Multiple-System Trauma - Hennepin County Medical Center

t w e n t y - y e a r a n n i v e r s a r y c o m m e m o r a t i v e e d i t i o n

Dear Readers:
Medical manufacturers and hospital administrators are fond of describing
new medical devices and facilities as “state of the art.” The term has always
struck me. In the time it takes to ship and install a new medical device,
doesn’t it usually lose “state-of-the-art” status? How long does an up-todate
emergency department or intensive care unit remain “state of the art?”
Between the execution of a clinical research trial and the actual
implementation of its findings, will the findings become obsolete?
Yet, that’s one of the primary joys of medicine—the way the field constantly
evolves. It was only fifty years ago that a sharp increase in multiple-system
trauma (an increase traced to motor vehicles) led to the development of
what we now call emergency medical services (EMS). It was almost thirty
years ago that emergency care as a certified RN specialty came into
existence. And it was just twenty years ago that Hennepin County Medical
Center became the first in the state to become an American College of
Surgeons (ACS) Level 1 trauma center.
To commemorate the twenty-year anniversary of Hennepin’s trauma
designation, in this issue we present several recent multiple-system trauma
cases that clearly benefited from the “state of the art.” Without the recent
evolutions in trauma care and resuscitation, the patients presented here
would likely have died early in their clinical course. In the sections called
EMS Perspectives and Trauma Care Profile, you’ll hear from long-time
EMS, MD, and RN providers about where trauma care has come in the last
50 years and where it is going in the next 50 years.
The theme for our fall issue will be bedside ethics. If you have an
interesting case study you’d like to contribute, see the author’s guidelines
on the Approaches in Critical Care Web site at www.hcmc.org/approaches.
We’d love to hear from you.
Sincerely,
Michelle H. Biros, MD, MS
Approaches in Critical Care editor-in-chief
Department of Emergency Medicine
Hennepin County Medical Center
®
Every Life Matters

Contents Volume 2 | Approaches in Critical Care June 2009
Approaches in Critical Care
Editor-in-Chief
Michelle Biros, MD, MS
Managing Editor
Linda Zespy
EMS Perspectives Editor
Robert Ball, EMT-P
Graphic Designer
Karen Olson
Marketing Director
Ted Blank
Patient Care Director,
Critical Care and
Emergency Services
Kendall Hicks, RN
Patient Care Director,
Behavioral and
Rehabilitative Services
Joanne Hall, RN
Printer
Sexton Printing
Photographers
Raoul Benavides
Lisa Fleming
Karen Olson
Clinical Reviewer
Arthur Ney, MD, FACS
Events Calendar Editor
Susan Altmann
Case Reports
2 A 29 year-old male surviving an extreme free-fall
Chad E. Roline, MD
5 Cardiac arrest after blunt trauma: Hemorrhagic shock from bleeding
from a pelvic fracture
Mohamed A. Ibrahim, MD
8 Trauma during pregnancy
Mike Galle, MD
10 Trauma Care Profile
Arthur Ney, MD, FACS, Hillie Prose, RN, and Ernest Ruiz, MD reflect on
the history and future of trauma care
12 EMS Perspectives
Fifty years of trauma care
15 Photo Essay
The evolution of emergency care
17 Calendar of Events
19 News Notes
To submit an article
Contact managing editor Linda Zespy at approaches@hcmed.org. The editors reserve the right to
reject editorial or scientific materials for publication in Approaches in Critical Care. The views
expressed in this journal do not necessarily represent those of Hennepin County Medical Center, its
editors, or its staff members.
Copyright
Copyright 2009, Hennepin County Medical Center. Approaches in Critical Care is published twice per
year by Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
Subscriptions
To subscribe, send an email to approaches@hcmed.org with your name and full mailing address.
Approaches in Critical Care | Commemorative Issue | June 2009 | 1

Case Reports
Treating Multiple-System Trauma:
Three Case Reports
Managing patients with multiple-system
trauma is a complex undertaking. A
multidisciplinary approach is essential
for good patient outcomes. A skillful
resuscitation requires a sound understanding
of trauma and resuscitation
principles and good technical skills.
The clinicians involved must engage in
reasoned and rapid decision-making as
well as excellent communication. The
stakes are high; most patients with
multiple-system trauma are young and
otherwise healthy and, if they survive
their injury, have the potential to lead
full and productive lives.
The following case reports involve a
diverse set of patients with multiplesystem
trauma and describe the care
decisions made in each instance.
A 29 year-old male surviving an
extreme free-fall
by Chad E. Roline, MD
Department of Emergency Medicine
Hennepin County Medical Center
Abstract
Although there is a general correlation
between the height of a fall and the
likelihood of death, a number of complex
factors can make survival possible
in free-fall impact events from extreme
heights. This case involves a 29 yearold
male who survived a 17-story fall
without long-term disability.
Case report
Following a night of heavy alcohol consumption,
a 29 year-old male returned
with his friends to a downtown
Minneapolis hotel. He then reportedly
began running down a hallway and collided
with a double-paned, floor-to-ceiling
window at the end of the corridor.
He crashed through the glass and fell,
feet first, 17 stories. Initially, he landed
on an asphalt-covered metal awning
one floor above the ground. The structure
collapsed to the street upon
impact. He was initially unconscious at
the scene and required fire department
extrication from the awning.
Upon arrival at the emergency department,
the patient’s vital signs were:
blood pressure 118/68, pulse 94, respirations
21, and oxygen saturation
100% on 10 liters face mask. He was
awake and extremely combative, complaining
of severe pain in his lower
extremities. In order to facilitate his
evaluation, and because of the serious
mechanism of injury and worry about
life-threatening injuries, he was intubated
with rapid-sequence intubation.
Despite successful endotracheal tube
placement, the patient was noted to
have intermittently poor oxygen saturation
observed on pulse oximetry. His
breath sounds were decreased bilaterally
and a large amount of crepitus was
appreciated throughout the neck and
anterior chest wall. His abdomen was
obese and soft. His pelvis was stable
to anterior compression and he had no
obvious step-off along the length of his
spine. His right lower leg was noted to
have an open tibia-fibula fracture.
A portable chest radiograph was significant
for bilateral pneumothoraces,
which were managed with chest tubes.
Computed tomography (CT) scans of
the head, cervical spine, chest,
abdomen, and pelvis demonstrated
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Case Reports
The trauma team at Hennepin treats a patient in the stabilization room of the emergency department.
bilateral pulmonary contusions and a large amount
of air in the mediastinum and anterior chest wall
extending into the neck. No intracranial or intraabdominal
injuries were found. His blood alcohol
level was measured at 0.247 g/dL.
Due to the tenuous nature of the patient’s oxygen
saturations, a bronchoscopy was performed
by the emergency physician. This revealed
blood several centimeters proximal to the carina.
Because of concern that this could indicate a
tracheal tear, cardiothoracic surgery was consulted.
A repeat bronchoscopy was performed in
the operating room with no obvious tracheal
defect appreciated with blood again identified
above the carina. He was cleared by cardiovascular
surgery and underwent intramedullary nail
fixation of his fractures. A third bronchoscopy
was performed 72 hours after admission and
again showed no tracheal tears or lacerations.
Following this procedure, the patient was successfully
extubated and his chest tubes were
removed. He quickly improved and was transferred
out of the surgical intensive care unit. The
patient continued to do well on the floor and was
discharged home on hospital day seven. The
patient had an uneventful post-hospital course
and recovered fully from his orthopedic injury.
Discussion
Falls are a common cause of trauma presenting
to the emergency department and second only
to motor vehicle collisions in causing traumarelated
deaths in the U.S.
Falls from extreme heights are a small subset of
these events. These falls can be due to occupation-related
accidents, such as mishaps during
construction, acts of violence when a person is
pushed, or self-inflicted events where a patient
leaps from a high vantage point as an act of
attempted suicide or psychotic behavior. In
1996, Risser estimated that, using 12 feet as an
average height of one story of a building, the
height lethal to 50% and 90% of the population
for elevated falls was four and seven stories,
respectively.
Over the years, several investigators have
attempted to identify factors that contribute to
the survival of that rare individual who withstands
a free-fall from heights that would be
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Case Reports
expected to be fatal. In 1965, Snyder performed
a review of 137 cases of people surviving such
extreme falls. His report included personal
investigation of each site and analysis of the
details surrounding each incident. Snyder concluded
that most survivors were young, overall
healthy males who fell in a feet-first orientation.
He also concluded that alcohol intoxication may
reduce trauma in some falls by creating a state
of “muscular relaxation.” However, it may be that
this study simply confirmed that young, intoxicated
males are more likely to suffer such a fall in
the first place, due to increased risk-taking
behavior in this population.
“Being young and healthy clearly
helped his survival, while the influence
of his intoxication is more a matter
of debate.”
Most important to consider in free-fall survival
are basic physics principles, including:
Impact velocity. Impact velocity is
intrinsically related to the distance of the fall.
As an example of the effect of distance, one
study estimated that a person falling from 32
stories would reach a terminal velocity of
approximately 120 miles per hour.
Impact energy. Impact energy involves the
kinetic energy accumulated by the body in
free-fall, which on impact is converted into
mechanical energy and heat. The
mechanical energy that is not absorbed by
the impact surface is transmitted into the
body resulting in injury.
Impact force. Impact force is determined by
the mass of the patient and the amount of
deceleration on impact. The degree of deceleration
is influenced by the substance (e.g.
concrete, sand, etc.) encountered.
Free-falls are associated with a unique pattern
of injuries. In several studies of patients who fell
from a significant height, the lower limbs were
the most frequent anatomical location of injury
cited, with the most common lower-limb injury
being calcaneal fractures. The same axial loading
forces causing these fractures are transmitted
to the spine. Most vulnerable is the junction
of the thoracic and lumbar spines due to the
more mobile nature of the lumbar spine relative
to the thoracic spine.
The predominant lethal injuries following free-fall
events are massive head injuries, liver injuries,
and, less commonly, thoracic injuries.
Devastating brain and head injuries are a
frequent cause of immediate death in these
patients. Liver injuries are most often large
lacerations with the right lobe most commonly
involved. Thoracic injuries can include
pulmonary injuries, a hemothorax, a pneumothorax,
and thoracic aorta injuries. It is theorized
that thoracic injuries are more likely when the
patient lands on the buttocks as the impact
forces cannot be dissipated by flexion of the
hips and knees, resulting in a much larger force
being transmitted to the trunk.
The patient above illustrates several important
concepts in free-fall injuries. He was young,
healthy, and intoxicated. Being young and
healthy clearly helped his survival, while the
influence of his intoxication is more a matter of
debate. In addition, he fell feet first and landed
on an object that collapsed, allowing the time of
his deceleration to the concrete to be significantly
prolonged. The extended duration of his
deceleration decreased his impact force to a
survivable level.
In conclusion, free-fall trauma should be recognized
as a distinct form of blunt trauma that
presents with a constellation of injuries that
should be anticipated, with injury severity
dependent on more factors than simply the
height of the fall. While in general, greater
height predicts a higher mortality, this case illustrates
how in rare circumstances such falls can
be survived.
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Case Reports
Cardiac arrest after blunt trauma:
Hemorrhagic shock from bleeding from
a pelvic fracture
by Mohamed A. Ibrahim, MD
Department of Surgery
Hennepin County Medical Center
Abstract
The most common cause of shock in the trauma
patient is loss of circulating blood volume from
hemorrhage. While pre-hospital cardiac arrest
due to blunt trauma is rarely survivable, the
patients with the best outcome from traumatic
arrest generally have treatable injuries, receive
early endotracheal intubation, and undergo
prompt transport to a trauma center for definitive
management. This case report presents the successful
outcome of a patient with traumatic cardiac
arrest from hemorrhagic shock and illustrates
the importance of well-coordinated prehospital
care and aggressive resuscitation.
Case report
A 59 year-old male road construction worker
with no major medical problems was run over
and dragged by a heavy gravel truck at a road
construction site. At the scene, he was alert and
appropriate with a Glasgow Coma Scale score
of 15 with stable vital signs. He complained of
severe left hip pain and less severe right leg
pain. Obvious injuries noted at the scene
included large contusions and abrasions to the
right side of his abdomen and chest. He also
had a degloving injury to his right leg. He was
transported by ground ambulance to the
nearest hospital.
In the emergency department, initial plain radiographs
demonstrated unstable comminuted
pelvic ring fractures (see Figure One on the next
page) and a right lower-extremity fracture. This
was open with extensive soft-tissue degloving.
He was hypotensive and hypothermic.
Resuscitation with fluids and blood products,
along with rewarming maneuvers, were ongoing.
His hypotension responded to fluid resuscitation.
Given the degree of injuries and initial hemodynamic
instability, a decision was made very early
in the course of the initial treatment to transfer
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Case Reports
the patient by air to a regional Level 1 trauma
center for definitive management. For airway
protection, stabilization, and control while in air
transport, endotracheal intubation was performed.
While preparing for air transport, the
patient suffered rapid clinical deterioration and
loss of vital signs with pulseless electrical activity
(PEA) cardiac arrest.
Figure Two. This coronal slice CT scan shows wide diastasis of the left
sacroiliac joint.
He was emergently taken to the angiography
suite where a left transected superior gluteal
artery was found. The left gluteal artery and
internal iliac were coiled. This stabilized his
blood pressure in the 120-130 systolic range.
Figure One. This pelvic x-ray shows a comminuted ring fracture and large
sacroiliac joint separation.
Aggressive cardiopulmonary resuscitation was
undertaken according to the advanced cardiac
life support (ACLS) guidelines. After approximately
30 minutes of aggressive ACLS, the
patient regained a perfusing sinus rhythm. Along
with volume resuscitation, including large
amounts of blood products, the pelvic ring was
stabilized using the military anti-shock trousers
(MAST) garment. Once stabilized with ongoing
resuscitation, he was transferred by air for definitive
care. At this point, he had received eight
units of packed red blood cells, four units of
plasma, and five liters of crystalloids.
On arrival to the Level 1 trauma center, his initial
blood pressure was 70/40 with a heart rate of
160. Additional resuscitation was undertaken,
including administration of additional blood products
and placement of a large-bore, centralaccess
catheter (9 French trauma catheter).
Computed tomography (CT) scans were
obtained. Along with the pelvic fracture (see
Figure Two on this page), the CT scan showed
free fluid in the abdomen without an identified
solid organ injury. This prompted an exploratory
laparotomy to rule out mesenteric or hollow
visceral injury. The blood was from his pelvic
injury and no additional injuries were found. His
right extremity injuries were treated with debridement,
temporary closure, and splinting. He was
transferred to the surgical intensive care unit for
ongoing resuscitation and management.
By hospital day two, he was alert and appropriate.
He met ventilatory weaning parameters and
was extubated. On hospital day four, he underwent
repair of his complex pelvic fractures. His
other extremity injuries were managed with multiple
operative interventions as well. He was discharged
to an acute inpatient rehabilitation unit
on hospital day 25.
Discussion
The most common cause of shock in a trauma
patient is the loss of circulating blood volume
from ongoing hemorrhage. For that reason,
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Case Reports
shock in a trauma patient should be presumed
to be due to hemorrhage until proven otherwise.
Cardiopulmonary collapse following trauma has
several possible causes, including:
Hypoxia from airway obstruction,
pneumothorax, or tracheobronchial injury;
Injury to a vital structure, such as the heart
and great vessels;
Severe head or spinal cord injury with
secondary cardiopulmonary arrest;
Severely restricted cardiac output from
tension pneumothorax or pericardial
tamponade; or
Extreme blood loss leading to hypovolemic
shock, as in this patient’s case.
Hemorrhagic shock has been classified according
to the magnitude of blood loss. It is worth
noting that signs of shock, such as hypotension,
tachycardia, and confusion, may not be evident
until more than 30% of blood volume has been
lost (Class III shock). Treatment should be instituted
as soon as shock is suspected or identified,
typically before the source of hemorrhage
is located. Occasionally, especially in young,
healthy patients, blood pressure initially may be
maintained until a precipitous cardiovascular
collapse ensues, as occurred in this case.
Aggressive volume resuscitation is indicated for
patients with blunt trauma and hypovolemic
shock. One of the most common terminal
cardiac dysrhythmias in trauma patients is
pulseless electrical activity (PEA). Successful
resuscitation from cardiac arrest in this
situation often depends on restoration of
adequate circulating blood volume.
This patient’s case demonstrates the typical
presentation of patients with an ongoing source
of hemorrhage who initially respond well to volume
resuscitation efforts but then deteriorate
hemodynamically. These patients usually require
operative or invasive interventions to control
hemorrhage. In this case, the cause of ongoing
blood loss was superior gluteal artery transsection
from his pelvic fracture.
The morbidity and mortality associated with
pelvic fractures was appreciated centuries ago.
Prior to the 1900s, the mortality rate for pelvic
fractures was well over 80%. Various modalities
have been developed over the years to treat
pelvic hemorrhage, including the MAST garment,
external fixators, packing, and angiographic
embolizations. Today, with the multidisciplinary
approach to the treatment of pelvic
fractures—including pre-hospital personnel,
emergency physicians, orthopedic specialists,
trauma surgeons, and interventional radiologists—mortality
is rare unless associated with
large-vessel laceration.
“Prior to the 1990s, the mortality
rate for pelvic fractures was
well over 80%.”
As shown in this case, better outcomes are
seen when timely interventions are instituted,
even in cases involving large pelvic-vessel
lacerations. Clearly, this patient’s outcome
was greatly improved by the rapidity with which
aggressive cardiopulmonary resuscitation and
ongoing support was undertaken. Transfer for
definitive therapy for his ongoing hemorrhage
was pursued well in advance and coordinated
with the receiving facility, where arrangements
were in place and ready upon the
patient’s arrival.
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Case Reports
⊳ To left, paramedics at the scene
of the 35W bridge collapse in
August of 2008.
Below, Hennepin paramedics in
their inaugural ride over the new
35W bridge.
Trauma during pregnancy
by Mike Galle, MD
Department of Surgery
Hennepin County Medical Center
Abstract
Trauma care is complicated in pregnant patients
because of the physiologic and anatomic
changes that occur during pregnancy. Vital signs
may be deceiving and treatment decisions must
consider the viability of the fetus as well as the
traumatized pregnant patient. In the face of fetal
distress, prompt obstetrical care and emergency
delivery may be necessary. This case illustrates
that, in the traumatized pregnant patient, the
best way to ultimately care for the fetus is to stabilize
the mother.
Case report
A 37 year-old female was discovered lying in
mud at the scene of the 35W bridge collapse in
Minneapolis, MN in the summer of 2008. The
circumstances of her accident were not known.
Pre-hospital personnel reported that she was
extremely agitated, disoriented, and unable to
follow commands.
On presentation to the emergency department,
she was found to be pregnant near term with no
major external signs of musculoskeletal trauma.
Her vital signs were stable, except for mild sinus
tachycardia and hypertension. She was maintaining
her airway and breathing on her own but
was clearly confused and screaming unintelligibly.
Breath sounds were clear bilaterally. She had
palpable distal pulses in all extremities. All
extremities moved spontaneously but, due to
her confused state, she was given a Glasgow
Coma Scale score of 12. Pupils were equal and
reactive to light. A Focused Assessment with
Sonography in Trauma (FAST) exam was performed
which showed no intra-abdominal or
pericardial fluid collections. The fetus was
visualized and an initial fetal heart rate of 150
was noted.
Because of her altered mental status and
extreme agitation despite intravenous sedation,
the decision was made to intubate the patient to
facilitate subsequent evaluation and care. After
two attempts, she was successfully endotracheally
intubated. A second fetal ultrasound was
performed, which showed a decreased fetal
heart rate. An OB/GYN specialist was present
throughout the case and, when the fetal heart
rate declined, the OB/GYN made the decision to
take the patient to the operating room for emergent
cesarean section. The diagnoses at this
point, based on her clinical assessment, included
blunt force trauma with likely traumatic brain
injury and intrauterine fetal distress.
The patient underwent immediate, uneventful
cesarean section at 34 weeks gestation. There
was no operative evidence of intra-abdominal
injury. On entering the uterus, there was clinical
evidence of placental abruption but the fetus
was quickly and uneventfully extracted. A
healthy, 2.8-kilogram baby was delivered and
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Case Reports
was discharged from the hospital soon thereafter
without incident.
Following her cesarean section, the patient
underwent CT scanning of her head, which
revealed a diffuse, moderate subarachnoid
hemorrhage. (See Figure One on this page.)
A ventriculostomy catheter was placed but the
patient had no prolonged episodes of intracranial
hypertension. She continued to have altered
mental status and remained intubated for some
time following admission. She required tracheostomy
tube placement as well as gastric
feeding tube placement on hospital day 12. Her
mental status slowly improved and the patient
was discharged to an inpatient rehabilitation
facility on hospital day 22.
The patient was last seen in neurosurgery clinic
in January 2008 and was doing well. Her tracheostomy
tube had been removed as well as
her G-tube. She complained of intermittent
headaches and memory lapses but was expected
to make a full neurologic recovery. Her baby
was doing well.
Discussion
Moore in 2004 found that the leading cause of
maternal mortality in the pregnant patient is
obstetric complications; the second most common
cause of mortality is trauma, which is estimated
to occur in up to 7% of all pregnancies.
The care of the pregnant patient in trauma follows
the same parameters as generalized trauma
care. The first priority is intervention aimed
at stabilization of the mother. In the pregnant
patient, there is an increase in total blood volume.
Tachycardia and hypotension may not be
evident until 30% of the blood volume is lost.
Thus, the vital signs may not be helpful in determining
hemodynamic stability. The treating
physician should therefore have a low threshold
for administering volume in the traumatized
pregnant patient, even in the absence of altered
vital signs. Frequently, the venous return to the
heart is compromised due to caval compression
by the uterus. This can be alleviated by tilting
the patient to the left or placing her in a left
lateral decubitus position or direct uterine retraction
to the left.
The examination of the pregnant woman in trauma
should include a pelvic examination to look
for vaginal blood or evidence of membrane rupture.
The most common fetal injury in trauma is
placental abruption, which can quickly lead to
fetal demise. A deceleration in fetal heart tones
is commonly associated. In the face of any hard
signs of fetal compromise or uterine pathology,
an immediate caesarean section may be the
only way to salvage the pregnancy.
This patient was presumed to have a head
injury based on her clinical evaluation that was
not immediately life-threatening. The fetus
demonstrated decreased heart tones, however,
which is an ominous sign. The best course of
action in this situation was immediate delivery of
the fetus.
Agalar F, et al. Factors affecting mortality in urban vertical
free falls: Evaluation of 180 cases. International Surgery.
1999: 271-74.
American Heart Association. Part 10.7: Cardiac arrest
associated with trauma. Circulation. Nov 2005: 112.
Beery P, Ellison C. Surgery in the pregnant patient. 17th
ed. Sabiston Textbook of Surgery. Saunders. 2004.
Gupta SM, et al. Blunt force lesions related to the height
of a fall. American Journal of Forensic Medicine &
Pathology. 1982: 35-43.
Moore, et al. Trauma. 5th Ed. McGraw Hill. 2004.
⊳ Figure One. This
CT scan shows subarachnoid
blood and a
ventriculostomy catheter.
Suggested Readings/Bibliographies for Case Reports
Risser D, et al. Risk of dying after a free fall from height.
Forensic Sci Int. 1996;78: 187.
Snyder RG. Human survivability of extreme impacts in
free-fall. FAA Office of Aviation Medicine Report No. AM
63-15. Aug. 1963.
Tan S, Porter K. Free fall trauma. Trauma. 2006: 157-167.
Warner KG, Demling RH. The pathophysiology of free-fall
injury. Annals of Emergency Medicine. 1986: 1088-93.
Approaches in Critical Care | Commemorative Issue | June 2009 | 9

Trauma Care Profile
Q and A withQ and A with
Arthur Ney, MD, FACS, Hillie Prose, RN,
and Ernest Ruiz, MD
Arthur Ney, MD, FACS
Hillie Prose, RN
Ernest Ruiz, MD
During their careers at Hennepin
County Medical Center, the three clinicians
interviewed for this issue’s
Trauma Care Profile witnessed the rise
of emergency medicine as a specialty
and actively nurtured its growth.
Arthur Ney, MD, FACS (trauma
surgeon and chief of trauma), Hillie
Prose, RN (retired director of emergency
nursing), and Ernest Ruiz, MD
(retired chief of emergency medicine)
shared their thoughts about how trauma
and emergency care has evolved
and where the specialties might go in
the twenty-first century.
What was the emergency
department like when you started?
Hillie Prose: In 1950, we were the
emergency hospital for the city of
Minneapolis but emergency work—the
critical care—was done on the stations.
The ambulance didn’t even stop in the
ED. The ED was mostly an admitting
area with minor injuries cared for there.
Nurses ran the place and doctors,
interns, and surgery residents rotated
in. We didn’t even have an IV set up
until 1968. Then in 1971, Dr. Ruiz was
assigned to be chief of emergency
medicine. There were things we needed
in the ED but we didn’t have the
budget, so in his garage, he built a lot
of inventions to improve patient care.
Ernest Ruiz: In those days, there were
very few devices being developed that
were particularly useful in the emergency
department, so if you came up
with an idea, you had to convince a
corporation to take a look at it or build
it yourself. As a result, I ended up
trying to make a lot of things myself.
Examples? I used a small inner tube to
make a cushion to put under a
patient’s head. It was connected to a
valve that was connected to compressed
air and operated with a foot
pedal. So when you went to intubate a
patient, you could adjust the head level
until you had the best view possible.
Now, there are devices that do the
same thing. For a few years, we used
a device I devised for auto-transfusion
of blood in trauma. I used tubing that
was used at the time in cardiac surgery
and blood banking. It was a little complicated
but finally commercial varieties
of autotransfusers came out that were
much easier to use.
In the last 50 years what was
the most important advance in
trauma care?
Arthur Ney: Probably the biggest
change is the improved accuracy of
diagnostic testing. This has resulted in
a dramatic shift in the management of
injured patients, with nonoperative care
now being the standard for many
injuries. Exploratory surgery to identify
and control hemorrhage was commonplace
50 years ago. Many complex
injuries are now managed with minimally
invasive techniques or non-operatively
with physiologic resuscitation.
When we first started using CT scans
in the 1970s, a single slice would take
about five minutes. With modern scanners,
we can frequently evaluate the
head, chest, and abdomen in not much
longer than that. This has resulted in
significant improvement in safety in
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Trauma Care Profile
obtaining these tests and allowed the evolution
of nonoperative management for many different
types of injuries.
Ernest Ruiz: There are many things on the list
that are right up there, like the availability of
blood and management of blood administration.
That was a big advancement. The development
of thoracic/cardiac surgery was a big advance.
And we can’t forget the good pre-hospital care
that came along in the early 1960s, when there
was recognition of how to immobilize a patient,
which led to a decrease in the number of
patients with neck and spinal injuries. Another
very important advance was the advent of CT
and MRI scanning. In the end, the advent of
emergency medicine itself, as a specialty, has
been a tremendous thing. It used to be that EDs
were staffed with doctors and nurses who had
not been trained in trauma or emergency critical
care. Now such training is available. So the
advent of emergency medicine tremendously
affected the quality of care.
Hillie Prose: (In the 1970s), the emergency
medicine program started, and Hennepin’s program
was the second in the nation. We also
became the first in the nation for training in
emergency room nursing. In those years, there
was tremendous change in how we took care of
critical patients.
“It may be possible to begin the
imaging process in the pre-hospital
phase, using ultrasound and other
heretofore-unknown methods of
imaging so that proper treatment can
begin then and there.”
What will trauma care look like in 50 years?
Arthur Ney: One of the dramatic changes of the
last 50 years has been in critical care and nutrition
management and I think it’s an area poised
for future innovation. There will likely be significant
improvements in restoring the altered physiology
that occurs from prolonged shock. Right
now, the interventions we use often work shortterm
but occasionally lead to multi-system organ
failure or a systemic inflammatory response
down the line. I suspect we will have genetic
typing that will give us information to be able to
manipulate cytokines and the inflammatory
response. That could prevent many of the late
deaths following trauma.
Ernest Ruiz: I think the further refinement of
imagery is going to be a big thing in the future. It
may be possible to begin the imaging process in
the pre-hospital phase, using ultrasound and
other heretofore-unknown methods of imaging
so that proper treatment can begin then and
there. Minimally invasive surgery is going to
expand and that will make the management of
certain kinds of cases safer and faster for the
patient. Neurosurgery has made great strides
over the years with advanced imagery and the
ability to operate through vascular channels
rather than by opening the cranium. Perhaps
there will be new ways of protecting the brain
from further bleeding while that kind of treatment
is getting underway. Then hopefully someday
someone will figure out how to let the nerves
actually reconnect, both in the brain and with
spinal cord injuries.
Arthur Ney: Looking back reinforces how important
it is to be willing to learn new things and
accept change as an important part of being a
good practitioner at all levels. The key is to
work these changes into standard practice and
develop a system of education and mentoring
that minimizes the learning curve and makes
new knowledge available to everyone.
Arthur Ney, MD, FACS, has been a trauma surgeon at
Hennepin since 1985 and added the role of chief of trauma
in 1987.
Hillie Prose, RN, arrived in the emergency department in
1948 and became department director in the 1960s. As the
specialty evolved and physicians became more integrally
involved, she became director of emergency nursing and
filled that role until she retired in 1977.
Ernest Ruiz, MD, became the chief of emergency medicine
in 1971 and held that title until he retired in 1985.
Approaches in Critical Care | Commemorative Issue | June 2009 | 11

EMS Perspectives
_______________
The emergency
room of Hennepin
County Medical
Center in the 1960s.
____________________
EMS Perspectives: Fifty Years of Trauma Care
by Robert Ball, EMT-P
Hennepin Emergency Medical Services
Hennepin County Medical Center
In the day-to-day challenges of
emergency medical services (EMS)
care, it can be easy to forget how
much trauma care has changed even
within the 23 years I have worked as a
paramedic. In fact, it was just 20 years
ago that Hennepin County Medical
Center became the first hospital in
Minnesota to achieve the American
College of Surgeons (ACS) Level 1
trauma center verification.
The evolution in trauma care that led to
the trauma designation system, and
the evolving role of EMS professionals
in trauma care, is a fascinating story of
persistent innovation, questioning, and
willingness to try new ideas.
EMS in the 1960s
The original reason for the development
of modern EMS in the 1960s was
the skyrocketing increase in death and
disability due to motor vehicle trauma.
In a famous 1966 National Academy of
Sciences paper entitled, “Accidental
Death and Disability: The Neglected
Disease of Modern Society" (many
simply call it the “EMS White Paper”),
authors pointed out that a soldier shot
in the jungles of Vietnam had a better
chance of survival than a motorist in
the U.S. The original emergency medical
technician (EMT) curriculum was
steeped heavily in trauma; the first
EMT textbook was published by the
American Academy of Orthopedic
Surgeons.
At the same time, researchers were
trying to find ways to reduce death
from sudden cardiac arrest and heart
attacks. In 1966, J. Frank Pantridge,
MD, of Belfast, Northern Ireland
equipped an ambulance with a portable
electrocardiograph and medication,
and began responding to cardiac calls.
He was able to demonstrate that an
ambulance staffed with a physician and
nurse could improve care for patients
with acute cardiac events.
12 | Approaches in Critical Care | Commemorative Issue | June 2009

EMS Perspectives
In the U.S., physician-staffed ambulances were
attempted by some hospitals, most notably St.
Vincent’s Hospital in New York, but the prohibitive
cost of such operations caused researchers
to examine whether non-physicians could perform
many of the same functions. Eugene
Nagel, MD, established the first experimental
paramedic program with the Miami Fire
Department in 1967. Because commercial cardiac
equipment was not yet available, Nagel
helped push the development of telemetry
equipment to share patient information with a
physician at a hospital.
New decisions: Care vs. quick transports
The late 1960s and early 1970s were a period
where the EMTs who staffed most ambulance
services often deepened their education in order
to become paramedics. This increase in training,
and a continuing increase in available tools and
technology, led to loftier goals in terms of providing
advanced life support for trauma patients as
well as cardiac or medical patients.
During this time period, it was not uncommon for
paramedics arriving at the scene of a serious
trauma to secure the patient to a backboard,
intubate, use cardiac monitoring, place multiple,
large-bore intravenous (IV) lines, and apply and
inflate anti-shock trousers—all before the patient
was transported to the hospital.
Unfortunately, this did not improve survival rates
in trauma victims and often had the opposite
result. Because of this, many tiered EMS
systems—systems using both basic life support
(BLS) and advanced life support (ALS)
ambulances—changed their dispatch priority.
Trauma cases, no matter how serious, were
reverted to basic life support calls. Unlike paramedics
of the era, EMTs would not only quickly
identify the serious trauma patient but also
recognize that there was little they could do for
the patient aside from transport to the closest
appropriate hospital.
While the use of such terms as “scoop and run”
was antithetical to the concept of paramedicine,
paramedics realized the need for a better understanding
of the priorities in trauma and a better
process of weighing the potential benefit of field
management of a patient vs. the potential risks
of delaying transport. Patient assessment priorities
changed. Instead of merely examining the
ABCs of airway, breathing and circulation, paramedics
were learning to perform a fast initial
exam that included level of consciousness and
obvious hemorrhage. For the severely injured,
only problems in those areas were managed
immediately. With rare exceptions, treatments
such as IV access and cardiac monitoring were
no longer to be performed at the scene. To
avoid unnecessary delays at the scene, even
full “head-to-toe” surveys and vital signs often
were performed in transit to the hospital.
Where to transport?
One of the remaining questions was often,
“Which hospital?” By the early 1980s, designated
trauma centers and trauma systems were
taking hold, due in large part to the persistence
of R. Adams Cowley, MD—often described as
the father of trauma medicine—who convinced
legislators and hospitals that patients should not
always be brought to the nearest hospital but
may be best served by the hospital most
equipped to treat severe trauma.
In Minnesota, the question of where to bring
patients was easier to answer in the rural part of
the state. Because of the large distances
between hospitals in rural areas, the best hospital
for serious trauma usually was the closest, at
least until the patient could be stabilized for
transfer to a larger, more trauma-oriented facility.
In the greater Minneapolis area, the question
was more difficult. There were many large hospitals,
all of whom needed patients. In the early
to mid-1980s, most hospitals in the west metro
accepted critical trauma cases. Realistically, this
meant many trauma patients were stabilized and
transferred to another facility for tertiary care.
In 1989, Hennepin County Medical Center
became the first ACS-verified Level 1 trauma
center in Minnesota. At the time, EMS teams,
who had greatly improved scene times (the
EMS system required a scene time of less than
10 minutes, except on extrication calls), still
secured nearly every patient to a backboard.
Fluids were poured in by the liter and D50
sometimes was ordered for head-injured
Approaches in Critical Care | Commemorative Issue | June 2009 | 13

EMS Perspectives
⊳ Intern Per Wickstrom provides
care in a Hennepin ambulance in the
late 1960s.
⊳⊳ Hennepin’s fleet of ambulances
in 1964.
patients, who also were being hyperventilated
at rates more closely associated with a resting
pulse rate than a respiratory rate.
The intervening decades have seen significant
changes in the pre-hospital management of
trauma. Recently, EMS professionals have taken
a more proactive approach to research. Rather
than theorizing and using common sense, EMS
agencies, medical directors, and paramedics are
taking a much harder look at patient outcomes
before changing practices.
Today, the head-injured patient may receive
some hyperventilation as part of their treatment,
but often treatment is based more on end-tidal
CO2 levels than mere guesswork. Intravenous
access remains a staple of the trauma patient
but the amount of fluid infused has changed
greatly. Only the severely burned patient and
the trauma patient with critical hypotension
receive any significant fluid bolus. Otherwise,
the access is present to administer analgesics
and to be available for blood products on arrival
at the hospital.
On the horizon
One trauma care subject that has recently been
reexamined has been the use of analgesics. For
decades, paramedics were warned that providing
patients with medications for pain relief was
to be avoided in the field, except in the case of
cardiac chest pain. The concern was that pain
medications could mask physical signs and
symptoms or have side effects not easily treated
in the field.
Today, EMS professionals, along with other
providers, are recognizing that reduction of
suffering must improve. In some parts of the
country, the synthetic narcotic fentanyl is finding
a niche in EMS care. Fentanyl’s short half-life
makes it easier to titrate and allows for an easier
switch to different analgesics, if desired, once
the patient reaches the hospital. The medication
also is safe for use in hypotensive patients, thus
allowing pain management even in the serious
trauma patient.
Even today, there are other times we in EMS do
too much. Today, the severely injured and those
with suspected spinal injuries continue to require
immobilization. However, increasingly EMS professionals
have recognized that even a treatment
as simple as a backboard is not without
risk and, along with the discomfort and anxiety
that can occur with immobilization, may not be
the best choice for some patients. We also now
recognize that many traumatic cardiac arrests
cannot be resuscitated and that extended resuscitation
attempts can burden the family and
hospitals and even sometimes create unnecessary
risks for the EMS agencies transporting
such patients.
In the future, the art and science of EMS trauma
care will continue to be an amalgamation of
technology, medicine, and education. Exciting
new developments are just over the horizon.
Technological advances, combined with improved
education, may mean being able to implement
some version of imaging in the pre-hospital setting.
The development of artificial blood products
for trauma victims continues to face challenges,
but we are on the frontier of such discoveries.
The increase in use of telemedicine will mean
outlying hospitals will have more resources to
determine which patients need to be moved to
a trauma center and which are best served by
remaining in the community.
Looking ahead, one thing is clear: the advances
we see in the next fifty years will be every bit as
monumental as those we have experienced in
the last five decades.
14 | Approaches in Critical Care | Commemorative Issue | June 2009

Photo Essay
Twenty-Year “Trauma 1” Anniversary Commemorative Edition
Photo Essay:
The Evolution of Emergency Care
These photos were provided by the
Hennepin History Museum, which
also houses equipment, supplies, and
uniforms that track the progression
of American medicine, beginning with
Hennepin’s opening in 1887. For hours
and location of the museum, visit
www.hcmed.org or call 612-873-2512.
In 1911, the first electric ambulance was
purchased for Hennepin. The idea of
motorized ambulances had received unexpected
publicity a few years earlier when
President William McKinley became one of
the first to ride in an electric ambulance
after an assassination attempt in 1901. The
state-of-the-art transportation did not help
save him; McKinley died eight days after
being shot.
In 1894, Hennepin County
Medical Center (then known as
Minneapolis City Hospital) rented
its first ambulance—a covered
wagon, a team of horses, and a driver—for
$1.50 per run. At the time, the hospital had
been open for seven years. Daily cost for
each patient was 89 cents. Like most
Americans, staff members worked a sevenday
week. Day shift workers worked 89
hours per week while night shift workers
worked 77 hours per week.
Beginning in 1916, this single room served
as Hennepin’s emergency department
(ED). Nurses, at Hennepin and at most
hospitals across the nation, were the
primary staff members for the emergency
room. As the workweek was shortening
across the U.S., it also decreased at
Hennepin, where health professionals now
worked just 56 hours per week.
Approaches in Critical Care | Commemorative Issue | June 2009 | 15

Photo Essay
In 1963, the first trauma
training course in Minnesota
was organized at Hennepin.
Throughout the 1960s, the
concept of emergency
medicine was evolving
rapidly with the realization
that the lessons learned on
the battlefields of Korea and
Vietnam could be applied on
the home front.
In 1967,
Minnesota’s first
suicide prevention
hotline, housed in
Hennepin’s ED, was
launched. Attitudes
toward suicide as a
health issue were
still developing; in
the early 1960s,
attempted suicide
was a felony in
North Dakota,
South Dakota,
and several
other states.
In 1938, the same room
still functioned as the ED,
but surgery interns joined
nurses in staffing it. The
following year, the standard
workweek for Americans
dropped again to 48 hours.
In 1969, director of
emergency nursing
Hillie Prose, RN
created a plan to
help stabilize critical
patients. Initially, the
plan revolved around sending nurses to inpatient floors to
stay with patients until they were fully stabilized. In time,
the strategy involved a special stabilization room in the
emergency department to help stabilize critical patients
on arrival. Later, the accreditation program for Level 1
trauma designation made a stabilization room a required
element of providing Level 1 care to trauma patients.
In 1986, care for the most
urgent patients was improved
when a helipad was built on
top of a parking facility at
Hennepin. Also in 1986,
Hennepin opened an urgent
care center next door to the
ED. The convenience and
lower cost led to thousands of
such centers opening around
the U.S. in the late 1970s,
1980s, and 1990s.
In 1989, Hennepin became the first in Minnesota
to achieve Level 1 trauma verification.
In the early 1990s, as part of a
national trend toward eventual
elimination of storage rooms like
these (medical records
department, 1951), the Hennepin
ED became a beta test site for
one of the first electronic medical
record systems in the country.
In 2009, Hennepin celebrated
twenty years as a Level 1 trauma center.
16 | Approaches in Critical Care | Commemorative Issue | June 2009

Calendar of Events
To register for a course,
visit www.hcmc.org and
click on “Professional
Education and Training.”
For questions or additional
information, contact Susan
Altmann in Medical
Education at Hennepin
County Medical Center at
(612) 873-5681 or
susan.altmann@hcmed.org
unless another contact person
is provided. Classes are
at Hennepin County Medical
Center unless otherwise indicated.
Many courses fill
quickly; please register early
to avoid being wait-listed.
June
June 5_________________________________
CPR for MDs, for HCMC staff
June 10________________________________
CPR/BLS, for HCMC staff
June 16________________________________
Healthcare Provider CPR, for G1 residents
June 17-22_____________________________
Advanced Cardiac Life Support, for G1 residents
June 17________________________________
CPR for MDs, for HCMC staff
June 23-24_____________________________
Pediatric Advanced Life Support - Provider
June 24________________________________
Pediatric Advanced Life Support - Renewal
July
July 7__________________________________
Advanced Cardiac Life Support - Instructor
Renewal
July 6-7________________________________
Advanced Cardiac Life Support - Instructor
July 8 and 10____________________________
Advanced Cardiac Life Support - Provider, for
HCMC staff
July 9__________________________________
CPR/BLS, for HCMC staff
July 10_________________________________
CPR for MDs, for HCMC staff
July 14-15______________________________
Advanced Trauma Life Support
July 21-22______________________________
Advanced Pediatric Life Support
Approaches in Critical Care | Commemorative Issue | June 2009 | 17

Calendar of Events
August
August 5_______________________________
Healthcare Provider CPR
August 5 and 7__________________________
Advanced Cardiac Life Support, for HCMC staff
August 11-12____________________________
Advanced Cardiac Life Support
August 12______________________________
Advanced Cardiac Life Support - Renewal
September 22-23_________________________
Pediatric Advanced Life Support - Provider
September 23___________________________
Pediatric Advanced Life Support - Renewal
September 30 and October 2_______________
Advanced Cardiac Life Support, for HCMC staff
September 28 - October 2__________________
First Responder
August 13______________________________
CPR/BLS, for HCMC staff
August 7_______________________________
CPR for MDs, for HCMC staff
August 19______________________________
CPR for MDs, for HCMC staff
August 25______________________________
Advanced Cardiac Life Support, renewal for
HCMC staff in a.m.
August 25______________________________
Advanced Cardiac Life Support, renewal for
HCMC staff in p.m.
September
September 3-4___________________________
First Responder Refresher
September 9____________________________
Healthcare Provider CPR
Hennepin Connect magnet v2 3/31/08 10:16 AM Page 5
September 15___________________________
CPR/BLS, for HCMC staff
September 15-17_________________________
Emergency Medical Technician Refresher
course at Edina Training Center
September 11___________________________
CPR for MDs, for HCMC staff
Rapid access to Hennepin physicians
for referrals and consults
Services available 24/7
1-800-424-4262
612-873-4262
18 | Approaches in Critical Care | Commemorative Issue | June 2009

News Notes
News Notes
Earth tones and
natural sunlight
provide a healing
environment for
patients and staff
members.
Patient rooms
have a view of
part of downtown
Minneapolis and
light-filtering
window blinds.
New intensive care units open
Two new units, a 24-bed medical intensive
care unit (MICU) and a 24-bed
surgical intensive care unit (SICU),
have opened at Hennepin County
Medical Center. The units’ openings
are the first phase of a plan to concentrate
inpatient medical and surgical
intensive care to one critical care floor
at Hennepin.
“These contemporary units are
designed to respond to the needs of
our patients and create a comfortable,
safe, healing environment in an ideal
work area for our exceptional medical
and surgical caregivers,” said Lynn
Abrahamsen, chief executive officer at
Hennepin. “We are pleased to be able
to enhance the patient experience to
match the excellent clinical outcomes
expected at HCMC.”
The MICU and SICU units were
designed with input from patients,
family members, and staff. The units
include all private patient rooms with
flat-screen televisions, thermostats,
and light-filtering window blinds.
Nursing work stations, placed between
every two rooms, support direct views
of the patient.
_______________________________
New neurological studies
begin in Minnesota emergency
departments
Two pharmaceutical treatments, one
for continuous seizures and the other
for strokes, will be studied in Minnesota
emergency departments as part of the
Neurologic Emergencies Treatment
Trial (NETT) Network, a nationwide
effort to improve the outcomes of neurological
emergency patients through
interventional clinical research.
Approaches in Critical Care | Commemorative Issue | June 2009 | 19

News Notes
New neurological studies begin in
Minnesota emergency departments cont.
The first trial, called RAMPART (Rapid
Anticonvulsant Medication Prior to Arrival Trial)
is a double-blind, randomized clinical trial to
evaluate the efficacy of midazolam (Versed)
given intramuscularly vs. lorazepam (Ativan)
given intravenously.
The second trial, called ALIAS (Albumin in
Acute Ischemic Stroke) provides ischemic
stroke patients with a high dose of Albumin or a
placebo of intravenous fluid in addition to the
regular course of medications given to ischemic
stroke patients. The study seeks to determine
whether the Albumin is associated with a fuller
recovery. Investigators will continue to track
patients for 12 months after their emergency
department visit.
_______________________________________
Hennepin recognized for outstanding
patient satisfaction
Hennepin County Medical Center has been
recognized by HealthPartners for outstanding
achievement in patient satisfaction.
Each year, HealthPartners conducts more than
2,000 interviews with HealthPartners members
who have been hospitalized in Minnesota during
the previous year. This year’s results show that
more than 75% of participating Hennepin
patients rated themselves as “very satisfied”
with the care they received at Hennepin.
Just four Minnesota hospitals—Hennepin
County Medical Center, Woodwinds Hospital,
Lakeview Hospital, and Ridgeview Medical
Center—achieved a rate of over 75%.
_______________________________________
Pediatric stroke protocol available
Pediatric stroke is a rare but often deadly affliction.
According to a recent article in the journal
Stroke, an estimated 2,904 children were
admitted to U.S. hospitals with ischemic stroke
between 2000 and 2003. A new pediatric stroke
protocol, now in use at Hennepin County
Medical Center, is available to other interested
medical facilities. The protocal provides uniform,
standardized acute stroke care guidelines for
pediatric patients.
The protocol addresses care for children 4-18
years of age with a new onset neurological
deficit (without evidence of intracerebral hemorrhage).
As part of the protocol, a diagnostic
angiography must demonstrate an arterial
occlusion, and intra-arterial thrombolytics must
be initiated within eight hours of symptom onset.
For more details, see the protocol at
www.hcmc.org/approaches.
_______________________________________
New Web site provides medical
education
A new medical education Web site offers
instructional videos, online courses, and an
extensive database of diagnostic images to help
users learn more about the practice of emergency
medicine.
The Web site, maintained by the Department of
Emergency Medicine at Hennepin County
Medical Center, recently was recognized by the
American Thoracic Society for its high-quality
educational images.
To view the site, visit www.hqmeded.com.
“This year’s results show that more
than 75% of participating Hennepin
patients rated themselves as ‘very
satisfied’ with the care they received
at Hennepin.”
20 | Approaches in Critical Care | Commemorative Issue | June 2009

For more information
To download additional resources for
critical care clinicians, please visit the
Approaches in Critical Care Web site
at www.hcmc.org/approaches.
There, you’ll find:
An electronic version of
Approaches in Critical Care that
you can email to colleagues
A pediatric stroke protocol
An adult traumatic brain injury
ED protocol
A pediatric traumatic brain injury
ED protocol
Free stroke care materials,
including a stroke care protocol, a
Cincinnatti Prehospital Stroke
Care badge card for EMS
professionals, patient education
fact sheets, and more
®
Every Life Matters

The medical illustration on this issue’s cover was
produced in France in the mid-1700s as a collaboration
between noted printmaker Jacques Gautier d’Agoty
and the surgeon Jacques-Francois-Marie Duverney.
The printmaker created separate copper plates, each
engraved with a different part of the image and coated
with a different color of ink. The ink impressions were
then overlaid onto paper.
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