With as many as 30 bank robberies occurring in Washington state every month, the psychological effects on tellers can be devastating. To help them cope, the Harborview Center for Sexual Assault and Traumatic Stress (HCSATS) and the Federal Bureau of Investigation (FBI) began the Bank Personnel Group in early 1999, the first program of its kind in the nation.

“Bank personnel who attend this group are generally very loyal, long-term employees,” says Janet Brodsky, MSW, lead social worker for the Bank Personnel Group. “They are accustomed to handling stress well and staying calm. After an armed robbery, they often report nightmares, feel more vulnerable or trapped behind the counter, and in general find their ability to cope with stress is compromised.”

The Bank Personnel Group meets monthly at the HCSATS and gives bank employees access to immediate support and strategies for coping and recovering. Many participants have expressed instant relief when they meet others who share the same history and symptoms. So far, all the participants have been women.

One woman experienced 19 robberies in 15 years, but it was only after a friend was killed during one of them that she sought help. Another teller saw such a strong resemblance between the physical characteristics of the armed robber who held her at gunpoint and one of her friends that she later found it difficult to maintain the friendship. Although she was initially nervous about attending the group, she says, “the similarities between my own experience and other group members? experiences were astonishing and helpful.”

The FBI reports that there were 334 bank robberies in the state of Washington in 1999. These statistics place the Seattle Division of the FBI as the third largest division for number of bank robberies out of the FBI?s 56 national field offices. In 116 of Washington?s robberies, subjects either brandished a weapon or inferred that they were carrying one. It was confirmed that in 30 of these robberies the subject was wielding a deadly weapon.

According to Kera Wulbert, Victim-Witness Coordinator for the FBI, the FBI?s Seattle Division was inundated by requests from concerned bank managers to provide trauma debriefings following robberies for their affected bank personnel. “Bank tellers have to return to the scene of the crime every day and remain professional,” she says. “The Seattle Division recognized a void in available counseling services for this population of crime victims and sought to create new resources for them within King County. In developing the Bank Personnel Group, the collaborative goal of the FBI and Harborview, is to help innocent victims regain stability in the aftermath of experiencing a violent crime.”

Wulbert and Brodsky recently presented information about their program to bank managers from Washington and Oregon in an effort to encourage managers to replicate this model around the Northwest.

For decades, motor vehicle safety standards have been based on the results of tests with crash dummies. Now research being conducted at Harborview Medical Center that involves real crash victims may help to save lives and reduce injury.

Over the past three years the medical community has begun to share findings with automobile safety engineers through the Crash Injury Research and Engineering Network (CIREN), made up of eight trauma centers nationwide. One of these sites, Harborview, recently obtained renewed funding from the National Highway Traffic Safety Administration (NHTSA), with a five-year grant for $2.2 million. Initial funding was provided by General Motors.

Trauma centers and safety engineers now deposit crash information into a core database located at the Volpe Center in Cambridge, Mass. The data bank includes detailed information on the exterior and interior components of the occupants? cars along with a list of their injuries with corresponding X-rays and CT scans.

The mathematics of crash investigation are complex and injuries vary widely, depending on the degree and force of impact, says Dr. David Grossman, co-director of the Harborview Injury Prevention and Research Center (HIPRC), principal investigator for the project, and a 91̽»¨ (UW) associate professor of pediatrics. After a patient is admitted to Harborview and has consented to the research, HIPRC crash investigator Rob Kaufman visits the crash scene to take measurements and determine how the crash occurred. The damaged vehicle is then measured to calculate the force of the impact and the interior is thoroughly examined for occupant contacts, such as traces of skin and fabric, or even female makeup patterns on the air bag, which reveal the split-second stages of the crash.

Similar findings are often not obtainable through crash-dummy tests. Even when wearing seatbelts, the victim?s thighbones take significant force, depending on their position, says Dr. Allan Tencer, director of the biomechanics laboratory at Harborview and a 91̽»¨associate professor of orthopaedics. “But about 30 percent more force is added to the femur by contracting muscles when applying brakes or bracing for impact,” he adds. “Dashboard designs don?t take that extra force into account and they may be too stiff, despite dummy tests predicting that the forces acting on the femur are too low for fracture.”

The cars selected for investigation include all makes of passenger vehicles, light trucks and vans, but there is a special focus on later models equipped with airbags. Patients are selected for the severity of injuries, and they must have been restrained by either a seat belt or a deployed airbag, says Kathleen Loeffler, trauma research nurse for the CIREN project at HIPRC. She conducts interviews with survivors, who make up about 80 percent of the crash victims examined. Patients are followed after six to 12 months to see how they have recovered both physically and psychologically. Each trauma center reviews about 50 cases per year.

Injuries are graded by severity and mechanisms. Cases have shown that:

* In a head-on collision, the occupant can slide under the belt and dashboard if the seatbelt is worn too loosely. Sometimes the floor pan and dashboard can intrude and cause injuries. It?s crucial that the seatbelt be worn snugly.

* With more sport-utility vehicles and trucks on the road, many of these vehicles are crashing into smaller cars. In side collisions, there is a greater chance of chest injuries on the near-sided occupants because the impact is higher on the smaller car.

* Children often get injured because the shoulder straps on seatbelts don?t fit properly if they are not using booster seats.

* Passengers who use only the automatic shoulder strap without wearing a manual lap belt have a higher risk of liver lacerations. It is imperative that both of these belts be worn properly.

* Passengers wearing lap belts but no shoulder strap (usually in the back center seat), or who put the shoulder strap behind their back, have a higher risk of breaking the first or second lumbar vertebrae, causing paralysis or perforating the small bowel.

Event data recorders, now contained in late-model GM cars, can be very useful in reconstructing crashes, says Grossman. These record information such as when the airbag deploys, the crash force and whether the occupant was belted.

“Federal vehicle crashworthiness data can take up to two years to be released,” says Kaufman. “CIREN can get feedback to the engineers and NHTSA more quickly on the new models and help improve the safety designs. For the first time the medical community, automotive engineers, crash investigators and other related professions have united to improve trauma care and vehicle safety.”

Routine counseling in trauma centers for those injured due to alcohol abuse can significantly reduce further excessive drinking and prevent future injuries, according to a study at Harborview Medical Center, published in the November issue of Annals of Surgery.

Alcohol is often linked to trauma–about 50 percent of patients admitted to trauma centers throughout the United States are intoxicated, and among them approximately 85 percent have a serious problem with alcohol. Trauma centers routinely treat the injuries, but ignore the underlying alcohol problem, says Dr. Larry Gentilello, lead researcher of the study and a 91̽»¨ (UW) associate professor of surgery, based at Harborview.

Between October 1994 and November 1996, blood alcohol levels and questionnaires were used to screen 2,574 trauma patients for alcohol problems after they were taken to the emergency department of Harborview, a level 1 trauma center. Positive results were found in 1,153 patients, or 45 percent. Patients were randomly assigned to receive a brief, 30-minute counseling session on alcohol problems, or received standard trauma center care. Follow-up interviews were conducted at 6 and 12 months.

A total of 336 patients were randomized to the intervention group and 396 were randomized to the control group. The content and structure of the interventions varied according to the severity of the patient?s alcohol problem, but focused on communicating facts about how blood alcohol levels increase the risks of car crashes, boosting awareness of the patient?s responsibility and giving encouragement to help overcome the problem. A month later, the patients received letters summarizing the conversation and offering further support.

To obtain objective information that the intervention had a beneficial effect, researchers used records from every hospital within Washington state to determine if patients in the study were re-admitted to any hospital for treatment of a new injury over the next three years. There was a 48 percent reduction in injuries requiring hospital admission over the next three years.

The patients in the intervention group were found not only to have decreased alcohol use and trauma recurrence, but also a decrease in risk-taking behavior, such as driving while intoxicated arrests, traffic violations, alcohol-related arrests and other types of arrest.

A number of studies have documented that alcohol-related injuries motivate patients to reduce or stop their drinking, most likely because injury has a major impact on the patient that often reduces their drinking for a period of time, says Gentilello. The purpose of the intervention is to capitalize on the motivating effects of the recent, life-threatening injury in order to help patients take the steps needed to obtain counseling, participate in self-help groups, or take advantage of other means to reduce or eliminate their use of alcohol.

“We are not proposing that we have a cure for alcoholism by virtue of a 30-minute counseling session,” says Gentilello. “The intervention capitalized on the motivating effects of the injury, which resulted in a change in outcome when compared to controls, and that appeared to last for the study duration period.

“As with most chronic diseases, many patients will relapse. If an intervention is performed at each relapse event, whether it be in a trauma center, general medical ward, or even a doctor?s office, the overall effect may be a significant reduction in cumulative drinking amounts by the patients over their lifetime.”

Trauma centers are ideal sites for intervention programs because injuries are the leading cause of death for people with alcohol problems, and most alcoholics will injure themselves at one time or another, he adds. Furthermore, since one out of eight hospital beds in the United States are occupied by an injured patient, routine provision of alcohol counseling in trauma centers has the potential to have an enormous impact on public health.

The 91̽»¨ (UW) Chronic Fatigue Syndrome Cooperative Research Center, based at Harborview Medical Center, has received funding from the National Institute of Allergy and Infectious Diseases (NIAID) to examine familial predisposition to the illness.

The grant covers a second four-year stage for the multi-faceted research program that includes:

Comparing children of chronic fatigue syndrome (CFS) cases and children of healthy controls to determine the impact of parental illness;

Examining how the perception and responses of intimate partners of CFS patients impact the patient?s functional disability;

In-depth studies of identical twins (one with CFS and the other without).

Studies of twins are a unique opportunity to adjust for inherited and environmental factors such as exposures and early life experiences, according to Dr. Dedra Buchwald, lead researcher and director of center and 91̽»¨associate professor of medicine.

Over the past four years, the center recruited 312 pairs of twins from around the country for telephone interviews. Among them, 22 sets have come to Harborview for sleep studies, tests on immune systems, pulmonary and exercise function, immune and virological tests, brain mapping, cognitive tests and more. In the next four years, the same twin sets will return for more focused studies.

CFS causes severe unexplained fatigue among healthy adults or adolescents, affecting sleep and memory, and causing muscular and joint aches. Symptoms can lead to disability, both due to and resulting in psychological distress, social dysfunction and other factors that perpetuate illness.

Three CFS Cooperative Research Centers were awarded a total of $1.9million from NIAID. The other centers were the University of Medicine and Dentistry in Newark, NJ, and the University of Miami.

Hearing that a loved one has died after trauma could be the most emotionally devastating news one might ever hear. How this news is delivered has an immense impact on how people will later reflect on those initial moments of loss.

“You have to know that you?re creating a lifelong memory ? people will likely remember every detail of the conversation. Even if they don?t remember the words, they will remember the feelings,” says Becky Pierce, nurse manager of the Trauma Intensive Care Unit (TICU) at Harborview Medical Center in Seattle, who has spoken on the topic nationwide.

At Harborview, a study began in 1996 on how to best break bad news to people close to trauma victims. Interviews were conducted with 50 family members about six months following the death of a loved one who was treated in the Emergency Room or the TICU. The findings were presented Sept. 17 at the American Association of the Surgery for Trauma in Boston by Dr. Gregory Jurkovich, chief of trauma at Harborview Medical Center and professor of surgery at the 91̽»¨ School of Medicine.

The nurses who conducted these interviews sensed that those who felt their situations were handled well were able to move on more easily. “Although several people refused to respond initially, they later changed their minds,” says Pierce. “It was found that people were hungry to talk about their experiences and that everything was crystallized in their minds. If their memories were bitter, the anger was instantly expressed.”

The most important aspects of delivering bad news were attitude, clarity of information and privacy. “People didn?t like being strung along, and didn?t want any sugar-coating,” she says. “They also didn?t think that touch or hugs were important ? in fact all the men said that anything more than a handshake was inappropriate. According to social workers, unwelcome touch interrupts with the necessary flow of emotions.”

Doctors are advised to feel their way into the process of giving information about the death, says Pierce. “For instance, when people stop asking questions, it means they have heard all they can handle and it would be a burden to hear more. If you volunteer too much detail, you risk creating a bad memory. However, it?s important to allow them to obtain more information later.”

People got the most comfort from being left with the sense that everything possible had been done to save the patients? lives. “If information is unclear or not readily available or if doctors are uncaring, people also have to deal with anger, which interferes with the grieving process,” Pierce explains.

Relating news of death is the responsibility of the doctor who is the most aware of the events surrounding the death, who can speak frankly and knowledgeably, and has an empathetic demeanor, says Jurkovich. The seniority of the doctors was less important than their manner, and the family members? most positive comments described those who expressed sympathy and sensitivity.

“The doctor who spoke with us asked us what kind of man dad was,” said one respondent. “It gave us a chance to talk about him. That was a very positive memory.” “The ER doctor initially called my mother,” said another. “He talked with her and figured out she was frail and alone. He called her neighbor and me and made sure someone was with her before telling her of my brother?s almost certain death.”

A private room in which to break the news and letting the family remain there is important, as is allowing them time with the body if they wish. Several respondents expressed gratitude at being able to see the patients as soon as they left the ER, whether or not they were presentable, if the prognosis looked bad. “In the past, we would try to first stabilize the patient but found it might be too late,” says Pierce. “At first there was concern that the family would be disruptive, or that we needed to protect them from the patient’s appearance, but they?re usually so overwhelmed they prefer to go back to the waiting room and appreciate the opportunity to see the reality of what?s happened. People often feel cheated if they miss seeing someone during their last minutes of life.”

Other recommendations, now in effect at Harborview, included assigning a nurse to the family through the admission and death process to help facilitate the flow of information. Social workers and chaplains are also present whenever available.

Although most responses from the survey were positive, a few physicians were found to be insensitive. “Some doctors are good at delivering bad news, but we need to train those who don?t have the natural skills and are uncomfortable in such a highly emotional situation,” says Jurkovich. “There is increasing recognition that medical training needs to be extended beyond the science of illness and into the art of caregiving.” He plans to extend the project to study the effect of stress on resident physicians, and results will be incorporated into a teaching program.

A multi-center study to help prevent acute respiratory distress syndrome (ARDS) and pneumonia among trauma patients began Sept. 1 to test the efficacy of a naturally occurring protein.

Bacteriacidal permeability increasing protein (BPI) is found naturally in white blood cells and acts to kill bacteria. It also binds endotoxin, a poison formed on the surfaces of bacteria that is thought to play a role in developing ARDS. ARDS is an uncontrolled inflammatory response in the lung leading to prolonged ventilatory dependency, a longer ICU stay and a high mortality.

The randomized control study involves approximately 30 medical centers and is expected to enroll 1,600 patients. Harborview Medical Center expects to enroll 25 patients in the Seattle area over the next four months, says Dr. Avery B. Nathens, 91̽»¨ fellow in trauma and critical care based at Harborview and sub-investigator of the study. Those studied will be trauma patients (excluding head injury), aged between 16 and 75, and require two or more units of blood.

A preliminary study on BPI two years ago showed a reduced incidence of severe complications among those who took the drug intravenously over 48 hours, with no significant adverse effects.

The principal investigator of the study is Dr. Ron Maier, surgeon-in-chief at Harborview. It is sponsored by drug manufacturer Xoma.

Can vitamin supplements help critically ill patients recover from their injuries? A collaborative study by Harborview surgeons and dietitians is evaluating the efficacy of anti-oxidant vitamin supplementation in intensive care unit (ICU) patients at Harborview.

Many critically ill trauma patients develop acute respiratory distress syndrome (ARDS), an uncontrolled inflammatory response in the lung leading to prolonged ventilator dependency, a longer ICU stay and higher mortality.

“It doesn’t seem to matter what type of injury you have, if it’s severe enough, you can develop ARDS,” says Dr. Avery B. Nathens, 91̽»¨ fellow in trauma and critical care based at Harborview. “Vitamins C and E have anti-oxidant properties and a number of preliminary studies have demonstrated that they can limit tissue injury caused by oxidants, suggesting that supplementation with these vitamins may prevent the development of ARDS.”

Now halfway through, the one-year study has so far found that many trauma patients admitted to Harborview have lower than normal levels of vitamins C, possibly due to poor intake of the vitamin in their daily diet, says Nathens.

To evaluate whether antioxidant vitamin supplementation reduces the chances of developing ARDS, all general surgical patients entering Harborview’s ICUs for a minimum of 48 hours will receive either standard amounts of the vitamins or IV supplementation with vitamin C in combination with vitamin E within 24 hours of admission. Patients with head injuries, sickle cell anemia and those taking the anticoagulant Coumadin are excluded from study enrollment.

So far more than 100 patients out of an expected total of 300 patients have taken part. As patients enter the study at the time of ICU admission, any individual may be withdrawn from the study at the request of their next of kin or their physician. Principle investigators are Dr. Ronald Maier, 91̽»¨professor of surgery; Dr. Gregory Jurkovich, 91̽»¨professor of surgery; and Nathens.

Manipulating gene expression levels in rats? brains can help to understand the causes of clinical depression, according to psychiatric research at Harborview Medical Center.

Depression may stem from low levels of serotonin, caused by malfunctioning components of the serotonin neurotransmitter system. In particular, the 5-HT1b autoreceptor, a cellular protein that inhibits or brakes serotonin release from nerve cells, may be excessively active in depression.

So far it has been found that among rats treated with common antidepressants like Prozac or Paxil, the receptor level decreases. However, these currently accepted antidepressants often take several weeks or longer to take effect.

Various studies are under way at Harborview to find out how the 5-HT1b autoreceptors cause depression. The latest study involves introducing extra copies of the gene for 5-HT1b receptors into serotonin neurons in the rat brain using viral-mediated gene transfer, known as gene therapy.

“This technique is a research tool that allows us to dissect the steps in the physiology of depression,” says Dr. John Neumaier, a 91̽»¨ assistant professor of psychiatry based at Harborview. After the gene is introduced, more 5-HT1b receptors are made, modeling the depressed state.

Preliminary results suggest that the rats show signs of depression in behavioral tests, and may allow new medications to be tested that may work better or faster than current medications. Neumaier is also testing combinations of medications to see whether they can reduce 5-HT1b receptors more rapidly than current antidepressants.

In animals that have been stressed by swimming in a tank of water, some learn to give up and are termed “helpless” while others keep trying to get out of the water. Neumaier has found that the 5-HT1b gene is turned up more when the animals show signs of helplessness by just floating in the water. “We want to see if we can prevent depressive behavior by studying how to prevent rats from increasing their 5-HT1b receptor levels when they are under mild stress, such as swim stress,” he adds. This can be seen by how rats respond to the stress behaviorally and by measuring the 5-HT1b receptor levels.

The study is funded by the National Alliance of Research for Schizophrenia and Depression, the National Institute of Mental Health, Eli Lilly and the Royalty Research Fund of the 91̽»¨.

New clinical research on teenagers with AIDS not only examines how quickly their immune systems recover with combination therapy, but also gives many of them the opportunity to obtain the latest treatment.

Earlier this year, the Teen Young Adult Clinic in the Madison Clinic at Harborview Medical Center was one of 12 sites around the nation to receive funding from the National Institute of Health for more clinical research on teens with HIV.

“If kids were not on this research protocol, they might not be on the combination therapy,” says Dr. James Farrow, who directs the Teen AIDS program at Harborview, and is also faculty in adolescent medicine and associate professor of medicine and pediatrics at the 91̽»¨. “When they first start treatment, we try to use a protease inhibitor-sparing regime ? this means using combinations of other AIDS medications. We add the protease inhibitor if the illness becomes serious, as this maximizes its effectiveness.”

Some data show that this regime works just as well as the full treatment among teens. The figures among adults are not as compelling, he points out. Because adults are infected longer and their viral loads are higher, they often require the full combination treatment.

Treatment compliance is a major problem among adolescents, adds Farrow, as the treatment requires taking large quantities of pills and produces side effects, although there are attempts to simplify the regimen. “It requires a strong case-management approach to appointments,” he says. “We try to act as an advocate and treatment partner, and emphasize health education, focusing on diet and exercise.”

There are an estimated 80 teenagers in King County with AIDS. Among them, some 60 percent know they have the disease, about 30 percent of them are receiving care, and about 15 of them are active patients at Harborview or in the pediatric AIDS program at Children?s Hospital. Unlike the adult AIDS population, which is 91 percent male, females make up 50 percent of the teen sector. Most females under 16 contracted AIDS through sexual activity. In the 16-20 age group, about 75 percent of males were infected through homosexual activity. Only 25 percent of all teen patients have a history of injection drug use or have known sexual contacts with injection drug users.

More than half of the patients over 16 have been homeless. Many of them live in shelters, group homes or transitional housing. Typically there is at least a year delay from diagnosis to seeking care, and usually it is the case manager or their primary care provider who talks them into initiating care.

“There is a lot of denial, even when they have their first appointment,” says Farrow. “Our message to them is that HIV intention is now quite compatible with long life and they have to view it that way. There are a lot of options for treatment. Several new drugs are coming on line each year so we can stay ahead of the infection with regular care. Unlike many adults, very few adolescents are drug-resistant and continuous treatment improves the ability to control resistance.”

The Teen Young Adult Clinic at Harborview is a collaborative treatment program of the Madison Clinic, Northwest Family Center, the 91̽»¨Adolescent Medicine Program and the Pediatric Aids Clinical Trials Unit.

Tuberculosis is an old disease with a new resurgence, a comeback facilitated by various health and social factors — poverty, the AIDS virus, drug use, exposure through travel, and decreased public health surveillance. “Tuberculosis among foreign-born persons is also a major contributor to the disease’s resurgence in the United States,” says Dr. Carey Jackson, director of the International Medicine Clinic at Harborview Medical Center and assistant professor of medicine at the 91̽»¨. “And compliance with preventive therapy is low priority among new refugees — they have so many adjustment issues.”

It is well-known that TB can be prevented in newly arriving immigrants through a six-month course of preventive treatment among those exposed to the bacteria. But compliance is also affected by the social stigma of the disease, misunderstandings about symptoms and the best treatment, and the tedium of daily long-term therapy. To this end, Harborview, in partnership with the Seattle-King County Tuberculosis Clinic, designed an outreach program to enhance the acceptance of TB preventive therapy among Seattle area?s refugees, now mainly arriving from Russia, the Balkans and Somalia.

The goal of the two-year program, which began in May, is to educate the refugees soon after arrival about the importance of following the daily preventive regimen for the oral TB medication. (Those who already have the disease are usually treated with a combination therapy.) Historically, certain immigrant groups don’t like taking this kind of medication for a variety of reasons, adds Jackson. “There are certain myths that persist — Isoniazid could damage their kidneys, or they overestimate the risk of hepatitis or nausea. They typically stop after two to three weeks instead of the six to nine months required.”

Last year, the federal refugee program increased funding to Public Health-Seattle & King County to facilitate community-based TB prevention services with more active follow-up with patients. Through an intensive case management approach, focus groups are conducted to learn about how various ethnicities view the disease, says Dr. Charles Nolan, director of the Health Department?s TB Clinic at Harborview.

The new program now has 55 patients receiving TB preventive therapy, and another 300 to 400 are expected to join in the coming year. Three case workers deliver medicine to homes monthly and have personal contact with the refugees every two weeks. The federal funds have been matched by the Annie Casey Foundation and the Firland Foundation. “The TB service is also a hook to get at-risk people to get connected to systems they need to support their well-being,” says Nolan.

Tuberculosis is still the number-one killer among infectious diseases in the world, with about three million deaths a year. Disease rates are more than 100 per 100,000 in Somalia, about 70 per 100,000 in Eastern Europe and 7 per 100,000 in the United States. The infection rate, defined as people with latent TB infection, varies from 30 percent to 50 percent in the worst-affected countries, compared with 5 percent in the United States.