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  1. 1. Biting the Hand That Feeds You Spring 2007 Situation CRITICALA Publication for Providers of Trauma and Critical Care
  2. 2. © 2007 North Memorial Health Care_07027 Situation Critical is published two times a year to inform trauma and critical care providers about news and events at North Memorial and to provide helpful information related to patient care. If you would like to be added to (or removed from) our mailing list, please contact Sharon Stieg, Situation Critical editor, at (763) 520-5063. You can also send an e-mail message to Your questions, comments and suggestions for upcoming articles are also welcome.
  3. 3. Table of Contents Dear Friends, It has been several months since my last Situation Critical introduction, and I hope this one finds you well. While our publication took something of a sabbatical since our last 2006 issue, we’ve been anything but idle at North Memorial. This past October, we completed the third and final phase of our Emergency Department construction project. Emergency Services Director Maribeth Woitas and Medical Director Craig Matticks led an incredible (some thought impossible) effort to simultaneously renovate and operate a major emergency center without disruption to patient care. Their staff deserves a great deal of credit for a job well done, and I want to thank all of you for your patience and cooperation during the project, as this was critical to its success. Without skipping a beat (literally weeks after the official grand opening), the ED became the first department at North Memorial to begin using Epic –the name given to our new Information Technology transformation that will be taking place over the next three years. The rollout of Epic will use software to automate and connect the hospital’s many different business and clinical care functions into one seamless system. As with any change, this new system will take some getting used to, but is a necessary advance to enhance our level of service to patients and streamline work processes for employees. Thanks in advance for bearing with us as we get up to speed. As you may know, state lawmakers approved a plan for a new Maple Grove hospital that would entail a partnership between North Memorial and Fairview Health Services. Construction on that hospital is slated to begin this summer, and a separate outpatient center on the same campus will open at the end of this year. The outpatient center itself (aka ambulatory care center) will be owned and operated solely by North Memorial and will include urgent care services. We’re excited to bring a full-range of health care services closer to the residents of Maple Grove and surrounding communities. Warming weather is just around the corner, and that means busier months ahead for those of us in emergency care. Best wishes for a safe spring and summer! G. Patrick Lilja, MD, FACEP Medical Director, Emergency and Trauma Services Letter from Dr. Lilja 2 North Memorial in the News 4 Feature Story: Biting the Hand That Feeds You 9 Center of Excellence 10 Outstate Partner Profile 11 Meet Our Staff 12 Calendar of Events
  4. 4. North Memorial in the News Situation Critical | Spring 20072 Maple Grove Hospital Update North Memorial announced last year that it will build a new hospital in Maple Grove in a joint venture with Fairview Health Services. The new hospital will be located on North Memorial’s 30-acre Maple Grove health campus. Construction on the new hospital will begin in Spring 2007 with the hospital scheduled to open in December 2009. North Memorial will open a medical office building and outpatient center on the Maple Grove campus later this year as part of Phase I of the project. The new hospital, when built, will be connected to the outpatient center. North Memorial Emergency and Trauma Services Physicians Recognized for Professional Excellence J. Kevin Croston, MD, North Memorial’s Surgical Director of Trauma, was recently recognized by the Minnesota Medical Association (MMA) with a Community Service Award. According to a MMA press release, Dr. Croston received the award for his work to advance Minnesota’s new Statewide Trauma System, stating that he has, “campaigned vigorously for a statewide trauma network that was recently approved by the Minnesota Legislature. This network will improve trauma care and increase the survival rate of trauma victims in both urban and rural Minnesota.” Dr. Croston was one of three physicians to receive a Community Service Award during the MMA’s 2006 Annual Meeting in Minneapolis. G. Patrick Lilja, MD, North Memorial’s EMS Medical Director, received an Award of Merit at the 2006 Minnesota Public Safety Service Awards program in November. He was recognized for 35 years of work dedicated to health and public safety for the citizens of Minnesota. Dr. Lilja began his career at the University of Minnesota and then at Hennepin County Medical Center in Emergency Medicine. He has had many past positions as advisor, board member, examiner or instructor. Dr. Lilja currently is the Medical Director for Emergency and Trauma Services at North Memorial and for North Memorial Ambulance. He holds appointments as a clinical professor for the University of Minnesota and Family Practice and Community Health. Also, Dr. Lilja has had numerous publications and guest speaking engagements. According to a program description, the Award of Merit is given to a public safety officer or citizen for excellent and unusual accomplishment as recognized by superiors, fellow officers or concerned citizens. G. Patrick Lilja, MD, receives an Award of Merit at the 2006 Minnesota Public Safety Service Awards program. J. Kevin Croston, MD
  5. 5. Situation Critical | Spring 2007 3 North Memorial in the News Emergency Department is Officially Complete North Memorial officially opened the doors to its newly renovated Emergency Department (ED) in October of 2006. The new department features natural lighting and colors that promote healing and comfort. Its 48 private rooms (up from 34) can accommodate any patient care need, regardless of one’s illness or injury. This improvement helps eliminate the time traditionally required for an appropriate treatment room to become available and therefore expedites patient care and comfort. Past patients and ED staff were consulted during the planning process, and the result of that feedback is a facility that fosters enhanced care, customer service and staff satisfaction. Dr. Craig Matticks, Emergency Services Medical Director, describes the department as one that “truly reflects the future of emergency care.” North Memorial Welcomes Longville to its EMS Family 24-7 ALS Ambulance Base Expands North Memorial’s Coverage in the Brainerd Region By Pat Coyne, Outstate Director North Memorial Ambulance On December 31, 2006 North Memorial became the ambulance service provider for Longville, Minnesota and the surrounding area. Located in Cass County approximately 55 miles north of Brainerd, it is in the heart of the beautiful North Central Lakes Region and has become a popular destination for many vacationers in both summer and winter. Simply put, Longville is one of the most beautiful places in the state. It is also a medically underserved area, being almost 50 miles from any one of three hospitals serving the region. Therefore, rapid access to high-quality EMS is critical for the well-being of people who live, work or vacation there. The ambulance service was previously operated by the City of Longville and a joint powers board and had been negatively impacted by the undesirable trinity of low volume, inadequate reimbursement and declining volunteerism. Neighboring communities came together with a common goal to provide reliable, high-quality ambulance service and formed a subordinate taxing district to fund operations. The district is being administered through Cass County, which is responsible for arranging ambulance service for communities previously served by the city. North Memorial was selected as the provider for the area by demonstrating the capacity to exceed the criteria set forth by the communities. This includes providing advanced life support service using paramedics and EMTs who respond from a full-time ambulance base. The Longville service will be part of North Memorial Ambulance’s Brainerd Region, which also has bases in Brainerd, Pine River, Cross Lake and Aitkin. Longville joins more than two-dozen ambulance bases North Memorial operates in eight regions across Minnesota and Western Wisconsin. Nearly sixty thousand patients are served annually. North Memorial’s vision in Longville and elsewhere is to “Inspire each other to give our patients and their families compassionate, remarkable care.” Longville Brainerd Twin Cities
  6. 6. Situation Critical | Spring 20074 Introduction There are 65 million dogs in the United States, according to the American Pet Products Manufacturers Association (APPMA). Dogs can be wonderful pets, and dogs can play a special role in the lives of their owners. Dogs can add to the mental and physical well-being of adults, and they can enrich the development of children. Most dogs will never bite a human. However, the interaction between people and dogs can result in injuries related to dog bites; in very rare cases, it can even result in death. When a dog bite occurs, emergency medical personnel must be knowledgeable about how to treat the bite effectively. Injuries in the U.S. Related to Dog Bites Americans have a 1-in-50 chance of being bitten by a dog each year, according to the Centers for Disease Control and Prevention (CDC). Almost five million people are bitten each year in the U.S. by dogs, or almost two percent of the population. Of these five million bites, approximately 800,000 (about one out of every six bites) require medical care. Almost 1,000 bites per day result in visits to hospital emergency departments (368,000 patients per year).1 Some studies published in JAMA (Journal of the American Medical Association) indicate that bites are the second most frequent cause of visits to U.S. emergency departments (injuries associated with certain sports and recreational equipment were first).2 Dog bite injuries account for more emergency department visits than playground injuries, bikes, mopeds, ATVs, inline skating and skateboard injuries combined.6 The median age of patients bitten by dogs is 15 years, and children have the highest rate of injury resulting in visits to emergency departments. (The youngest patient in those studies was <1 year and the oldest patient 91 years.) Among children, boys aged 5 to 9 years experience the highest incidence of dogbite.2 It has been estimated that almost half of all children have been bitten by a dog at some point in their lives.2 Children are normally at greatest risk from a dog bite because they play with dogs more often, have less experience in anticipating a dog’s behavior, are more likely to engage in activity that stimulates or alarms a dog, and are less able to defend themselves when a dog becomes aggressive.3 Half the children requiring medical care are bitten on the face,1 (see Figure 1) and children seen in emergency departments are more likely than older patients to be bitten on the face, neck and head (73 percent versus 30 percent) followed by the upper and lower limbs. It is a common misconception that dog bites are generally inflicted by “fighting dogs” or strays.4 Over half the dog bite injuries (58 percent) occurred at a home or in a familiar place.2 The vast majority of biting dogs, more than 75 percent, belong to the victim’s family or a friend.1 Approximately every 40 seconds someone comes to an emergency department in the U.S. for a dog bite-related injury.4 Dog bite-related injuries were triaged in the emergency department as urgent-emergent in about 46 percent of the cases. The remainder of cases was triaged Biting the Hand That Feeds You David J. Roberts, MD and Barbara G. Roberts, JD Safety Tips For Dog Owners4 Figure 1 • Dog owners should try to socialize puppies to people of all ages and both sexes, especially children. A toddler looks, sounds and acts differently than a 6-year-old child, a teenager, a 30-year-old, or an elderly adult. The critical age for a dog’s socialization is between 3 and 14 weeks of age; continue to socialize your dog at least until it reaches 1 year of age. • Supervise all interactions between your dog and children or strangers, and never leave infants or children alone with a dog of any size. • Do not mistreat your dog. Avoid physical or aggressive games like tug-of-war and wrestling. Instead, encourage retrieving games or games that involve training (e.g., hiding a toy that your dog has to find). • Don’t let your dog roam.6 This child was bitten by a neighbor’s dog (labrador mix). Her wounds were repaired in the OR by a plastic surgeon.
  7. 7. Situation Critical | Spring 2007 Biting the Hand That Feeds You as non-urgent.2 Dog bites result in approximately 44,000 facial injuries (see Figures 2 and 3) requiring medical treatment each year.1 Ninety-six percent of patients making dog bite-related emergency department visits were treated and released, and four percent were admitted to the hospital or admitted to another facility.2 The majority of dog bites are not fatal, but unfortunately there are about 20 dog bites in the U.S. every year which result in death (see Figure 4). For each dog bite fatality in the U.S., there are about 670 hospitalizations, 16,000 emergency department visits, and 21,000 other medical visits (office and clinic). Approximately 187,000 dog bites each year do not receive medical attention in the U.S.2 Although dog bite fatalities are very rare, the majority of fatalities involve children. About 7 out of 10 dog bite fatalities each year will be kids. By contrast, the chances that a victim of a fatal dog attack will be a burglar are 1 in 177. Merritt Clifton, editor of Animal People, has published a detailed study of U.S. and Canadian dog-related injuries and deaths from 1982 to November 13, 2006. The Clifton study summarizes the number of serious dog-inflicted injuries by breed. It includes fatalities, maimings (permanent disfigurement or loss of limb) and other dog-related injuries requiring extensive hospital treatment. The study is complied from press accounts of dog-related injuries attributable to clearly identified breeds, as designated by animal control officers or others with canine expertise. Attacks by police dogs, guard dogs, and dogs specifically trained to fight are excluded from the Clifton study.3 Not all of the injuries or fatalities in the Clifton study deal with dog bites, however. For example, one elderly patient died as a result of a fall from an overly rowdy greeting by a German shepherd mix; one child was killed by strangulation when a beagle tugged on a leash which was around the child’s neck; one child was strangled by a chain tied around a pit bull’s neck; and one 6-month-old child was apparently suffocated in bed by the family Rottweiler. Yet, the majority of the Clifton study deals specifically with dog bites.3 5 Figure 3 Figure 2 Figure 4 This young man was attacked by a pit bull. Bites to the mid face (nose, lips) are especially common. Patient in Figure 2 after repair by a plastic surgeon. This young woman from San Francisco was fatally mauled by two large Mastiff breeds. The dogs’ owners were convicted of manslaughter and second degree murder.
  8. 8. Situation Critical | Spring 20076 Most experts agree that the idea of a child-friendly or bite-averse breed of dog is a myth. However, those experts often concede that some breeds may be more suitable than others for certain environments or social conditions. Yet most dog behavior remains a result of inherited traits modified by training and socialization after a puppy is born. Perhaps the most important influence in a dog’s comfort around adults and children is the opportunity to interact positively with them when the dog is a young puppy (i.e., under four months of age).4 According to the Clifton study, a few canine breeds and mixes are responsible for the majority of dog bite-related injuries and deaths in the U.S. and Canada. Pit Bulls, Rottweilers, Presa Canaries (Bull Mastiff) and their mixes are responsible for 74 percent of the attacks included in the study; 68 percent of the attacks on children; 82 percent of the attacks on adults; and 68 percent of maimings. Of these breeds, pit pull terriers are noteworthy for attacking adults almost as frequently as children suggesting they may have less inhibition about attacking people who are larger than they are. In addition,“domesticated” wolves or wolf hybrids kept as pets appear to have attack patterns which are more dangerous than the majority of dog species.3 Intact male dogs appear more likely to inflict serious injuries than females or castrated males.1 Of course, numerous animals fitting these profiles will live amicably among humans and never bite. According to the Clifton study, Pit Bulls, Rottweilers, Presa Canaries and their mixes were responsible for 65 percent of the dog-related fatalities that occurred during a period of 24 years in the U.S. Other breeds were also responsible, but to a lesser extent: German Shepherds, Huskies, Alaskan Malamutes, Doberman Pinschers, Chows, Great Danes, St. Bernards and Akitas. Since 1975, fatal attacks have been attributed to dogs from at least 30 breeds. In more than 75 percent of the cases covered by the Clifton study, the life- threatening or fatal attack appears to be the first known dangerous behavior by the dog. In some instances, the injuries or fatalities were caused by attacks from multiple dogs at once (See Figure 5). In another case, it was caused by rabies.3 Sixty-five percent of reported bites take place while a dog is being played with, fed, teased, abused or separated from another dog. Thirty-five percent of dog bite victims are involved in normal, non-provoking activities before a dog attacks.6 Neonatal deaths resulting from dog bites, for example, usually involve a sleeping baby.5 Biting the Hand That Feeds You Tips For Non-Owners To Avoid Being Bitten4 • Never approach a dog you do not know. • Never run from a dog if it approaches you. • If a dog approaches you, stand still and do not look directly at him. Avoid screaming or yelling at the dog because it may scare or threaten it. If the dog’s owner is close, wait until the owner reaches the dog and restrains it before you move any closer or continue on your way. Remain calm and do not act excited. • Always ask permission from an adult owner before petting a dog you do not know, and never enter a fenced area if a dog is in the yard unless an adult owner accompanies you. • Never approach a dog that is tied up. Do not reach over or through a fence or car window to pet a dog even if you know it well. • Never approach a dog that appears to be sleeping. • Never try to take something from a dog or physically break up a fight between two or more animals. • Pay attention to a dog’s body language and behavior. Be particularly cautious if a dog’s ears are laid back; if it appears fearful (e.g., tail between its legs or cowering); if it appears lethargic, injured or sick; if it is with puppies; if it is eating; if it is chewing on a bone or drinking; or, if a dog appears aggressive (e.g., it growls, stiffens its body, stares, or bares its teeth). Figure 5
  9. 9. 7Situation Critical | Spring 2007 Biting the Hand That Feeds You Emergency Department Treatment of Dog Bite Injuries Initial wound management of dog bite injuries usually consists of confirming that a patient is medically stable, followed by taking and recording a history. Medical conditions associated with a high risk of infection after a dog bite should be recorded, including: chronic disease, chronic edema of the extremity, diabetes mellitus, immunosuppression, liver dysfunction, previous mastectomy, prosthetic valve or joint, splenectomy and systemic lupus erythematosis. In the absence of risk factors, only about five percent of dog bites become infected, which is less than human or cat bites. Other pertinent information includes the time of the injury and the general health, immunization status, and current location of the dog. This information should be noted in the record and, depending on applicable law, reported to local authorities. A patient’s tetanus immunization status, current medications and allergies should also be recorded. Tetanus vaccine and tetanus immune globulin should be administered, as appropriate.5 During the physical exam, emergency health care professionals should measure and describe the wound (e.g., laceration, puncture, crush or avulsion). In addition, providers should assess the range of motion of the affected and adjacent areas, documenting nerve, vascular and motor function (see Figure 6). If feasible, diagrams and photographs may be useful, particularly if there are irregular wounds, signs of infection or a high risk of infection.5 Dog bite wounds can be contaminated with dirt, feces, soil or saliva. If possible at the scene or before transport to the hospital, washing with plain soap and water is advisable. In the Emergency Department, prompt and thorough irrigation with sterile saline solution will significantly reduce the rate of infection. Infiltration of wound margins with plain lidocaine or bupivacaine will reduce the discomfort of this procedure. Avoid epinephrine in local anesthetic solutions, because it impairs local perfusion and increases infection rate. Removal of necrotic or devitalized tissue is important, but it is equally important not to debride so much tissue that wound closure and appearance are compromised. In the event of puncture or crush marks near a joint or bone – especially from larger animals – consider x-ray of the affected area, looking for bony injury or signs of joint penetration (pneumarthrosis – air in the joint).5 The role of wound closure is controversial, and varies by location. Puncture wounds, wounds that appear clinically infected, and wounds more than 24 hours old, may have a better outcome with delayed primary closure (suturing several days later in the absence of any signs of infection) or healing by secondary intention (natural healing without suturing). Most physicians will close fresh (<8 hours) and uncomplicated wounds on the face, where cosmesis is a priority. In contrast, most physicians will not close bite wounds on the hands or feet, because they are much more likely to become infected. Delayed, primary closure of such wounds – if they remain clean – after several days is another option. Plastic surgery or general surgery consultation is appropriate for complex wounds or those requiring significant debridement. For wounds involving joints or other bony structures, orthopedic consultation should be considered.5 A patient’s risk of infection with rabies virus should be assessed immediately. Although canine rabies is relatively rare in the U.S. (the most commonly reported cases of rabies virus involve wild animals, specifically raccoons, skunks and bats), cases of rabies virus associated with dog bites still occur. This risk increases when the dog is a stray or feral, and when the bite occurs outside the U.S. (the risk of rabies virus varies by country). A college student traveling through Nepal was bitten by a sleeping dog when she bent over to pet it. The wound was minor, did not become infected, and she disregarded it. Many weeks later – long after her return to the United States – she died of encephalitis. Examination of her brain revealed the rabies virus. A long incubation period – often weeks to months – is typical of rabies. The virus slowly travels up the peripheral nerves and spinal cord to the central nervous system (brain). Those bitten by a non-provoked dog, a stray dog, a feral dog, or a dog outside the U.S., should be considered at higher risk for rabies infection than patients bitten by a provoked dog, a pet dog or a dog within the U.S.5 Figure 6This patient was bitten by his own dog on the wrist, resulting in ulnar nerve injury.
  10. 10. 8 Situation Critical | Spring 2007 The first consideration in rabies risk assessment is whether the dog is available for rabies testing or confinement and observation. Second, a judgment must also be made as to whether it is prudent to wait for test results or completion of the 10-day quarantine and observation period before starting rabies post-exposure prophylaxis (PEP). Several factors determine whether a patient should receive rabies PEP following a dog bite. These include whether there was penetration of the skin by teeth; the location of the bite (if the bite occurs to the face or head, rabies PEP is more often started prior to obtaining the results of rabies testing or completion of the observation period – as distinguished from bites to an extremity); the severity of the bite (the deeper the bite, the more likely that rabies PEP will be promptly started); whether the bite was provoked (any unprovoked attack, including bites during feeding or handling a dog, is considered more serious than a provoked bite); and, vaccination status of the dog (rabies is extremely rare in vaccinated dogs).7 Generally speaking, if a dog’s vaccination against rabies cannot be promptly confirmed, if the dog cannot be observed or if the dog’s behavior is suspicious, the dog bite victim should receive rabies immunization promptly. Rabies immunization should begin within 48 hours after a bite, and it can be discontinued subsequently if the dog is proven to be free of rabies virus.5 Many states have resources available to answer questions about possible rabies exposure. In Minnesota, an epidemiologist from the Minnesota Department of Health (MDH) is available 24 hours a day at (651) 201-5414 to discuss possible rabies exposure to human dog bite victims. Unlike the relatively rare rabies virus, about five percent of dog bite wounds will become infected with various bacteria.8 Crush injuries, puncture wounds and hand wounds are more likely to become infected than scratches or tears. The majority of dog bite infections are polymicrobial (i.e., multiple bacterial species). The most common aerobic organisms (i.e., requiring oxygen to survive) are Pasteurella multocida and Staphylococcus aureus, and they occur in 20 to 30 percent of infected dog bite wounds. Anaerobic organisms (i.e., growing without oxygen) have also been implicated in infected dog bites.5 Treatment of a dog bite injury patient with prophylactic antibiotics for 3 to 7 days appears appropriate, unless the risk of infection is low, i.e., the wound appears superficial and the patient is not in a high risk group for infections. If frank cellulitis (infection of the skin recognized by erythema spreading beyond the wound edges) is evident, a 10 to 14 day course of treatment is indicated. Amoxicillin- clavulanate (Augmentin™ ) is the antibiotic of choice for dog bite injuries. Doxycycline appears to be an acceptable alternative for patients who are allergic to penicillin, provided the patient is ≥ 8 years and not pregnant. A macrolide antibiotic (erythromycin, clarithromycin, or azithromycin) can be used, but the risk of treatment failure appears greater because of antimicrobial resistance. More effective antibiotic combinations include clindamycin (Cleocin™ ) and a fluoroquinolone in adults or clindamycin and trimethoprim-sulfamethoxazole (Bactrim™ , Septra™ ) in children.8 Daily parenteral injections of ceftriaxone (Rocephin™ ) may be appropriate if compliance is a concern.5 Regrettably, outpatient treatment of infection sometimes fails and a patient needs to be hospitalized. Reasons for hospitalization from dog bite injuries include: systemic signs of infection (fever, sweats or chills); severe or rapidly spreading cellulitis or advancement of cellulitis past one joint; and involvement of a bone, joint, tendon or nerve. Intravenous ampicillin-sulbactam (Unasyn™ ) is the antibiotic of choice, but surgery may be more important. For patients hospitalized with deeper infection or abscess formation, surgical consultation should be promptly obtained because of the risk of worsening infection and tissue damage.5 Surgical exploration, debridement of devitalized tissue, and drainage of abscesses can be life-saving. Conclusion Thousands of years after dogs were first domesticated and welcomed into human homes, they remain a part of our culture. Most would agree that the benefits of responsible dog ownership outweigh the risks. However, dog bite injuries are all too common, their complications painful and their treatment expensive. Death is fortunately Biting the Hand That Feeds You What To Do If A Dog Attacks You4 • Surrender anything you have if a dog attacks you (e.g., bag, purse, jacket) in the hope that the dog will bite the item and not you. • If you fall to the ground, curl into a small ball and wrap your hands and arms around your head. Be quiet and remain still until the dog has left before you get up. Continued on page 9.
  11. 11. 9Situation Critical | Spring 2007 Center of Excellence Acute Stroke Program North Memorial continues to be among the best in the country in providing emergency care to stroke patients through our comprehensive acute stroke program. The Stroke Team provides thrombolytic therapy to stroke patients that exceeds the national average. North Memorial also offers state-of-the-art interventional neuro-radiology services featuring intra-arterial rt-PA, clot retrieval devices, angioplasty and carotid stenting. The Stroke Center has a registry that captures data on all of our stroke and TIA patients. This registry allows us to monitor patient outcomes and improve stroke care. The Heart and Stroke Center provides care to stroke patients and their families. This 80-bed care center offers staff specially trained in stroke management, including certification in the National Institutes of Health Stroke Scale. North Memorial is the only hospital in the Twin Cities currently participating in the NIH funded multi- center CREST study comparing carotid stents and endarterectomy. We also participate in a variety of ongoing studies to work toward better treatment and prevention of stroke. rare, for dogs usually bite once out of fear rather than repeatedly with intent to kill. Prompt and attentive treatment by emergency care providers will help reduce pain, infection, disfigurement and other complications of these injuries. References 1 Phillips, Kenneth M.“Dog Bite Law”. <http://www.>, Last Updated November 6, 2006. Last Accessed January 28, 2007. 2 Weiss, Harold B., Friedman, Deborah I, and Coben, Jeffrey H.“Incidence of Dog Bite Injuries Treated in Emergency Departments.” JAMA, Vol. 279, No. 1, January 7, 1998. 3 Clifton, Merritt. Editor, Animal People.“Dog Attack Deaths and Maimings, U.S. & Canada, September 1982 to November 13, 2006.” 4 Mertens, Petra.“Dog Bite Prevention,” University of Minnesota, College of Veterinary Medicine, <http:// dogbiteprevention>, last accessed January 29, 2007. 5 Presutti, R. John.“Prevention and Treatment of Dog Bites,” American Family Physician, April 15, 2001. 6 “Facts About Dog Bites.” City of Minneapolis, Animal Care and Control, < environment/docs/dogbitebrochure>, last accessed on- line on February 5, 2007. 7 “Management of Possible Rabies Exposure in Humans”, Minnesota Department of Health, <>, last accessed on-line on February 5, 2007. 8 The Sanford Guide to Antimicrobial Therapy, 36th ed, 2006. Biting the Hand That Feeds You: Continued from page 8 Stroke Prevention, Care and Rehabilitation Services at North Memorial By Irfan Altafullah, MD Stroke Center Medical Director Stroke is a devastating condition with significant mortality and morbidity. The only proven effective treatment for acute stroke is thrombolytic therapy (“clot busters”) which can only be given within three hours of the onset of stroke symptoms. Nationally, less than 10 percent of all patients with acute stroke receive this treatment, largely because they do not reach a hospital within the treatment time window. There are several promising therapies currently being researched to improve the care of stroke patients. One such intervention is Near Infrared Laser Therapy which has shown positive results in animals and in small preliminary studies in humans. The laser treatment is non-invasive, painless, and is applied to the skull. The entire treatment lasts about 40 minutes. A current FDA- approved study is evaluating the effectiveness and safety of laser therapy in patients up to 24 hours after onset of stroke symptoms. The Stroke Center at North Memorial remains at the forefront of clinical stroke research in the search for better ways to treat stroke. Clinical Stroke Research with Near Infrared Laser Therapy
  12. 12. Situation Critical | Spring 200710 St. Joseph’s Area Health Services, Park Rapids Located in Park Rapids, Minnesota, St. Joseph’s Area Health Services was established in 1946 by the Sisters of St. Joseph in Crookston. Today, it is a JCAHO-accredited hospital offering comprehensive inpatient and outpatient care to residents of Hubbard County and portions of Becker, Cass and Wadena counties. St. Joseph serves a rapidly growing, rural resort area of more than 25,000 people (with a summer population that exceeds 50,000). A particularly unique patient service at St. Joseph’s is the hospital’s Patient Compassion Closet. This unique resource provides patients in need with clothing and sometimes funding for needs like transportation or medication. Communication and Development Manager Cynthia Rooney explains that hospital staff donate to a patient compassion fund that provides monies for patients during a time of crisis. “Some of these funds are used to purchase clothing for our compassion closet,” she says.“Secondly, an area church provides sets of children’s clothing for us. The outfits, which include socks, underwear, pants and a top, are labeled according to size and gender.” By having these supplies readily available, clinical staff are better able to concentrate on a patient’s health needs without the stress of trying to figure out how to clothe the patient to get them home.“It’s a very nice added service that we’re happy to offer our patients,” says Rooney. Outstate Partner Profile • Licensed beds: 50 • Average inpatient days each year: 6,135 • Average emergency room visits each year: 10,600 • Number of employees: 400 St. Joseph’s by the Numbers Source:
  13. 13. Situation Critical | Spring 2007 11 Meet Our Staff Dan DeSmet Title: Manager - North Memorial Ambulance - Marshall Region (Redwood Falls, Marshall, Minneota & assist with AC 3) Education: • Bachelor’s Degree from St. Cloud State University in Criminal Justice & Health • Education, Paramedic Certificate from McKennan Hospital - Sioux Falls, SD • Registered Emergency Medical Technician, National DRE (Drug Recognition Expert) Professional Experience: I began my emergency health care career in 1990 by completing an EMT program during my senior year at Minneota High School. I worked for Minneota Ambulance and continued that experience while completing my college education at St. Cloud State University. Following my college education, I began working as a police officer and dispatcher for the city of Marshall. I was trained as a paramedic through McKennan Hospital in Sioux Falls and began working for North Memorial Ambulance in Marshall in 1997. I transitioned from the Marshall Police Department to the Lyon County Sheriff’s Department as a full-time deputy in 1999 and continued working as a paramedic for North Memorial Ambulance in Marshall. In 2005, I accepted my current position as Manager for the Marshall Region of North Memorial Ambulance. Favorite Part About My Career: The favorite part of my career is the fast-paced and ever- changing work environment. Some days I can go from a warm and cozy office to the middle of a blizzard in a matter of seconds. And the nature of my work is also ever changing. While in the office, I can be working on a yearly budget and the next minute be intubating a critically injured patient in a ditch. Personal Interests: Some of my personal interests include hunting, biking and swimming when the weather permits. Additionally, I am also an avid storm chaser and enjoy watching a summer thunderstorm. Megan Hartigan Title: Air Care/ Criticare Supervisor since Fall, 2005 Education: • AS - Emergency Medical Care and Rescue • AS - Nursing • Completing BS in Community Health/ Management Professional Experience: • Served as an EMT in rural Wisconsin • Paramedic at North Memorial Ambulance (first female hired) • One of the original Flight Paramedics with Air Care; served five years as Air Care Supervisor • RN at a Level II Trauma Center • Flight Nurse/Supervisor/ Director of Air Operations for another air care service • Appointed to the Emergency Medical Services Regulatory Board with term expiring this year Favorite Part About My Career: Each phase of my career has offered many rewards. I enjoy the adventure of the working environment, even in adverse conditions. I appreciate the ability, knowledge and dedication of the wide variety of people I have the opportunity to come in contact with. I have confidence that our patients are being served by knowledgeable, competent, top-notch crews. Personal Interests: I am married with four daughters, a dog, hamster and fish. We live on a lake in rural Minnesota and I love outdoor silent sports such as swimming, kayaking, running and biking.
  14. 14. Date Time Conference Title Presenter Room 4/20/07 Acute Med/Surg Mgmt Conference* Dr. Smith V.DeMong 1210-1300 Identification of Dementia 1300-1400 Documentation & Coding L.Vorhes, C. Pfeifer V.DeMong 4/27/07 Stabilization Room Conference Dr. Kolar V.DeMong 1210-1300 Case Presentations Dr. Soberay 1300-1400 Ortho X-Ray Tutorial #3 Dr. Allegra V.DeMong 5/1/07 Emergency Medicine Noon Conference Dr. Roberts Ridgeview 1210-1300 Seizures 1300-1400 Calculation Lab #3 Dr. Allegra Ridgeview 5/18/07 Acute Med-Surg Mgmt Conference* Dr. Taylor Pinecrest/ Lakeshore 1210-1300 DVT Update 1300-1400 Documentation & Coding L.Vorhes, C. Pfeifer Pinecrest 5/21/07 Trauma Grand Rounds* Dr. Roberts Pinecrest 1210-1300 Toxic Peripheral Vascular Accidents Dr. Knapp 1300-1400 Emergency X-Ray Tutorial #3 Dr. Allegra Pinecrest 6/5/07 Emergency Medicine Noon Conference Dr. Barnhart Ridgeview 1210-1300 Hypertensive Emergencies 1300-1400 Calculation Lab # 3 Dr. Gengerke Ridgeview 6/8/07 Trauma Grand Rounds* Dr. Roberts V.DeMong 1210-1300 Liver Trauma Drs. Steiner, Moser 1300-1400 Emergency X-Ray Tutorial #3 Dr. Travnicek V.DeMong 6/15/07 Acute Med/Surg Management Conference V.DeMong 1210-1300 TBA 1300-1400 Documentation & Coding L.Vorhes, C. Pfeifer V.DeMong 6/22/07 Stabilization Room Conference Dr. Kolar V.DeMong 1210-1300 Case Presentations Drs. Gengerke, Travnicek 1300-1400 Ortho X-Ray Tutorial #3 Dr. Nelson V.DeMong North Memorial Medical Center Emergency Medicine and Trauma Conferences April – July, 2007 Calendar of Events Situation Critical | Spring 200712 Attendance by medical students and residents required. *North Memorial Health Care is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. North Memorial Health Care designates this educational activity for a maximum of 1 AMA Physician’s Recognition Award™ category 1 credits. Physicians should claim only those credits commensurate with the extent of their participation in the activity. If you need auxiliary aides or services identified in the Americans with Disabilities Act, please contact North Memorial Continuing Medical Education prior to the program at (763) 520-7274. For directions or more information about any of the conferences, contact Dr. Roberts at
  15. 15. Calendar of Events Situation Critical | Spring 2007 13 Air Care’s Annual Spring Emergency Care Seminars – FREE Information: (763) 520-3021 or visit (click News and Events) You are invited to join us at one of the upcoming free seminars for emergency care providers. Following are program dates and locations: Topics may vary from one location to the next, but all will be conducted between 6 and 9 p.m. and will include two 60-minute general sessions and three 20-minute breakout sessions. A complimentary dinner and registration begin at 5:15 p.m. Sessions are designed to meet continuing education requirements for nurses and EMTs. Trauma 101 Multi-System Care of the Trauma Patient for the Nurse Working in a Non-critical Care Setting September 19 from 8 a.m. to 4 p.m. Information: (763) 520-5999 or visit (click For Health Care Professionals) This course will give you the tools you need to respond quickly to a wide variety of multi-system trauma involving different patient needs, ages, cultures and severity of presenting symptoms. Registration is $99 for professionals or $49 for North Memorial employees ($8/box lunch). Beyond the Secondary Survey Critical Care Trauma Nursing Course Monday & Tuesday, October 22-23 from 8 a.m. to 4 p.m. Information: (763) 520-5940 or visit (click For Health Care Professionals) While many courses cover initial trauma evaluation and resuscitation, this 2-day program will use lecture and case studies to give you the skills you need to provide care for these patients after the initial resuscitation period is completed. Registration is $149 ($16/box lunches both days). Intended for nurses who have at least one year of critical care experience. April 25 Air Care 4 Princeton Base May 2 Air Care 2 Brainerd Base May 8 Air Care 1 Lakeville Base Date Time Conference Title Presenter Room 7/13/07 Trauma Grand Rounds* Dr. Roberts Pinecrest 1210-1300 Smoke Inhalation: CO or Cyanide? 1300-1400 Emergency X-Ray Tutorial # 1 Pinecrest 7/20/07 Acute Med/Surg Mgmt Conference* V.DeMong 1210-1300 TBA 1300-1400 Documentation & Coding L.Vorhes, C. Pfeifer V.DeMong 7/27/07 Stabilization Room Conference Dr. Kolar V.DeMong 1210-1300 Case Presentations 1300-1400 Ortho X-Ray Tutorial #3 V.DeMong North Memorial Medical Center Emergency Medicine and Trauma Conferences April – July, 2007 Attendance by medical students and residents required. *North Memorial Health Care is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. North Memorial Health Care designates this educational activity for a maximum of 1 AMA Physician’s Recognition Award™ category 1 credits. Physicians should claim only those credits commensurate with the extent of their participation in the activity. If you need auxiliary aides or services identified in the Americans with Disabilities Act, please contact North Memorial Continuing Medical Education prior to the program at (763) 520-7274. For directions or more information about any of the conferences, contact Dr. Roberts at
  16. 16. EmergencyandTraumaServices 3300OakdaleAve.N. Robbinsdale,MN55422 Non-ProfitOrg. U.S.Postage PAID Minneapolis,MN PermitNo.3784 Pleasesharethiswithyourstaff.