Sunday, January 29, 2012

Comsewogue's Reindl's heartwarming story

January 29, 2012 by STEPHEN HAYNES / stephen.haynes@newsday.com
Hope Reindl, center, poses for a portrait with
Candace Reindl remembers the phone call -- "Come to the school! Hope collapsed!" -- and the frantic, frightening sequence that followed.
As the mother ran from their home to Comsewogue High School, little more than a block away, her initial thought was, "She must've injured her knee."
Candace entered the gymnasium to find her 17-year-old daughter unconscious on the basketball court, with two coaches performing CPR and more than 50 students huddled nervously. Candace joined in the resuscitation effort. No response, she said.
Hope stopped breathing for six minutes.
"You can't put into words what that's like," Candace said of that May 4 evening last year. "There are no words."
Inscribed on the back of Hope Reindl's Comsewogue bowling jersey, in place of her name, is "D-Fibb." It's short for defibrillator, the electronic device that shocked her heart back into rhythm and saved her life.
The senior joined the team this winter and has adopted the moniker. That she can make light of it now, nearly nine months later, "is nothing short of a miracle," Hope said.
Thanks to the quick thinking of coaches Justin Seifert and Rick Miekley, Hope survived a near-fatal heart attack in what doctors termed an "aborted sudden cardiac death."
"She would've died had she not had an immediate intervention," said Dr. Laurie Panesar, a Stony Brook University Medical Center cardiologist who treated Hope. "Sudden cardiac death is what it sounds like. It's scary because it's sudden and doesn't come with many warning signs."
It's also rare (one in 300,000) in youngsters with no genetic predisposition, Panesar said.
Hope, a lifelong athlete in good physical condition with no history of heart problems, according to her parents, collapsed eight minutes into an intramural basketball game.
"She scored a basket early but looked lethargic a couple minutes later," said Seifert, the girls varsity basketball coach. He was supervising the game, which started at about 7 p.m. "She suddenly stopped and went into a crouch, and I ran to her. I started talking to her, then she collapsed."
Seifert said he signaled for Miekley, the boys coach, and called 911. Hope's breathing was "labored," Seifert said, "and within a minute, it stopped."
The coaches said they had a student retrieve the AED (automated external defibrillator) from the hallway just outside the gym while they performed CPR. Shortly thereafter, Hope's mother arrived.
"I was yelling, 'Come back! Fight!' '' said Candace Reindl, a former elementary schoolteacher who had received CPR training.
Once the device was set up, "it started looking for a heartbeat and then warned that a shock was advised," Seifert said. He and Miekley were putting their AED training to use for the first time. "You hit the button, stand back and pray."
Hope soon gasped for air, he said, and they continued CPR until the paramedics arrived.
"The stars aligned well for this girl," Panesar said, adding that the resuscitation was "tantamount to what she'd have gotten in an ER."
Hope was taken to Mather Hospital in Port Jefferson, where she was stabilized before being transferred to Stony Brook that night. Hope's father, Carl Reindl, said she regained consciousness the next morning (May 5), though she had difficulty processing and retaining information.
She had an internal defibrillator implanted (above the heart, beneath the pectoral muscle) on May 6, her parents said, and was discharged the next day. "All her organs were functioning normally," Panesar said, and she made quick progress.
Hope, who said she has no memory of the collapse or her time in the hospital, returned to school 10 days later.
"I never used to think anything could happen to me," Hope said. "To think, if I wasn't where I was, the outcome would've been very different . . . I can't thank enough."
Hope's May 4 varsity softball game had been rained out, and friends invited her to play pickup basketball. She was a star catcher drawing college interest and her parents, fearing a basketball injury, reluctantly permitted her to go.
What Hope suffered was "catecholaminergic polymorphic ventricular tachycardia," Panesar said. "It's an episode brought on by stimulation from the nervous system. In her case, it was sports."
Hope's life has mostly returned to normal, but she says she no longer can play sports that involve contact or can induce bursts of adrenaline. That includes softball.
She's now looking at colleges with visual arts and culinary programs. The ordeal and subsequent restrictions are "extremely frustrating," Hope said.
As well, Candace has concerns that her other children (Emma, 18, Owen, 14 and Aidan, 13) could be susceptible to a similar episode.
The positive, obviously, is that Hope survived and now is aware of the condition. She had felt palpitations "a few times" while catching on hot days, she said, "but I didn't think it was abnormal."
Monthly visits to the cardiologist have returned clean results and the internal defibrillator, which monitors heart rate, has detected no irregularities thus far, Carl said.
Last fall, Hope was cleared to participate in two scholastic sports: bowling and golf. She had bowled only recreationally ("maybe once a year'') previously, but she tried out two weeks before the season and earned a starting position. The 234 she rolled in her first game Dec. 6 "was like hitting a home run," she said.
Turns out Hope, who had received all-district honors in softball after batting .474 in her junior year, was good at even more sports than she realized. She finished the regular season with a 147 average and helped Comsewogue clinch the League III bowling title last week. The Warriors will compete in Saturday's Suffolk championship tournament.
"For someone who hadn't really bowled before to do so well," teammate Christina Raccasi said, "it's amazing."
Since the incident, the Reindls and Comsewogue have raised money for the Louis J. Acompora Memorial Foundation, which helps provide AEDs to schools. The Comsewogue boys and girls bowling teams share a device, coach Brian Frimmer said, and at home matches, it's kept in a bag at the foot of their scorer's table.
Hope has promised to be careful -- and Frimmer monitors her pace -- but at Hope's behest, teammates have agreed to "not baby me."
As for the "D-Fibb" nickname: "There's no point in being down about it," Hope said. "Why not have a little fun with it?"
Teammates Renee Rocco and Deanna Clark said Hope "being able to joke about it" makes everyone less worried.
"Remembering that day and then seeing her smile now is the most rewarding thing," Seifert said. "How happy she looks to be alive."
Posted by la12 at 4:58 PM
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Monday, January 23, 2012

  • AHA Scientific Statement

Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation

A Scientific Statement From the American Heart Association for Healthcare Providers, Policymakers, and Community Leaders Regarding the Effectiveness of Cardiopulmonary Resuscitation

  1. Benjamin S. Abella, MD, MPhil;
  2. Tom P. Aufderheide, MD, FAHA;
  3. Brian Eigel, PhD;
  4. Robert W. Hickey, MD, FAHA;
  5. W.T. Longstreth Jr, MD, FAHA;
  6. Vinay Nadkarni, MD, FAHA;
  7. Graham Nichol, MD, FAHA;
  8. Michael R. Sayre, MD;
  9. Claire E. Sommargren, RN, PhD, FAHA;
  10. Mary Fran Hazinski, RN, MSN, FAHA
Key Words:
 
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Introduction

Sudden cardiac arrest (SCA) is a leading cause of death in the United States and Canada. In the United States, each year ≈330 000 people die of coronary heart disease out of the hospital or in emergency departments. Of these, >150 000 SCAs occur out of the hospital.1,2 Despite the development of electrical defibrillation and the more recent implementation of lay rescuer defibrillation programs, the vast majority of these victims do not leave the hospital alive. In studies over the past 15 years, only 1.4% of patients with out-of-hospital arrest in Los Angeles, Calif, survived to hospital discharge3; in Chicago, Ill, the number was 2%,4 and in Detroit, Mich, it was <1%.5 Conversely, a few municipalities such as Seattle, Wash, report much higher survival rates from SCA—more than 15% in 1 study6—which suggests that survival rates need not remain so low. Recent work in Europe and elsewhere has confirmed that a higher survival-to-hospital discharge rate is indeed a realistic goal, with survival rates as high as 9% reported in Amsterdam7 and 21% in Maribor, Slovenia.8
The American Heart Association (AHA) uses 4 links in the “chain of survival” to illustrate the time-sensitive actions required for victims of SCA: (1) early recognition of the emergency and activation of emergency medical services (EMS), (2) early bystander cardiopulmonary resuscitation (CPR), (3) early delivery of shock(s) from a defibrillator if indicated, and (4) early advanced life support and postresuscitation care. Immediate bystander recognition of the emergency and EMS activation are critical. In many communities, however, these actions may be followed by significant delays, because the time interval from activation of EMS to arrival of these medical personnel may be 7 to 8 minutes or longer.4 Therefore, initial care in the first critical minutes after SCA, including performance of CPR and potential use of an automated external defibrillator (AED), depends on the actions of people near the victim. Although the majority of cardiac arrests occur in the home, the presence of trained and willing rescuers and the availability of an AED are critical whether the cardiac arrest occurs in a public space or at home.
Every 5 years, the AHA Emergency Cardiovascular Care (ECC) Committee publishes revised guidelines for resuscitation care.9 The “2005 American Heart Association Guidelines for CPR and ECC” emphasize 3 important concepts:
  • High-quality CPR is an important determinant of survival from SCA.
  • More victims of out-of-hospital SCA should receive bystander CPR.
  • CPR must be performed effectively by bystanders and healthcare providers.
CPR is an inexpensive and readily available technique that can save lives. Therefore, the number of people trained in CPR must increase, and the quality of CPR provided by every rescuer must improve.
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Background: Bystander CPR Can Save Lives

Cardiac arrest is defined as the sudden cessation of functional cardiac mechanical activity, as confirmed by the absence of signs of circulation, including absence of response to stimulation, absence of breathing, and absence of a detectable pulse. SCA is often precipitated by a sudden arrhythmia, ventricular fibrillation, which causes the heart to quiver so that it cannot generate blood flow. The treatment of ventricular fibrillation requires chest compressions and delivery of shocks with a defibrillator. Chest compressions during CPR can generate a small but critical amount of blood flow to vital organs such as the brain and heart until circulation is restored by defibrillation or other therapy.
A number of reports have illustrated that bystander CPR can substantially improve rates of survival from SCA.10–14 A bystander is a person who happens to be near the victim and who is not part of the organized emergency response system. In most events, the bystanders do not have professional healthcare education. Earlier initiation of CPR improves survival rates, and when bystanders perform CPR well, the victim’s chance of survival improves. In several studies, high-quality CPR was associated with a marked improvement in survival to hospital discharge.10–12 Furthermore, recent evidence suggests that CPR may be particularly important in cases of prolonged cardiac arrest (ie, an arrest duration of >4 to 5 minutes without treatment).15,16
CPR is a highly accessible therapy that requires little medical training and no equipment when provided in its most basic form. Potential rescuers from school age to the elderly can learn CPR skills. In places where widespread first-responder CPR training has been provided (eg, as part of community lay rescuer AED programs), survival rates from witnessed SCA associated with ventricular fibrillation have been reported to be as high as 49% to 74%.17,18 Therefore, equipping the public with the skills to perform the first 3 links in the AHA chain of survival can make a dramatic difference in survival from SCA.
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The Problem: Bystander CPR Rates Are Low

If bystander CPR can markedly improve outcomes, why are survival rates from out-of-hospital SCA still so poor? The low rate of bystander CPR performed is a significant contributor. Studies have documented that in many communities, only 15% to 30% of SCA victims receive bystander CPR before EMS personnel arrive at the scene.19,20 Low rates of bystander CPR have been documented even in settings where trained rescuers were present. Given that the time interval for EMS arrival is often 7 to 8 minutes or longer and that survival falls 7% to 10% for each minute without CPR,13 the lack of bystander CPR has a large impact on outcomes.
Some investigations have shown that even when CPR is performed by trained healthcare professionals, the quality of CPR delivered is often poor and often does not comply with AHA guidelines.21,22 These observational studies documented the fact that experienced providers delivered chest compressions that were too shallow, were interrupted frequently, and, in 1 report, were accompanied by an excessive rate of rescue breathing.
A number of theories have been proposed to explain why bystanders hesitate to perform CPR even when trained. Some surveys indicated a reluctance among some potential providers to perform mouth-to-mouth breathing, in part because of concern about transmission of infectious disease. However, a recent survey of bystanders who were present at actual arrest events does not support this concern.23 Another impediment to the learning and delivery of bystander CPR may be the complexity of resuscitation guidelines and instructional materials. Such complexity increases the likelihood that bystanders will fail to learn CPR skills, will fail to recall them, or may lack the confidence to perform CPR because they fear performing it incorrectly. This “fear of failure” is the most commonly cited concern in a recent survey of bystanders who witnessed an SCA event.23 In addition, some bystanders may decline to perform CPR because of fear of legal liability because they may not be aware of the “Good Samaritan” legislation that provides limited immunity for rescuers in the majority of states and municipalities.
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Recommendations to Increase Rates of Bystander CPR

CPR is a potentially lifesaving intervention that can be implemented by the public without the need for expensive equipment or professional credentials. If the rate and quality of bystander CPR are increased substantially, the potential exists to save the lives of thousands of victims of SCA each year. A number of straightforward methods can achieve this goal.

Broaden CPR Training

To accelerate CPR education, creative new approaches are required to reach a larger public audience. The development and validation of a 22-minute self-instructional CPR course by the AHA (Family and Friends CPR Anytime) has provided a tool for education outside the classroom (Table).24 Community and corporate programs should be developed to encourage CPR education with both traditional and self-instructional CPR training programs. One route to broader CPR training might be through recently developed AED programs. The Cardiac Arrest Survival Act (CASA; Public Law 106-505) mandated establishment of lay rescuer AED programs in federal buildings (Table). A large number of municipal and state governments have recently instituted mandates for AED programs in public sites such as schools, shopping malls, and gymnasiums. Governmental agencies should be encouraged to provide CPR training for anticipated rescuers as part of a comprehensive community lay rescuer AED program. Creative approaches might yield important results. For example, legislators might consider training in basic CPR as a prerequisite for high school graduation or encourage programs to provide hospital-based CPR training to family members of patients at risk for SCA. The AHA has provided information to schools to help them prepare to respond to medical emergencies, including SCA.25
View this table:
Table. Examples of Internet Resources for CPR Training and Implementation
However, expanded CPR training may not provide a solution for the large fraction of cardiac arrests that occur in the home, where only a few untrained witnesses may commonly be present. The development of dispatcher-assisted “telephone CPR” may allow for CPR instruction in real-time even when rescuers have not received prior training and otherwise might not participate in a resuscitation attempt. This may be especially important for the majority of arrests that occur at home, without the availability of either trained rescuers or AEDs. Studies have investigated variations of dispatcher-assisted CPR instruction26,27 and have found this “training” method to be a promising technique to engage bystanders in direct resuscitation care. Communities should implement dispatcher-assisted CPR programs based on currently available models, because they represent a cost-effective method to reach the most important population: untrained witnesses to actual cardiac arrests. Such programs will require special attention to the actual recognition of cardiac arrest itself so that CPR can be initiated. For example, bystander reports of patient “breathing” must not overlook the gasping respiratory pattern common in early cardiac arrest and therefore miss opportunities for bystanders to provide CPR.28

Provide Reassurance to Increase Participation

Bystander reluctance to perform CPR is a crucial barrier to lay rescuer action during an emergency and must be addressed. The public should be informed that the risk of disease transmission is very small. There have been no reported cases of transmission of human immunodeficiency virus (HIV) or hepatitis through performance of CPR. In conjunction with Occupational Safety and Health Administration recommendations for workplaces, policymakers should mandate that mouth-to-mouth barrier devices and gloves be available wherever AEDs are stationed, to facilitate CPR performance in addition to AED use. Information about Good Samaritan legislation should be included in CPR classes and materials and posted prominently near AED installations. The public must understand that when bystanders perform CPR immediately, the victim’s chance of surviving cardiac arrest can double or triple at little risk to the rescuer.

Improve EMS and CPR Quality

Community lay rescuer and EMS programs should include a process for continuous quality improvement that includes a review of resuscitation efforts, quality of CPR, and CPR instructions provided to bystanders by dispatchers. Healthcare provider systems that deliver CPR should implement continuous quality-improvement processes that include monitoring the quality of CPR delivered during any attempted resuscitation. These monitoring data should be used to maximize the quality of resuscitation care delivered, including the quality of CPR performance. At present, a variety of devices have been developed to both measure and provide feedback on the performance of CPR in the form of either defibrillators with additional CPR monitoring capabilities or stand-alone devices that can be used by rescuers even before a defibrillator can be brought to the scene of an arrest.21,22,29–31 Some of these devices can also record CPR performance and provide opportunities for debriefing and training. Such tools may have an important impact on this quality-improvement goal in coming years.

Future Directions

Several newer training modalities may have a great impact on CPR training in the near future. The use of Internet–based CPR education and certification may augment the reach of current training programs, especially in light of the expanding access to the Internet via television, mobile telephone, and other personal devices.32 Under certain circumstances, simpler methods of bystander resuscitation, such as chest-compression-only CPR, may also encourage broader participation and remain an area of active scientific investigation.27 For EMS, hospital systems, and other professional CPR providers, the use of rigorous simulation with video recording and debriefing may serve as a staple in resuscitation training; the use of such patient simulators is a rapidly expanding area of current research.33,34

Research Recommendations

To address possible methods to increase bystander CPR participation, a number of important research questions deserve attention. What educational methods lead to the highest quality of CPR in the broadest fashion possible? What are the optimal target populations for CPR education (ie, who is most likely to witness a cardiac arrest event)? Can dispatch-assisted CPR successfully provide “just-in-time” training in a variety of communities? What are the public perceptions that serve as barriers to CPR participation? Targeted funding for such research questions may yield new directions to strengthen the CPR link in the chain of survival.
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Recommendations Summary

On the basis of the above discussion, the following recommendations can be made:
  • Government agencies at the local, state, and federal level should provide CPR education in such settings as school systems and government-funded hospital and clinic systems.
  • EMS and 9-1-1 systems should implement and support dispatch-assisted CPR programs.
  • CPR instructors, EMS leaders, and government agencies should strengthen public awareness of Good Samaritan laws and of the dramatic lifesaving potential of bystander CPR.
  • EMS systems and CPR instructors should focus efforts on rigorous CPR performance and quality-improvement efforts in resuscitation care; when CPR certification is needed, CPR instructional programs should always include an objective CPR quality assessment for certification.
  • Research funds should be targeted toward improving methods of CPR education, improving skill retention, and developing creative methods to widen the scope of current CPR training and education.
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Conclusions

To maximize the chance of a successful resuscitation outcome, CPR must be started as soon as possible after a victim of SCA collapses. Improved survival rates depend on a public trained and motivated to recognize the emergency, activate EMS or the emergency response system, initiate high-quality CPR, and use an AED if available.
Ample evidence has shown that CPR works. “Pushing hard and pushing fast” maintains a small but critical amount of blood flow to the brain and heart that can significantly improve the chance of survival for victims of SCA. Performance of high-quality bystander CPR can be increased through widespread dissemination of self-instructional CPR courses, effective public education about the low risks of performing CPR, continuous CPR quality-improvement processes for lay and professional rescuer programs, and meaningful legislative initiatives designed to support and encourage layperson action during an emergency. Through these actions, which are intended to encourage and broaden CPR training, thousands of additional lives can be saved every year.
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Acknowledgments

Disclosures
View this table:
Writing Group Disclosures
View this table:
Reviewer Disclosures
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Footnotes

  • The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
  • This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 13, 2007. A single reprint is available by calling 800-242-8721 (US only) or by writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0436. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
  • Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.
  • Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the “Permission Request Form” appears on the right side of the page.
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Sunday, January 8, 2012

Parents credit optional athletic heart screening for saving son’s life

Mary Garrigan Journal staff | Posted: Saturday, January 7, 2012 6:00 am

It was the best $60 that Scott and Sarah Lepke ever spent.



In November 2010, the Lepkes opted to pay the extra money for an optional athletic heart screening for their son, Matt. The ultrasound test, through Transmed Inc.'s Screening America program, was offered by the Beresford School Di strict. The Lepkes' decision was more about supporting the sports program at the school, where Scott was the high school principal at the time, than it was about any concern for their son's health.



"We never, ever thought that there was a problem with him. He'd been an athlete his whole life," said Sarah of her 12-year-old son.



But the ultrasound revealed a life-threatening defect in Matt's heart - a large hole between his left and right atrium that had been there since birth. So large, in fact, that it went undetected during routine physicals that might have caught smaller, noisier heart murmurs.

"That's the thing with murmurs - the bigger they are, the less likely you are to catch them," said Scott, who has been superintendent of the Custer School District since July. "His was so big, that it wasn't making a noise."



But a routine echocardiogram performed by an ultrasound technician at the Beresford school revealed Matt's severely enlarged heart. About two weeks later, the family received a letter advising them against any athletic activity until Matt could be evaluated by a cardiologist. The report propelled the Lepkes into a medical crisis that ended in open-heart surgery at a University of Minnesota hospital one year ago this month.



His parents credit the heart screening with saving their son's life, not to mention his basketball career.



Today, Matt is a healthy, happy eighth-grader in Custer who lettered in soccer this fall and is playing middle school basketball this winter. He was a baseball standout in Beresford last summer and ran track in the spring.



"Eight weeks after his heart surgery, he was playing in a basketball tournament," said his dad, even if he had to wear a special chest protector over his still-healing surgical scar.



Matt is thrilled to be back on the hardwood in Custer this season, and he's hopeful that his basketball career will include some time under the tutelage of Custer coaching legend Larry Luitjens. "Yeah, I really want to play for Larry Luitjens," Matt said.



The Lepkes, who joke that they are living their athletic dreams through their only child, say Matt was "raised in gyms" as his father's teaching and coaching career took him from Wayne, Neb., to Chamberlain, Yankton, Milbank and Beresford before the family moved to Custer in July. They hope Custer is their last move.



"We'v e been all over. We love it here," Scott said.



And as superintendent, Scott hopes to make heart screenings available to all Custer school athletes, regardless of their ability to pay.



The optional screenings cost $79. Scott is exploring the possibility of creating a foundation that would be funded by professional athletes with a connection to South Dakota, people who "would like to give back" to kids in their home state.



"I can't stress how important it is," said Scott. "I personally would like to see it done on every kid. Matt went to all his sports physicals and no doctor was going to pick up on this. So I've been trying to tell this story as much as I can. I talk to superintendents and athletic directors all over the state."



The screenings offer peace of mind to all parents, but for "that one kid" whose heart defect is discovered, it is "everything," he said.



Over the years, Matt's body had compensated so well for his overworked heart that there was no outward sign that he was sick.



Once cardiologists diagnosed his heart p roblem, they also discovered that his liver and spleen had become enlarged, too.



"He never, ever looked like a kid who needed heart surgery," his dad said.



But he did.



"The whole right side of his heart was enlarged," said Sarah, a registered nurse, who knew that Matt's heart tissue had stretched to accommodate the blood that it could no pump effectively. "As a nurse, I knew way more than I needed to know."



Today, the only sign of Matt's successful surgery is a long scar down the middle of his chest.



Even before the six-hour operation was over, his heart had returned to its normal size.



Although rare, hypertrophic cardiomyopathy - commonly defined as an enlarged heart - causes the sudden cardiac death of 3,000 or more young people annually, said Ne'Cole Werdel, a cardiac ultrasound sonographer for Transmed, Inc. Among those are high-profile athletes like NBA basketball star Hank Gathers, who died in 1990, and all-star pitcher Darryl Kile, who died in 2002.



< p class="MsoNormal">Recently, a star basketball player from Michigan shot his team's winning points before collapsing and dying from an enlarged heart. And during a Rapid City Stevens High School football practice in 2008, Ryan Gramberg, 16, collapsed and died of an enlarged heart.


Preventing sudden cardiac death in young athletes like Ryan or Matt - typically people ages 12 to 34 - is Screening America's mission, said Werdel. The company has offices in Sioux Falls and Watertown and offers screenings in schools statewide.



Custer hosted a screening for about 17 student athletes in October, and other area schools, including Lead/Deadwood and Newell, have of fered the screenings. Another is scheduled for Jan. 23 in Spearfish.



For now, Matt is focused on his first basketball game on Jan. 19, but his longer-term career plans always included becoming a doctor, even before his own health problems.



In light of his medical history, he says he has already picked a specialty: cardiology.



Contact Mary Garrigan at 394-8424 or mary.garrigan@rapidcityjournal.com
Posted by la12 at 4:11 PM
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