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Trauma & Injury Prevention Section Newsletter - March 2012

circle_arrowChair’s Welcome - Trauma & Injury Prevention Section Newsletter - March 2012
circle_arrowState Prescription Drug Monitoring Programs - Trauma & Injury Prevention Section Newsletter - March 2012
circle_arrowResearch Focused on Post-Traumatic Neuroinflammation - Trauma & Injury Prevention Section Newsletter - March 2012
circle_arrowSAVIR at the Forefront of Advocacy Efforts - Trauma & Injury Prevention Section Newsletter, March 2012
circle_arrowStopping the Bullets From Travelling - Trauma & Injury Prevention Section Newsletter, March 2012
circle_arrowUpdates on Pediatric Trauma and Injury Prevention - Trauma & Injury Prevention Section Newsletter, March 2012
circle_arrowACS - Committee on Trauma (ACS-COT) Liaison Report - Trauma & Injury Prevention Section Newsletter, March 2012

Chair’s Welcome - Trauma & Injury Prevention Section Newsletter - March 2012

Megan L. Ranney MD MPH FACEP
Dept of Emergency Medicine
Brown University/Rhode Island Hospital
  

Thank you for choosing to participate in the ACEP Trauma & Injury Prevention Section.  I am thrilled to be taking over as your Chair, and look forward to an exciting year ahead.  I am also happy to announce that Kit Delgado, MD, at Stanford University, has assumed the position of newsletter editor. 

As we all know, injuries are the leading cause of death for people aged 1-44 in the US,1 and represent over one-third of ED visits each year.2  Yet injuries are eminently preventable.  To quote a single recent success story:  2010 marked the lowest percentage of drinking drivers and lowest number of drunk-driving episodes reported since 1993.3   Through the combined efforts of emergency physicians, public health professionals, legislators, concerned citizens, automobile engineers, and law enforcement, we have succeeded in reducing the incidence of drunk-driving episodes by 30% in just four years.  However, there is still more to be done.  As we know all too well from our ED shifts, more than 4 million Americans continue to drive drunk.4   To continue to make progress on this and other trauma/injury prevention issues, our section needs to work together to advance our field. 

To quote from our Board guidelines, our section’s role is to:

  1. To provide a forum for the exchange of information among ACEP members involved in injury control activities
  2. To educate ACEP members about the emergency physician's role in injury prevention.
  3. To serve as a resource to the members and leadership of ACEP in the area of injury control.
  4. To promote ACEP involvement in research in injury control.
  5. To promote ACEP involvement in the development of governmental policy regarding injury prevention and control issues.
  6. To foster liaison relationships with other organizations involved in injury control activities.

This newsletter hopes to meet some of these objectives.  We give you a small taste of the variety of activities that our section members conduct, ranging from health policy research, to basic science research on trauma, to investigations of predictors of injury, to advocacy on behalf of patients’ and providers’ needs.  You can check out our section website, at https://www.acep.org/traumasection/ , for more details on our current and past activities. 

That said, our section can only be as strong as our membership.  I know that we are all busy.  But this section is ACEP’s voice for trauma & injury prevention.  Without your participation, we cannot possibly meet our goals.   So we urge you to get involved!  We welcome any efforts, big or small: 

  • newsletter submissions
  • section grant ideas
  • advocacy efforts
  • proposals for speakers for our meeting in Denver
  • proposals for didactics for the 2013 Annual Meeting 

Thank you for everything you do, in your own ED as well as on the local and national level, to support the advancement of trauma care and injury research. 

Please don’t hesitate to email me with thoughts or suggestions. 

Respectfully yours, 

Megan L. Ranney MD MPH FACEP
Dept of Emergency Medicine, Brown University/Rhode Island Hospital  

References 

  1. NCIPC: Web-based Injury Statistics Query and Reporting System (WISQARS) http://www.cdc.gov/injury/wisqar 
  2.   http://www.cdc.gov/nchs/fastats/ervisits.htm 
  3.   “Vital Signs: Alcohol-impaired driving among adults – United States, 2010.”  MMWR 2011 60(39): 135-1356.  Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a4.htm 
  4.  “Vital Signs: Alcohol-impaired driving among adults – United States, 2010.”  MMWR 2011 60(39): 135-1356.  Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a4.htm 
  5.  


State Prescription Drug Monitoring Programs - Trauma & Injury Prevention Section Newsletter - March 2012

State Prescription Drug Monitoring Programs: Are They the Answer to America’s New Public Health Epidemic? 

Casey Grover, MD
Stanford-Kaiser Emergency Medicine Residency
 

Non-medical use of prescription medication in the United States has become a public health epidemic according to a November 2011 report from the Centers for Disease Prevention and Control (CDC).1,2 Approximately 7 million Americans use prescription medications for non-therapeutic reasons each year, resulting in over 700,000 Emergency Department (ED) visits yearly, and nearly 15,000 deaths per year.1-4 Deaths from prescription opiates have more than tripled since the mid 1990s, and death from overdose on prescription medications accounts for as many years of productive life lost (YPLL) as deaths from motor vehicle crashes.1-2  

Approximately 10% of patients chronically taking prescription opiates use high daily doses and seek care from multiple prescribers. This group accounts for about 40% of all overdoses, and represents a population that is high risk for death and likely also involved with drug diversion.5             

The ED is a frequent place at which such patients seek care. This leaves us, as Emergency Physicians, in a key position to intervene upon this high-risk group. What can we do? 

Prescription monitoring programs are state-run programs that are becoming increasingly used to identify patients with high-risk prescription medication use.6-7 Physicians are provided a list of any controlled substances that have been recently prescribed to a patient through the use of a secure web-based portal. A recent study in Annals of Emergency Medicine provided prescription monitoring program access to Emergency Physicians (EPs) in an Ohio ED, and found that access to this information changed discharge prescribing in 60% of cases.8 Having access to this information is also a great piece of data to bring to the bedside. Reminding a patient that he has received 200 tablets of Vicodin within the past two weeks makes it easier to let the patient know that you are concerned that he has a problem with opiates, and that you do not feel comfortable giving him any refills.  

While most states in the United States now have prescription monitoring programs, little is known about how to interpret the information obtained in prescriptions records. While a patient that has received oxycodone 12 times in the past month from 8 different doctors clearly has a problem, prescription monitoring programs have not yet been studied well enough to know how to interpret more borderline cases. In our study on this topic, we found that patients with greater than 6 narcotic prescriptions per month, or greater than 6 providers in a two-month period raised EP concern for problematic prescription opiate use. Interestingly, potency of the opiate medication in the prescription medication (hydrocodone vs oxycodone) did not change EP concern for problematic use.9 Further research is ongoing, and will hopefully provide us with better information on how to best use these valuable prescription monitoring programs.  

In the meantime, the rising tide of non-medical use of prescription medications suggests that this is a problem that we will be seeing frequently in the ED. If you don’t already have access to your state’s prescription monitoring program, try the following link for information on prescription monitoring programs across the U.S.: http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#4

Correspondence   

References:

  1. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers – United States, 1999 – 2008. MMWR Morb Mortal Wkly Rep. 2011; 60: 1487-92.
  2. Centers for Disease Control and Prevention (CDC). CDC Grand Rounds: Prescription Drug Overdoses – a U.S. Epidemic. MMWR Morb Mortal Wkly Rep 2012; 61: 10-13.
  3. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD
  4. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2006: National Estimates of Drug-Related Emergency Department Visits. DAWN SeriesD-30, DHHS Publication No. (SMA) 08-4339, Rockville, MD, 2008.
  5. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011; 12: Suppl 2: S26-S35.
  6. Gilson AM, Kreis PG. The burden of the non-medical use of prescription opioid analgesics. Pain Med. 2009; 10: S89-100
  7. Barrett K, Watson A. Physician perspectives on a pilot prescription monitoring program. J Pain Palliat Care Pharmcother. 2005; 19: 5-13.
  8. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56: 19-23. e1-3.
  9. Grover CA, Garmel GM. How do Emergency Physicians interpret prescription narcotic history when assessing patients presenting to the Emergency Department with pain? (Abstract). Ann Emerg Med. 2011; 58: S319-320.
  10.  


Research Focused on Post-Traumatic Neuroinflammation - Trauma & Injury Prevention Section Newsletter - March 2012

Research Focused on Post-Traumatic Neuroinflammation May Lead to Discovery of New Therapeutic Targets and Diagnostic Tools for TBI 

Adam Chodobski and Joanna Szmydynger-Chodobska
Department of Emergency Medicine, Alpert Medical School of Brown University
 

Traumatic brain injury (TBI) encompasses a wide range of insults delivered to the brain by external forces resulting in temporary or permanent cognitive, physical, and social decline. In the mild TBI (mTBI) end of the spectrum, the pathological effects of injury, which were previously not well characterized or understood, are now receiving a great deal of attention among neuroscientists and in the media. A better understanding of pathophysiology of brain injury thanks to laboratory and clinical research has improved survival and outcomes from severe TBI. However, effective diagnosis and care for mTBI and concussion are currently in an evolutionary phase despite the progress that has been made in neuropsychological screening, evaluative tests, and neuroimaging techniques. The complexity and interdependent nature of pathophysiological processes triggered by TBI may explain why many single-mechanism neuroprotective interventions have shown significant therapeutic potential in animal models of TBI, but have failed to demonstrate consistent improvement of outcome in neurotrauma patients. 

In the Neurotrauma and Brain Barriers Research Laboratory at the Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, a team of researchers together with fellow clinicians is working on a variety of projects with a common goal of advancing our understanding of TBI pathophysiology. The major interest of this laboratory, which is led by Dr. Adam Chodobski, is in the post-traumatic neuroinflammation and its role in promoting the formation of cerebral edema and neuronal loss that lead to neurocognitive deficits observed in TBI patients. In a paper published in the Journal of Neurotrauma (2010,27:1449), the group has demonstrated that in severe TBI, vasopressin amplifies the post-traumatic synthesis of proinflammatory mediators, which results in increased influx of inflammatory cells into the injured brain parenchyma, more edema, and the larger extent of neuronal damage. They have also shown that these vasopressin actions are mediated by the c-Jun N-terminal kinase signal transduction pathway. Currently, the group is studying other components of this signaling cascade looking for new potential therapeutic targets in TBI.  

Another interest of the Chodobski lab is in molecular, cellular, and functional changes that occur after TBI at the blood-brain and blood-CSF barrier – the gatekeepers of the brain – and their role in the brain inflammatory response to injury. While it is generally thought that the inflammatory cells enter the injured brain across the blood-brain barrier residing in parenchymal and pial microvessels, the Chodobski group has shown that also the blood-CSF barrier and CSF pathways play important roles in post-traumatic invasion of neutrophils and monocytes (J Cereb Blood Flow Metab 2009,29:1503; 2012,32:93).  

The most recent focus of the Chodobski lab is on clinical studies of mTBI and concussion, particularly in children. Currently, there is no established method for predicting the recovery period and/or determining the optimal treatment recommendations for individual mTBI patients. The availability of objective and quantitative measures to clinicians would improve their ability to obtain diagnostic and prognostic information about the patients, and may eventually help identify individuals who could benefit from targeted mTBI therapies. Based on the data obtained from animal studies of experimental TBI, the laboratory, together with clinicians from the Department of Emergency Medicine, is currently conducting clinical investigations on serum inflammatory biomarkers in both pediatric and adult TBI patients with varying severity of injury. The overall aim of these studies is to define a panel of biomarkers with diverse serum kinetics that would allow for better diagnosis and prediction of neurocognitive recovery in mTBI and concussion. 

The long-term goal of the Chodobski group is to develop combination treatments for TBI directed against multiple targets, and thus having complementary therapeutic effects. If successful, such therapy may offer the most hope for early treatment of TBI patients. 

Correspondence  


SAVIR at the Forefront of Advocacy Efforts - Trauma & Injury Prevention Section Newsletter, March 2012

SAVIR at the Forefront of National Violence and Injury Research Advocacy Efforts 

Joneigh S.Khaldun, MD
Emergency Physician, George Washington University
Co-Chair, SAVIR Advocacy and Public Policy Committee
 

The Society for Advancement of Violence and Injury Research (SAVIR) is an organization of academic researchers, public health professionals and clinicians that provides leadership on violence and injury prevention and care research.  SAVIR members regularly serve as leaders and advocates for furthering national and local violence and injury research efforts. The past year has been particularly active, and there are plenty of opportunities to get involved! Highlights from the current or past year include:

  • Ongoing co-sponsorship of congressional briefings on the importance of injury and violence research- the next one is scheduled for March 12, 2012.
  • Submitted an invited white paper to the NIH’s National Institute of Child Health and Human Development (NICHD) on the importance of expanding and supporting violence and injury research.  The director of NICHD has proposed to its Council a plan to establish an injury research branch in October 2012. (http://www.savirweb.org/assets/438_nichdletterfinal020612.pdf)
  • Meeting with Obama administration leadership to advise and support federal injury prevention efforts, including Dr. Howard Koh, Assistant Secretary of Health and Surgeon General Dr. Regina Benjamin.
  • Ongoing meetings with key Congressional staff members to support federal injury funding- we were recently successful in stopping the elimination of the Centers for Disease Control (CDC) injury funding for youth violence!
  • Submitted guidance on the National Prevention Strategy, a federal document to guide the nation’s public health and prevention efforts and called for under the Affordable Care Act.  (http://www.savirweb.org/assets/343_savirrecommendationsforna.pdf)
  • Received funding from the CDC’s National Center for Injury Prevention and Control to evaluate state Core Violence and Injury Prevention Programs in collaboration with Safe States Alliance.
  • Working closely with Trust for America’s Health to develop a national violence and injury report card on 10 injury topics, in conjunction with Safe States Alliance.
  • Co-Sponsored a national injury conference with Safe States Alliance in April 2011.
  • Publishing a regular column in the peer-reviewed journal, Injury Prevention.
  • Ongoing training and educational resources for practitioners and public health professionals.
  • And much more……

It is an extremely important time for violence and injury professionals! While injury continues to be the number one cause of death for Americans between the ages of 1 and 44, the threat of decreased funding and support for violence and injury research and programs is real. There is plenty of work to be done and opportunities for advocacy. SAVIR continues to be at the forefront of these efforts, and we would like to extend a special invitation to ACEP members to join SAVIR, become active in the organization and help decrease the burden of injury on our society! 

Correspondence 


Stopping the Bullets From Travelling - Trauma & Injury Prevention Section Newsletter, March 2012

Nathan Irvin, MD
Robert Wood Johnson Clinical Scholar, University of Pennsylvania
 

“That bullet hit more than just my son. It has riddled my entire family with emotional and psychological wounds that persist today… I remember eating all day and still being unable to fill the void of emptiness inside of me.” These poignant words were expressed by a Philadelphia mother who has been grieving the loss of her son for nearly 18 years.  As physicians, it is very easy to have a myopic view of injury and treatment, focusing only on the individual that was directly injured and ignoring the collateral damage the bullet does to the health of the family and community. I argue that if we do so, we fail as physicians to recognize the true public health impact of the bullet. Research demonstrates that experiencing violence, both directly and indirectly is associated with PTSD, depression and substance abuse, which all inflict significant morbidity on populations beyond just the individual that was directly impacted by the physical bullet.1 Whether it is dealing with the psychological and emotional sequelae of violence and premature death, living in persistent fear of harm in an unsafe community, or using unhealthy coping mechanisms like over-eating, weapon carrying or drugs to deal with the hurt and pain, a single bullet affects more than just the individual with the physical wound- it affects communities of people.  

Failing to acknowledge and address these collateral injuries has devastating effects on the health of the community and society. People suffering from symptoms of PTSD tend to have higher burdens of chronic diseases which can lead to increased health care costs and ED visits.2 These symptoms are also thought to contribute to the cycle of victimization that claims nearly 17,000 lives annually and results in over 1.8 million ED visits each year.3,4 Family units and earning potential are too often shattered as individuals are shuttled between jail and the grave or subjected to lives burdened by physical and emotional disability from their injuries which prevent them from providing for their loved ones. These bullets definitely hit more than just one individual and many of these injuries go unaddressed.  

“We must stop the bullets from travelling” eloquently stated this mother when asked about solutions to this problem.  In order to do so, we must move beyond just addressing the physical wounds of individuals directly injured by violence, but also address the adverse effects this violence has on larger families and communities.   Employing a “Trauma- Informed Care” model, wherein both systems and providers of care approach patients with an understanding of the role trauma and violence plays in their lives is both practical and essential to stopping the impact of these bullets. By viewing our patients through a lens that is inclusive of the impact that trauma and violence has on their lives and health, we validate their experiences and empower them to address some of the issues affecting them. In doing so, not only will we be able to provide better care, but we will also have the awareness to align them with the resources that will allow them to heal from these wounds that are so often overlooked. 

Correspondence 

References

  1. Kessler, R etal. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry. 1995;52(12):1048.
  2. Solomon, S etal. Trauma: Prevalence, Impairment, Service Use, and Cost. J Clinical Psychiatry. 1997; 58 [suppl 9]:5-11.
  3. CDC. Web- based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2007). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). [2010 Jun 14] Available from URL: www.cdc.gov/injury.
  4. Corbin, T etal. Developing a Trauma-Informed, Emergency Department-Based Intervention for Victims of Urban Violence. Journal of Trauma and Dissociation. 2011;12:510-25.
  5.  


Updates on Pediatric Trauma and Injury Prevention - Trauma & Injury Prevention Section Newsletter, March 2012

New studies on the evaluation and management of blunt head trauma & new epidemiologic data showing current trends in physical abuse and pediatric drowning                                                          

Eva Delgado, MD FAAP
Department of Emergency Medicine, Children’s Hospital & Research Center Oakland
 

Just two years after The Lancet published validated prediction rules to identify and thereby limit CT use in children at very low risk for clinically important traumatic brain injury (ciTBI) after head trauma, several planned secondary analyses have reached publication.  

Holmes et al. Do Children With Blunt Head Trauma and Normal Cranial Computed Tomography Scan Results Require Hospitalization for Neurologic Observation. Annals of Emergency Medicine. 2011;58:315-321. 

In Annals of Emergency Medicine’s October 2011 edition, Dr. James Homes and colleagues from PECARN (Pediatric Emergency Care and Applied Research Network) demonstrated that a child with GCS 14-15 and a normal head CT after blunt trauma is a candidate for discharge home. The study followed the course of both admitted and discharged children meeting these criteria, noting that only 0.05% of the children who were initially discharged but returned for repeat evaluation had traumatic findings on repeat neuroimaging. More of the admitted patients had findings on repeat imaging, even when accounting for discharged patients lost to follow-up, suggesting there is some other factor not measured that demonstrates need for admission. Importantly, none of the children with normal initial scans warranted neurosurgical intervention, even if repeat imaging was deemed necessary and/or revealed positive findings.  

Nigrovic et al. Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms. Archives of Pediatric and Adolescent Medicine. 2011; E1-E6.

The online version of Archives of Pediatric and Adolescent Medicine from December 2011 published data to suggest that children with isolated severe injury mechanism are at low risk of clinically important TBI (i.e. resulting in death, neurosurgery, intubation, admission > 2 days with finding on head CT), and therefore do not require head CT. Dr. Nigrovic and other PECARN contributors analyzed data collected on children with a severe injury mechanism defined as:  MVC with a death, ejection or rollover, un-helmeted child struck by automobile, fall > 3 feet in those < 2 years or > 5 feet in those > 2 years, or high impact object hit to the head. Clinically important TBI was less likely in the 1486 cases with no other PECARN clinical predictors for ciTBI when compared to cases with one or more predictors, and ciTBI was more likely as more risk factors were added to injury mechanism (i.e. agitation, sleepiness, vomiting, skull fracture). Only 3 of the 1486 were diagnosed with ciTBI, and all of them had significant facial trauma that prompted the head CT. Notably, none of these children needed neurosurgery.

Leventhal et al. Using US Data to Estimate the Incidence of Serious Physical Abuse in Children. Pediatrics. 2012; 129:

Dr. Leventhal’s group at Yale identified 4569 US hospitalizations and 300 deaths due to serious injury from physical abuse in 2006. Children with Medicaid insurance were more likely to suffer serious injury due to abuse than due to other causes, and children < 1 year were more likely to die from their injuries. The national cost for abused children was $73.8 million that year. The authors hope this data will fuel prevention programs. 

Bowman et al. Trends in US Pediatric Drowning Hospitalizations, 1993-2008. Pediatrics. 2012; 129: 275-281.

Dr. Bowman and his colleagues in injury prevention and research at Johns Hopkins and Arkansas Children’s Hospital reported a decline of 51% in pediatric hospitalization rates for drowning from 1993 to 2008. As described in the study published in Pediatrics in February 2012, the authors noted prior knowledge showing a downward trend in drowning-related fatalities with little prior data on hospitalizations of survivors who often suffer significant long-term morbidity.  They also reported a decline in in-hospital mortality of 42% over the same period, with the speculation that this could be attributable to pre-hospital care. Of drowning mechanisms, bathtub-related drowning events warranting hospitalization declined significantly for the 0-4 year age group, suggesting that injury prevention efforts should continue to focus on these scenarios as well as recreational situations.

Correspondence 


ACS - Committee on Trauma (ACS-COT) Liaison Report - Trauma & Injury Prevention Section Newsletter, March 2012

February 2011

Rick Murrary, EMT-P
Director, ACEP EMS and Disaster Preparedness Department
 

NHTSA National EMS Culture of Safety Project

ACEP is the lead on the NHTSA National EMS Culture of Safety Project that will develop a strategy document for a new ‘Culture of Safety’ for EMS. The National “Culture of Safety” Conference was held on June 27 – 28, 2011 in Washington, DC. Almost 100 people attended representing national EMS and fire organizations, EMS managers, educators, field providers, as well a federal partners from NHTSA, EMSC, DHS, and HRSA. The group discussed key safety issues facing EMS that will be the priorities for developing the strategy document. The first draft of the strategy was shared with the project Steering Committee in September and released for public comment in December 2011. Public review and comment will be solicited over the coming months as several additional draft versions are developed. A National Review Meeting will be held in Washington, DC in the summer of 2012 to review and finalize the strategy document. We are pleased to have Dr. Jeff Salomone as the ACS-COT representative to this important project. The web site for this project is www.emscos.com  

DHS/FEMA Grant – Interactive Web-based Game

The College is nearing completion on the DHS/FEMA funded project to develop an interactive learning game for children to learn home disaster preparedness. We hope the game will go live in the next few weeks as soon as DHS gives the final approval to release it. The web site is up and running so you can see some of graphics of the game. www.disasterhero.com

CDC Grant – Patient Surge Templates

The College is working with the CDC on a project to promote hospitals and EMS services to use the Patient Surge Templates from Terrorist Bombings templates. These templates are designed to assist facilities in the review of their existing disaster plans to insure they properly prepare for a patient surge from a terrorist bombing. The templates actually can be used to prepare for almost any patient surge event, not just terrorist bombings. For additional information on this project contact Rick Murray in the ACEP EMS Department.  

NATIONAL EMS Week 2012

National EMS Week 2012 will be observed May 20 – 26. The theme for this year is EMS: More Than A Job. A Calling. The EMS Week Planning Guides were recently sent to the printer and will be mailed in the near future. Information for 2012 will be posted on the web soon at www.acep.org/emsweek . We welcome any ideas or suggestions you may have for the EMS Week kit or the project in general.

ACEP EMS and Disaster Preparedness Department

Rick Murray, EMT-P, Department Director 

Pat Elmes, EMT-P (Ret.) Department Manager 

Deanna Harper, EMT-I, EMS/Disaster Response Coordinator 

Deb Fly, Administrative Assistant 

1-800-798-1822 ext 3260


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