Boone Health SUMMER 2021
Empowered by
KNOWLEDGE With genetic testing from Missouri Cancer Associates, a young mom gets ahead of an increased cancer risk. P G. 8
PG. 12
The Team Inside the Truck
Nursing at Stephens College The Bachelor of Science in Nursing is a partnership between Stephens College and Boone Health. Practice your skills in a brand new hospital simulation lab, and become a member of the Boone Health community. Plus, our total tuition and fees are almost $9,000 lower than that of Mizzou’s nursing program, and you’ll be a nursing student from day one. There’s no secondary application your sophomore or junior year. Start nursing classes right away and graduate in three years into a high-earning profession. Boone offers tuition remission for employees and their families.
Interested in the possibilities? Schedule a quick virtual conversation about program costs, scholarships and your academic readiness. We can help you apply for Fall ’21 entry!
Register now at
stephens.edu/nursing
+
Table of Contents CEO Troy Greer
20
Director of Marketing & Public Relations Ben Cornelius Communications Consultant II Jessica Park Digital Communications & Marketing Consultant II Madison Loethen Marketing Consultant I Erin Wegner Photography Sadie Thibodeaux Contributing Writers Kaitlyn Bailey, Gretchen Holmes, Ben Holt, MD., Kate Lohman, Tara Phillips, Jenny Workman
Follow us Check us out on Facebook, Twitter, Instagram, Pinterest and YouTube.
Please submit comments or feedback to erin.wegner@boone.health or call 573.815.3217
12
16
26
1600 East Broadway Columbia, MO 65201 573.815.8000
For a FREE subscription, call 573.815.3392 or visit boone.health/my-boonehealth and click on the subscription link on the right side of the page.
5
A Note from Troy
20
An Easy Fix for Vertigo
6
Hospital Headlines
Nursing and Pumping Tips
8
22
Empowered by Knowledge
Get to Know a BHC Doctor
12
24
The Team Inside The Truck
25
Get to Know a BHC Nurse
Turkey Lettuce Cups with Red Pepper Jelly
26
Hit The Trails
These Knees Are Made For Racing
28
When in Season
A Culture of Wellness
30
Foundation News
14 16 18
A NOTE FROM TROY
Bringing Boone Health Closer to Home
F
or most of us, health care doesn’t begin at the hospital, but in the doctor’s office. Establishing a medical home with a primary care provider, or PCP, can mean better outcomes for you and your family. Your PCP not only provides regular preventive care and recommended health screenings, but they can also refer you for testing, specialty care and other services. Your PCP can see a more comprehensive picture of your overall health, personal health history and family history. People with chronic conditions like diabetes find it easier to manage and maintain their health when under the care of a PCP. We know that having a medical home makes a significant impact on your health, which is why Boone Medical Group has 11 primary and family care clinics located throughout mid-Missouri, in addition to our two Convenient Care clinics, Diabetes and Endocrinology clinic, Surgery and High-Risk Breast clinic, and our new Heart Surgery clinic. Boone Health provides services to 26 counties in mid-Missouri, covering a large and diverse area. Each clinic is set up to meet their community’s needs, but whether our patients are seen by Aaron Whiting, MD at Boone Medical Group Boonville, Drs. Paul and Maria Bernabe in Osage Beach, or nurse practitioner Kelli Cash in Centralia, they can expect the same high standards of quality, patient-centered care and excellent customer service. Boone Medical Group comprises over 90 providers who believe in Boone, with the ability to easily refer patients to Boone Health’s laboratory, imaging, therapeutic, surgical and home care services. Before our transition to independence, Boone Medical Group had been managed separately from Boone Hospital Center by BJC Medical Group. This year has presented a grand opportunity to better
support our providers and to make it easier to bring Boone Health closer to your home, whether you live in Columbia or Camdenton. To bring our clinics under the Boone Health umbrella, Chad Pew has recently joined as Senior Vice President of Provider Services. Chad will be responsible for Boone Medical Group and our providers, and his goals include strengthening the relationship between our clinics and hospital-based services as well as assessing our community’s health care needs and opportunities for growth. Chad will also lead collaborations with independent and referring physicians in our service area, so even if your so even if your established medical home isn't with Boone Medical Group, your PCP can still refer you to our services.
As you can see throughout this issue of My Boone Health, while acute care is important, health isn’t just a concern when we’re ill or injured — it’s an overall approach to life. Having a medical home and getting check-ups and health screens are significant for our health and wellbeing, but I also encourage you to check out the articles on cultivating wellness, hiking Missouri’s beautiful trails, or buying in-season produce. I wish you and your family a healthy summer.
Troy Greer CEO, Boone Hospital Center
Boone.Health/My-Boone-Health
5
HOSPITAL HEADLINES
Boone Health Welcomes Chad Pew Chad Pew has joined Boone Health as the Senior Vice President of Provider Services. In this role, Chad will be responsible for the Boone Medical Group and other employed physicians. He will also lead collaborative efforts with independent and referring providers. Chad holds a bachelor’s degree from Chadron State College, an MBA from the University of Nebraska at Omaha, and is a certified medical technologist. He is a fellow of the American College of Healthcare Executives. Chad began his career as a medical technologist working in hospital laboratory. He has over 20 years of healthcare experience, 10 of those in an executive role. Most recently Chad was interim CEO of a hospital in Washington State. Previous to that he has served as a Chief Operating Officer in Wyoming and in the Lovelace Health System in Albuquerque.
Boone ICU Nurse Honored for 30 Years’ Certification Karen Ross, Boone Hospital Director of ICU, Stepdown and Respiratory Therapy, has been honored and nationally recognized from the American Association of Critical Care Nurses, or AACN, for having consistently maintained CCRN certification for 30 years. CCRN certification is one of the most advanced professional credentials that can be achieved by an acute or critical care nurse. Certification not only reflects a nurse's clinical skills, specialized knowledge and experience, it's also been proven to result in better patient outcomes. Congratulations, Karen! And thank you for your commitment to the nursing profession and your patients.
6
BOONE HEALTH
Summer 2021
Cardiac Cath Lab Boone Health is nearing completion of a three-phase, $7.3 million expansion of its cardiac catherization lab. The expansion began in February 2020. The project includes upgrading equipment, the addition of a fifth procedural room with electrophysiology capabilities, and five new pre- and postoperation holding rooms.
Congratulations to our 2021 Professional Excellence in Nursing Awards Winners
Beyond Boone Award
On May 5, 2021, Boone Health held its Nurses Week Virtual Celebration. Emcee Monica Smith, MSN, RN, NE-BC, FACHE, Chief Nursing Officer and Chief Operating Officer, recognized PNDP nurses, certified nurses, nurse residency program graduates, DAISY and BEE Award winners, and announced the winners of our 2021 Professional Excellence in Nursing Awards, or PENA. Nominated by their fellow Boone teammates, our PENA nominees embody the teamwork, spirit and valuable contributions by individual nurses and nursing teams that make Boone Health an excellent place to work and to receive healthcare.
This award is for an individual registered nurse who has led an innovative project, process or program to improve a patient’s care, process, project or patient outcomes.
Partner in Caring Award
The DAISY (Diseases Attacking the Immune System) Award is an international recognition program that honors the skillful, compassionate care nurses provide every day. This award recognizes a nurse leader who serves as a role model and cultivates a culture of compassion and exemplary practice.
This award recognizes three care team members other than registered nurses whose contributions and positive attitudes help our nursing staff provide excellent patient care. SZU CHAO, PCT, Surgical Specialties
This award recognizes a registered nurse who is actively involved outside the hospital in unpaid community service activity. Volunteering reflects and supports our mission to improve the health of the people and communities we serve. ERIN HOWSER, BSN, RN, OCN, Infusion and Treatment Center
Innovation in Nursing Award
TERRY BALLARD, BSN, RN, CRNI, Infusion and Treatment Center
Transformational Leader in Nursing Award
This award recognizes a Boone Health director, manager or supervisor who leads by example and is a champion for change and innovation. NATALIE BAYER, BSN, RN, Pain Clinic
DAISY Nurse Leader Award
DAVID FORTE, Unit Secretary, Medical Specialties
MICHELE SPRAGUE, MSN, RN, Neurology and Oncology
KIM OLIVER, Social Worker, ED
Excellence in Professional Nursing Award
Year One Wonder Award
This award recognizes two graduate nurses who show promise as exceptional members of the Boone Health nursing staff. MULIJA CALDAREVIC, BSN, RN, GI Lab
JESSICA FLESHMAN, BSN, RN, Emergency Department
Excellence in Nursing Education Award
This award recognizes two registered nurses who excel in teaching, mentoring or precepting skills in a clinical or classroom environment. CECILIA BOESSEN, RN, Medical Specialties
ZOE PREVETTE, BSN, RN, CWOCN, Wound Care
Nursing Spirit Award
This award recognizes two registered nurses who consistently demonstrate outstanding spirit and a positive attitude towards the practice of nursing. CARMA BUSHNELL, RN, RN-BC, Wound Care DENISE MCLAREN, RN, Pain Clinic
Our most prestigious nursing award, the Excellence in Professional Nursing Award recognizes three registered nurses who excel in the overall art and practice of nursing. JESSICA ABERCROMBIE, BSN, RN, Medical Specialties
RENAE CROW, BSN, RN, VA-BC, Infusion and Treatment Center NICOLE WEHNER, RN, Neurology and Oncology
Innovation in Nursing Team Award
This award honors a nurse-led team that has implemented a new project, process or program that improved a patient’s care or a process, contributed to excellent patient outcomes or improved quality outcomes. Employee Health Team
DAISY Team Award
The DAISY Team Award recognizes the collaboration by a nurseled team of two or more people that identifies and meets a patient’s or patient family’s needs by going above and beyond the traditional role of nursing. GI Lab Team
Boone.Health/My-Boone-Health
7
EMPOWERED KNOWLEDGE BY
With genetic testing from Missouri Cancer Associates, a young mom gets ahead of an increased cancer risk.
A
s Jennifer Frerking, busy mom of a 3-year-old, attended her annual check-up at Women’s Health Associates, she was considering taking a leap. Every year at her appointments with OB/GYN Stephanie Womack, MD, Jennifer was told to visit Boone Health’s High Risk Breast Clinic. Jennifer’s mother is a breast cancer survivor, which she knew put her at much higher risk, but now she had another person’s wellbeing on her mind. She says, “I had thought about getting genetic testing before, but I don’t think I would have actually done it if it wasn’t for my daughter. Becoming a parent makes
8
BOONE HEALTH
Summer 2021
you think about things differently — I realized I wasn’t invincible and should go ahead and do this.” At her first appointment at the High Risk Breast Clinic, Jennifer met with Boone Medical Group Surgery nurse practitioner Tiffany Carmichael, APRN, who explained genetic testing to her. “Tiffany talked to me about my risks and suggested the genetic blood test. I decided that was something I wanted to do, and I got the test through Missouri Cancer Associates,” says Jennifer. Tiffany explains that if you have a strong family history of breast cancer or other
characteristics of cancer within your family, having a genetic mutation can increase your risk of developing cancer. Genetic testing is an excellent option to know your risk. “Knowing this information gives you the ability to increase your screening for breast cancer or take preventative options such as prophylactic surgery, where you remove one or both breasts to lower your risk of cancer. If you qualify and you’re ready to move forward with genetic testing, it’s as easy as a blood draw in the office. Once that’s complete, it usually takes somewhere between seven to 14 days to get your results,” says Tiffany.
Jennifer and her daughter Olivia.
Boone.Health/My-Boone-Health
9
“Genetic testing can be scary, but it can also be empowering.” — TIFFANY CARMICHAEL, APRN
10
BOONE HEALTH
Summer 2021
For information on the High Risk Breast Clinic, visit www.boone.health/breasthealth or call 573.815.8145
At Missouri Cancer Associates, Jennifer met with nurse practitioner Gloria Drouin, APRN, MSN, for her genetic test. Missouri Cancer Associates uses a program developed by Invitae, a clinical genetic testing company, that helps providers determine which genetic test is ideal for screening cancer risks in each patient. “I use a software that Invitae provides to develop the patient’s family pedigree. Based on this pedigree, I determined which panel test would be best suited for Jennifer based on her family history of cancer,” says Gloria. When Jennifer received her results the week after her blood draw, she was initially relieved. “The results said I didn’t show a mutation for an increased risk of breast cancer, but it did show a mutation that can present a higher risk of colorectal cancer. When I got the results, I remember just feeling glad it didn’t say a higher breast cancer risk because that was my primary concern with my family history,” Jennifer says. Shortly after receiving her results, Jennifer received a call from Tiffany at the High Risk Breast Clinic. Tiffany explained there is some evidence supporting a correlation between her mutation and a predisposition to breast cancer. The evidence, however, is preliminary and insufficient to make a determination regarding these relationships. “That was stressful to hear, but I’m so glad she followed up with me. We scheduled an appointment to talk about my options, which include immediate and increased screenings and even preventative surgery — that’s something I find scary to think about, but they explained it to me in a very reassuring way,” says Jennifer. “Genetic testing can be scary, but it can also be empowering,” says Tiffany. “If you think you have a genetic mutation risk, have the conversation. Know what all your options are, then decide how you want to move forward.” For now, Jennifer’s plan is to get frequent early mammograms and MRIs, and in
“I realized I wasn’t invincible and should go ahead and do this.” — JENNIFER FRERKING
a few years, start regular colonoscopies. She says she’s incredibly grateful for the knowledge she gained from having genetic testing and would recommend it to anyone with a family history. “The whole experience was very eyeopening. I have proactive options to consider now, and I probably wouldn’t have started the early screenings
otherwise,” says Jennifer. Because a potentially cancerous gene was found during Jennifer’s screening, Invitae offered to test her mother and other close family members at no cost. “They actually found the gene in my mom, too, which is good to know. It puts into perspective how serious this could be,” Jennifer says. By Madison Loethen
Boone.Health/My-Boone-Health
11
W
Team members stand with one of the new ambulance vehicles.
The Team Inside the
Truck
Dedicated EMS professionals and top-of-theline technology create a dream team that helps community members in need. 12
BOONE HEALTH
Summer 2021
e all know the large, blue, often loud and flashing Boone Heath ambulances that can be seen all over Columbia and Boone County. They represent the lifesaving resources available at a moment’s notice to our community. Inside these iconic vehicles rides a team of talented individuals dedicated to service. Boone Health Ambulance Services has five different locations throughout Boone County and is staffed by 52 individuals. 75 percent are trained paramedics and 25 percent are trained emergency medical technicians. Paramedics are licensed healthcare professionals who can provide advanced life support to patients before they reach a hospital, and EMTs provide general medical care and patient monitoring. Boone Health paramedics and EMTs work together in the field and on the job. “We have a passionate and dedicated team. They are very skilled and often save lives. I really appreciate their good attitude and how well they work together. The team is always looking out for their patients and are able to communicate well with them,” says Marc Carr, Boone Health Emergency Medical Services Manager. Recently the team received two new ambulances. These trucks have top-ofthe-line features, including the Safety Vision camera system. This camera system provides live view cameras and recording services both inside and outside of the vehicle. Cameras located in the driver’s bay and in the patient area monitor patient and medic interactions. Additional cameras placed around the outside of the truck and help drivers monitor the vehicle’s blind spots and areas behind the truck. “These cameras are incredibly helpful and are our equivalent of police body cameras,” says Marc. Marc says a big reason the department was able to get the new vehicles was because of the system’s recent transition to independence. “The local Boone Health leadership has been very supportive, and these new vehicles are really going to help us serve our community,” says Marc.
Boone Health Ambulance Services works with other local first responders to provide emergency services coverage.
The Safety Vision camera system includes a camera placed inside the driver’s bay.
Boone Health Ambulance Services supports the community by providing EMT services at large gatherings.
One of two new Boone Health ambulances.
One of the current ambulances is currently undergoing upgrades, including installation of the Safety Vision cameras. Funds for the upgrades are provided by the Boone Hospital Foundation, which receives support from community members. “We are very grateful for the donation from the foundation and the upgraded vehicle,” says Marc. You can follow along with the Boone Health Ambulance Services on their Facebook page, Boone Health EMS. The page is often updated by Marc himself and contains pictures of the EMS team on the job. By Madison Loethen
Boone Health Ambulance Services are present at house fires to provide care to anyone in need.
Boone.Health/My-Boone-Health
13
Turkey Lettuce Cups with Red Pepper Jelly Do you love the flavors of summer vegetables, but feel stuck in a salad rut? Try these easy and delicious Turkey Lettuce Cups. It puts a twist on ingredients such as lettuce, carrots, and red peppers. Using familiar foods in a different way is key to keeping good nutrition interesting and appetizing.
Enjoy! 14
BOONE HEALTH
Summer 2021
For more information, visit booneweightloss.org or call 573.815.6447
INGREDIENTS
• ½ T sesame oil
• 3 scallions, finely chopped, white and green parts separated
• 1 T minced or grated ginger
• 2 cloves garlic, grated or minced • 1 lb lean ground turkey • Kosher salt
• ½ C chopped water chestnuts
• 1 carrot, peeled into ribbons with a vegetable peeler • ¼ C Spicy Red Pepper Jelly (recipe follows) • 2 T reduced-sodium soy sauce • ¼ C small cilantro sprigs
• 1 large head bibb lettuce, leaves separated E A S Y S P I C Y R E D P E P P E R J E L LY
• 1 C sugar-free apricot preserves
• 1 red bell pepper, roughly chopped
• 1 tsp red pepper flakes (adjust to preference) • ¼ C white vinegar • Kosher salt
DIRECTIONS
Prepare Red Pepper Jelly: combine all ingredients for red pepper jelly in a blender. Puree until smooth. Transfer to a small saucepan and bring to a simmer of medium heat. Cook, stirring often, until thickened and syrupy, approx. 10 minutes. Transfer to a jar and cool completely.
1.
Heat sesame oil in a large skillet over medium heat. Add the scallion whites, ginger, and garlic. Cook, stirring, until golden, 1-2 minutes. 2. Increase the heat to medium high and add the turkey and ½ tsp salt. Cook, stirring and breaking up any clumps, until browned, about 4 minutes. 3. Add water chestnuts, carrots, ¼ C red pepper jelly and soy sauce. Cook, stirring, until carrots are slightly wilted, about 2 minutes. 4. Transfer turkey mixture to a bowl. Top with scallion greens and cilantro sprigs. Serve on lettuce leaves. Serves 4 Adapted from www foodnetwork.com
Jennifer Tveitnes, RD, LD Clinical Dietitian, Bariatrics
Boone.Health/My-Boone-Health
15
These Knees Are Made For
Racing Story by Ben Holt, MD, Columbia Orthopaedic Group.
16
BOONE HEALTH
Summer 2021
HOW ACTIVE CAN MY NEW KNEE BE?
Many patients question how active they can be with a knee replacement. Don Prevost can answer that question. Don has led a very active life. Long before his knee problems, he was significantly involved in running, hiking, playing handball, and motorcycle racing. That’s right. Racing, not just riding. Don was introduced to motorcycle racing in the Marine Corps. While stationed in Japan, he attended an exhibition race event sponsored by Yamaha. Since he had some riding experience, he was asked to participate. He took second place. After returning to the states, he began racing with a local motorcycle club. That was in 1970. He also has his pilot’s license. Clearly, Don has led a very active life. Around 2006, Don began having increasing problems with his knees. Whether the cause was his active lifestyle, genetics, or injuries is not known, but his knees began to interfere with his lifestyle.
“Simple things like going to the mall, going shopping, and getting in and out of the car became a painful experience.” -DON PREVOST
He could no longer live the active life he loved because of his arthritic knees. He tried exercises, oral medication, and steroid injections. However, none of these measures gave him relief from his knee pain. He owned a machine shop but couldn’t tolerate the standing he needed to do in his business. “Simple things like going to the mall, going shopping, and getting in and out of the car became a painful experience,” says Don. Don was referred by a friend to see me, Dr. Benjamin Holt of Columbia Orthopaedic Group, about his knees. “Once Dr. Holt saw the X-rays, it was so apparent that the joints were boneon-bone and that surgery was the only recourse. Things had gotten so bad that it became painfully clear to me that surgery was what I had to do,” says Don. Don had both knees replaced at the same surgery in 2008. “In about six weeks I was getting around pretty good. I can’t stress enough the importance of sticking with the physical therapy. It makes all the difference in the world,” says Don. Don answers the question as to how active a person can be after a knee replacement by listing things he can still do with his replaced knees: “I still ride and race motorcycles, kneel down to do house projects, go on walks with my wife, work in my machine shop, maintain my 10-acre property, and go for long drives with no pain, and the surgery has had no effect on my medical certificate for my pilot’s license.” Not every patient can be as active as Don after knee replacement, but he is living proof of what is possible. By Dr. Benjamin Holt, Columbia Orthopaedic Group
Boone.Health/My-Boone-Health
17
W E L ofL A Culture
WELLNESS
NESS How individuals and organizations can support a healthier community.
BY JENNY L. WORKMAN, BOONE HEALTH COMMUNITY HEALTH MANAGER
W
hen most people hear the words health or wellness, they may think of diet and exercise, but health and wellness go far beyond what we eat or how we move our bodies. According to the World Health Organization, or WHO, health is “a state of complete physical, mental and social well-being.” Our health matters whether or not we have an illness or medical condition, and it can be affected by our economic situation, physical environment, personal characteristics and behaviors. We can’t always choose the state of our health, but we can make active, conscious decisions to foster wellness. The WHO defines wellness as the optimal state of health for groups and individuals. It’s a positive approach to living and an active process of change and growth to feel our best. Wellness covers multiple areas of our lives, including emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual well-being. For each area, we can take active steps to improve our overall wellness.
8 18
BOONE HEALTH
Dimensions of Wellness
(and how to support them)
Summer 2021
SOCIAL: Connect with our family, friends, colleagues and community and build a strong support system. • • • • •
Reconnect with old friends or meet new people. Enjoy family dinners or lunch with coworkers. Volunteer in your community. Join a club or organization. Express your gratitude for others and give compliments.
EMOTIONAL: Develop and strengthen skills to cope with stress. • • • • •
Establish a routine. Laugh! Don’t take life so seriously. Seek support from family members, friends or a professional counselor. Practice mindfulness activities. Make and keep a gratitude list.
PHYSICAL: Prioritize your body’s needs for physical activity, balanced nutrition, sleep and medical care. • • • • • •
Use a standing workstation or yoga ball at your desk. Join a recreational league or team sport. Replace sugary snacks with whole fruit. Get a good night’s sleep by turning off electronics before bedtime. If you smoke, make a plan to quit. Set up your medical home with a primary care provider and get regular check-ups and recommended health screenings.
INTELLECTUAL: Exercise your creative abilities and expand your knowledge and skills. • • • • •
Do crossword puzzles or other brain games. Attend a play, sporting event, or live concert. Learn how to play an instrument or speak another language. Read for pleasure. Attend a community class or workshop to learn a new skill.
For more information, email jenny.workman@boone.health or call 573-815-3263
SPIRITUAL: Embrace your search for meaning and purpose in the human experience. • • • •
Engage in a religious practice, like prayer, meditation, or attending services. Commit a random act of kindness. Make time to connect with nature. Keep a journal and reflect on your personal growth.
O C C U PAT I O N A L : Draw personal satisfaction and enrichment from your work. • • • • •
Focus on what you like about your job. Write out your career goals. Take breaks away from your desk or workspace. Connect with your coworkers. Look for professional development opportunities.
FINANCIAL: Build satisfaction and security with your current and future situation. • • •
Attend financial literacy classes or meet with a financial advisor. Track your spending habits to understand how and where you spend money. Set a goal for saving money.
E N V I R O N M E N TA L : Promote pleasant and stimulating environments that support personal and community wellness. • • • • • •
Connect with nature — play or exercise outdoors. Participate in a community clean-up event. Recycle, reduce and reuse personal belongings. Walk or bike to work or errands a few times a week. Visit the farmer’s market to buy locally sourced foods. Adjust your home or office lighting and add more natural light if possible.
Most of us spend over half our waking hours at work — and chances are good we’re not taking care of our health as well as we could be. When we work somewhere with a culture that embraces wellness, it can make a significant difference not just at the office, but in our overall lives. Workplace wellness programs can not only result in fewer sick days, more productivity and less turnover — they also build camaraderie among employees working together to meet wellness goals, providing support and improving morale. Personally, I’d want to work for an employer who cares about their employees’ health and well-being, which is one reason why I joined Boone Health as their new Community Health Manager. Community outreach and employee wellness are my passions — I not only have over 25 years of experience in this field, I’m a Mizzou grad who’s enjoyed building relationships with organizations throughout mid-Missouri, and I look forward to collaborating with our community partners in my new role. I also lead Boone Health’s Employee Wellness initiatives, and I am excited about fostering a strong culture of wellness for my coworkers. While the pandemic and our transition to an independent health care organization presented many challenges, there are also opportunities for change. Boone Health Community Wellness is using this opportunity to strengthen our ability to help local organizations empower their employees to make positive lifestyle changes. Our programs will provide the resources, education and support necessary to help employees know and lower their health care risks and successfully make lifestyle changes, including screenings, presentations, health challenges and more, with each program tailored to fit our community’s needs. For more information about Boone Health Community Wellness, feel free to contact me at 573.815.3263 or jenny.workman@boone.health
Boone.Health/My-Boone-Health
19
An Easy Fix for
J
oe Bayer said it best when he described lying down for bed as being on a “merry-go-round.” “You’re sitting perfectly still, but everything around you looks as if it is spinning out of control,” Joe says. Joe was suffering from BPPV, otherwise known as benign paroxysmal positional vertigo, a vestibular disorder that is the most common cause of vertigo. With this condition, one feels a false sense of spinning. This usually occurs when someone moves their head, such as when they look up, tilt their head, lie down, or roll over in bed. Someone with BPPV may also experience symptoms like vomiting, loss of balance, and nausea. Though not life-threatening, BPPV can be frightening due to its paroxysmal, or sudden, onset.
An Inner Ear Issue
In the inner ear, complex mechanisms of canals, nerves, crystals, tiny hair cells and fluids serve as part of the body’s balance system. BPPV occurs when those crystals become dislodged and find their way into one or more of the three semicircular canals in the ear — this interferes with the normal fluid movement that these canals use to sense head motion, which then results in confusing signals to the brain. The dislodging of the crystals can sometimes be associated with a head injury, migraine, inner ear infection or disease, diabetes, or osteoporosis. However, Boone Therapy Physical Therapist Rachel Beanland says the vast majority of the cases she sees happen for no apparent reason. “Most times patients simply lie down for bed or stand up from lying down and notice the room is spinning,” Rachel says.
Diagnosing and Treating BPPV
In 2020, Joe came to Boone Therapy after the spinning sensation became unbearable at night. “Joe had nystagmus, which confirmed he had BPPV,” Rachel says. Nystagmus is a rapid, involuntary movement of the eyes. A medical professional can watch for nystagmus with tests like the Dix-Hallpike, which involves holding the patient’s head and having them lie back on a table quickly, with their head tilted to one side and slightly lower than the shoulders. The Dix-Hallpike allows gravity to move the dislodged crystals and trigger vertigo. If the condition is confirmed, a physical therapist can reposition the crystals or otoconia in the inner ear with a simple procedure known as the Epley maneuver, or canalith repositioning. “The maneuver moves the crystals out of the canals so they stop causing symptoms,” Rachel says. The Epley maneuver is a series of rapid changes in the position of the head. It’s similar to the Dix-Hallpike test — the Epley maneuver follows the final position of the Dix-Hallpike test – but involves an additional rolling of the body to one side while the patient’s head is held in position. The maneuver is repeated three to four times. If a patient doesn’t get full relief from the Epley maneuver, Rachel says other maneuvers can work depending on the canal the crystal is in.
20
BOONE HEALTH
Summer 2021
For more information, visit www.boone.health/therapy or call 573.815.3868
Rachel Beanland, PT performs the Epley maneuver on Lisa Bowman.
Rachel Beanland, PT working with Lisa Bowman.
Rachel adds that the majority of patients, including Joe, are better in one session. Others may require one or two follow-up sessions.
The Role of Boone Therapy
Joe Bayer and Lisa Bowman have both benefited from Boone Therapy. Lisa was referred to Boone Therapy after experiencing pain from a work injury 17 years ago. Rachel began working with Lisa earlier this year. “I noticed Lisa had a nystagmus while she was performing an exercise during one of our sessions,” Rachel says. Once confirming Lisa was suffering from BPPV, Rachel performed the Epley maneuver. “Rachel cured me in less than five minutes,” Lisa recalls. “It’s crazy to think
Joe Bayer and Rachel Beanland, PT.
that something I had been living with for 17 years was fixed within five minutes.” Lisa also appreciates the educational component of Boone Therapy, saying Rachel helps her to know what is expected of her during each movement. Rachel says she has enjoyed getting to know Lisa and Joe through the years. Part of building relationships with her patients is also establishing trust. “The treatment for BPPV isn’t always pleasant because I am stimulating the symptoms of vertigo by putting the head into positions that move the dislodged crystals,” Rachel says. “Building relationships and trust with my patients helps them understand my knowledge and why I am asking them to do what they need to do.” By Kaitlyn Bailey
“Rachel cured me in less than five minutes,” Lisa recalls. “It’s crazy to think that something I had been living with for 17 years was fixed within five minutes.” Boone.Health/My-Boone-Health
21
B R IN G IN G UP B O O N E B A B IES
NURSING AND PUMPING TIPS Breastfeeding is not only a nutrition option that’s best for your baby’s development, it can also be a valuable bonding experience. As a nurse and lactation consultant, I encourage you to enjoy the sweet memories you're making with your child. Of course, there will be times when you may be unable to nurse your baby but still want to provide your little one with the nutritional benefits of breast milk. Whether you’re waiting on a new baby to arrive or they’re already here, you may have questions about how to pump breast milk, especially when you return to work. Here are some helpful pointers to get you started and keep you going!
WHEN SHOULD I START PUMPING?
Unless your baby is unable to latch, I encourage most moms to wait before pumping and not start right after delivery. Always put your baby to the breast first before you pump, so that you can establish a good latch early – and then feed your baby often. For mothers whose babies are in our NICU, we recommend pumping or handexpressing breast milk shortly after delivery to provide stimulation to the breast.
CAN I EXCLUSIVELY PUMP AND BOTTLE-FEED MY BABY?
Yes. Many women are successful with pumping and feeding, however, the first few days of pumping may be discouraging for moms. This is because colostrum is very thick and hard to pump – most moms will see nothing or just a few drops from their first few days using a breast pump. Nursing babies can pull colostrum out much better than pumps or hand-expressing. For best results, start breastfeeding, then transition to pumping and feeding once your full milk supply is in. Count your baby’s wet diapers (see chart) and watch for weight gain to make sure your child is getting enough to eat. In their first few days, your baby only needs small amounts of breastmilk often. If you think your baby is not getting enough to eat, contact your physician or nurse.
HOW OFTEN SHOULD I PUMP? BY TARA PHILLIPS, RN, IBCLC, NURSE AND LACTATION CONSULTANT, BOONE FAMILY BIRTHPLACE
22
BOONE HEALTH
Summer 2021
You should pump and feed between 8 to 12 times within 24 hours – ideally, this means you’ll be pumping and feeding every 1 to 3 hours around the clock. Your breasts need this stimulation to produce breast milk – the more milk that is taken
HOW MANY WET DIAPERS IS NORMAL? out, the more milk your body will make!
HOW DO I USE A BREAST PUMP PROPERLY?
Follow the instructions that come with your pump, including the correct sizing for your flange. If you have questions about your flange size, talk to your physician or lactation consultant. Pumping should not hurt. Breast pumps are designed to mimic the speed and suction strength of a baby. The suction strength should be set for your maximum comfort level and should never cause nipple trauma. The speed should also simulate how a baby nurses: Use a faster speed when you start pumping to get milk to start flowing, then you can reduce the speed to drain the breast.
HOW DO I GET A BREAST PUMP? WHAT ELSE SHOULD I BUY WITH IT?
Most health insurance companies offer a free breast pump when you have a baby. Check with your insurance provider about where to order. You can also check the website aeroflowbreastpumps.com to see which pumps your insurance company offers, plus instructions on how to order. A hands-free pumping bra is helpful. It allows your hands to be free to massage the breast while pumping, which can increase your milk supply. When ordering pumping supplies, I say less is more. Many moms order too much, only to wind up with products they don’t use.
HOW CAN I PREPARE TO PUMP WHEN I RETURN TO WORK? • Federal law requires employers to give employees reasonable break time to pump breast milk for a nursing child for one year after the child's birth. They are also required to provide a place, other than a bathroom, that is shielded from view and free from intrusion by coworkers and the public, to express breast milk*. Talk to your boss about planned pumping breaks and where you can store your milk. Breast milk is a food product, so it is safe to store in the refrigerator at work. • Look for a childcare option that will support your breastfeeding journey. • While at home, continue to breastfeed to encourage milk supply and enjoy skin-to-skin contact with your little one. • Try to pump every time your baby would normally feed during the day. This will also help your milk supply. • Increase your water intake and eat a well-balanced diet to help with milk production. • Decreased stress also helps. Try to set a calm atmosphere when you pump at work – play videos or look at pictures of your baby to help with letdown. • Get support! Connect with a breastfeeding support group to share your questions and experiences with other moms. Remember, breastfeeding is also a learned skill. Boone Family Birthplace’s Better Beginnings with Breastfeeding classes provide education, support and guidance. Sign up online at www.boone.health/birthplace
LOOK FOR LIGHT YELLOW TO CLEAR URINE. DAY ONE:
1 WET DIAPER
DAY TWO:
2 WET DIAPERS
DAY THREE:
3 WET DIAPERS
DAY FOUR:
4 WET DIAPERS
DAY FIVE:
5 WET DIAPERS
DAY SIX AND ONWARD:
6 WET DIAPERS
*Break Time for Nursing Mothers, U.S. Department of Labor, www.dol.gov/agencies/whd/nursing-mothers
Boone.Health/My-Boone-Health
23
GETTING TO KNOW A BHC DOCTOR
Dr. Christopher Schiavo Boone Hospital Center Hospitalist
I
grew up in Saint Louis, attended medical school at UMKC and completed my residency training at IUPUI in Indianapolis, Ind. I married my college sweetheart Kaitlin in 2015. In 2019, we moved to Columbia, my wife’s hometown, where I began working for Boone Hospital while my wife opened her own dermatology practice. We welcomed a new addition to our family in 2020 – our energetic and always curious son, Jax.
Why did you get into the health care field? Beside always loving science and helping others, my volunteer experiences in a NICU unit during high school for the March of Dimes let me observe first-hand how doctors could positively impact patients and their families, which motivated me to pursue my career in medicine. What interested you in your particular specialty? I was interested in the variety that hospitalist medicine offers and the opportunity to work closely with other medical specialists. The patient mix is always different, so no two days are quite the same, and the work is always challenging, interesting and engaging. What is the most rewarding aspect of your job? Being able to see the transformation of my patients throughout their stay is the most rewarding experience. When patients are first admitted to the hospital, they are often feeling unwell, scared and vulnerable. During this distressing time, patients place their trust in their physicians to take care of them. By treating the patient’s illness and providing compassionate care, it is remarkable to witness their improvement. And it is always wonderful to see patients returning home feeling well again. What is the most challenging aspect of your job? The lack of continuity can be challenging. While I enjoy the higher acuity that hospital medicine entails, I am envious of the primary care providers who have long term relationships with their patients. Since I only have the opportunity to take care of patients during their hospitalization, I often wonder how they are doing after they have left my care. What advice would you give someone looking to become a doctor? Pursue as many shadowing and volunteering opportunities as you can to gain insight into the medical field. Medicine continues to evolve and become more specialized. It can seem daunting, but more exposure to the field may confirm your decision to become a doctor. While it takes many years and significant dedication to
24
BOONE HEALTH
Summer 2021
become a physician, it can be extraordinarily rewarding. If you have the interest and the ambition, never stop your pursuit. What do you see changing in health care in the next five to 10 years? I think it will be interesting to see how telemedicine evolves over the next several years. Physical exams are such a large component of medicine that I see limitations in its utility; however, we have had great experiences using telemedicine at Boone Hospital to provide specialty consultations with infectious disease physicians and psychiatrists. I anticipate telemedicine will bring more specialized services to patients who would otherwise not have access to them, which will be beneficial to the healthcare system. What do you enjoy doing outside of work? My wife and I love to cook and try new recipes together. This year, we’re also trying to plant some of our own vegetables in our backyard garden. We hope to be able to use some of the vegetables that we grow in our cooking! We also enjoy taking walks in the park with our favorite puppy, Marley. What advice would you give to someone who is going to be a patient in a hospital for a period of time? This year has been especially difficult for patients and their families. COVID-19 has brought visitation restrictions at most hospitals which have left many patients feeling isolated. If you ever feel lonely, do not hesitate to let us know. Your care team members will be happy to arrange a video or phone call for you to talk to your friends and family members. Most importantly, we will always be there to lend an ear and talk with you.
GETTING TO KNOW A BHC NURSE
Laura Schneider, MSN, RN, CEN Emergency Department
I
was raised in Hermann, Missouri, the greatest place in the world. I did my undergraduate studies at State Fair Community College in Sedalia. While working at Boone Health, I completed my BSN and MSN through Central Methodist University. I have worked in the Boone Hospital Center Emergency Department since 2013. My husband, Todd, and I are raising our three children, Briggs, Baylor and Bodee, in his hometown of Mount Sterling, MO.
Why did you get into the health care field? My dream since I was young was to be a labor and delivery nurse. I couldn’t imagine anything more exciting than being a part of the happiest day of a person’s life. Plus, I love talking and, in health care, there is always someone around to talk to. What interested you in your particular specialty? My nursing instructors had a few years of listening to me talk about my dream of being a labor and delivery nurse. For my senior practicum they made me go to an emergency room instead. I fell in love with that specialty very fast and have yet to work in Labor and Delivery — the days in the Emergency Department are never boring or the same. What is the most rewarding part of your job? The most rewarding part of my job is having the opportunity to make a difference in a patient's or family member's life on what may be the worst day they’ll ever have. But I also take pride in getting to work alongside of some of the most intelligent, amazing people I’ve ever come in contact with. What is the most challenging aspect of your job? The most challenging part is knowing that we can’t “fix” everyone. That’s a hard one to swallow. What do you see changing in the next 5 to 10 years? The advancement in healthcare technology is rapidly growing. I think that’s a trend we will continue to see. What has changed in your field since you started practicing? Health care is constantly evolving. There are now
different EMRs, telehealth options, and so many other changes, especially with the pandemic this past year. What do you enjoy doing outside of work? Spending time with my family. Our kids love being on the farm, so I spend many days with them on our cattle farm. What advice would you give someone looking to become a nurse? Do it! Nursing isn’t a job, it’s a lifestyle. You will never find a more rewarding yet challenging profession.
Boone.Health/My-Boone-Health
25
Hit the
Trails Missouri offers thousands of options for enjoying outdoor exercise.
26
BOONE HEALTH
Summer 2021
W
ith warmer weather and the sun shining, it’s a great day to go for a hike. Over 1,000 hiking trails across Missouri offer a great opportunity to enjoy fresh air, invigorating exercise and impressive landscapes, including beautiful groves of trees, granite rock formations over 1 billion years old at Elephant Rocks State Park in Belleview, and waterfalls at Rocky Falls near Van Buren.
PLAN YOUR HIK E
Before you venture out, always plan your hike ahead of time. Know what the weather will be like that day and decide what you need to bring with you. Every person should take a water bottle, good hiking shoes and appropriate clothing for the weather. During the cooler months, dress in layers so you can adjust clothing to your comfort level. You don’t need expensive equipment to get started – athletic shoes are fine for hiking paved and less rugged trails. (If you’d like to get comfortable hiking boots, read below for tips.) And don’t forget to wear and bring your sunscreen!
KNOW THE TRAIL
Missouri trails have various difficulty levels. It’s best to start with easier trails and then progress with distance and difficulty level as you get more experience. For safety, try to hike with a friend who has some hiking experience. You can also use websites to find trails that will accommodate your fitness level and experience, including wheelchairaccessible trails: • www.alltrails.com/us/missouri • www.traillink.com
You should also check the state parks website for: • Trail length and ruggedness — easy, moderate, challenging or difficult. Many parks offer multiple trails for different fitness levels • Temporary closings due to trail maintenance • Public restrooms and picnic areas • Dog-friendly trails — please use a leash with your pet! • Hunting seasons. Whatever season it is, always stay on the trail for your safety. You’ll also be less likely to step on a snake or stumble into poison ivy!
FIND THE RIGHT SHOES FOR YOU
While athletic shoes will work for walking easy and moderate trails, boots can enhance your comfort and safety on more adventurous hikes. Ellen Turner’s “Guide to Choosing the Right Hiking Boots” at muchbetteradventures.com says comfort is important when shopping for hiking shoes. Lighter shoes are comfortable for long hikes. If you need ankle support for rugged trails or weak ankles, consider hiking boots instead of a hiking shoe. Boots should be sturdy yet allow for bending. Try on several pairs of boots to compare each shoe’s weight and comfort. Wear hiking socks when you try on new shoes. Hiking socks are wool or polyester-blend socks that offer protection against water and weeds. Walk around in the shoes or boots before buying to get a sense of their
overall comfort. Pay attention to whether or not the shoes rub against your heels. Boots should allow wiggle room in the front and top of the shoe. If you’re inbetween sizes, Turner recommends going up to the larger size. Decide if you want a leather or fabric boot based on your hiking plans. Leather boots typically last longer, but they can be heavier and warm in the summer. Waterproof boots are great for walking in wet weather and terrains. After selecting for comfort, compare the cost of the boots. Look for the highest quality boot you can afford. Generally, you get what you pay for, so expect to pay more for good hiking boots. Search online for customer reviews, brand comparisons and different price options. After purchasing new hiking boots, break in the boots by first wearing them on shorter hikes. Make sure the boots feel comfortable before going on a longer hike.
ADDITIONAL PREPARATIONS In addition to bottled water and weatherappropriate clothes, good supplies to bring on a hike include sunscreen – apply before you leave the house and bring some with you to reapply later, especially after sweating – a hat, a small snack like a granola bar, and a GPS device like Alltrails or Gaia GPS. Hiking sticks and poles can provide stability and help you keep your balance as you hike. To prevent muscle soreness, always stretch after hiking. Take pictures of the scenery but remember to leave nature where you found it for everyone to enjoy. Above all, enjoy hiking the trails and taking in all the beauty that nature offers! By Gretchen Holmes, MS, Boone Health Exercise Physiologist
Boone.Health/My-Boone-Health
27
WELLNESS
WHEN IN SEASON
Know the best time to buy produce and enjoy the benefits!
W
hen produce is said to be in season, that means it’s at its ripest and most plentiful, making it the best time to enjoy those fruits and vegetables. For example, fruit is in its prime during the summer months in the Midwest. Many berries, watermelons, peaches and plums will be the freshest from July to mid-September or even into October. Why buy produce in season? • The produce is cheaper. Unless there has been unusual weather or crops have been damaged, in-season produce will be significantly cheaper than in off-season months. Check local grocery ads for sales on in-season fresh fruits and vegetables. • In-season produce tastes better. In addition to being picked at peak harvest and ripeness, in-season produce is usually fresher because it has less distance to travel to the grocery store. • It’s easier to find at your local farmers' market. Buying produce at a farmers’ market also gives you a direct line to the grower, so you can ask questions about the produce and how it was raised. • Knowing when produce is in season can help you grow your own fruits and vegetables. Even if you’ve got one tomato plant on your porch, it’s still rewarding to eat something you grew yourself.
What if I need produce that’s not in season? • Frozen fruits and vegetables are a great substitute for fresh produce. Sometimes, it can be more cost-effective to buy frozen. Frozen produce is also picked at peak ripeness and immediately frozen, so you still get a quality product. • Buy fresh produce in season, then freeze it for later months. According to the USDA, most fruits and vegetables will last 8 to 12 months if frozen from the date of purchase. • Don't forget about canned goods. Canned fruits and vegetables have a longer shelf life than their fresh or frozen counterparts. • When buying canned fruit, watch out for added sugars from syrups – fruit is already sweet enough! Instead, look for no-sugar-added or packed-in-juice canned fruit. • When buying canned vegetables, try to choose products with as little sodium as possible. Look for no-salt added or low-sodium canned vegetables. Having a recipe for fresh, in-season fruits and vegetables can inspire you to buy and enjoy these healthy foods. Here are some easy summertime recipes for in-season summer produce! By
Kate Lohman, MS, RDN, LD, Boone Health Cardiovascular Rehab
The Seasonal Food Guide (seasonalfoodguide.org) is a great resource to look up seasonality of fruits and vegetables by state, month or produce type. You can also download the Seasonal Food Guide app, which includes cooking tips for produce and lets you set reminders when specific produce comes into season.
28
BOONE HEALTH
Summer 2021
Bluey Smoothie Recipe from the American Heart Association as part of their Healthy For Good initiative at recipes.heart.org
INGREDIENTS • 1 cup blueberries, frozen • 2 cups peaches, sliced, frozen • 2 cups spinach • 1 cup milk, fat-free • 1 teaspoon honey
DIRECTIONS • Add all the ingredients into a blender. • Blend until the mixture is smooth, about 1 to 2 minutes, stopping to scrape down mixture if needed. • Pour into 2 glasses and serve.
Berry Compote Recipe adapted from the Pritikin website at www.pritikin.com
INGREDIENTS • 1 cup berries (use your favorite!) • 1 tablespoon Splenda
DIRECTIONS • In a saucepan, combine ingredients and cook over medium heat until thickened. Stir occasionally. • Reduce heat and continue cooking until reaching desired thickness. • Serve on top of oatmeal, pancakes, ice cream, etc.
Boone.Health/My-Boone-Health
29
FOUNDATION NEWS
Columbia Professional Firefighters Donation On March 3, Columbia Professional Firefighters IAFF Local 1055 presented Boone Hospital Foundation with a check for $2,363. This generous gift was directed to Boone’s Harris Breast Center and was made in honor of Rachel Smith. Rachel is an assistant fire marshal with the Columbia Fire Department and has served this community for nearly 20 years. Rachel was diagnosed with breast cancer in September 2019. After multiple tests, surgery, chemotherapy, and radiation, Rachel is still serving the citizens of Columbia. She is grateful to her Missouri Cancer Associate physician, Dr. Liana Makarian, and the Harris Breast Center staff for the care she received. After Rachel received her diagnosis in 2019, her colleagues rallied around her and sold T-shirts to the community to show their support and to raise both awareness and funds. Our community is fortunate to have such a compassionate group who gives back to help other strong women like Rachel. Thank you, Columbia Professional Firefighters, for your donation.
Supporting Nursing Certification Over the past year, Boone Hospital Foundation has proudly funded 25 nurses from various departments to assist them in achieving certification in their specialty area. Boone Health continually sets goals to increase the certification rate of nurses and help in their personal and professional growth, which ultimately leads to providing the best patient care possible. Research shows that having a larger share of nurses with bachelor's degrees and certifications improves mortality rate. Certified nurses demonstrate they have the knowledge, skills, and abilities to provide high quality care to patients and improve clinical care. The nurses of Boone Health are an instrumental part of this hospital, and we are proud to be a part of their journey towards advanced nursing education. This investment literally touches thousands of patients and helps Boone Hospital Center be one of the best places to receive care in mid-Missouri.
Hospital Week Yogurt Bar On May 12 the Boone Hospital Foundation showed their appreciation to Boone Health’s dedicated staff by providing a yogurt bar. It was such a treat to give back to our health care professionals and physicians after a stressful year battling the pandemic. We also wanted to show our gratitude to our dedicated colleagues who have been working tirelessly before, during, and after our transition to becoming Boone Health. Left to right: Bree Anderson, Foundation Coordinator; Paul Mehrle, Board President; Dr. James Roller, Board Member; Jan Beckett, Board of Trustees Representative and Board Member; Barb Danuser, Executive Director; Troy Greer, Boone Health CEO
30
BOONE HEALTH
Summer 2021
O UR
CENTENNIAL
Com m u n it y C a mp ai g n
Continues
2021
CALENDAR OF EVENTS JULY 12
Golf Tournament AUGUST 24 - 25
Scrubs on Site OCTOBER 21 - 22
Scrubs on Site OCTOBER 30
Centennial Gala Commemorating Boone Hospital's 100 Years of Service We are so incredibly thankful for the community support we have received already. If you are still interested in supporting our 2021 Centennial Community Campaign, donate through our website at www.boone.health/Foundation. One hundred percent of your donation will go towards the cause and fund you designate it for. Thank you for sharing the gift of health!
Your gift advances a legacy of caring. C ELEBRATING OUR PAST ... EMBRACING OUR FUTURE !
DECEMBER 2021
CoMo Gives Campaign Thank you to our 2021 Board Members Leadership Board President: Paul Mehrle
Boone Health Representative: Amy Begemann
Board VicePresident: Betsy Vicente
Active Boone Physician Representative: Dr. Tim O’Connor
Board Secretary: Nancy Thomas Board Treasurer: Larry Swindle
Community Members Wally Bley
Representatives
Sara Jeffrey
Board of Trustees Representative: Jan Beckett
Will Markel
Board of Trustees Representative: Randy Morrow
Dr. James Roller Genie Rogers Jolene Schulz Becky Willard
Boone.Health/My-Boone-Health
31
Boone Hospital Center 1600 East Broadway Columbia, MO 65201 573-815-8000
NONPROFIT U.S. POSTAGE
PAID
COLUMBIA, MO PERMIT 286
