THE PLACE FOR PEDIATRIC EMERGENCY AND TRAUMA CARE • State’s largest team of pediatric emergency physicians • 24-hour, direct access to critical care areas • Pediatric trauma surgeon in-house 24/7 (Minneapolis) • Backed by the full resources and facilities of Children’s
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CONTENTS VOLUME 16, NO. 3
2
Index to Advertisers
3
IN THIS ISSUE
M AY / J U N E 2 0 1 4
Emergency Medical Services — We are in Good Hands By Charles G. Terzian, M.D.
4
PRESIDENT’S MESSAGE:
Emergency Department Utilization: Abuse or Opportunity? By Lisa R. Mattson, M.D.
5
TCMS IN ACTION
By Sue Schettle, CEO Page 32
EMERGENCY MEDICAL SERVICES
6
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Minnesota Trauma System William G. Heegaard, M.D., MPH, and John L. Hick, M.D.
8
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Colleague Interview: A Conversation with Robert C. Thomas, M.D.
12
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Operation Boreas Reach — September 2013 By James Young, M.D.
15
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Emergency Medical Services: The Newest Board Certified Physician Subspecialty By Aaron Burnett, M.D.
17
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Emergency Response to 35W Bridge Collapse By John L. Hick, M.D., and William G. Heegaard, M.D., MPH
Page 23
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Better Together By Katherine Grimm, MPH
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Senior Care — Providing Better Outcomes in Trauma Care By Kevin Croston, M.D.
23
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Don’t Treat Kids Like Little Adults: The Benefits of Treating Pediatric Emergencies in a Pediatric Care Setting By David A. Hirschman, M.D.
26 Page 27
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Fast-TrackerMN.org — Help When You — and Your Patients — Need it By Linda Vukelich
27
Medical Student Lunch ’n Learn
28
Spotlight on Books New Members
29
In Memoriam Career Opportunities
32
Ernest Ruiz, M.D.
Page 12
MetroDoctors
LUMINARY OF TWIN CITIES MEDICINE
The Journal of the Twin Cities Medical Society
On the Cover: From pediatrics to adults, Twin Cities hospitals provide specialized trauma and emergency care services. Articles begin on page 6.
May/June 2014
1
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
May/June Index to Advertisers TCMS OfďŹ cers
President: Lisa R. Mattson, M.D. President-elect: Kenneth N. Kephart, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Matthew Hunt, M.D. Past President: Edwin N. Bogonko, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, Program Manager, Honoring Choices MN (612) 362-3704 kpeterson@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com
Allina Health System........................................31 Audiology Concepts .........................................10 Children’s Hospitals and Clinics........................ Inside Front Cover Coldwell Banker Burnet..................................27 CrutchďŹ eld Dermatology.................................. 2 Fairview Health Services .................................29 Fraser .....................................................................11 Healthcare Billing Resources, Inc. ...............25 HCMC .................................................................14 Lakeview Clinic .................................................31 Lockridge Grindal Nauen P.L.L.P. ...............16 Minnesota Epilepsy Group, PA ....................20 MMIC ................................ Outside Back Cover MOFAS ..................................Inside Back Cover Multicare Associates .........................................18 Saint Therese.......................................................20 Sanford Health ..................................................31 St. Cloud VA Medical Center .......................30 Transform 2014 .................................................22 Uptown Dermatology & SkinSpa................25 Whitesell Medical Locums, Ltd. ..................29
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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.
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May/June 2014
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Emergency Medical Services — We are in Good Hands AS A SURVEYOR FOR AN ACCREDITATION organization
and a consultant with physician education, I get to travel around the country and visit many different types of facilities — many of them regional trauma centers, either in major metropolitan areas or rural areas. I also get to interact with many physicians, especially Emergency Department physicians, at the various locations and discuss the type of patients they see and the challenges that they encounter. Not being a native to Minnesota and not having done any medical education or training here except for ACLS, my colleagues on the editorial board were very astute in suggesting “Emergency Medical Services” as the topic for this edition. I knew from ACLS training and recertification that there is some “cutting edge” care management research and coordination taking place in the Twin Cities. In addition, my experience as a hospitalist at United Hospital made me well aware of disaster preparations because of the exposure I had to initiatives that took place during the Republican National Convention in 2008. However, the extent and level of coordination among the various health care entities, physician groups and branches of the military were relatively unknown to me. In this edition, I am proud to introduce our readers to a vast array of services available in the Twin Cities area and throughout the state. This edition, though not comprehensive, gives us an excellent idea of the various emergency services we have; the trauma network with real life and hypothetical exercises; variety and levels of trauma services offered and their availability and an insightful colleague interview with one of the leaders of emergency care services. I have always wondered about the different levels of trauma services and the terminology used by various facilities. Now I have been educated by Drs. Heegaard and Hick. With the education comes a better appreciation of coordination that occurs from a state-wide perspective. The level of cooperation among the health facilities and local authorities I have always known was a regulatory requirement for accreditation. Despite having to inquire and By Charles G. Terzian, M.D. Member, MetroDoctors Editorial Board
MetroDoctors
The Journal of the Twin Cities Medical Society
discuss policies at the facilities I visit out of state, I never knew the extent of cooperation here in my own backyard. We are enlightened by Katherine Grimm as to the aspects of the Metropolitan Hospital Compact. My colleague Dr. Young and I have have had casual conversations about some of the activities of the Air Force Reserves. The mock disaster drill delineated in “Operation Boreas Reach’” portrays what is happening behind the scenes to assure the safety of our patients in the event of a disaster. They have “raised the bar” for disaster planning, which was already set high as evident in the way the Medical Resource Control Center responded to the 35W bridge collapse. We are given an insider view to the actual process that took place with the article by Drs. Hick and Heegaard. Our colleague interview with Dr. Thomas posed poignant questions of this leader about the challenges to ED medicine: the future of emergency care and how his group participates and integrates with emergency services in the Twin Cities area. Complementary to this interview is the information provided to us by Dr. Burnett describing the new specialty certification for emergency medical services. The last part of this edition highlights specialized services we have for select patient populations. As has been quoted from “cradle to grave” we present information from Dr. Hirschman about the uniqueness of pediatric emergency care and the distinction of how care from the elderly differs from that of the usual adult population as presented by Dr. Croston. And, a new resource for acute access to psychiatric services and mental health resources is now available online through Fast-TrackerMN.org. To conclude this informative issue the editors, through Dr. Segal, pay tribute to Dr. Ernest Ruiz the founder of HCMC’s emergency medicine residency program and his outstanding contribution to emergency medicine.
May/June 2014
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President’s Message
Emergency Department Utilization: Abuse or Opportunity? LISA R. MATTSON, M.D.
THE EMERGENCY DEPARTMENT (ED) IS NO LONGER JUST A PLACE for emergent medi-
cal situations. The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 under President Reagan and was intended to ensure that all individuals with an acute illness receive necessary medical care regardless of their ability to pay. Consequently, EDs have become the safety net of health care and often morph into the local walk-in clinic. It is generally accepted that chronic medical conditions and non-emergent medical problems are better served outside the ED, which is not typically designed to provide comprehensive continuity of care or preventive care, and where care is more costly. It has been found that the median cost of ED care is more than twice that for outpatient hospital care (Urgent Care) and five times more costly than office-based visits. One of the goals of the Affordable Care Act is to make insurance affordable so more people can obtain their health care outside the ED. Yet insurance does not necessarily affect ED utilization. According to a Minnesota Department of Health survey, the privately insured are just as likely to use the ED as the uninsured, with those in publicly funded programs being the most likely to use the ED. There are many reasons why a growing number of people identify the ED as their primary source for medical care. The decreasing supply of primary care providers make it more difficult for many to get timely appointments. Others face barriers to traditional care based on mental health issues, substance abuse, homelessness, domestic violence, difficulty finding child care, transportation, or inconvenient clinic hours. In addition, the complexities of health care often make it difficult for even the most educated patients to know how to navigate the current system so, for many, it is simply easier to go to the ED. Like most of the country, Minnesota has seen an increase in ED use. Preliminary data from the Minnesota Department of Health (MDH) shows that from 2007 to 2010 the rate of ED use increased by 10 percent and that only 38.7 percent of ED visits were truly emergent and likely not preventable. Almost half of ED visits were non-emergent, emergent but treatable in a primary care setting, or emergent but potentially avoidable if the patient’s condition had been managed more effectively in an outpatient setting. In 2010, the cost of this care was $460 million and accounted for 46 percent of total ED costs for that year. In 2011, Atul Gawande introduced us to the Camden Coalition in Camden New Jersey, one of the first projects designed to decrease ED use. Dr. Jeffrey Brenner has organized care coordination teams in Camden, New Jersey to manage the social, behavioral, and medical needs of those most likely to over-use the ED. They work on medication reconciliation, education, follow up after hospital discharge, pain management, management of chronic conditions (e.g. diabetes, asthma), assistance with appointments, and coordinating access to housing, substance abuse centers, and other community resources. These efforts have resulted in decreases in ED use with concomitant improvement in health and decreased costs. Similar programs are emerging across the country with the hopes of decreasing inappropriate utilization of health care resources with a subsequent decrease in costs and improved population health. Closer to home, Hennepin County launched the Hennepin Health ACO project in January 2012. A mainstay of Hennepin Health is team-based care coordination that includes physicians, advanced practice nurses, nurses, behavioral health specialists, human service and public health practitioners, pharmacists, community health workers, employment specialists, and others. These care coordinators help individual patients better navigate the health care system. One of Hennepin Health’s innovative features is the reinvestment initiative; projects that are initiated with a portion of Hennepin Health’s year-end budget. These projects fill social, behavioral, and medical (Continued on page 5)
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May/June 2014
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
TCMS Appoints 15 to MMA Policy Council
Thanks to all who volunteered to serve on the MMA’s new Policy Council which is being piloted as a way to engage physicians in various advocacy related topics. The TCMS Executive Committee appointed 15 TCMS members to serve on the Council. Members include: Chris Johnson, M.D., Craig Walvatne, M.D., Doug Pryce, M.D., Jessica Heiring, M.D., Chris Reif, M.D., Leah Anderson (medical student), Pete Dehnel, M.D., Evan James (medical student), Alexander Feng (medical student), Laurie Drill-Mellum, M.D., Ramnik Dhaliwal, M.D. (resident), Stuart Cameron, M.D., Ken Kephart, M.D., Mark Eggen, M.D. and Neil Shah, M.D. Watch for more details
about ways to engage in the work of the Policy Council moving forward. Diabetes Prevention Project
TCMS, along with the MMA and three other state and county medical societies, have been invited to partner with the AMA on a Diabetes Prevention Project. This project falls under the AMA’s “Improving Health Outcomes” umbrella and the National Diabetes Prevention Program stemming from the 2010 Health Care Reform Law. TCMS and MMA will be offering CME presentations later this spring on “Pre-diabetes, Diabetes and the Physician’s Role.” Clinics interested in participating in the pilot project should contact Nancy Bauer at (612) 623-2893, nbauer@ metrodoctors.com. Visit our website for
President’s Message (Continued from page 4)
gaps in the system in hopes of yielding additional cost savings by improving health care quality and diverting members from costly emergency department care. These cost savings, in turn, will allow Hennepin Health to fund additional reinvestment initiatives. Programs like these are hoping to prove that savings from interventions outweigh the program costs, but experts agree that utilization and costs often increase in the beginning of the care management programs. Change doesn’t happen over night and may not be apparent for more than 24 months after initiating the interventions. In the first two years of the Hennepin Health project, there has been an 8.4 percent reduction in ED visits and an increase in outpatient utilization. Emergency departments provide an important role to the public, providing care to 20 percent of the population at least once every year. The Affordable Care Act will result in more people having insurance coverage, but this is not the panacea to our health care woes. Many are concerned that our EDs will continue to see an increase in activity. Rather than viewing this as an abuse or drain on the system, we should look at it as an opportunity to identify those members of the population who have the greatest unmet health care needs, so we can intervene with programs like Hennepin Health to provide education, advocacy, and preventive strategies that address not only the immediate health of the patient but some of the barriers that interfere with appropriate access to comprehensive health care. 1) MDH/Health Economics Program, “Utilization of Health Care by Insurance Status,” Issue Brief, November 2013.
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The Journal of the Twin Cities Medical Society
more information www.metrodoctors. com. Look for the link to “Pre-diabetes, Diabetes and the Physician’s Role.” Foundations Exploring a Merger
Did you know we have two foundations? When TCMS formed at the end of 2009, as a result of a merger between the two metro-based medical societies (East Metro and West Metro), we chose not to merge the respective East and West Metro Foundations. Four years post-merger we are now beginning to explore whether or not there are opportunities for the residual Foundations to merge. A Merger Discussion Committee has been formed and will be making a formal recommendation later this year. Honoring Choices Minnesota
Momentum continues to grow as the HCM movement expands in Minnesota and other parts of the country. The name “Honoring Choices” is being licensed in multiple states, our consulting agreements continue to expand as word spreads. On May 7, we are partnering with the University of Minnesota School of Medicine to offer a new one-day Multicultural Advance Care Planning seminar called “Honoring Choices Across Cultures” as part of the Global Health Course curriculum. On May 9, HCM staff will lead a Facilitator Training course to teach basic advance care planning skills. The East Metro Foundation granted 10 scholarships to 1st and 2nd year medical students to participate in this educational opportunity. May/June 2014
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Emergency Medical Care Medical Organizations Services
Minnesota Trauma System
T
rauma is the third leading cause of death in Minnesota, claiming the lives of approximately 2,500 Minnesotans each year.(1) The Minnesota State Trauma System was implemented in 2005. Before 2005, Minnesota was one of only nine states that had no formal state trauma system. The benefits of a trauma system are far-reaching; an estimated 15 to 20 percent improved survival rate was observed among severely injured patients when trauma system implementation is successful.(2) The goal of the statewide trauma system is to get the patient the right prehospital care, and transport to the right hospital with the right resources. This is a laudable but challenging goal, however, significant progress has been made since 2005. In Minnesota, the Commissioner of Health certifies all trauma center designations. Minnesota currently has four trauma center designations. The levels refer only to resources and do not suggest a ranking of the quality of care. Rather, all designated trauma hospitals are expected to provide high quality trauma care consistent with currently accepted standards of practice. The highest trauma designations are Level I and II. These trauma hospitals must successfully pass a rigorous on-site evaluation and certification process by the American College of Surgeons. Most Level III and IV trauma centers are designated through the state-sponsored certification process administered by the Minnesota Department of Health. Specific By William G. Heegaard, M.D., MPH, and John L. Hick, M.D.
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May/June 2014
William G. Heegaard, M.D., MPH
John L. Hick, M.D.
descriptions of Level I through Level IV trauma centers are listed below: •
Level I *
A Level I Trauma Center is a regional resource that provides definitive care for virtually any trauma patient. It provides the injured patient with access to the most comprehensive resources for their treatment. A Level I center is capable of providing total care for every aspect of injury — from prevention through rehabilitation. Elements of Level I Trauma Centers include: • 24-hour in-house coverage by general surgeons, and prompt availability of care in surgical and critical care sub-specialties. • Referral resource for communities in nearby regions. Level 1 centers often receive severely injured patients referred from lower level trauma centers. • Leadership in prevention and
• •
public education to surrounding communities. Continuing education for trauma team members. Comprehensive quality assessment program. Organized teaching and research effort to foster new innovations in trauma care.
Level II
A Level II trauma hospital provides definitive care for most complex and severely injured patients. Like the Level I, the emergency physician and general surgeon are immediately available to the trauma patient. While several specialists and surgical subspecialists are also available, fewer are required for Level IIs than for Level Is. Level II centers are also not required to conduct research or provide training in trauma to resident physicians. Patients requiring specific sub-specialty surgical resources (e.g. microvascular, cardiac surgery) may be referred to a Level I center.
MetroDoctors
The Journal of the Twin Cities Medical Society
Level III
A Level III Trauma Center has the ability to provide prompt assessment, resuscitation, and emergency surgery for injured patients. A general surgeon is available within 30 minutes to assist with the resuscitation and to provide rapid surgical intervention if required. Since Level III centers provide some degree of orthopedic surgery and have an intensive care unit; they often admit trauma patients and care for them definitively. However, complex patients and those requiring surgical subspecialties may be transferred to Level I or II trauma hospitals depending on the resources of the particular Level III. Level IV
A Level IV trauma hospital provides initial resuscitation and stabilization for the severely injured patient. Surgical services are not required to be available so seriously injured patients are transferred to a higher-level facility for definitive care. Emergency department personnel have trauma-specific training and protocols are in place to facilitate the rapid assessment and disposition of the patient.
Level III and IV hospitals must also participate in trauma quality assurance programs and assure appropriate education and certification of their providers. As of December 2013 Minnesota had 131 out of 136 hospitals designated within the trauma system. Eight hospitals were designated as Level I trauma centers, seven hospitals Level II, 30 hospitals designated as Level III, and 85 hospitals designated as Level IV trauma centers. The MN Trauma System also has regional trauma advisory councils work with local partners to improve trauma care including protocol development, research, and educational activities. The MN Trauma Registry is a new statewide database that will help guide prevention and educational activities as it becomes more robust. The MN State Trauma System has come a long way in a short time and is expected as it matures to offer a better understanding of the causes and care of trauma in the state that can help improve the system for everyone. More information can be obtained on the Minnesota statewide trauma system website http://www.health.state.mn.us/ traumasystem.
References Minnesota State Trauma Advisory Committee website, Minnesota Department of Health. Minnesota State Trauma Advisory Committee website, Minnesota Department of Health. * Sources: American Trauma Society http://www.amtrauma. org/resources/trauma-categorization/index.aspx. Minnesota Department of Health http://www. health.state.mn.us/traumasystem.
William G. Heegaard, M.D., MPH, Assistant Chief, Dept. of Emergency Medicine, Hennepin County Medical Center, Associate Professor of Emergency Medicine, University of Minnesota School of Medicine. Dr. Heegaard can be reached at: (612) 8733961, or william.heegaard@hcmed.org. John L. Hick, M.D. is a faculty emergency physician at Hennepin County Medical Center and serves as their Medical Director for Emergency Preparedness and an Associate EMS Medical Director in addition to other state and federal roles in disaster preparedness. Dr. Hick can be reached at: (612) 8734908, or john.hick@hcmed.org.
Metro Area Hospitals Trauma Level Designation • • • • • • • • • • • • • •
Abbott-Northwestern Hospital – Level III Abbott Northwestern WestHealth – Undesignated Children’s Hospitals and Clinics, Minneapolis – Level I Pediatric Children’s Hospitals and Clinics, Saint Paul – Level III Fairview Ridges Hospital – Level III Fairview Southdale Hospital – Level III Gillette Children’s Specialty Healthcare – Level I Pediatric Hennepin County Medical Center – Level I Hennepin County Medical Children’s Hospital – Level I Pediatric Lakeview Hospital – Level III Maple Grove Hospital – Level IV Mayo Clinic Health System – New Prague – Level IV Mercy Hospital – Level II Methodist Hospital – Level III
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The Journal of the Twin Cities Medical Society
North Memorial Medical Center – Level I Level 1 North Memorial Medical Center Level 1 Pediatric (pediatric) – Level II Pediatric Level 2 Level 2 Pediatric Northfield Hospital – Level IV Level 3 Regina Medical Center – Level IV Level 4 Regions Hospital – Level I Ridgeview Emergency Dept. at Two Twelve Medical Center – Level IV Ridgeview Medical Center – Level III St. Francis Regional Medical CARVER Center – Level III St. John’s Hospital – Level III St. Joseph’s Hospital – Level III United Hospital – Level III Unity Hospital – Level III University of Minnesota Amplatz Children’s Hospital – Level III University of Minnesota Medical Center, Fairview – Level II Woodwinds Health Campus – Level III
ANOKA
HENNEPIN
RAMSEY WASHINGTON
DAKOTA SCOTT
May/June 2014
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Emergency Medical Care Medical Organizations Services
Colleague Interview: A Conversation with Robert C. Thomas, M.D.
R
obert C. Thomas, M.D. is currently the Chief Executive Officer of Emergency Physicians, P.A. (EPPA) and The Urgency Room. He obtained his medical degree from the Medical College of Wisconsin and completed his emergency medicine residency at Hennepin County Medical Center where he was chief resident. He is board certified in emergency medicine. Dr. Thomas joined EPPA in 2002, and has served as the emergency department medical director at Mercy Hospital, a Level II Trauma Center. Dr. Thomas has been an integral part of bringing new care delivery models to the EPPA team.
As a whole, how do you see emergency medicine evolving over the next 10 years and what sort of impact will that have on emergency physician groups? I expect dramatic changes in the field of emergency medicine over the next five to 10 years. The changes can be divided into two main categories: changes in the general health care market, and changes in emergency medical care. The general health care market will likely affect emergency medicine with patient volume fluctuations related to the Affordable Care Act (short term increase), Insurance Exchanges (short term increase), an aging population (long term increase) and Accountable Care Organizations (long term decrease). Health care is also moving to a direct to consumer market, rather than business to business, which will create more cost transparency to the patient/consumer. This can be a challenging proposition in an emergency department where physicians are attempting to stabilize, resuscitate, and rule out life-threatening processes. The care provided in emergency departments is likely to change as well. Standardization of care for particular disease processes will increase. Patients that present to emergency departments will be more complex, and more ill, as non-hospital facilities care for the less acute patients. I also expect that emergency departments will be asked to find ways to prevent hospitalizations for illnesses that we typically would admit today. 8
May/June 2014
In summary, emergency medicine will experience unpredictable volumes of high acuity, complex, value-oriented patients, who will need to be treated in a standardized fashion in the lowest cost environment possible, all while attempting to meet or exceed patients’ expectations. Emergency medicine groups who are able to achieve excellence under those conditions will succeed.
Describe the current and future supply and demand for emergency physicians. For the Twin Cities metro area, there is an adequate supply of board certified emergency physicians. This is primarily due to having three high quality emergency medicine residency programs in the southeast part of the state. However, there is still a significant need for well-trained board certified emergency physicians in less densely populated, more rural parts of the state. There may always be challenges filling these positions with emergency medicine residency trained physicians, due to lower patient volumes, and their locations outside the metro area. As independent physician groups utilize more advanced practice clinicians (physician assistants and nurse practitioners), we may begin to find that we have an oversupply of board certified emergency physicians in the Twin Cities metro area. If these physicians want to remain in the state, they may need to gravitate to the more rural locations. MetroDoctors
The Journal of the Twin Cities Medical Society
How does EPPA see themselves collaborating with external physicians and their practices to better the communities they serve as these changes evolve? EPPA has been collaborating very well with physicians in the hospital setting for many years. We have had a great experience collaborating with primary clinics and specialty clinics to provide a seamless transition with our Urgency Rooms as well. However, the need for communication and collaboration will only increase as the medical community attempts to decrease the duplication of services and to increase the use of protocol driven care. EPPA expects to play an integral role in transitioning patient care between emergency departments, urgency rooms, primary clinics, observation units, and inpatient hospital units.
What is the relationship between EPPA leadership and/or the individual site specific EPPA physicians and those involved in the management/operations of hospital emergency departments — ideally and actually? As a large independent physician group with the bulk of our work hours occurring in the evenings, on weekends, and on holidays, it can be difficult to maintain clear communication internally as well as with administration/operations of hospital emergency departments. However, we have exceptional physicians who provide medical direction and who practice clinically in each of our contracted hospital emergency departments. This provides intimate knowledge of clinical operations, which can then be communicated to hospital administrators. In fact, working the “front door” of our hospitals, and interacting closely with all facets of the hospital, provides our physicians with a very unique perspective on operations throughout the hospital, not just the emergency department.
In the ED milieu, what is the role/expectation/limitation of non-emergency medicine board certified clinicians? I am an emergency medicine residency-trained physician, so I have an inherent bias that my training provides me and my similarly trained colleagues an important skill set that is difficult to replicate. However, not all patients that visit the emergency department require our full skill set. There are providers who are well-trained and experienced enough to care for a subset of emergency department patients. Most emergency departments utilize physician assistants and nurse practitioners in some capacity to assist with the care and throughput of patients in high volume departments. The American College of Emergency Physicians has published guidelines for the use of advanced practice clinicians in emergency departments. But when a patient is complex and critically ill, there is no substitute for the training provided by an emergency medicine residency. MetroDoctors
The Journal of the Twin Cities Medical Society
What do ACOs mean for EPPA and emergency medicine as a whole? The ultimate goal of an Accountable Care Organization (ACO) is to improve the alignment of care and services for patients and populations so that the cost of care goes down without compromising the quality of care provided. This will require more communication among providers and ancillary services, and improved transitions between levels of care. A corollary is that patients will need to be directed by ACOs to the appropriate level of care with the appropriate cost. With the Urgency Room in the market, there is now a level of care that encompasses both urgent care and emergency care in one location, serving the needs of both patients and ACOs. EPPA is excited to be able to provide a wide spectrum of cost-effective care which will benefit patients and ACOs. Emergency medicine as a whole can expect that the growth of effective ACOs will initially lead to decreasing volumes in emergency departments, as lower acuity patients are directed to lower acuity environments. However, as the Affordable Care Act and Insurance Exchanges get into full swing, we likely will see a transient increase in volumes. And as the population ages, it can also be expected that the proportion of patients presenting to emergency departments will be more complex and of higher acuity.
How does The Urgency Room, and other standalone ERs fit into the mix? The Urgency Room (UR) is designed to give patients and communities an acute care alternative that provides a similar breadth of emergency care expected in an emergency department, along with an exceptional patient experience, but for a lower cost than a traditional emergency department. We are staffed with board certified emergency physicians who also practice in busy emergency departments, caring for the highest acuity patients in the metro area. Our physicians in the URs have all the tools they need to handle any emergency. At the Urgency Room we strive to meet “The Triple Aim” — High Quality, Exceptional Experience, and Excellent Value. EPPA believes that as the cost of health care is shifted to individuals and families, the Urgency Room will represent the best acute care alternative.
Describe the relationship of EPPA to our community EMS system. How do you insure QA and improvements, intra-systems cooperation versus competition, stewardship of community resources? Minnesota has an exceptional EMS system. In fact, many of the pioneers that created emergency medicine as a nationally recognized medical specialty are from Minnesota. The work (Continued on page 10)
May/June 2014
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Emergency Medical Care Medical Organizations Services Colleague Interview (Continued from page 9)
and innovation of these same pioneers was also instrumental in the development of our EMS system. The emergency medicine physician community in the Twin Cities metro area is quite close. Most independent and hospital employed physician groups provide some degree of medical direction to the EMS system. QA is provided by the medical directors and staff of each of the EMS groups. In our community, EMS cooperation is the rule, and competition is invariably constructive.
Giving back to the community is a value espoused by many physicians. Does EPPA as a group and/or your individual members participate in volunteer EMS or public safety activities outside the emergency department? If so, please describe. Emergency physicians provide the safety net for the communities in which we serve. We care for all patients that arrive at our doors irrespective of their ability to pay. As a result, large proportions of the care emergency physicians provide is never compensated, or is greatly discounted. So, one could argue that every time we work a shift in an emergency department we are giving back to
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our community. Even so, I am always amazed at the energy of EPPA’s physicians. EPPA puts on a Certified Emergency Nursing (CEN) course each year which is taught by our physicians. We routinely provide case-based education to nursing staff at our hospitals, and many of our physicians participate and direct international medical missions.
Does/how EPPA partner in educational efforts with various student and/or community groups? EPPA partners with the University of Minnesota Medical School to give their first and second year medical students valuable clinical experience in community hospital emergency departments. We have educational agreements with regional physician assistant schools to provide their students hands-on emergency medicine clinical rotations. We also participate in the education of medical residents and paramedics. But our strongest educational program is our medical scribe program. We have developed an exceptionally valuable experience for undergraduate and graduate students that are planning for a career in medicine. As part of their onthe-job training, they gain detailed knowledge of various medical disciplines, medico-social issues, electronic health records and pathophysiology.
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Emergency Medical Care Medical Organizations Services
Operation Boreas Reach — September 2013
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n late September 2013, the officers and airmen of the 133rd Airlift Wing of the Minnesota Air National Guard were called into action. Terrorists had hijacked a freighter in Lake Superior loaded with toxic chemicals and enough explosives to turn the ship into a weapon of mass destruction. Their intended target was the Port of Duluth and the City of Duluth. Their intention — meet their demands or they detonate the ship and its contents and injure or kill thousands in a Weapon of Mass Destruction attack. The decision is made to evacuate the city of Duluth. The Governor requests that the National Guard be activated and the President issues the orders. The 133rd Airlift Wing of the Minnesota National Guard is called up. It is chosen because it has the aircraft large enough to execute an evacuation. It is also chosen because it has extensive experience over 10 years and two wars of evacuating medically stable and unstable patients from Iraq and Afghanistan back to the United States. The nurses and medics of the 109th Aeromedical Evacuation Squadron have thousands of hours in the air managing some of the most severe injuries and medical issues imaginable. In addition, the 133rd Medical Group has extensive experience in relief and humanitarian operations all over the world. The Medical Group (MDG) has the assets to not only establish refugee operations but facilitate disaster operations through its MASF (Mobile Aeromedical Staging Facility) and CERF (Cbrne (Chemical By James Young, M.D.
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Biological Radiological Nuclear Explosive) Enhanced Response Force) packages. The orders for the 133rd were: 1. Establish a refugee center for 3,0005,000 evacuees from the city of Duluth at Camp Ripley Military Reservation outside of Little Falls, MN. 2. Evacuate non-ambulatory patients from the three major Duluth hospitals via aeromedical evacuation flights to accepting hospitals in Minneapolis and St. Paul. There was just one catch. The operation would call for taking patients from one electronic patient tracking system at the sending hospital, placing that patient into the local EMS tracking milieu, then placing that patient into the military tracking system, then placing that patient into another EMS tracking system and finally having that patient end up in another patient tracking/record keeping milieu at the receiving hospital. All of the systems are proprietary and none of them directly communicate with each other.
Each transition of care required a signout or some form of patient handoff. As a Hospitalist in my civilian career, one transition of care is fraught with challenges and potential for errors, even within a common EMR environment. Imagine five handoffs between differing health care professionals, EMR’s and even systems. It was staggering to contemplate how this would work and even more daunting to realize that no one had EVER attempted this before. The purpose of Operation Boreas Reach was to train military and civilian medical teams to work in this sort of an operational environment. There were numerous operational objectives for each of the groups and squadrons of the 133rd and for the civilian partners in the exercise. However, at the end of the day — Operation Boreas Reach was about patient transfers. It was about moving hundreds of patients (simulated and paper) without losing records or lives. It was about performing a nearly impossible task under high-stakes conditions with flawless efficiency and near perfect accountability. I am proud to say that I was a part of this operation and to report that at the end of the day every single patient under the care of the 133rd was accounted for. No major adverse medical events occurred and no lives were lost (simulated or otherwise). Shortly after the exercise was concluded, I was asked by my hospital medicine leadership to discuss the exercise at an educational luncheon. I wasn’t sure what I’d say but I needed to find a takeaway. At the end of the day I think the takeaway has to do with the how. How were we able to
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move these patients without losing them either in the medical or the logistical sense? Planning. This was an exercise, a fire drill of sorts. We knew this was coming so we did have some time to plan. A great military thinker once said that no plan survives first contact with the enemy. Once the operation was underway, some of the things that we thought we knew to be true were not. We had to adjust our plans accordingly and adapt to the changing tactical environment. So, too, is it with discharge planning and hospital medicine. Social workers call up saying that the nursing home you thought was a lock fell through. The patient wants to go to a transitional care unit in Wisconsin rather than Minnesota. You need to have a quality plan but need to adapt when the plan goes south. Whether it’s finding the building of opportunity for patient staging, finding extra bodies to move patients, OR coping with the fact that 10 minutes before discharge the patient wants their home-going medicines to go to the OTHER Walgreens in
Hudson, WI, a good plan is key but flexibility and adaptability are just as critical. Leadership. I am very lucky — I have been blessed with some of the most gifted commanders that I think anyone could ask for. My Group Commander and my Element
Maj. Duane Linn with the 133rd Airlift Wing, instructs Airmen on what he is expecting during the exercise, Boreas Reach, Duluth, Minnesota. The exercise simulated a terrorist incident in Duluth that resulted in civilian evacuations to the Twin Cities and Camp Ripley. The training partnered with 14 civilian agencies and utilized many of the 133AW capabilities to help both Airmen and civilians react better when facing disasters. (U.S. Air National Guard photo by Senior Airman Kari Giles.)
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Commander are knowledgeable, patient yet decisive, consensus building, but leaders. They also have the experience to acknowledge a good idea when they hear it. They have also allowed so many of us, whether in the enlisted ranks or the officer corps, to run with ideas and improve the unit. Many of the adaptations I discussed above would not have been possible without commanders willing to listen and trust their officers and airmen to execute their missions. Physicians are the commanders of their care teams (whether we like it or not). It is easy to be dictatorial and dogmatic, but it is also essential to recognize that ideas come from all directions. Just because someone may have a different title doesn’t disqualify their idea from consideration. I have learned to trust my team to execute the mission of quality patient care on a day-to-day basis. In so doing, we have become more successful executing our plans and tackling challenges. Commitment, Morale, and Execution. The people in the Air National Guard, indeed the whole of the Armed Forces, are some of the most incredible, passionate, determined, and committed people I’ve ever met in my professional life. Every time I muster for drill I am honored to (Continued on page 14)
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Emergency Medical Care Medical Organizations Services Operation Boreas Reach (Continued from page 13)
be among them and to work with them. The dedication they bring to every task is impressive and it’s what makes our work so fun and so often successful. It is that commitment that leads to the successful execution of our mission tasks. Morale of the team is something that I think is often underestimated by providers and health care organizations. Dedication and commitment to duty only gets you so far. If you’ve got a demoralized team, you’re not going to get 100 percent effort and, in health care, that’s unacceptable. I’ve worked hard in my own daily practice to contain praise publicly, educate privately, and be supportive 100 percent of the time. Not always easy when things are tense, but essential to a good operational environment. Communication. Communication was the key for us. We had access to sophisticated
patient tracking software that had not only proven itself for us on the battlefields of Iraq and Afghanistan but we also had access to MNTRAC, which is a remarkable piece of technology. MNTRAC can quite literally tell you the status of every hospital in the state and track every patient in an ambulance rig. It is phenomenal. The patients had excellently crafted (simulated) discharge summaries and records. We maintained meticulous paper charting of our patients when they were under our care. However, at the end of the day, it was communication directly with the teams. It was the EMS team in Duluth communicating patient status changes to the MASF team at Duluth International. It was the AES crews telling us about med administration and patient condition at time of arrival in MSP and us communicating our work to the Allina EMS crews. Despite all of the best technology available to us, the thing that aided us most was reaching out to a colleague and asking or getting information from them.
I genuinely believe that our success in this operational environment was directly related to the high quality, focused, professional communication between dedicated, committed and excellent professionals. I will admit that I relied pretty heavily on the EMR to do some of the talking for me. I now more regularly take the extra step and reach out to another provider or RN to discuss the case. I believe that there are more lessons that will come out of this exercise and that these will have applicability to not only disaster scenarios, but our daily practice as well. James Young, M.D. is a Family Physician and Hospitalist at United Hospital in St. Paul, MN. He is a Major in the 133rd Medical Group, 133rd Airlift Wing, Minnesota Air National Guard. Dr. Young will be assuming the role of Joint Task Force Surgeon of the Minnesota CERF-P team in the Summer of 2014.
Sometimes saving lives requires 19 operations and over 120 units of blood. Watch their stories of survival at hcmc.org/trauma25
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Hennepin County Medical Center is proud to have served the region for 25 years as Minnesota’s first Level I Trauma Center.
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Mike
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Montrell
The Journal of the Twin Cities Medical Society
Emergency Medical Services: The Newest Board Certified Physician Subspecialty
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n 2006 the Institute of Medicine’s Committee on the Future of Emergency Care in the U.S. published “Emergency Medical Services at the Crossroads.” This work provided a broad, indepth assessment of the state of readiness of our nation’s front line emergency care delivery system. This committee recommended standardizing the medical oversight of EMS and improving the scientific basis of prehospital medicine through the development of a subspecialty certification in EMS through the American Board of Emergency Medicine (ABEM).1 The National Association of EMS Physicians (NAEMSP) had been organizing EMS medical directors since its founding in 1984. Through its peer reviewed journal, Prehospital Emergency Care, NAEMSP had been building the evidence basis for prehospital medicine. Together with the American College of Emergency Physicians (ACEP), NAEMSP submitted an application for EMS subspecialty certification to the American Board of Medical Specialties (ABMS) in 2009. In 2010 all 24 member boards of ABMS unanimously approved EMS as the sixth board certified subspecialty offered through ABEM. In doing so they identified EMS as a clinical specialty focusing on the care of patients outside of traditional medical care facilities. “The purpose of subspecialty certification in EMS is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the
By Aaron Burnett, M.D.
MetroDoctors
prehospital environment and to facilitate further integration of prehospital patient treatment into the continuum of patient care.”2 This recognition required the development of a formal curriculum for training EMS physicians and in 2012 the Core Content of EMS Medicine was published in Prehospital Emergency Care.3 This was followed by accreditation of EMS fellowships by the Accreditation Committee on Graduate Medical Education (ACGME) in 2013. Today, there are two ACGME accredited EMS fellowships in Minnesota, one at Regions Hospital in Saint Paul and the other at HCMC in Minneapolis. Minnesota is known for innovation in EMS and our state frequently leads the way in defining best practices in prehospital medicine. Part of this tradition is due to the many leaders in EMS who practice in Minnesota. Dr. G. Patrick Lilja, the EMS medical director at North Memorial for many years, literally wrote the chapter on prehospital medicine in Tintinalli’s Textbook of Emergency Medicine. Dr. Daniel
The Journal of the Twin Cities Medical Society
Hankins (Mayo EMS) has served two terms as the president of the Association of Air Medical Services while Dr. Keith Wesley (HealthEast EMS) has served as the state medical director for both Wisconsin and Minnesota. Dr. RJ Frascone (Regions Hospital EMS), a full professor at the University of Minnesota medical school, has helped develop the scientific foundation of prehospital medicine through clinical and translational research. New techniques and technologies in prehospital resuscitation are often first developed in the streets of our cities and the back of our ambulances. Dr. Brian Mahoney was a leader in defining the benefits which public access defibrillation brings to victims of cardiac arrest. An innovative, team-based approach to CPR, termed “pit crew CPR,” was developed by Dr. Charles Lick (Allina EMS) which has revolutionized the way in which cardiac arrest resuscitations are choreographed. The concept of active compression-decompression CPR with intrathoracic pressure regulation (ITPR) was pioneered here and was proven to double the rate of neurologically intact survival following out-of-hospital cardiac arrest.4 Our EMS physicians have helped define new pathologies such as excited delirium and are developing novel approaches to prehospital chemical restraint, pediatric analgesia and airway management. A new prehospital concept, the Community Paramedic, was developed here under the medical direction of Dr. Michael Wilcox. Citizens in Minnesota are served by EMS systems which have a high level of involvement by their physician medical (Continued on page 16)
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Emergency Medical Care Medical Organizations Services Emergency Medical Services (Continued from page 15)
directors. The Medical Director Standing Advisory Committee (MDSAC) is a component of the MN EMS Regulatory Board designed to maintain physician oversight of the medical aspects of EMS. The MDSAC is composed of EMS physicians from both rural and metro regions and includes representatives from family medicine, emergency medicine and pediatrics. Rural EMS medical directors were instrumental in the inception of our state trauma system through their development of trauma triage and interfacility transport guidelines. Our helicopter EMS systems decrease the time for patients with time sensitive conditions to reach definitive care. Myocardial infarction patients in Minnesota benefit from innovative prehospital protocols which allow a paramedic to activate the coronary catheterization lab at Level 1 Heart Hospitals based on the paramedic’s identification of STEMI on
Active physician involvement in prehospital medicine is streamlining medical care and facilitating the transition from prehospital to in-hospital patient care.
a 12 lead EKG. This has led to decreased door to balloon times which have been shown to improve outcomes for patients. Active physician involvement in prehospital medicine is streamlining medical care and facilitating the transition from prehospital to in-hospital patient care. Cardiac arrest is an example of an acute pathology which is primarily encountered outside of a hospital and initially treated by EMS providers. Traditionally cardiac arrest has had a dismal prognosis; however, with advances in prehospital cardiac
arrest management, return of spontaneous circulation is becoming more common. The establishment of the Minnesota Resuscitation Consortium (MRC) at the University of Minnesota brings together EMS medical directors, emergency physicians and cardiologists to connect prehospital and in-hospital initiatives to improve survival from out-of-hospital cardiac arrests. This multidisciplinary approach solidifies the chain of survival at the physician level and has led to several prospective projects and peer reviewed publications. From public access defibrillation and bystander CPR to state of the art prehospital interventions such as active compression-decompression CPR with intrathoracic pressure regulation to hospital-based therapies including early coronary angiography and post resuscitation therapeutic hypothermia, the MRC is demonstrating the benefits of active, engaged and sub-specialized EMS physicians. Aaron Burnett, M.D., Assistant Medical Director, Regions Hospital EMS, Assistant Professor, Department of Emergency Medicine, University of Minnesota. Dr. Burnett can be reached at: Aaron.M.Burnett@ HealthPartners.Com. (Endnotes) 1. Emergency Medical Services: At the Crossroads. Recommendation 4.4. Washington, DC: The National Academies Press, 2007. 2. Mark T. Steele, M.D. President, American Board of Emergency Medicine. https://www.abem. org/public/subspecialty-certification/emergency-medical-services/ems-announcement. Accessed February 19, 2014. 3. Perina, Debra G., et al. “The core content of emergency medical services medicine.” Prehospital Emergency Care 16.3 (2012): 309-322. 4. Res Q Trial.
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The Journal of the Twin Cities Medical Society
Emergency Response to 35W Bridge Collapse
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n August 1, 2007 at 6:02 p.m. the Interstate 35W bridge collapsed into the Mississippi River, killing 13 and injuring 127 persons. Rapid and effective Emergency Medical Services (EMS) response occurred with 44 casualties distributed to area hospitals by ambulance, predominately HCMC (24), University of MN (11) and North Memorial (9). The Medical Resource Control Center (MRCC) is part of the HCMC EMS dispatch center. It acts as a coordination point for EMS on a daily basis, and has responsibility during a mass casualty event for alerting hospitals, assuring adequate EMS response, and tracking patients. MRCC sent multiple messages to hospitals and other agencies providing updates through the evening as the event unfolded. All EMS services in the metro area utilize a common incident response plan, which helped greatly in the ďŹ rst hour of the event until command could gather enough information to begin directing activities across the nearly 1.5 mile response area. Despite multiple hazards at the scene, there were no responder injuries. Due to EMS agency cooperation there were no delays answering usual 911 calls in the metro area during the incident response. University of MN is the closest East Bank hospital and received many walk-in patients. HCMC is the closest West Bank hospital and did not receive walk-ins but received multiple critical patients by ambulance in rapid succession beginning 35
By John L. Hick, M.D., and William G. Heegaard, M.D., MPH
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John L. Hick, M.D.
minutes after the bridge fell. Both hospitals activated their disaster plan right away, and were ready with supplemental staff and supplies at the time the ďŹ rst patient arrived (which is unusual given the proximity to the event — usually patients arrive without warning). Both hospitals had practiced and rapidly instituted their surge capacity plans and opened space in the Emergency Department and inpatient units (HCMC had two ICU beds available at the time the Alert was declared and had 35 beds available within a few hours. Ten ORs and all three CT scanners were available for patients within the hour). North Memorial elected not to activate their disaster plan based on smaller casualty numbers, but wished in retrospect that they had done so in order to address all the media, patient tracking, and other management issues that occurred as the night went on. Though all critical patients were cared for the night the bridge fell, a number of patients presented on a delayed basis to hospitals around the metro area with
The Journal of the Twin Cities Medical Society
William G. Heegaard, M.D., MPH
muscular complaints and, in one case, a spinal compression fracture. Spinal column fractures were very common in the casualties due to the vehicles falling up to 120 feet from the bridge deck to the river. Fortunately, no patients had spinal cord injuries. We are fortunate in the metro area to have the Metropolitan Hospital Compact which helps to coordinate regional responses to incidents; in this case, however, the main function was information sharing and patient tracking (in conjunction with MRCC). In a larger event the Compact would help to move patients and resources as required to balance the needs of the incident across the region (see article by Katherine Grimm on page 19). Although this tragic incident was not a medical disaster (did not overwhelm community resources), it was a major mass casualty event that was handled well by
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Emergency Medical Care Medical Organizations Services 35W Bridge Collapse (Continued from page 17)
the EMS and hospital system despite numerous challenges. However, there were lessons learned (as described below) which can assist other hospitals in future responses. Minneapolis can be proud of the way in which its citizens and systems responded, and then rebuilt; and the metro area is fortunate that we have a very robust regional response system for disasters which makes successful responses not only possible, but expected.
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Despite information from the field, some of the best information in the early phase of the event came from television. Hospitals must have paper/temporary tracking and record systems as electronic systems cannot keep up during rapid presentations of casualties.
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Numbering systems for disaster patients hold the potential for confusion — consider state names or other names rather than number strings. Be deliberate about who is included in disaster page groups — assure that all key personnel are paged including support services (blood bank supervisor, for example) but not ALL personnel are paged (as the event is extremely rare that would require literally all personnel to respond). Assure adequate supplies for trauma response — with just-in-time inventory, stocks of specific trauma trays, medications, intravenous fluids, and
Photo by Andrew Worrall.
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other critical supplies may be inadequate. Consider placing supplies on a designated cart and practice pharmacy “pulls” of disaster medications. Incoming telephone lines were jammed at closest hospitals, and the capabilities of internal phones and radios were not well understood. Public information officers were overwhelmed by the volume of requests for information, the need to monitor media, and family requests for information. Surgeons needed up-to-date information from the ED to the OR to know if more casualties were arriving that might need surgery. Excess staff reported to the ED from all areas of some of the hospitals — where they were not able to be used.
John L. Hick, M.D. is a faculty emergency physician at Hennepin County Medical Center and serves as their Medical Director for Emergency Preparedness and an Associate EMS Medical Director in addition to other state and federal roles in disaster preparedness. Dr. Hick can be reached at: (612) 8734908, or john.hick@hcmed.org. William G. Heegaard, M.D., MPH, Assistant Chief, Dept. of Emergency Medicine, Hennepin County Medical Center, Associate Professor of Emergency Medicine, University of Minnesota School of Medicine. Dr. Heegaard can be reached at: (612) 8733961, or william.heegaard@hcmed.org.
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The Journal of the Twin Cities Medical Society
Better Together
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hances are your health care facility has an emergency or disaster plan. Regulatory agencies such as the Centers for Medicare and Medicaid and accreditation agencies such as Joint Commission and DNV require these plans for hospitals. The Emergency Operations Plan, or “EOP” as some call it, is based on a Hazard Vulnerability Analysis or “HVA” which assesses the probability and impact that a variety of hazards would have on the facility and its operations. Plans are built to address the highest risk items. Each facility’s vulnerabilities and plans will differ depending on the location of the facility, the age of the building(s), and the services that are provided. Established plans need to be tested in a drill or exercise to ensure they are effective. Once all this is done, you can check off the preparedness box, right? Wrong. Siloed plans have failed in disasters time and again. Plans are built on assumptions. Are the assumptions of hazard vulnerability and risk shared with your community partners? Are there other hazards that you haven’t addressed? Do you reference in your plan what other agencies will do and do they know they are in your plan? Much benefit can be had from sharing your facility’s Hazard Vulnerability Analysis and Emergency Operations Plan with your local community partners. The city and county within which your facility resides each has their own Emergency Operations Plan with their own assumptions. Until you talk with them, you won’t know whether or not your assumptions and plans align. Emergency management is all about relationship building.
By Katherine Grimm, MPH
MetroDoctors
Many health-related hazards will extend beyond one community. Therefore, having congruent plans among health care providers within an entire region makes sense. If your facility is part of a hospital system in the Twin Cities seven county metro area, your plan is most likely integrated with the other health care facilities in the area through a non-legally binding contract called the “Metropolitan Hospital Compact.” This agreement, established in 2002, signifies the belief and commitment of its signatories that in the event of a disaster the medical needs of the community will best be met if the region’s hospitals cooperate with each other and coordinate response efforts. Whether a member hospital (those offering emergency services) or an associate member hospital (those not offering emergency services), all 30 hospitals are part of the compact. Other advisory members of the compact include organizations such as The American Red Cross, Emergency Medical Services, public health and emergency management to name a few. Most health care systems include their affiliated clinics
The Journal of the Twin Cities Medical Society
and long-term care facilities in their plans, but in recent years we have also reached out to clinics and long-term care facilities not affiliated with a hospital system. We continue to expand and evolve to meet the changing health care needs of our community. Even our name “Metro Hospital Compact” does not reflect the full extent of our reach, so we have recently been using the word “coalition” to describe ourselves. In 2013 we built a public website www. metrohealthready.org to share our work. Together since 2002, we have established regional plans such as the metro burn surge plan, pediatric surge plan and alternate care site plan complete with staffing scenarios for situations where hospitals are overwhelmed. We have developed template plans for behavioral health, evacuation and workplace violence and fatality management which facilities can adopt or adapt into their own policies and procedures. We are embarking on plans for crisis standards of care and business continuity. We have established platforms for information sharing such as identical radios with hospital-specific channels, a web-based system for sharing bed capacity and tracking patients for reunification. We have established plans for a Regional Hospital Resource Center (RHRC), a one-stop shop for data and intelligence collection, aggregation and dissemination between the coalition members to enable a common operating picture for everyone. We have purchased cache equipment such as cots for the alternate care site and interchangeable decontamination equipment for the region’s emergency departments. We have worked with the state and other regions to build a mobile medical unit (Continued on page 20)
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Emergency Medical Services Better Together (Continued from page 19)
and mobile medical team to deploy for disasters. We have exercised our plans in artificial and real event scenarios such as: the bridge collapse where some partner hospitals were surged; received patients from H1N1 where we coordinated messages and policies on visitation; and supply chain shortages such as the most recent saline shortage. The metropolitan region is one of eight health care regions in the state with similar preparedness frameworks. The Minnesota Department of Health uses this health care preparedness framework to distribute federal preparedness grants such as the Healthcare Preparedness Program (HPP) Grant which is managed by the Office of the Assistant Secretary for Preparedness and Response (ASPR). Federal grants such as these have advanced hospital preparedness since 2002. As preparedness grant funding shrinks, as it is projected to do, the framework we have established should allow us to continue coordination and planning with our partners. Our community expects health care to continue during disaster and FEMA has designated us as critical infrastructure. If you are not a member of the Metropolitan Hospital Compact or want to learn more about our coalition, please visit our website at www.metrohealthready.org or email us at prepared@metrohealthready. org. Katherine Grimm manages the Emergency Management program for Maple Grove Hospital in Maple Grove, Minnesota and North Memorial Healthcare in Robbinsdale, Minnesota. She has worked in the field of hospital emergency management for over nine years. She is currently Chair of the Minneapolis/ St Paul Metropolitan Hospital Compact, serves on a variety of community emergency preparedness committees and is a member of Minnesota’s type 3 all-hazards incident management team. Katherine is a state-certified emergency manager, received her Masters of Public Health Degree from the University of Minnesota, School of Public Health in Minneapolis and is a Ph.D. candidate in that program. She can be reached at: Katherine. Grimm@MapleGroveHospital.org. 20
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Senior Care Providing Better Outcomes in Trauma Care
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onsider, for a second, a 76-yearold motorist with poor vision who has just been sideswiped in an intersection by another vehicle after failing to yield properly. This man is one of many his age that has an increased chance of facing a medical emergency as they grow older. He may not understand the intricacies of the trauma center where doctors and nurses will work to save his life or whether or not those doctors and nurses are armed with the appropriate knowledge of his accident to ensure the appropriate methods of treatment are taking place. All he knows is that an ambulance has picked him up and that he is headed to the ER. If he were able to stay conscious long enough to consider facing this plight at his age, there could be an endless amount of things to worry about. According to the U.S. Census Bureau, the elderly population in our country is booming. By the year 2050 it is expected to reach 80 million — more than twice what it is now. Historically, this demographic of the population has leaned heavily and repeatedly on ER resources. In no place is this more evident than at North Memorial Medical Center — where senior citizens make up over one-third of patients that are treated in our trauma center. North Memorial is among a select number of hospitals in the Upper Midwest operating a trauma center with Level I Adult Trauma verification — the highest level a trauma center can achieve. Our hospital admits more than 2,600 patients every year with traumatic injuries and sees thousands more in the emergency By Kevin Croston, M.D.
MetroDoctors
department (ED). Essentially, North Memorial has the resources to treat every possible injury that arrives at its doors. But not all of these trauma patients are the same. Elderly patients often require a different set of care standards than the rest of the population. While most trauma centers are similar in the way they respond and deliver care, North Memorial differentiates itself — especially when it comes to older patients like the 76-year-old car accident victim. From his transport and arrival through discharge and community re-entry, North Memorial has a system in place to ensure that he will get the absolute highest level of care possible throughout his entire ordeal. Pre-Hospital EMS System
One of the things that differentiates our trauma response and patient care is our pre-hospital emergency medical service (EMS) system. Because North Memorial employs our own EMS teams (which include paramedics all over Minnesota and Wisconsin) we set a protocol for communication between paramedics and trauma staff so that every bit of information that can help our trauma team is relayed and they can go about treating the patient quickly and effectively. An example of this protocol is known as the “hard stop.” The hard stop is essentially a time-out that takes place as paramedics deliver the patient. For a period of 15 seconds, movement and treatment stops. Doctors and nurses listen to the paramedics as they relay all important details about the patient (in our example, the 76-year-old car accident victim). The trauma team will find out if the man was
The Journal of the Twin Cities Medical Society
wearing a seatbelt, how much blood was at the scene and whether the crash was hit head-on or from the side. These answers are critical as they imply different injuries and provide the trauma team with details paramount to the patient’s care. Specialized Geriatric Trauma Care
North Memorial takes a team approach to elderly care that emphasizes care coordination. We’ve addressed an elderly patient’s care needs before the patient has deteriorated to the point where the ER is the only option. Currently, there is no such thing as geriatric certification and North Memorial is taking the lead on developing and implementing geriatric specific care guidelines (as guided by the Trauma Quality Improvement Project and the American College of Surgeons) since older patients require different treatment, testing and care. Kevin Croston, M.D., is the Chief Medical Officer at North Memorial Health Care.
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Don’t Treat Kids Like Little Adults: The Benefits of Treating Pediatric Emergencies in a Pediatric Care Setting
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rauma is the leading cause of death and disability in children. More children are killed or disabled by traumatic injuries than all other causes combined. Injury also accounts for 43 percent of emergency department visits by children, with the greatest number occurring among infants and toddlers. The critically injured do better, in terms of both mortality and morbidity, at a Level I trauma center.1 Research has also shown that there are measurable benefits for pediatric trauma patients to be treated at a children’s hospital.2 3 4 Time is of the essence when treating critically injured patients, but so is providing the right resources to best meet the patient’s needs. With the aid of triage protocols and medical supervision, emergency care providers match patients to the most appropriate medical facility — avoiding the added time it would take to transfer the patient from hospital to hospital. For the critically injured child, this often means bypassing the closest medical facility and going to the nearest Level I or II pediatric trauma center. In June of 2013, the trauma center on the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota was verified as a Level I pediatric trauma center by the American College of Surgeons’ (ACS) Committee on Trauma, which means that we have the depth of resources and personnel to handle the most challenging trauma cases, regardless of severity of injury. Children’s admits more than 600 pediatric trauma patients a year — the largest provider of such care in the state.
children’s hospital in the country, even before seeking Level I verification, Children’s had one of the largest and busiest pediatric emergency programs in the nation with a staff of 150 and more than 90,000 visits annually. What Makes Pediatric Patients Different From Adult Patients?
There are four ACS-verified Level I pediatric trauma centers in Minnesota, including Children’s, and 44 such centers in the nation, according to the ACS (there are also 34 Level II pediatric trauma centers in the U.S., including two in Minnesota).5 Children’s has the only pediatric trauma center in the Twin Cities that is housed within a free-standing children’s hospital. To become verified as a Level I pediatric trauma center requires a variety of pediatric trauma specialists on duty 24/7. For Children’s, this meant adding a number of pediatric trauma specialists to a staff that already included a wide variety of pediatric specialists. As the sixth largest
By David A. Hirschman, M.D.
MetroDoctors
The Journal of the Twin Cities Medical Society
It is important that children are treated at a center that specializes in pediatric trauma care because children have a much different make up than adults. For instance, children have shorter necks and tracheas than adults, so managing an airway can be difficult and anxiety-provoking for a physician who has less pediatric experience. In addition to the differences in size and anatomy, there are other distinct differences between children and adults, such as: • Cardiac arrest in children is often caused by respiratory arrest, which is not the case with adults. • Injury to the central nervous system is common among pediatric trauma patients, but children recover differently than adults. • Kids are not little adults, so you don’t just give proportionally less anesthesia (Continued on page 24)
Specialists at Children’s Level I Pediatric Trauma Center
In House 24/7 • Pediatric surgeons • Pediatric critical care intensivists • Pediatric emergency medicine physicians • Neonatologists • Pediatricians
On Call 24/7 • Neurosurgeons • Orthopedic surgeons • Cardiothoracic surgeons • Ophthalmologists • All other pediatric medicine specialists
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Emergency Medical Care Medical Organizations Services Don’t Treat Kids Like Little Adults (Continued from page 23)
to a child. Pain management and anxiety control are significant areas in which best practices for adults are not optimal for children. • Abuse is a common cause of trauma in the pediatric population. Since the signs are often subtle and tend to occur in children under the age of three, it is essential for clinicians to be skilled in identifying child abuse. Finally, there are advantages to the pediatric setting in helping children recover. Just as the “Golden Hour” is critical for reducing mortality among trauma patients, the care received during the following month is critical for reducing morbidity. Having all the resources in one pediatric facility significantly reduces the time it takes to provide the best and most appropriate care for the child. It also means that from the moment children are brought in to receive trauma care, to their last day of rehabilitation, many of them never have to leave the familiar surroundings and staff. This continuum of care benefits the patient’s emotional well-being and recovery. Why is a Pediatric Setting Important?
We have found that the depth and breadth of the surrounding pediatric hospital brings distinctive advantages to pediatric trauma care. Let’s look at two examples of how the breadth and depth of a children’s hospital is critical to addressing pediatric emergencies: ECMO and image scanning. Pediatric ECMO
For children who have suffered a serious injury and are in respiratory failure, ECMO, or extracorporeal membrane oxygenation, is a life-saving treatment that temporarily acts as a patient’s heart and lungs while he or she recovers. It is typically used in patients who haven’t responded to standard advanced life support, such as treatment with a ventilator or medications. One type of patient seen all too often during the winter is the child who has fallen through the ice into a lake or river and is suffering from hypothermia. 24
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A child life specialist at Children's Hospitals and Clinics of Minnesota comforts and relaxes a young patient through play while a care team addresses her injury in the emergency department. Photo by Brady Willette, Willette Photography, Inc.
Children’s puts these patients on ECMO for rewarming — considered to be the best practice that produces the best neurological outcomes.6 ECMO for children is quite different than that for adults, and it takes the expertise and experience that comes with a significant volume of pediatric patients at a pediatric hospital with a cardiovascular center to do it well. Gentle Imaging
Many adult hospitals conduct a whole body CT scan or X-ray for all trauma evaluations — children and adults — because it is cost efficient and speeds processing and evaluation.
Pediatric hospitals have begun to be concerned about the long-term impact of too much radiation exposure, especially for children. Research has shown that the more you expose a child to radiation, the more likely the child will someday develop cancer. For instance, pediatric centers are increasingly reluctant to do CT scans of the neck due to increased risks of developing leukemia and head and neck cancer.7 Despite these concerns, one in five pediatric patients get more than the maximum radiation dose recommended by the U.S. Food and Drug Administration — and many are getting twice the maximum, exposing them to a 1-in-100 risk of developing cancer.8
MetroDoctors
The Journal of the Twin Cities Medical Society
Children’s addressed these concerns by creating a radiation safety program in which pediatric patients are imaged gently. When providers must perform head CT scans or X-rays, we use the lowest resolution and radiation levels necessary to find the fractures. When a child presents with abdominal pain that has not been caused by injury, we are less likely to scan — and more likely to suspect something else, such as appendicitis. The result is that patients at a pediatric trauma center are likely to receive much lower exposure to radiation than they would receive at an adult trauma center. Whether establishing an airway, prescribing the correct medication and dosage, taking a non-operative approach when possible, or offering a family-centered environment to promote care and healing, a hospital environment that specializes in treating children makes a critical difference. David A. Hirschman, M.D. is the co-medical director of the Emergency Department at Children’s Hospitals and Clinics of Minnesota. He specializes in pediatric emergency medicine and trauma services. He received his medical degree from the University of Minnesota School of Medicine and completed residencies in pediatrics and emergency medicine. Dr. Hirschman can be reached at David.Hirschman@childrensmn.org, or (612) 813-6843. (Endnotes) 1. MacKenzie, et al, “A National Evaluation of the Effect of Trauma-Center Care on Mortality,” New England Journal of Medicine, Jan. 26, 2006. 2. Densmore, J., et al, (2006). Outcomes and delivery of care in pediatric injury. Journal of Pediatric Surgery, 41, 92-98. 3. Potoka, D., et al, “Improved functional outcome for severely injured children treated at pediatric trauma centers.” The Journal of Trauma, 51:824-832, 2001. 4. Potoka, D., et al. (2000). Impact of pediatric trauma centers on mortality in a statewide system. The Journal of Trauma, 49 (2), 237-245. 5. American College of Surgeons. Verified Trauma Centers. http://www.facs.org/trauma/verified. html. Accessed March 13, 2014. 6. New England Journal of Medicine. 7. Pearce, MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet, 380: 499-505. 8. Wang, SS. Children’s CT Scans Pose Cancer Risk. Wall Street Journal, June 7, 2012.
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Emergency Medical Care Medical Organizations Services
Fast-TrackerMN.org Help When You—and Your Patients—Need it
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he acute need for psychiatric services and mental health resources is well-documented. Unfortunately, the lack of available services often means that patients experiencing psychiatric illness often end up in the emergency department. We can’t prevent all psychiatric emergencies, but we can help patients access By Linda Vukelich
care earlier, and prevent some of them. The Minnesota Mental Health Community Foundation (founded by the Minnesota Psychiatric Society) has developed a search engine specifically to find mental health resources for your patients. This online, intuitive, searchable and real-time tool supports patient-centered, integrated care by linking providers to better serve Minnesotans living with mental illness. Physicians can use it to
TCMS Forum The Tobacco Industry of Today: E-Cigarettes, Hookahs and Other Flavored Products
Wednesday, May 28, 2014 5:30 p.m. – Social Hour 6:00-7:30 p.m. – Program Ramada Plaza Minneapolis 1330 Industrial Boulevard, Minneapolis, MN $25 members/ $40 non-members. Students/residents no charge.
Speakers and Panelists: “What do we Know About E-Cigs?” Anne Joseph, M.D., MPH Wexler Professor of Medicine, Director, Applied Clinical Research Program, U of M
“The Attraction of Hookahs, Flavored Cigars and Other Products” Betsy Brock, MPH Director of Research, Association for Nonsmokers-MN
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“National and Local Legislative and Policy Landscape” Janelle Waldock, MPH Co-Chair, Raise it for Health Coalition
Question and Answer with Panelists Moderated by Peter Dehnel, M.D., chair, TCMS Policy and Legislative Committee
refer patients to local providers and to tell them about other resources. Patients can use it to learn more about mental illness, available therapies and their providers. And, when emergency resources are needed, the crisis numbers for each county are on every page. Fast-Tracker is easier to use than Google; because it immediately gets you to the relevant information, bypassing any advertising. The provider availability is up-to-date because it is maintained by the providers themselves so it improves access to referral resources. Providers can find treatment protocols and guidelines direct from the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. Minnesota advocacy organizations including NAMI Minnesota and the Minnesota Mental Health Association have agreed to share their recovery and support group information. Fast-Tracker was designed by doctors to improve communication between primary and specialty providers. This new tool has the potential to transform our system. Visit www.fast-trackermn.org and see for yourself. Bookmark Fast-Trackermn.org and use it whenever you are looking for resources or referrals. Help us get the word out and make Fast-Tracker the go-to resource for Minnesota’s mental health system. Share the website with your team — and encourage everyone to use it. Together we can improve communications, decrease barriers to care and reduce the need for psychiatric emergency services. Call (651) 407-1873 or email FastTrackerMN@ gmail.com for more information and get started today. Linda Vukelich is the Executive Director of Minnesota Psychiatric Society. She can be reached at (651) 407-1873, or l.vukelich@ comcast.net.
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The Journal of the Twin Cities Medical Society
Medical Student Lunch ’n Learn A medical student Lunch ’n Learn on the topic of Electronic Cigarettes — “What we know and what to tell patients” — was held on Tuesday, February 18, 2014 at the U of M Medical School. Speakers included Kola Okuyemi, M.D., MPH, Professor of Family Medicine and Community Health, and Betsy Brock, MPH, Director of Research, Association for Non-Smokers-Minnesota.
Kola Okuyemi, M.D., MPH, Professor of Family Medicine and Community Health.
Betsy Brock, MPH, Director of Research, Association for Non-Smokers-Minnesota.
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Birkeland & Burnet MetroDoctors
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Bruce Birkeland / 612.925.8405 / BirkelandBurnet.com
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Spotlight on Books MetroDoctors is pleased to promote books recently published by past and present TCMS members. To include your recent publication, contact Nancy Bauer at nbauer@metrodoctors.com. Disclaimer: Publication of book titles does not constitute endorsement by TCMS or the MetroDoctors editorial board. Minnesota’s Contribution to Open Heart Surgery Written by Paul F. Gannon, M.D., retired Twin Cities’ CV surgeon, the book chronicles the breakthrough work of Minnesotabased cardio-vascular surgeons. It includes stories about Drs. Owen Wangensteen, F. John Lewis, C. W. Lillehei, Clarence Dennis, and many others. Available now
from Alethos Press http://alethospress. com/openheart.htm or at Amazon.com.
Orthopaedics, Valley Bookseller (Stillwater), and BarnesandNoble.com.
The ProportionFit Diet Written by Nicholas J. Meyer, M.D., this is a simple guide for anyone to lose weight or maintain a healthy weight. Without involving supplements, extravagant meal plans, memberships or anything more than knowledge. The ProportionFit Diet finally explains a method of measuring portions by the cup that is so simple and effective anyone can do it. This is what we have all been waiting for: A simple, effective, and inexpensive guide to weight loss and lifelong weight management. Available at: www.proportionfit.com, Amazon.com, Lulu.com, Barnes and Noble, St. Croix
Trust Your Gut: Get Lasting Healing from IBS and Other Chronic Digestive Problems Without Drugs by Gregory Plotnikoff M.D. and Mark Weisberg, Ph.D. Trust Your Gut covers everything that a functional bowel patient can do for themselves outside of clinic. This book supports patient engagement, enhances physician time efficiency and strengthens the physician-patient relationship. The text is written in 8th grade English with many illustrative real-life examples that confirm that there is hope. Available: everywhere including online.
New Members Leslie A. Baken, M.D. Park Nicollet Clinic Internal Medicine/Infectious Diseases
Bart T. Endrizzi, M.D., Ph.D. Associated Skin Care Specialists, P.A. Dermatology
Thomas R. Barringer, M.D. Multicare Associates of Twin Cities Family Medicine Peter J. Boosalis, M.D. Valley Anesthesiology Consultants, PA Anesthesiology Carrie M. Borchardt, M.D. Children’s Hospital of Minnesota-St. Paul Child and Adolescent Psychiatry Gretchen Bosacker, M.D. Minnesota Life Family Medicine
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Michael L. Knudson, M.D. Emergency Physicians, P.A. Emergency Medicine
Neil A. Shah, M.D. Clarus Dermatology Dermatology
Thomas M. Hauth, M.D. HealthEast DowntownSt. Paul Clinic Internal Medicine
Jeannie T. Larson, M.D. Metropolitan Dermatology and Cutaneous Surgery, P.A. Dermatology and Otolaryngology
Holly Stenzel Taynton, D.O. North Memorial Clinic – Camden Family Medicine
Karen L. Hessel, M.D. North Clinic, P.A. Obstetrics and Gynecology
Marie C. Olseth, M.D. Marie C. Olseth, M.D., LLC Psychiatry
Carola A. Jerney, M.D. Allina Medical ClinicWest St. Paul Family Medicine
Benjamin N. Pofahl, M.D. Park Nicollet Clinic Family Medicine
Jennifer M. Klos, D.O. Comprehensive Health Care for Women Obstetrics and Gynecology
Maureen P. Utz, M.D. Metropolitan Dermatology & Cutaneous Surgery, P.A. Dermatology James C. Vance, M.D. Metropolitan Dermatology & Cutaneous Surgery, P.A. Dermatology, Dermatopathology
Kristin L. Sanders-Gendreau Allina Health – Maplewood Pediatrics Holly L. Schrupp Berg, M.D. North Memorial Emergency Services Emergency Medicine MetroDoctors
Ryan M. Williams, M.D. Prairie Care – Edina Adult Psychiatry, Child/Adolescent Psychiatry
The Journal of the Twin Cities Medical Society
CAREER OPPORTUNITIES
In Memoriam ROGER S. COLTON, M.D., passed away on January 2, 2014. Dr. Colton attended the University of Vermont College of Medicine and completed a fellowship in internal medicine and rheumatology. He later received a Masters in Medicine from the University of Minnesota and practiced for over 30 years in St. Paul. Dr. Colton became a member in 1996. JOHN N. HEINZ, M.D., passed away on March 10, 2014. Dr. Heinz graduated from Loyola University Stritch School of Medicine, and practiced at the Oxboro Clinics in Bloomington, Department of Internal Medicine. He became a member in 1958. NORTON ROGIN, M.D., passed away at the age of 95 on March 4, 2014. Dr. Rogin graduated from the University of Minnesota Medical School and practiced medicine and general surgery until retiring in 1988. Dr. Rogin became a member in 1986.
See Additional Career Opportunities on page 30.
Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient-centered, evidence-based care team. We currently have opportunities in the following areas: • • • • •
Dermatology Emergency Medicine Endocrinology Family Medicine General Surgery
• • • • •
Geriatric Medicine Internal Medicine Med/Peds OB/GYN Pediatrics
• Psychiatry • Rheumatology • Sports Medicine • Urgent Care
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail recruit1@fairview.org
Sorry, no J1 opportunities. fairview.org/physicians TTY 612-672-7300 EEO/AA Employer
WALTER SUBBY, M.D., age 99, passed away on February 6, 2014. Dr. Subby graduated in 1939 from the University of Minnesota Medical School. He completed a residency in pathology after serving in the Army and practiced at St. Mary’s hospital until retirement. Dr. Subby became a member in 1994.
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LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
ERNEST RUIZ, M.D. It has been a very long, a very eventful and a very meaningful journey! Dr. Ernest Ruiz began that journey in Southern California. He was born in Los Angeles and his early education and initial college years were spent in Pasadena. Unfortunately, that education was interrupted by the Korean conflict and Ernie spent two years as an enlisted man, decorated with a Purple Heart as a result of suffering serious shrapnel wounds on Pork Chop Hill followed by months of convalescence in a military hospital in Japan. After that war, his collegiate education was resumed in California and Louisiana, culminating in him earning a B.A. and M.D. at Stanford University. Off to Minnesota Ernie went — interning at the Minneapolis General Hospital (now HCMC) and then completing a general surgery residency under the direction of Dr. Claude Hitchcock. Just four years later, Dr. Ruiz became HCMC’s Chief of Emergency Medicine (EM) — a position he held for 21 years — and the founder of its acclaimed residency program. Ernie’s professional career blossomed at both HCMC and the U of M where he later assumed the position of Director of EM at the medical school, attaining the academic grade of Professor of Clinical EM and later the prestigious title of Emeritus Professor, a rank he still holds. Interestingly, his collegiate studies began as an art major, and his medical illustration talents have been a complementary accompaniment to his clinical and academic pursuits. His 13 book chapters stand as a testament to this multi-talented physician. Their subjects ranged through the gamut of EM — from a basic initial approach to the trauma patient to meaningful deliberations on airway obstruction, skeletal fractures and compartment syndromes. The list of his co-author collaborating colleagues reads like an all-star cast of superb Minnesota physicians: Drs. Joe Clinton (Ernie’s student, close associate and the current Head of the U of M Department of EM), Ted Peterson, Ramon Gustilo, Pat Lilja, Milt Ettinger, Gordon Rockswold, Dick Asinger and others too numerous to mention. His nearly 60 published articles 32
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with them covered a wide swath of emergency subjects including accidental hypothermia, cardiopulmonary arrest, head and spinal cord trauma, cardiac rupture and endotracheal intubation. Dr. Ruiz’s awards from his own professional organizations were accompanied more recently by the Charles Bolles BollesRogers Award and the Harold Diehl Award from the Minnesota Medical Alumni Society. Perhaps the most notable of the many Ernest Ruiz achievements, in addition to his long standing marriage and four accomplished children, was the publishing of Comprehensive Advanced Life Support: A course for rural emergency care teams — and then bringing its principles to virtually every corner of Minnesota, eight other states, plus significant international exposure. As part of his journey, this gospel was spread to thousands of emergency care clinicians and has undoubtedly resulted in untold instances of morbidity sparing and mortality saving. His personal qualities and generous brilliance have been accurately characterized as “team oriented, humble, inspirational, modest and a veritable ‘idea machine’ who thinks outside of the box before others even realize there is a box.” After his official retirement, the good doctor volunteered time and considerable talents to his community and profession in a variety of ways, even now regularly attending staff meetings and contributing knowingly. Yes, what an amazing journey it has been; a great ride — and it continues. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
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