Bryan Trauma Update | Fall 2015

TRAUMA UPDATE

News from the Trauma Center at Bryan Medical Center FALL 2015

Trauma team helps hunter overcome shotgun injuries

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arc Kinnamon of near Auburn and had limited cell Auburn doesn’t phone reception. Kenneth called consider himself a 911 but also called his wife to hunter; in fact, he would much give her a better idea of where rather be riding his motorcycle or they were. The sheriff and State lifting weights.

Patrol met up with Kenneth, and However, on Oct. 31, 2015, he was able to lead them and the Marc decided to join his brothers rescue squad to the cornfield.

Brian and Kenneth for an early Catherine Burroughs, EMT-B, morning turkey hunt to spend a member of the Johnson rescue time together before Brian squad, was aware the call inreturned home to California. The volved a gunshot wound, but she brothers were in a tree stand by did not know any other details.

0400 that Halloween morning.

When the rescue squad arrived Kenneth was setting up “in the middle of nowhere” they decoys out in the field when he had to crawl through a barbed heard three gun shots. He inwire fence to get to Marc. stantly heard Marc call out “You Catherine remembers getshot me” and not ting to the knowing whether scene and Marc was being seeing a a jokester or not, man yellKenneth began ing and to return back to pointing where his brothto where ers were. KenMarc was. neth found Marc Marc’s first lying facedown words to and not movCatherine ing; still trying were “Don’t to determine if touch Marc was kidding me” — she This chest X-ray shows many of or not, Brian and had no the shotgun pellets that struck Kenneth rolled idea that Marc Kinnamon. him over and a shotgun found holes in could put Marc’s clothes after he had been so many buck shots everywhere. shot with a 12 gauge shotgun.

Catherine and Deb Wilson, EMT, The brothers were in a field began reassuring Marc. They

Marc Kinnamon (center, in gray shirt) is surrounded by responders who were among those treating him after he was injured in a hunting incident. They are Kenneth Durant (left), Hillary Edwards, Twyla Antonides, Dave Allen, Catherine Burroughs and Darci Grafton. pulled up his shirt to assess the injuries and found a large amount of blood.

They loaded Marc onto a long spine board, maneuvered him out of the cornfield and trees through the barbed wire fence, and to an ambulance which transferred him to Nemaha County Hospital in Auburn.

The rescue squad was unable to get IV access to provide Marc with fluids and pain management, so they inserted an intraosseous (IO) in his leg.

Catherine estimates it took 30 minutes to get to the hospital.

Twyla Antonides, RN, was just starting her shift when her

pager went off. She received the call they had a GSW victim on the way. She immediately activated the trauma team and, because of Mechanism of Injury, also called StarCare for emergent transfer to Bryan Trauma Center. During Twyla’s assessment with Eric Eickhoff, PA, they observed several pellet holes in Marc’s face, arms, chest, leg and abdomen.

Marc arrived at Bryan Trauma Center at 0919 via StarCare. Dr. Reginald Burton was the trauma team leader, and during the initial assessment, Marc was found to be bleeding from multiple pellet wounds from his chest, neck, groin, flank, back, left forearm

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Gunshot victim has good outcome, but gives up hunting and fingers. A Focused Abdominal Sonography for Trauma (FAST exam) was positive, and a pellet was visualized in the septum of Marc’s heart.

This caused a pericardial effusion and a right pleural effusion. Dr. Richard Thompson, a Bryan Heart cardiothoracic surgeon, determined Marc needed emergent surgery.

Marc tolerated the open heart surgery well and became hemodynamically stable.

Marc spent 7 days on the Bryan West Campus. He doesn’t remember much from the morning he was shot. But he does recall having difficulty breathing, being on his hands and knees trying to breathe and his body feeling like it was on fire. Marc vaguely remembers a helicopter picking him up in the field, and he remembers that flight nurse

Auburn’s hospital earned trauma designation in ‘09 Nemaha County Hospital in Auburn has been a state designated trauma hospital since May of 2006.

“Receiving our Trauma designation and maintaining it is singularly the most impactful program that I’ve been a part of,” says Kermit Moore, the hospital’s chief operating officer.

The 16-bed hospital cared for 72 trauma patients from 2010-2014.

Although continuing education requirements can be difficult to obtain with limited training opportunities, the Nemaha County team has developed a response that significantly improves outcomes for trauma patients. n

Teather Campbell was very polite and held his hand and reassured him that he would get excellent care at Bryan Trauma Center.

His brother, Kenneth, is thankful the outcome was so good. He remembers Twyla the nurse in Auburn explaining to him that Marc would need to be life flighted to Lincoln. He states that she did a great job of explaining that, because of Marc’s mechanism of

injury (GSW), he was considered a Category 1 trauma. Kenneth is thankful that Nebraska has a well-established trauma system with protocols to guide the care and treatment of trauma patients.

Marc is back to work and enjoying his motorcycle. He is no longer considering becoming a hunter — in fact, he is done hunting. n

Helmets to patients promote bicycle safety Bryan Medical Center West is a Level II American College of Surgeons (ACS) verified trauma center. One of many requirements for reaching this level is the program must have an effective program that demonstrates community-based injury prevention efforts.

In June of 2014, Bryan Medical Center made a commitment by adding a full time trauma outreach and injury prevention coordinator to the trauma program. The first six months of the new position involved assessing the needs of the community regarding trauma care and injury prevention.

Due to a high amount of bicycle crashes and fatalities in the fall of 2014, trauma outreach and injury prevention coordinator Heather Talbott, MSN, RN, requested a report from the trauma registry regarding statistics on what percentage of patients were wearing bicycle helmets when they crashed and entered the emergency department.

Bryan trauma registrar Deb Schleiger, CSTR, found that from January 2014August 2014, the Bryan trauma team had cared for 266 bicycle crash victims. Only 16 percent of those patients were wearing bicycle helmets.

According to the Centers for Disease Control and Prevention (2015), bicycle helmets reduce the risk of head and brain injuries in the event of a crash and, according to Think First!, bicycle helmets are

85-87 percent effective in reducing risk for brain injury. Most people are aware that bicycle helmets are for every age; however, people usually don’t realize bicycle helmets are similar to car seats in the sense that if a helmet has been involved in a crash or has been damaged, it needs to be replaced.

This information led to the creation of the Bryan Bicycle Helmet Program. With the generous support of the Bryan Foundation, a pilot program was launched on the Bryan West Campus on May 5.

Through the program, any patient involved in a bicycle crash can receive a free bicycle helmet; because the trauma team is not always needed for these patients, the Emergency Department team at Bryan Medical Center West has gone above and beyond in recognizing these patients and owning this program.

So far more than 30 helmets have been given out, with the average age of patients receiving a helmet being 29. The oldest patient receiving a helmet is 73 and the youngest patient to date is 4. Three-fourths of the patients were not wearing helmets at the time of their crash.

With the support of the Bryan Foundation, the goal is to expand the Bryan Bicycle Helmet Program to the Bryan Medical Center East Campus when construction to the emergency department is complete.

If you are interested in supporting the bicycle helmet program, contact the Bryan Foundation at 402-481-8605. n

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Collaboration averts snakebite tragedy

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hen Josh was 6 years old, he realized that dinosaurs were gone and not coming back.

At that moment, he decided he would study snakes instead.

This passion has remained throughout Josh’s life.

He worked in the herpetology lab at the University of Nebraska-Lincoln while obtaining his degree, and he has an advanced certification to handle venomous snakes. Even with special certification and training, bites still can occur, as Josh came to personally realize in June.

During a routine feeding of a neonatal pit viper, the snake struck Josh’s hand, with one fang penetrating the cuticle of his right index finger. Josh says he immediately felt stinging that turned into a burning sensation, and he could see the streak of where the venom was along his finger.

At this point Josh properly caged the snake, found his bite protocol, and called emergency services. Fifty-four minutes later, Josh arrived at the Bryan Trauma Center.

Josh says at first he was most concerned about losing his finger. However, for the Trauma Team, their biggest

Quick snake facts Only four kinds of venomous snakes are indigenous to Nebraska: • • • •

Prairie Rattlesnake (Crotalus viridis).

Copperhead (Aqkistrodon contortrix).

Massasauga (Sistrurus catenatus).

Timber Rattlesnake (Crotalus horridus).

The most common snakes in Nebraska are the nonpoisonous bull snake, garter snake and smaller water snakes.

Snakes are most active during warmer temperatures — 75-90° F — and are inactive in extreme cold or heat.

The State Patrol rushed a supply of Antivipmyn from Omaha to treat Josh.

fear was the systemic response to the snakebite. His first set of labs showed that his Fibrinogen, PT/PTT and INR values were all undetectable — his blood could not effectively clot.

Josh was given six vials of Crotalidae Polyvalent Immune Fab (Ovine), “Crofab” anti-venom, while in the ER. During this time, Trauma Team leader Reginald Burton, MD, was on the phone with Jessi Krebs, curator of reptiles and amphibians at Omaha’s Henry Doorly Zoo. Mr. Krebs was very helpful and able to give a supply of Antivipmyn, an anti-venom that is specific to this species of snake.

With the help of the Nebraska State Patrol, 10 vials of Antivipmyn were quickly delivered from Henry Doorly Zoo’s stock to the Trauma Center’s ICU to continue treating Josh.

If you come across a snake: • Do not attempt to grab the snake, especially if you are uncertain what type of snake it is.

• Slowly take a few steps back — most snakes will retreat rather than chase or challenge you.

If you are bitten: • Remain calm and call 911.

• Do not apply ice or tourniquets.

• Do not attempt to suck out the venom.

If you can get a picture of the snake, do. However, do not attempt to catch or chase the snake.

While in the ICU, Josh’s symptoms increased, to include severe pain extending from his finger to his axilla, as well as severe nausea and abdominal pain. Josh began having signs of acute renal injury from the venom.

Expert consultation was provided

by Sean Bush, MD, an emergency room physician and envenomation specialist at East Carolina University.

Re-venomation syndrome can occur within days of apparent clinical improvement. The cause of this is not known, but it is postulated that venom in the lymphatic system gets trapped with the swelling, and when the pressure from the swelling improves, the venom is released into circulation. After further anti-venom treatment, Josh was able to be discharged to home a week after the bite.

In total Josh ended up receiving 24 vials of Antivipmyn and six vials of Crofab anti-venom.

Josh is very appreciative of the collaboration that occurred with Jessi Krebs from the Henry Doorly Zoo, the Nebraska State Patrol that delivered the Antivipmyn, Dr. Bush and the entire Trauma Team on the Bryan West Campus. n

Tips for medical professionals treating a snake bite victim: • Immediately draw labs.

• Draw lines/marks to indicate the area of swelling on first arrival. This helps monitor how fast and how much swelling is occurring.

• Immobilize and elevate extremity.

• Contact poison control center (1-800-222-1222).

• Avoid NSAIDs, due to increased risk of bleeding.

• Avoid Ice, prophylactic antibiotics and prophylactic fasciotomy.

• Avoid cutting and or suctioning of the wound.

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Athletic trainers are valuable teammates

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any young people and their families enjoy participating in youth sporting events. For many, a weekend softball tournament is a great way to spend quality time together. Bryan Medical Center employs and jointly manages with Lincoln Orthopaedic Center a number of athletic trainers who cover a variety of high schools during the school year.

During the summer months, these athletic trainers remain busy providing care to young people at sporting events, such as softball, YMCA events and Midget Football.

It was at one of these events that a 15-year-old athlete, Madison “Maddy” Schrader of Millard, was playing in a softball tournament in Lincoln.

During the game she dove for a ball in the outfield and struck her chest, chin and then forehead on the Madison Schrader (center) and her father, turf. Although she caught the ball, she Coach Brandon Schrader, are thankful athletic felt foggy at the end of the inning, so trainer Rachel Hall was on duty. a teammate’s parent gave Maddy an Ibuprofen. She took her turn at bat and made contact with the ball, but awake. She reported a headache rated as she returned to the dugout, something about 6/10 and dizziness of about 9/10. wasn’t right.

Maddy had an increasingly difficult time Her dad, Brandon Schrader — who’s communicating. During Rachel’s evalualso an assistant coach for the Sizzle softation it was also noted that Maddy had a ball team — recalls, “As Maddy was walkunilateral nystagmus during eye tracking. ing back to the dugout, I noticed she was It was quickly determined that crying. She said everything was all right, transport to a hospital was necessary. but she didn’t know why she was crying.

Maddy’s condition continued to deterioThat’s when I noticed her eyes were foggy rate, and the Emergency Action Plan (EAP) and tired-looking, so I instructed a couple was activated by fellow Bryan athletic of the other parents to take Maddy to the trainer Terry Adair, ATC, with EMS called athletic trainer.” for emergent transport.

At the medical tent Maddy was While waiting for EMS to arrive, greeted by long-time athletic trainer and Maddy was maintained in a seated Bryan employee Rachel Hall, ATC. position. A previous attempt to lay her in Rachel states, “She presented as supine on the treatment table immediextremely lethargic.” Her primary ately increased her agitation and lethargy. complaint was, “I can’t see,” with blurred In sitting, Maddy was able to open eyes vision to approximately 12 inches; her and obey simple directions; however, secondary complaint was difficulty staying these were very slow and delayed.

Rachel’s goal was to keep Maddy awake and responsive and stable until EMS arrived approximately 10 minutes after injury. During communication with Lincoln Fire and Rescue, another team affiliated spectator told EMS she had given Ibuprofen to Maddy after the initial injury.

She was transferred to Bryan West Campus as a Category 1 trauma. When she arrived at the trauma center and was evaluated by Dr. Stanley Okosun, assistant medical director of trauma, she was unresponsive and observed to have possible seizure activity. A CT scan of Maddy’s head was negative, and she was admitted to the Neuro/ Trauma Intensive Care Unit. The next morning, she began to have a seizure, although she had no history of seizures. She was transported to Children’s Hospital in Omaha for a pediatric neurology consultation. She was released from the hospital a few days later and continues to receive therapy in Omaha.

This incident is a prime example of the effective implementation of an Emergency Action Plan. The staff at the Doris Bair Softball Complex executed the EAP quickly and efficiently by opening gates and meeting and guiding EMS to the scene. After the event the staff were able to debrief, taking the opportunity to review what went well with the process and what improvements could be made.

The primary response of the staff was excellent; a secondary responsibility to help with crowd/spectator management during an incident was identified and defined. The medical tent can be a centralized high traffic location, and incidents often provoke curiosity and “helpers” looking for information, which can complicate the primary goal of providing care to the patient and family.

Because of the quick, effective assessment by the athletic trainers and the effective use of the EAP, what could

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have been a catastrophic event had a good outcome with full recovery expected.

Madison hopes to return to sports when she has been medically cleared.

Situations like this can also be used to help families involved in youth sporting events to understand concussions can be

a serious event — especially if they are not reported and the child continues to play, running the risk of secondary impact syndrome.

Special recognition goes to the Lincoln Fire and Rescue crew for their prompt and efficient response. n

Students find Advanced Trauma Camp to be educational and inspirational On June 30, trauma program manager Robbie Dumond and trauma outreach and injury prevention coordinator Heather Talbott of the Bryan Trauma Program participated in the Advanced Trauma Camp held at Central Community College in Grand Island.

The Advanced Trauma Camp is four days of immersion into health care related fields for students entering the 8th grade and higher. Bryan Trauma Center brought TraumaMan which allowed the students to learn about and practice inserting emergency airways as well as chest tubes. In addition to the TraumaMan experience, students also spent time learning basic first aid, visiting with and exploring a helicopter from AirCare in Kearney, as well as spending time with Nebraska State Patrol’s SWAT team.

The last day of the camp the students

These courses are in the Conference Center on the Bryan West Campus, unless noted otherwise.

ATLS — Feb. 11 and 12, 2016.

July 7 and 8, 2016.

Oct. 6 and 7, 2016, TBA. Dec. 8 and 9, 2016.

ATLS Refresher — Dec. 11, 2015.

Feb. 12, 2016.

Oct. 7, 2016, TBA. Oct. 14, 2016.

TNCC — Jan. 14 and 15, 2016.

March 1 and 15, 2016.

June 9 and 10, 2016.

Nov. 3 and 4, 2016.

ENPC — Oct. 21 and 22, 2015.

April 14 and 15, 2016.

Oct. 20 and 21, 2016.

Heather Talbott (left) guides a simulated chest tube insertion during camp.

A student uses TraumaMan to practice emergency airway clearing techniques, assisted by Robbie Dumond.

Sign up for these Trauma Courses

were asked to “run” a Mass Casualty Scene. Ten volunteers were moulaged and coached on how to act. The students were then asked to triage, treat and consider transportation methods to available and appropriate hospitals. During this fourday camp the students were able to gain a general understanding of the physical and emotional demands that health care providers face every day.

The students left the camp with a tremendous amount of respect for those that care for other people, and a new passion for wanting to be in the health care profession. n

Trauma Grand Rounds — Fourth Friday of every month except September, November and December.

Oct. 23 — Thoracic Trauma, by Bryan Heart cardiothoracic surgeon Robert Oakes, MD. Mock Trauma — Trauma Team members come to your facility and provide Mock Trauma training in a safe, non-threatening environment.

For additional questions regarding these courses or about free trauma education provided at your facility or in your community, contact trauma outreach and injury prevention coordinator Heather Talbott at 402-481-4087, or email heather.talbott@bryanhealth.org.

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Bryan pilots counseling program to identify PTSD and acute stress disorder

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he Bryan Trauma program is doing its part in striving to reduce the effects of acute stress disorder (ASD), which frequently leads to posttraumatic stress disorder (PTSD), through a pilot on the Neuro/Trauma Intensive Care Unit (ICU). With the help of Dr. Molly Burns, a licensed psychologist at the Bryan Counseling Center, inpatient trauma patients are evaluated and receive counseling before being discharged from the hospital.

ASD is characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event. The disorder includes symptoms of intrusion, dissociation, negative mood, avoidance and arousal (Bryant).

PTSD has been described as “the complex somatic, cognitive, affective, and behavioral effects of psychological trauma” (Ciechanowski). Both can lead to considerable social, occupational and interpersonal dysfunction.

The intent of the inpatient counseling pilot is to facilitate identification of those patients at risk for developing ASD or PTSD. It will also educate the patient and their family members of resources that can be used when discharged from the hospital.

The pilot began when the ICU nursing staff noticed patients were developing signs and symptoms of PTSD behaviors.

Compelled with the need to provide holistic care, a psychiatrist consult didn’t seem to be the best tool. These patients needed a counselor — someone to talk to and discuss their concerns, not

necessarily a prescription.

The pilot allows Dr. Burns to see patients in the acute care setting and grow a trusting relationship. These patients can then have continued therapy sessions after discharge with her, or she is able to assist finding resources for outpatient therapy in patients’ hometowns.

Changes in behavior and concentration, insomnia, depression, anxiety, thoughts of self-harm or suicide, alcohol and drug abuse are just a few of the common stress reactions to a traumatic event.

Our goal as a trauma system is to stop the PTSD cycle before a patient leaves the Bryan system. n References: Bryant, R. (2014, December 09). Acute stress disorder: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. Retrieved from UpToDate: http://www.uptodate.com.

Ciechanowski, P. (2015, May 04). Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis. Retrieved from UpToDate: http://uptodate.com.

Trauma Team welcomes Holly Persson Holly Persson, APRN-NP, has joined the Bryan Trauma Program. Her career includes many years of experience in acute care, cardiac and nephrology. She is certified as an Adult and Acute Care Nurse Practitioner.

She is from St. Paul, Nebraska. Holly received a Bachelor of Science in Nursing in 1999 from the University of Nebraska Medical Center, Omaha, where she obtained the Advanced Practice Registered Nurse Degree in 2005. She began working at Nebraska Kidney Care in 2007 and continues as a part-time employee there.

Holly is married to Scott Persson, PharmD, who also is a member of the Bryan Trauma Team. Holly and Scott live in Lincoln with their son Keaton and daughter Brynley. In her spare time, Holly enjoys spending time with family, working out and running.

Please join us in welcoming Holly in her new position. n

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Mock Trauma scenarios provide teaching moments throughout region

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he Bryan Trauma Program has reignited the Mock Trauma Program for outside hospitals and agencies. Mock Trauma utilizes stateof-the-art simulators to enhance learning through hands-on trauma care scenarios based on real-life trauma patients.

Participants have opportunities to care for simulated critically injured patients as a member of a multidisciplinary team in a nonthreatening environment. Debriefing after each scenario focuses on shared experiences, obstacles to change and strategies for success.

On May 8, members of the

Bryan Trauma Team led a Mock Trauma at Crete Area Medical Center.

“The Mock Trauma Day was a fantastic learning experience for our providers and staff in the comfort and convenience of our own environment. The multidisciplinary arrangement of having a trauma surgeon, trauma nurse and StarCare staff teaching it gave us a well-rounded perspective to improving trauma care,” says Dr. Amy Vertin, Emergency Department Director and Chief of Medical Staff at CAMC. “We were able to ask questions about patient management that was specific to our small rural

facility and limited available resources. Feedback from our providers and staff was overwhelmingly positive and we will no doubt have great turnout again the next time we do this course,” she adds.

“I highly recommend this educational approach to any facility wanting to improve the quality of trauma care they provide to their patients.”

For more information regarding the Mock Trauma Program, please email trauma outreach and injury prevention coordinator Heather Talbott at heather.talbott@bryanhealth.org.

In this photo, Dr. Stanley Okosun, assistant medical director of trauma, (left) teaches Tammy Schroeder, APRN, and Ellajean Bledsoe, PA-C, about FAST (Focused Abdominal Sonography for Trauma) exams at the Crete Area Medical Center.

Dr. Okosun uses the TraumaMan simulation mannequin to instruct Dr. Robin Bernard and the staff at Saunders Medical Center in Wahoo. Bryan Trauma Program members share their expertise through mock trauma scenarios at outside hospitals and agencies.

At CHI Health St. Mary’s in Nebraska City, Dr. Okosun demonstrates chest tube placement with Dr. Stacy Blum and physician assistants Mike Sebek and Doug Langemeier.

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Trauma Update is published for friends of Bryan Health. Your comments and suggestions are welcome. Direct correspondence to the Advancement Department at Bryan, or telephone the editor at 402-481-8674. Trauma Update also is available at bryanhealth.com/traumacenter.

Kimberly Russel, President and CEO, Bryan Health; John Woodrich, President and COO, Bryan Medical Center; Edgar Bumanis, Director of Public Relations; Paul Hadley, Editor

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If you would like to be added to the Trauma Update mailing list, call trauma outreach and injury prevention coordinator Heather Talbott at 402-481-4087, or email her at heather.talbott@bryanhealth.org.

Bryan joins Trauma Survivors Network The Trauma Survivors Network (TSN), a pro-

gram sponsored by the American Trauma Society,

provides trauma centers training and materials

Bryan Trauma Center joined the Trauma Survivors Network this year. Members Scott Schrader, APRN (left), Dr. Reginald Burton, Liz Dunklau, APRN, Robbie Dumond, Dr. Julie Walcutt, Heather Talbott, Jennifer Middlekauf and Deb Schleiger participated in the annual Celebration of National Trauma Survivor’s Day.

needed to establish and successfully maintain programs which address the psychosocial needs of trauma patients and their loved ones.

Bryan Trauma Center joined the TSN in 2015, and the goal is for full implementation in 2016.

Bryan Trauma Center, as well as several former patients, participated in the Celebration of National Trauma Survivor’s Day on May 20.

Watch for more information about this exciting new program. n