Table Of Content

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There’s a lot more than billing going on in a more information. HealthInformationSystems.Inc. Tomorrow'sSolutionsinToday'sPractice MedSTAR,DentSTAR,CHIRO,MAPS, REQUESTOR,andBKeeperaretrademarksofHIS. RHODE ISLAND THE FRANCIS COUNT A. LIBRAfi* OF MEDICIN BOSTON, MA MEDICAL JOURNAL AUG 1 4 1991 Volume 74, Number 8 August 1991 EDITORIALSTAFF StanleyM.Aronson,MD TABLE OF CONTENTS Editor-In-Chief KimberlyA.Poulton ManagingEditor EDITORIALS HugoTaussig,MD BookReviewEditor 349 Emergency Medical Services in Rhode Island SeebertJ.Goldowsky,MD RobertH. Woolard, MD Editor-In-ChiefEmeritus EDITORIALBOARD Our Saintly Legacy •EdwardR.Feller,MD Chairman Dr Barbara A. DeBuono, Director of Health •JosephAmaral,MD •StanleyM.Aronson,MD CONTRIBUTIONS-GuestEditor, RobertH. Woolard, MD EdwardM.Belser,PhD,JD 355 Trauma System Planning in Rhode Island PaulCalabresl,MD Melinda L. Komiske, MS •RichardA.Carleton,MD William J. Waters, Jr, PhD MargaretCololan,MSJ Catherine P. Millman, MBA •JamesP.Crowley,MD •PeterA.Hollmann,MD 361 Prehospital Emergency Care in Rhode Island •FrankJ.Schaberg,Jr.,MD PeterLeary MD •FredJ.Schlffman,MD RobertH. Woolard, WilliamJ.Waters,Jr.,PhD 365 Immobilization ofSkeletal Injuries •MemberofPublicationsCommittee PeterG. Trafton, MD, FACS 374 A View From AnotherSystem- OFFICERS The Alabama Experience KathleenC.Hlttner,MD RonaldA. Shaw, MD President RobertE.Baute,MD 379 Emergency Medical Residency Training and EMS: President-Elect The Beginning of the Future A.RobertBuonanno,MD DanielL. Savitt, MD Secretary 383 Disaster Management: Problems and Solutions FrancesP.Conklin,MD Treasurer Bruce Becker, MD, MPH, FACEP RichardWong,MD ImmediatePastPresident COLUMNS DISTRICTANDCOUNTY PRESIDENTS 392 HEALTH BY NUMBERS FredVohr,MD From Emergency Department to Inpatient: BristolCountyMedicalSociety Rhode Island Injuries 1988 WilliamF.Coscina,MD 394 THE RHODE ISLAND MEDICAL JOURNAL HERITAGE KentCountyMedicalSociety OrestZaklynsky,MD NewportCountyMedicalSociety FrankJ.Schaberg,Jr.,MD PawtucketMedicalAssociation JamesP.Crowley,MD ProvidenceMedicalAssociation Cover: Treatmentofafracture:afifteencenturywoodengravingby JosephR.Dotolo,MD theGermanartistHieronymusBrunschwig. WashingtonCountyMedicalSociety PatrickR.Levesque,MD WoonsocketDistrictMedicalSociety —RhoSudbescIrsilpatnidonMsed$i2c0a0l0Jopuerrnyaelaris(omwenmebderasndofputbhleiRshheoddmeoInstlhalnydbMyedtihceaRlhSoodceieItsyla—nd$M5ed0i0caalnnSuoaclileyt)y,P1u0b6liFsrhaendciasrtSitcrleeest,rePprroevsiednetncoep,inRihonosdoefItshleanadut0h2o9r0s3,anPdh:d4o01no-t3n31ec-e3s2s0a7rilSyinrgelfleecctoptiheeso$ff2ici0a0l policyoftheRhodeIslandMedicalSocietyunlessclearlyspecified AdvertisementsdonotimplysponsorshiporendorsementbytheRhodeIslandMedicalSociety Secondclasspostagepaid atProvidence,RhodeIsland ISSN0363-7913POSTMASTER:SendaddresschangestoRHODEISLANDMEDICALJOURNAL.106FrancisStreet,Providence,Rl02903 NationalAdvertising Bureau:StateMedicalJournalAdvertisingBureau.Inc,711 SouthBlvd.OakPark,Illinois60302 Phone708-383-8800 more There’s to X-Ray Portable Service than X-Rays. Yes, our main business is to provide you with fast, efficient, diagnostic X-Ray services, but we have much more to offer including a staff of . . . people who really care. • Diagnostic X-Ray Services • Same day reporting • EKG • 24 Hour Service • Holter-Monitoring* • Seven days a week • Ultrasound Services* *by appointment only We service the entire Greater Rhode Island area: • Nursing and Convalescent Homes • Shut-ins and Private Home Patients • Post Surgical Patients PORTABLE X-RAY SERVICE OF RHODE ISLAND Certified bythe R.l. Department of Health. Reimbursement provided by Medicare, R.l. Blue Shield and Medical Assistance. 100HighlandAvenue 120 DudleyStreet 154WatermanStreet 38 HamletAvenue Providence, R.l. Providence, R.l. Providence, R.l. Woonsocket, R.l. 331-3996 331-3996 273-0450 766-4224 EDITORIALS Emergency Medical Services in Rhode Island In the August and September 1 often find a startling lack of This volume of the Journal issuesoftheJournalyouwillfind information about prehospital should inform the medical com- articles which deal with emer- care among my medical col- munity about EMS. There is a gencymedicalservices(EMS)in leagues. Overthepastfewyears gulf to bridge before discussing Rhode Island. As the medical somuch hashappenedandcon- the present and future of EMS. consultant to the Division of tinues to transform ambulance Thephysiciancommunity must Emergency Medical Services at services, that an update is recognize the providers of res- theRhode Island Departmentof overdue. I am involved in sev- cue and prehospital care as ex- Health and the Director of the eral exciting developments in tenders of emergency care to Department of Emergency prehospital care such as the the community. In my associa- Medicine at Brown University prehospital administration of tion with Emergency Medical andRhodeIslandHospital,Ihave tissuetype-PlasminogenActiva- Technicians (EMTs) at all lev- tor(t-PA)study(PATS)with Drs bineeRnhiondveolIvseldainndemfoerrgtehencpyacsatre8 DMacvKiedndOa.llW,iltlhieamsevoalnvdinGge,orbguet ealnsd, Idhedaivceatfeodunpdartthneemrscainpapbrloe- years. largely unfunded system of viding prehospital care. As hos- Part of the practice of the trauma care reviewed by pitalandofficebasedhealthcare emergency physician involves MelindaKomiskewhichincludes providers, we must realize that theinterfacewithrescuegroups prehospital traumascoring and EMTs encounter obstacles to and the supervision of triage to the state's trauma cen- carewhichrequireheroicefforts prehospital care. The highest ter, and new regional planning on adailybasis. Theyservewell qualityofemergencycarewhich for disaster response now in- the population of Rhode Island can be provided to victims of volving the country's largest Di- by providing over 70,000 ambu- trauma and the seriously ill de- sasterMedicalAssistanceTeam lance runs each year. pends upon high quality (DMAT) coordinated by Dr High quality prehospital care prehospital care. With the be- Bruce Becker. The near future depends both upon the com- ginningsofacademicemergency (1994) will bring Rhode Island a mitment of the rescue workers medicine on the horizon, Dr Children's Hospital Emergency and physician involvement at Daniel Savitt, the future Brown Department and even higher several levels. Theprotocols by UniversityEmergencyMedicine expectation for pediatric whichEMTspracticearewritten Residency Director, and I hope prehospital care as outlined by bytheRhodeIslandDepartment to help mold high quality Drs Monica Kleinman and Wil- ofHealth EMS Medical Director, prehospitalcareinRhodeIsland. liam Lewander. DrRonaldShaw,withinputfrom August, 1991-Vol. 74 349 the Rhode Island Chapter of the New Testament, a masterpiece medicine. He too was martyred AmericanHeartAssociationand of eloquent poetry, is ascribed during the years when Dio- Rhode Island Chapter of the to him. Scholars have reviewed cletian ruled Rome. His name American College of Surgeons this bookoftheNewTestament; survives in the narrow trousers (ACS) Committee on Trauma, and while itcontainsgreaterde- originatinginVenice,nowcalled chaired byDrPeterTrafton.The scriptions of miraculous heal- pantaloons. daily radio dialogues between ing than do the other three There are other saints, not Rhode Island's emergency phy- Gospels (ie, Matthew, Mark and themselves physicians, whose sicians and Emergency Medical John) they nevertheless fail to names became eponymic of Technicians shape each indi- identify any part of the text certain diseases because they vidual patient's treatment. All which corroborates the alleged had been associated in some EMTtrainingrequires physician medical background of its au- manner with events of miracu- inputforcurriculumanddelivery thor. lous healing. Yet others were of lectures. Saints Cosmas and Damian, known as patrons of the medi- Althoughmanyphysiciansare fourth centuryphysicians,were cal profession. involved, more physician input martyred during the reign of The mode of martyrdom fre- quently determined the patro- is needed to improve our sys- Diocletian. The two brothers nymic domain of each saint. tem. would encourage physi- were born in the Middle East, I Thus, for example, Apollonia cians to become aware and in- studied medicine in Syria and received manyblows to herjaw volved in this dynamic clinical becausetheypracticed theirart during her final torment and arena. In an era of more power- withoutchargingafeetheywere laterbecamethepatronsaintof ful,effectiveandtime-dependent known widely as the Anargyroi dentistry. St. Erasmus had his therapies,suchasthrombolysis, (ie, without silver). The broth- intestines torn from him and even more will be demanded of ers would not reject their faith thusbecamethesainttobeven- emergencyencounters between and were accordinglycrucified. eratedwhenonewasseizedwith EMTs and our patients. Fortu- It is said that arrows were then abdominal colic. nately, we can look forward to shot at them but rebounded continued innovation and evo- upon the executioners. A cen- lution in prehospital care. turylatertheEmperorJustinian underwent a miraculous cure Robert H. Woolard, MD and dedicated a church in their honor, in Constantinople. The many murals, paintings and sculptures of the sainted physician-brothers depict them as Our Saintly Legacy youthful, attired in long robes and red hats and carrying the While many Western healers emblems of their trade - mor- and physicians have been ven- tars, medicine cases, and urine erated duringthepastthreemil- glasses. Five English churches lennia remarkably few have en- (in Kent, Sussex, Wiltshire and tered the ranks of formal saint- Herefordshire)arededicated to hood. Indeed, records indicate their memory and their relics that only 40 of the many thou- are found in Canterbury Cathe- sands achieving canonic saint- dral and numerous other hood have actually been physi- churches in Europe and the cians. Middle East. The two, insepa- The pre-eminent saintly phy- rable in history, also became sician is Luke the evangelist, the patron saints of numerous companion of St. Paul, and, ac- citiesincludingFlorence,Essen, cording to second century writ- Prague and Salamanca. ings, a physician ofGreekorigin St Pantaleon, said to be born probably born in Antioch. The in Venice about the year 305, is third of the four Gospels in the yet another patron saint of 350 Rhode Island Medical Journal The personal illnesses of the St. Fiachra's disease: hemor- the disease.) saintsbecameyetanotherpoint rhoids Sanfilippo's syndrome: of reference for those seeking St. Gotthards disease: hook- mucopolysaccharidosis(Named their divine intervention. Thus, worm (When the tunnels forthe not after the saint but after the SS. John, Lupus, Thomas and transalpine railroads were dug, physician who first described Avertin were said to have epi- near St. Gotthard s Pass, nu- this inborn error of metabolism lepsyandtheyhavethusbecome merous workers developed in 1963.) the patron saints of all move- ankylostomiasis. Modern epi- The historic records of most ment disorders. The name ofSt. demiologists ascribe the ende- of these canonized men and Avertin, a 12th century hermit micity to the widespread fecal women are incomplete. But it is from Tours, persists today as contamination of the tunnel unlikely that any of these pious the secular trade-name of the floors and the subsequent pen- soulscouldhaveenvisionedthat basal anesthetic, tribromo- etration of the larval worm their names would have been ethanol.St. Giles,an8thcentury through the bare feet of the immortalized principally byvir- Athenian hermit was said to be workers.) tue of an association with some lame and thus was later chosen St.LouisEncephalitis:(Named drearyhumanailment.Someone as patron of the crippled. His after the city, not the saint.) observed that the ultimate test benevolent intervention was re- St. Martin’s evil: delirium offameistohaveacrazyperson peatedly recorded and over 160 tremens. (Probably because St imagine that he is you. To this, Englishchurchesbearhisname. Martin’sfeastdaycoincideswith we may add the perpetuation of There are a moderate num- the pre-Christian feast of some names solely by their at- berofeponyms in medicinecar- Bacchus.) tachment to a dreaded disease. ryingthenames ofsaints.These St. Main's disease: scabies. include: MD (The herb, teasel orscabiosa, is Stanley M. Aronson, said to cure the disorder; in Eu- St. Agatha's disease: mastitis St. Anthony’s fire: ergotism rope, the plant is called iherbe St. Dymphna’s disorder: psy- de St. Main.) choses St. Roche's plague: (St. Roche was a profoundly pious French- Dr Barbara A. DeBuono, man, born during the end of the Director of Health 13thcentury.Hedevoted hislife tothecareofthe ill, particularly ThestateofRhodeIslandand duringthepestilenceofthe 13th ProvidencePlantationshasbeen century including the great bu- widely known for the effective- bonic plaguebeginning 1347.He ness and professionalism of its issaidtohavedevelopedabubo Department of Health. The re- on his left thigh and numerous cent selection of Barbara A. paintings depict this ulcer.) DeBuono, MD, MPH as the new St. Valentine's disease: epi- DirectorofHealthpreservesand lepsy. continues this tradition of ex- St. Vitus' dance: a form of cellence. rheumatic chorea. (Vitus, a 4th Dr DeBuonowas borninNew century Sicilian, would not re- York and received both her un- nounce his Christian faith and dergraduate and medical edu- was ultimately beheaded. Dur- cation at the University of ing the dancing mania epidem- Rochester in New York. ics eleven centuries later, those Shewasawarded herM D de- whoundertookpilgrimagetothe greein 1980.DrDeBuonounder- shrine of St. Vitus in southern went residency training in in- Germany were said to be cured ternal medicineat New England oftheir involuntarymovements Deaconess Hospital in Boston and, through transference, the and subsequently completed name St. Vitus affixed itself to fellowshipsininfectiousdisease August, 1991-Vol. 74 351 at the Brown University affili- theteachingofmedicalstudents administrative appointment as- ated hospital system. In 1984, at Brown University and has sured now that the great tradi- she was awarded a Master's de- published numerous scientific tion of preserving and enhanc- gree in Public Health at the articles in medical journals in- ing the public health - borne so HarvardSchoolofPublic Health cluding many in the Rhode Is- well by H. Denman Scott - will andwasappointedtothestaffof landMedicalJournal. continue in the capable and en- the RhodeIsland Departmentof Since Dr DeBuono has been ergetic hands of Barbara Health in the summer of 1986 as laboring in our midst for much DeBuono. Medical Epidemiologist. Subse- of the past decade, it would be quently she was appointed as gratuitoustowelcomeheratthis Stanley M. Aronson, MD Medical Director, Office of Dis- time to Rhode Island. We do, Kimberly A. Poulton ease Control within the Depart- however, happily embrace this ment of Health. MuchofDrDeBuono'sprofes- sional activities, beyond herad- ministrativeresponsibilities,has MAGNETIC RESONANCE IMAGING been concentrated upon the growingpublic health problems ofAIDS. Dr DeBuono is active in RI-MASS MRI, P.C. 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