the Honor Roll of America’s best hospitals by U.S. News & World Report. The adult teaching hospital of Washington University School of Medicine, Barnes-Jewish was the first adult hospital in Missouri to be certified as a Magnet hospital for its nursing excellence.

A LETTER FROM JULIE NASH

Dear Allied Health Professionals, Barnes-Jewish Hospital is a member of BJC HealthCare, one of the largest nonprofit health care organizations in the United States. Barnes-Jewish Hospital’s trauma program has earned the distinction of Level I verification from the American College of Surgeons, the highest national recognition possible. Barnes-Jewish Hospital is one of four hospitals in the state of Missouri to earn this honor. WA S H I N G TO N U N I V E R S I T Y P H YS I C I A N S

This edition of Innovate Level I showcases some of the injury-prevention projects Trauma Services at Barnes-Jewish Hospital supports. In particular, we are working to reduce the incidence of distracted driving and the trauma it can cause. By partnering with ABC’s Channel 30 to create the NO TEXT ZONE campaign, we hope to change a behavior that can result in serious injury and death. According to the National Highway Traffic Safety Administration, in 2010, more than 3,000 people were killed in crashes involving a distracted driver. And during daylight hours, more than 800,000 vehicles are being driven by someone using a hand-held cell phone. We hope you will join with us in our effort to change behavior and reduce distracted driving.

are the medical staff of Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center. Washington University EMS physicians provide medical direction for more than two dozen police, fire and ambulance agencies in the region.

This issue of Level I also features an update on Missouri’s Time-Critical Diagnosis (TCD) system. Implementation of this system is expected to begin soon. It is now our responsibility to educate the public about TCD and why the right care at the right time and in the right place is so critical for trauma patients. Please share this information with your family and patients so that we can ensure everyone knows the life-saving benefits of the new TCD system.

For more information or to make an appointment, call 314-TOP-DOCS (314-867-3627) or 866-867-3627 (toll free).

We at Barnes-Jewish Hospital want to say “thank you” to all of you for your amazing work. I am personally grateful for your dedication to our community. Our relationship with you is one we treasure, and we wish you and your family a safe and happy new year.

Innovate Level 1 is published biannually by Barnes-Jewish Hospital. Editor: Anne Makeever Managing editors: Rebecca Fleming, Julie Nash , MSN, RN

Sincerely,

Want to send a message to Julie Nash? Have questions or comments? Email innovate@bjc.org.

Julie Nash, MSN, RN Trauma and Acute Care Surgery Program Manager Barnes-Jewish Hospital

Physician editor: Douglas Schuerer, MD, director of Trauma Services Contributing writers: Judith Evans, Jamie Gagliarducci, Mary Konroy Address Changes: Innovate Level 1 Circulation Mailstop 90-75-585 4901 Forest Park Ave., Suite 1221 St. Louis, MO 63108 If you no longer wish to receive Innovate Level 1 or received multiple copies, call 314-TOP-DOCS (314-867-3627) or 866-867-3627 (toll free), or email innovate@bjc.org.

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Building a NO TEXT ZONE

In 2007, Lauren Wisdom was injured in a car accident

In September of 2007, Lauren Wisdom was on the last leg of a 90-minute drive from her uncle’s house to her home. Even at the young age of 17, she was familiar with the route, having driven it many times. So she and a friend were having a conversation—via text message.

30’s Missouri No Text Zone campaign.

while texting and driving. A recent graduate of Goldfarb School of Nursing at Barnes-Jewish College, Wisdom is a spokesperson for ABC Channel

When the sound of rumble strips caught her attention, Wisdom swerved back onto the highway, overcorrecting to avoid hitting a car in the next lane. That’s when her car flipped three times. Without a seat belt to hold her in place—she had unbuckled because the belt was chafing her shoulder—Wisdom was thrown through the driver’s-side window, landing 100 feet from her car on the opposite side of the highway. U.S. Department of Transportation statistics related to distracted driving,

including texting while driving, emphasize the need for text-free roads and highways. n

I n 2010, 3,092 people in the United States were killed in crashes involving a distracted driver and an estimated additional 416,000 were injured in motor-vehicle crashes involving a distracted driver.

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 ext messaging creates a crash risk 23 T times greater than driving undistracted.

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 ending or receiving a text takes S a driver’s eyes off the road for an average of 4.6 seconds, thereby creating a situation similar to driving the length of a football field at 55 miles per hour while blindfolded.

In 2012, Barnes-Jewish Hospital’s trauma services group joined with ABC’s Channel 30 to launch the Missouri No Text Zone campaign that asks drivers to take a “don’t text and drive” pledge. Wisdom was lucky—she sustained relatively minor injuries: bruised lungs, glass in her scalp and knees, and road rash. She recovered in two weeks. After the accident, Wisdom shared her story with high school classmates. Then she partnered with Sergeant Al Nothum of the Missouri State Highway Patrol and began to give talks about the dangers of distracted driving. Recently, she was featured in a video for Channel 30’s No Text Zone program. – j. gagliarducci For information about the Missouri No Text Zone campaign, visit bjhne.ws/gx. To view the Missouri No Text Zone video, visit BarnesJewish. org/notxtzone.

Distracted Driving Defined Distracted driving is caused by any activity that can divert a person’s attention from the primary task of driving. There are three basic types of distractions: (1) visual–taking your eyes off the road; (2) manual–taking your hands off the steering wheel and (3) cognitive–taking your focus away from the road. All distractions endanger driver, passenger and bystander safety. Distracting activities include:

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Texting

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Using a cell phone or smartphone

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Eating and drinking

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 alking to passengers T (particularly those in the back seat)

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Grooming

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Reading, including maps

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Using a navigation system

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Watching a video

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Adjusting a radio, CD player or MP3 player

Text messaging requires a driver’s visual, manual and cognitive attention. The State of Missouri currently has a texting ban for drivers 21 years of age and younger.

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Image courtesy of ABC Channel 30

In the News


Preventing Secondary Brain Injury in the Battlefield Glyburide, an oral medication prescribed to treat type II diabetes, may one day save soldiers from dying of secondary, blast-related brain injuries sustained in armed combat. Researchers at Washington University School of Medicine are currently testing this potential new use of the drug. And if the medication works prophylactically as researchers hope, a daily dose might also help high-impact athletes, like football players, avoid similar life-threatening injuries. Traditionally used as an antiglycemic medication, glyburide is known to block access to the brain’s sulphonylurea (SUR1) receptors, thereby potentially preventing brain edema, swelling and intracranial pressure caused by secondary brain injury— effects that can occur in the days and weeks following the initial injury. In combat, these injuries often result from invisible blast waves produced by improvised explosive devices. Research in animals has shown that glyburide works in preventing the harmful effects of secondary brain injury, but works better if it’s taken before the injury occurs. And that’s where the local, phase 1 study comes into play. “The first phase of the trial will be a proof of concept,” says Grant Bochicchio, MD, MPH, Edison Professor and chief of acute and critical care surgery, and principal investigator of the Glyburide Healthy Volunteer Study. The study’s goal is to determine the safety and tolerability of low-dose glyburide in healthy young adults. Specifically, the trial seeks to support a hypothesis that 1.5 mg/dl

daily of the drug is safe both cognitively and physically. The U.S. Department of Defense is sponsoring the study. “The dose is so low that we don’t anticipate any issues, but you never know until you do it,” says Bochicchio, who also oversees trauma services at BarnesJewish Hospital.

IMMEDIATE

The study also will include cognitive tests. “We want to make sure participants’ cognitive and dexterity performance is not inhibited by the drug,” Bochicchio says. Therefore, participants will perform computerized tests before and after the trial to gauge their memory and

BRAIN TRAUMA DELAYED

Primary Damage

Secondary Damage

• Scalp laceration • Skull fracture • Cerebral contusions • Cerebral lacerations • Intracranial hemorrhage • Diffuse axonal injury

• Ischemia • Hypoxia • Cerebral swelling • Infection

The week-long trial will involve 21 healthy subjects (both men and women) between 18 and 40 years of age who have no medical illnesses, no co-morbidities—and no diabetes. Subjects will be randomized to either oral glyburide or a placebo.

their understanding of spatial relationships, and to record the speed of their responses.

Volunteers will become inpatients at the medical center’s Clinical Research Unit within the Center for Applied Research Sciences. They will receive food that replicates the military’s Meals Ready To Eat and run on a treadmill three times a day to simulate the same sort of strenuous activity and caloric burn experienced on a battlefield. Participants will be closely monitored to see if they become hypoglycemic while on the treadmill or suffer any ill effects from hypoglycemia. “We will know in real time if there are any adverse results,” says Bochicchio. “It will be very obvious.”

“In theory, if this is safe, and if we continue to prove that glyburide is efficacious in brain-injury prevention, every soldier could be taking this pill while in warfare, and therefore wouldn’t succumb to the secondary affects of brain injury,” Bochicchio says. “It could revolutionize how we treat and protect soldiers.” Recruiting for the study began in December 2012. Of his research at Barnes-Jewish Hospital, Bochicchio says, “I want EMTs in the area to know that we are doing things in the lab, as well as in our practice, to improve trauma care locally and nationally.”

– m. konroy

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Photo courtesy of Abbott Ambulance

Time-Critical Diagnosis Paves the Way for Better Outcomes written by jamie gagliarducci

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issouri is the first state in the nation to comprehensively integrate the common processes involved in the medical treatment of time-critical conditions. Legislated by Missouri House Bill 1790, the state’s Time Critical Diagnosis (TCD) statute is designed to ensure the timely and appropriate emergency medical treatment for people who suffer trauma, stroke and the potentially fatal form of heart attack known as STEMI (ST-segment elevation myocardial infarction).

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In Missouri, the idea behind TCD was initially proposed by John William Jermyn III, DO, a Barnes-Jewish Hospital emergency physician, the first emergency medical services (EMS) director for the state of Missouri and an EMS advocate. “It is widely known in Missouri that Dr. Jermyn was the champion for the TCD system,” says David Tan, MD, medical director of Washington University EMS. “Unfortunately, the legislation passed one day after Bill

died, but without his work and passion for improving emergency medicine, this would not have come about.” The TCD statute passed in July 2008, but regulations that will mandate how TCD is implemented are still being considered. “The plan and the hope is that they will be passed in 2013,” says Brian Froelke, MD, Washington University emergency medicine physician at Barnes-Jewish Hospital. “A huge benefit of the bill is that it’s a living document, allowing the regulations to be updated as the practice of medicine changes.” The Missouri Department of Health and Senior Services has issued the Bill Warsing, CCEMTP, PNCCT, lead paramedic, specialty care transport (above left), and EMT Jeff Rehm, both with Abbott Ambulance, participate in a training session as part of continuing education for EMS personnel.

BARNES-JEWISH HOSPITAL AND WASHINGTON UNIVERSITY PHYSICIANS


“TCD’s goal is to ensure patients are transported to a hospital that has the equipment and infrastructure to offer the best outcome.”

— Bill Warsing, CCEMTP, PNCCT

following statement about TCD and its impact: “The TCD system represents the continuum of services, beginning with public education about prevention, recognition of signs and symptoms, and the importance of immediately seeking care. It then circles through the series of system components to emphasize evidencebased and best practices for incident recognition, first aid, 911 access, response coordination, prehospital response, transport, emergency department care, acute medical care and rehabilitation. Finally, it incorporates quality-improvement processes through the system.” TCD’s goal is to ensure patients are transported to a hospital that has the equipment and infrastructure to offer the best outcome. “It makes sense to transport patients with emergent conditions another four minutes so they will have access to the specialized care they need,” says Bill Warsing,

Time-Critical Stroke Care Barnes-Jewish Hospital and its Washington University physician partners have reduced door-to-needle time—the time it takes for patients with stroke to receive the clot-busting drug tPA after arriving at the hospital. Years ago, the door-to-needle time at BarnesJewish was 81 minutes. “Through a number of initiatives and improvements, that number has dropped to 38 minutes, which far exceeds the current national expectation of 60 minutes,” says David Tan, MD, medical director of Washington University EMS.

CCEMTP, PNCCT, lead paramedic, specialty care transport, with Abbott EMS/AMR. He is dual-licensed in Missouri and Illinois and has been a paramedic for 15 years. Warsing explains that before TCD, the law simply required that a patient be taken to the closest hospital. “Many patients thought that a hospital was a hospital; that you would get the same care no matter where you went.” But as health care has become increasingly advanced and procedures more complex, a one-size-fits-all attitude can be costly to the patient. Once the new TCD system is enacted, hospitals will be designated as trauma, stroke and STEMI centers by the state of Missouri and, by law, patients with these conditions may be taken to these recognized centers.

was first nationally recognized as a Level I trauma center by the American College of Surgeons in 1996 and has maintained that verification ever since. According to Froelke, TCD also provides a framework for transfers so that stroke and STEMI patients don’t have to wait the usual two-and-a-half hours for a transfer from a hospital that is not equipped to expedite their care. “Having lost my father to a stroke, I regard TCD in a very personal way,” says Tan. “The crucial link to survival is prehospital care–knowing the signs for these conditions, knowing what to do and where to take the patient. There is a reason that the state’s slogan for TCD is ‘Right care. Right place. Right time.’”

In fact, some area hospitals already have been designated as trauma, stroke and STEMI centers. Barnes-Jewish Hospital

The following initiatives are responsible for this reduction in door-to-needle time: > “ Code stroke:” Calls for a true sense of emergency when a stroke patient is brought into the hospital. Previously, such a patient received a neurology consult > “ Code stroke” activation: Gives prehospital personnel the authority to activate a “code stroke,” thus ensuring a neurology team is prepared for the patient’s arrival >C  ommunity education: Offers information about the importance of seeking immediate help for stroke and STEMI care >E  MS and first-responder education: Emphasizes the importance of delivering a patient to a facility that is equipped to immediately provide the best care >S  troke-care processes: Ensures a patient with a suspected stroke is moved directly to a CAT scanner and that a scan team is assembled and waiting for the patient’s arrival

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Trauma Services

Q&A

with Douglas Schuerer, MD, director of Trauma Services, Barnes-Jewish Hospital written by judith evans

Q. How does an emergency department differ from a trauma center?

A. A trauma center comprises various

specialties and areas of the entire hospital system that are set up to care for injured patients. An emergency department is a key element of the trauma center and the point where most trauma patients enter the system.

Emergency departments see everything from scratches to pneumonia to heart attacks. A trauma center has to be ready for much more, including people with major head injuries, people who are intubated and people who need to go straight to the operating room. Only trauma centers have a designated effort to care for acutely injured patients.

A. A Level 1 trauma center must:

> E  mploy a designated physician trauma director and a nurse trauma program manager

> The capability to perform emergency thoracotomies

> A blood bank capable of providing massive blood resuscitation

Q. H ow are trauma centers classified

> P  rovide outreach and injuryprevention programs

A. Trauma centers are designated

> E  mploy data analysts to ensure accurate data capture

and credentialed?

at the state and/or national level. Barnes-Jewish Hospital’s Trauma Center is designated by Missouri and Illinois, and verified by the American College of Surgeons. Designations are expressed as Level 1 through Level 4, with Level 1 being the highest. With its national Level 1 verification, Barnes-Jewish Hospital is one of only three adult trauma centers in Missouri operating at the top level.

Q. How do the resources of a trauma

center differ from those required of an emergency department that is not part of a trauma center?

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Douglas Schuerer, MD, at left, shares insights into a patient’s condition with members of the trauma team.

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> U  se a thorough performanceimprovement process

The facility must include:

> Inhouse computed tomography and magnetic resonance imaging > Interventional radiology > Operating rooms always available for general surgery, orthopedic surgery, brain surgery, spine surgery, vascular surgery and cardiothoracic surgery > An intensive care unit > Trauma resuscitation rooms

In contrast, emergency departments that are not part of a trauma center need only be prepared to treat general medical problems, such as minor lacerations, headaches, chest pain and abdominal pain.

Q. What kind of staffing does a trauma center offer?

A. Staffing requirements include the following professionals:

> T  rauma surgeons, who specialize in the care of traumatically injured patients, are the main requirement for a trauma center. The trauma attending surgeon must be at the patient’s bedside within 15 minutes. At BarnesJewish Hospital, trauma attending physicians are inhouse 24 hours a day, seven days a week.

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Trauma Care Facts and Figures* BARNES-JEWISH HOSPITAL’S TRAUMA CENTER RECORDED ABOUT

12,000 PATIENT VISITS IN 2012, RESULTING IN MORE THAN

2,500 ADMISSIONS

ABOUT HALF OF THE PATIENTS SEEN AT THE TRAUMA CENTER ARE TRANSFERRED FROM OTHER HOSPITALS A TRAUMA OCCURS

THE MOST COMMON REASONS

EVERY FOUR SECONDS

FOR A TRAUMA CENTER VISIT ARE

MOTOR-VEHICLE ACCIDENTS, FALLS AND ASSAULTS

IN THE UNITED STATES

AMONG AMERICANS UNDER THE AGE OF 44,

TRAUMA

THE MORTALITY RATE FOR SERIOUSLY INJURED PATIENTS

IS THE LEADING CAUSE OF DEATH AND DISABILITY

FALLS BY 20 PERCENT WHEN THEY ARE TREATED AT A TRAUMA CENTER

*Sources: Douglas Schuerer, MD, Washington University acute and critical care surgeon and director of Trauma Services at Barnes-Jewish Hospital; Julie Nash, MSN, RN, manager, Trauma and Acute Care Services; American Trauma Society

> A  trauma center also must have emergency-department physicians and specialists in surgical intensive care, orthopedic surgery and neurosurgery, among other specialties, available at all times. In an emergency department, such personnel may not be available. > R  adiologists, otolaryngologists, cardiologists, cardiac surgeons, pulmonologists, nephrologists and many other specialists must be on call at a trauma center. In an emergency department, such expertise often is unavailable. > A  t a trauma center, nurses have additional specialized trauma training. Nurse coordinators assure that protocols are adhered to and

that patients’ families understand acute trauma care. In emergency departments, such expertise and training is often lacking. > I njury-prevention coordinators and performance-improvement specialists are among the support staff at trauma centers but often are not available in emergency departments.

Q. What are the requirements for

continuing education for trauma center personnel?

A. Physicians and nurses who take care of patients at trauma centers must earn an additional eight to 16 hours of continuing education annually in trauma-related topics.

Q. What else sets a trauma center apart from an emergency department?

A. Trauma centers perform research to improve trauma care. Some of the Washington University studies in the trauma center at Barnes-Jewish include:

> Prevention of brain injury in trauma > B  leeding cessation in trauma patients > T  echniques to improve the healing of fractures > B  etter recognition of bowel injuries using CT scans

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Profiles New to the Trauma Services Team Jeffrey Bailey, MD

Stephanie Bonne, MD

Stephen Eaton, MD

Bailey spends just two days a month at Barnes-Jewish Hospital, but that time pays dividends in his full-time job as director of the Joint Trauma System at the U.S. Army Institute of Surgical Research in San Antonio, Texas.

Bonne is an instructor in acute and critical care surgery. “I had a very good surgeon mentor early in medical school who told me surgeons are very good at fixing things, and that’s what I like to do,” she says.

“It’s very rewarding to fix what may be wrong,” says Eaton, an instructor in acute and critical care surgery. He grew up in Alexander, Ill., which is about 30 miles west of Springfield, Ill. He earned a bachelor’s degree in biological sciences and a master’s degree in physiology from Southern Illinois

Stephanie Bonne, MD Jeffrey Bailey, MD “There are things that are learned in civil practice that are applicable to what we do in the military and vice versa,” says Bailey, a colonel in the U.S. Air Force and an assistant professor in acute and critical care surgery at Washington University. A 1996 graduate of St. Louis University School of Medicine, Bailey plans to live and work full time in St. Louis after retiring from the Air Force in 2015.

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A native of the Detroit area, she completed her undergraduate work at Kalamazoo College in Michigan. Bonne graduated from Rosalind Franklin University of Medicine and Science/The Chicago Medical School and completed her residency at the University of Illinois Metropolitan Group in Chicago. She moved to St. Louis in July 2011 as a critical-care fellow and became an acute-care surgery fellow in 2012.

Stephen Eaton, MD University Carbondale, and a medical degree from Ross University School of Medicine in Edison, N.J. He spent his surgical residency at Marshall University in Huntington, W. Va. Eaton came to Washington University as a surgicalcritical-care fellow in July 2011 and began an acute-care surgery fellowship in 2012.

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Calendar Robert Winfield, MD Though Winfield grew up in Naples, Fla., St. Louis feels like home. He was born in Granite City, Ill., and spent many summers there with his grandparents, aunts and uncles. “I consider myself a general surgeon who provides trauma

2013 CONTINUING EDUCATION OPPORTUNITIES For all courses, preregistration is required. To register or for more information, contact Barnes-Jewish Hospital Trauma Services at 314-362-9175. Unless otherwise noted, all classes take place in the Clayton Avenue Building on the hospital campus, 4353 Clayton Ave., St. Louis, Mo.

Advanced Trauma Care for Nurses (ATCN) June 19-20, 2013 October 24-25, 2013

Advanced Trauma Life Support (ATLS) April 25, 2013

Recertification course

June 13-14, 2013

New residents course

June 19-20, 2013

New residents course

July 11, 2013

Recertification course

August 29, 2013

Instructor course

October 24-25, 2013

Full provider class

EMS Liaison Meetings April 25, 2013 July 25, 2013

Robert Winfield, MD

October 17, 2013 Barnes-Jewish Hospital

and intensive care, and I’m very proud of that ability to do a wide range of surgical procedures.” Winfield completed his undergraduate work at the University of Illinois, where he earned degrees in biochemistry and humanities. He earned his medical degree at the Southern Illinois University School of Medicine and completed his internship and two residencies and was a research fellow at the University of Florida in Gainesville. He worked as a fellow in trauma surgery/surgical critical care at the University of California-San Diego before joining the Washington University faculty as an assistant professor of surgery.

Trends in Trauma Conference May 9-10, 2013 Ameristar Casino

Big Cedar Trauma Conference Oct. 3-5, 2013 612 Devil’s Pool Rd. Ridgedale, MO 65739

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One Barnes-Jewish Hospital Plaza Mailstop 90-75-585 St. Louis, MO 63110

FACILITATE TRANSFERS • COORDINATE ED & TRAUMA ACCESS • SCHEDULE PATIENT APPOINTMENTS • PHONE CONSULTS

Doctors’ Access Line

800-252-DOCS Call 24 hours a day, seven days a week

(3627)

To learn more about individual Washington University physicians, visit wuphysicians.wustl.edu/directory.aspx.


Innovate Trauma: Issue 3, Winter 2013