Time Sensitive Emergency

Stroke !!! Think F-A-S-T

By: Stu Willis, MD – Emergency Department Director, Boundary Community Hospital

A drooping face, weakness or numbness on one side, slurred or garbled speech … this might be a stroke!  Like heart attacks, a stroke is a life-and-death emergency; time is critical and every second counts, so think F-A-S-T and dial 9-1-1 immediately.

F-A-S-T is a reminder of some of the signs of a stroke:

FAST FACE – is there a droop on one side; have the person smile;

ARMS – is there weakness on one side; have them raise the arms, test the hand grip;

SPEECH – is there altered speech (slurred or unable to speak); have them say “the sky is blue;”

TIME – every second is crucial; certain procedures and medications must be done quickly.

Other sudden and unexpected signs of a possible stroke include, but are not limited to: confusion or difficulty understanding, numbness on one side or part of the body, trouble seeing with one or both eyes, dizziness, loss of balance or difficulty walking, and a severe headache, with no prior history (ex. migraine).

Stroke is the fifth leading cause of death in the U.S., Idaho, and Boundary County, killing 133,000 persons annually nationwide – about 1 in 20 deaths. Someone in the U.S. has a stroke every 40 seconds. The care for a stroke patient and the consequent disability results in over $34 billion in annual healthcare costs, as well as the anguish for the patient and the family.

There are two basic types of stroke –  An “ischemic” stroke is caused by a blood flow blockage, similar to a heart attack clot; “hemorrhagic” is a stroke caused by spontaneous bleeding in the brain (sometimes from a burst aneurysm). An emergency CT scan is needed to determine the difference. If the stroke is ischemic (clot blockage), a “clot-buster” medication must be administered within 3 hours of the onset of symptoms (up to 4 ½ hours in certain instances). So, “TIME is BRAIN!”

The hospital Emergency Department staff stands ready with 24/7 CT scan capability to determine if a stroke is “ischemic” or “hemorrhagic,” and can immediately deliver the “clot-buster” medicine when indicated. But it must start with the recognition of stroke signs and symptoms and dialing 9-1-1.

Worldwide, stroke is the second leading cause of death, after heart disease. Many experts feel enhanced public education to decrease the risk factors leading to stroke and the notable systems in place for early stroke identification and treatment have contributed to the lower death rates in the U.S.

Stroke is not just a disease of “old” people. A stroke can strike at any age, and in the U.S., about one-third of strokes occur in persons under the age of 65. Even persons in their twenties and thirties (or younger) can suffer strokes.

PREVENTION, through public education and intervention, is the key to lowering the stroke risk. The American Heart Association and American Stroke Association have identified seven key health risk factors and behaviors that influence the onset of heart disease and stroke in the U.S. These “Life’s Simple 7” are:

  1. Smoking – over 15% of the population smokes; in 2014 there were about 5,700 new cigarette smokers every day. If you smoke, STOP!
  2. Physical Inactivity – 30% of adults do not engage in leisure time physical activity. Even a little EXERCISE helps.
  3. Nutrition – improvements have recently been made in healthier eating, particularly increased whole grain, fruit, and vegetable consumption, with a decrease in sugar-sweetened beverage intake. The excessive use of sodium (salt) remains problematic. EAT SMART.
  4. Obesity – alarmingly, obesity is on the rise; the U.S. obesity rate has increased from 30.5 to 37.7% in the past 15 years. LOSE WEIGHT.
  5. High Blood Pressure – 86 million adults (30%) have hypertension and only 45% have it under control; three of every four first-time stroke patients have blood pressure over 140/90. Get a BP CHECK – 130/80 is nice, 120/70 even better.
  6. Cholesterol – 95 million adults (40%) have high cholesterol, and many don’t even know it. Have a CHOLESTEROL blood test – it can be treated.
  7. Diabetes – 31 million adults (12%) have diabetes, and 30% of them don’t know it; in addition, 34% of all Americans have prediabetes. Get a BLOOD SUGAR test – diabetes can be a killer.

As the first Pacific Northwest hospital to receive the Critical Access Hospital designation by the federal government, Boundary Community Hospital plays an essential role in meeting the healthcare needs of Bonners Ferry and the surrounding county.  Under the Idaho Time Sensitive Emergency System, the hospital was recently awarded the designation as a TSE Level IV Trauma Center. The hospital is now actively engaged in meeting the stringent criteria required for designation as a Level III Stroke Center.Stroke Awareness Month

Auxiliary Pie Sale a Success

Annual Pie Sale a Success

February 24, 2017 – Thank you to everyone who donated or purchased pies at the famous Hospital Auxiliary Pie Sale on Thursday, February 16. The fifty pies and cakes were sold out by Noon and the Auxiliary raised over $1,000.

Over the past year, monies raised through the annual pie sale and other fund raising events, including the ever-popular raffles, have been used to purchase Patio Furniture for the Extended Care Facility, an Ophthalmoscope for Emergency, a Pulse Oximeter and Over-bed Tables for Acute Care, a Rebounder for Physical Therapy, Deep Well Tables and a Mayo Stand for Outpatient Surgery.  In addition, the Auxiliary funded a bench for outside the Outpatient Services Lobby in memory of their member Annie Koon.

The Hospital Auxiliary, started in 1954 originally to assist at the Hospital, is seeking new active members to join the group. If you are interested, please come to the next meeting on March 14 at 11:30 a.m. at Chic-N-Chop. Women and men are welcome.


Behind the Scenes: Nurse Practitioners

Practical Healthcare for Rural Residents

Boundary Community Clinics is pleased to announce the addition of two new Nurse Practitioners as primary care providers. Beverly Yercheck, ANP-C who specializes in adult care and Janet Lukehart, FNP-C who specializes in family care will round out the schedule so that office hours will now be Monday through Friday. And yes, new patients will be accepted after April 1.


Janet Lukehart, FNP-C


Beverly J. Yercheck, ANP-C

Why an NP?

Living in a rural community can make access to healthcare challenging, especially with the growing shortage of medical doctors throughout the US, and especially in North Idaho. Originally trained to fill this void in the mid 1960’s, the professional designation of Nurse Practitioner (NP) was developed and has continued to grow.

Rural-Health-Day-2016-FBBAnnerAt a rural health clinic, the NP provides healthcare for individuals and families that include diagnosing and treating acute and chronic health problems, performing physical exams, diagnosing and managing minor trauma, ordering lab tests and other diagnostic services, prescribing medications, and teaching health promotion and disease prevention. Having a background in nursing and advanced training in medical care, NPs are in a unique position to provide complete care to their patients. As Medical Director, Susan Layeux, MD works with the NPs to provide the outpatient primary care that Boundary County residents require.  “It’s a practical solution for rural residents,” says Janet Lukehart. “Bev and I work closely with Dr. Layeux to ensure that our patients are taken care of in a timely fashion with the best healthcare available.”

BikeRodeo-NoYearEach year the clinic staff sponsors the Children’s Bike Rodeo held in conjunction with the Hospital Health Fair.  This year the event will be on Saturday, May 13, 9:30 am – 11:30 am near the Outpatient Services Lobby.  Not only will children be able to test their bicycle skills through the rodeo course, but also receive a free bike helmet while they last.

Boundary Community Clinics is proud to provide the vital health services you and your family deserve, delivered with professionalism and compassion – right here at home.


Hospital Designated Level IV Trauma Center


Hospital Designated Level IV Trauma Center

February 17, 2017

Bonners Ferry, ID – Boundary Community Hospital has been designated as a Level IV Trauma Center by the State of Idaho.  The designation for the Hospital is part of the Idaho Time Sensitive Emergency System (TSE) and is reserved for Hospitals that meet the stringent criteria established by the State as part of the statewide TSE system of care that includes three of the top five causes of death in Idaho: trauma, stroke, and heart attack.  Emergency Department Director, Dr. Stu Willis with Gina Gallette, RN have been spearheading the effort at Boundary Community Hospital.

According to Emergency Department Director, Stu Willis, MD, “As a rural community, we have an obligation to provide services that improve survivability. It is important for our Emergency Department staff to work together with local EMS at Boundary Ambulance and Life Flight Network in an organized process to be sure patients are treated or when required, transported to another Hospital for the appropriate level of care. In addition, prevention education is a key component of this, especially in regards to injuries and major trauma.”

As the first Pacific Northwest hospital to be awarded the Critical Access Hospital designation by the federal government, Boundary Community Hospital has always had an essential role in meeting the healthcare needs of Bonners Ferry and the surrounding county.  In 2012, 49.1% of preventable deaths in Idahoans under age 75 were the result of trauma, stroke, or heart attack. The TSE initiative is putting processes in place so the RIGHT PATIENT gets the RIGHT CARE at the RIGHT TIME, helping to ensure an optimal outcome, especially when TIME is critical.

The hospital is investing in the community through the fully-staffed Emergency Department with physicians and nurses experienced in emergency medicine, and certified in advanced trauma, cardiac, and pediatric care.  The Clinical Medical Laboratory and Diagnostic Imaging technologists are also available 24/7 so that tests can be performed when time is critical for patient treatment in a Time Sensitive Emergency.

Get Your Blue On!

Get Your Blue On!

Did you know colon cancer is the second leading cause of cancer deaths in the United States? Early detection and regular colon screenings beginning at age 50, or earlier if you are at high risk, can dramatically reduce your risk.

The ASGE (American Society for Gastrointestinal Endoscopy) reports that only 50% of the people who should be getting colonoscopies actually go out and get them done.

According to Shannon Rust, RN, Outpatient Surgery Manager at Boundary Community Hospital, “Colon cancer is preventable.  The problem is that people are uncomfortable talking about colonoscopies, and even more uncomfortable about actually having a colonoscopy.  I have had one done and the most uncomfortable part of the whole procedure was going without solid food for a day and having to wait until my procedure was done before I could drink my coffee!  The bowel preps have come a long way and are so easy now.  You no longer have to drink a gallon of chalky, bad-tasting liquid.  The prep mixes and dissolves completely in Gatorade…bingo…down the hatch, clear gut, nice nap.”

Colonoscopies and endoscopies are performed Wednesdays at the Hospital by Board Certified general surgeon Nathan Kanning, MD. He performs a wide variety of surgeries and outpatient procedures with a general focus on the abdomen and related organs including hernia repairs, biopsies, colonoscopies, and upper endoscopies.

So the next time your physician recommends a colonoscopy, remember you can get it done here on Wednesdays at Boundary Community Hospital in Bonners Ferry.

March is Colon Cancer Awareness Month. Join Boundary Community Hospital on Friday, March 3rd for Dress in Blue Day to raise awareness that colon screening, research and patient-supported initiatives can eliminate colon cancer from the top three cancer killers for good.

BFLL_BCH_Feb2017Get Your Blue On! For Colon Cancer Awareness – Wear Blue on March 3rd

Cold Weather Safety

January 19, 2017 (for the Bonners Ferry Herald)
By Stu Willis, MD and Pete Cassidy, RN
Boundary Community Hospital Emergency Department

Brrrrrrrrrrrr! It’s cold out there!

Photo by Keith Johnson

Photo by Keith Johnson

The weather outside may be frightful, after all, we live in North Idaho and six months out of the year it’s cold and wet, windy and sometimes miserable. Did you know that the most common cold weather injuries in our area are hypothermia, frostbite, chilblains (sometimes called frost nip) and “trench foot?”

HYPOTHERMIA occurs when the body core temperature drops significantly below normal. It can be a life-threatening emergency and should be treated immediately. It is more common in children and the elderly because they sometimes do not recognize the signs – frostbite and hypothermia can come on within minutes.
Conditions leading to hypothermia, even in only mildly chilly weather, include improper clothing and equipment, wetness, fatigue/exhaustion, dehydration, and poor food intake. And, alcohol use may “numb you to the danger.”

Signs/Symptoms of hypothermia:
Watch for the “umbles” — stumbles, mumbles, fumbles, and grumbles which indicate changes in coordination and levels of alertness

Mild hypothermia signs:
1) Shivering out of control
2) Unable to do complex tasks, but can still walk and talk
3) Reduced blood flow to the limbs and skin

Moderate hypothermia symptoms include:
1) Dazed consciousness
2) Loss of fine coordination
3) Slurred speech
4) Violent shivering
5) Irrational behavior- “I don’t care” attitude

Severe symptoms include:
1) Shivering in waves
2) Falling to the ground; can’t walk; curling into a fetal position
3) Pale skin, dilated pupils, decreased pulse rate
4) Muscle rigidity develops

If you suspect someone has hypothermia, call 9-1-1 and try to reduce heat loss by changing them to dry clothes and adding more clothes. Increase their physical activity, find shelter, and be sure they eat and drink – carbs, proteins, fats and hot liquids help bring the temperature up.

FROSTBITE occurs as fluid in the cells freeze with exposure to cold temperatures. The crystals damage the tissues. The most common locations for frostbite are the hands and feet, and exposed superficial skin such as the nose, lips, and ears.

Signs/symptoms of frostbite include:

  • Numbness in affected areas
  • Tingling, blistered, swollen, or tender areas
  • Pale, yellowish, waxy-looking skin
  • Frozen tissue feels wooden to the touch
  • Significant pain after rewarming

Recommended treatment for mild frostbite is placing the affected part in “warm” water, 98-104 F. Do not allow the affected part to refreeze!!! And avoid excessive heat, or rubbing the area. Moderate to severe frostbite should be treated by medical professionals. Always SUSPECT HYPOTHERMIA if frostbite has occurred.

Some “Be Safe” precautions:

  • Supervise children when they are out in the cold
  • Older children/teens and others participating in outside winter activities should be encouraged to use the “buddy system” to look for early signs of cold injury
  • Be sure to wear gloves or mittens and hats
  • Keep feet dry and avoid tight socks and boots
  • Remember C-O-L-D
    • Keep it Clean
    • Avoid Overheating
    • Wear it Loose and in Layers
    • Keep it Dry
  • Avoid alcohol, caffeine, and tobacco/nicotine

So, when the temperature drops and snow starts falling, watch for the signs and know when you need to go see your doctor or come to the emergency department for treatment. We live in a beautiful place, with all kinds of weather, so be safe and enjoy those cold weather activities.

Orthopedic Clinic Expands

January 18, 2017
The Orthopedic Clinic at Boundary Community Hospital is expanding. Mike Schicker, DO from North Idaho Orthopedics and Sports Medicine in Ponderay will have specialist clinic hours on Friday mornings starting in January 2017. Dr. Schicker joins Dr. DiBenedetto and Travis Taylor, NP-C offering Boundary County residents two days of orthopedic clinic in Bonners Ferry at their office in Building C on the south side of the Hospital off Comanche Street. “Dr. Schicker is a welcome addition to our local Provider-Based Specialist Clinics,” states Craig Johnson, Hospital CEO. “He will be expanding our local surgery options once the Surgery Suite is upgraded, utilizing the funds from the Supplemental Levy recently passed by Boundary County voters.” To schedule an appointment, call (208) 265-9817 and ask for a Bonners Ferry appointment.

Hospital Auxiliary Raffle a Success

Hospital Auxiliary Raffle a Success
December 16, 2017

Patients waiting at the Outpatient Services entrance at Boundary Community Hospital now have a place to sit. A hummingbird metal bench has been donated by the Boundary Community Hospital Auxiliary in memory of Annie Koon with the quote “Volunteers do not necessarily have the time, they have the heart.”


Shown the Hospital Auxiliary members with Elden and David Koon and Hospital Administrator Craig Johnson.

Following the dedication ceremony, the Hospital Auxiliary held their Holiday Raffle.  There were gift certificates and baskets donated by 24 local businesses.  Money raised from this event will be used to purchase items for the Hospital.  The Auxiliary recently purchased a Mayo Stand to be used for general and orthopedic surgeries performed at the Hospital.

Winners in this drawing were:
Life Flight Network – Melenie H.
Pizza Factory – Terri B.
Mandy’s Gift Gallery – Eric W.
Mugsy’s Restaurant – Melenie H.
Akin’s Harvest Foods – Kristyn R.
Picturesque Salon – Alisa Y.
Subway Restaurant – Shirley D.
Subway Restaurant – Patty K.
Baby-Go-Round – Jan B.
Larson’s Department Store – Bobbie N.
Larson’s Department Store – Deb B.
Mi Pueblo Restaurant – Patty K.
Katie Blumenauer Photography – Kris L.
Bonners Bookstore – Evelyn R.
Sugar Plum Floral – Ruba D.
Sugar Plum Floral Wreath – Jae B.
Doggy Doo Pet Salon – Sheley D.
Oriental Garden Restaurant – Eda Mae S.
A Little Comfort Quilting – Jan B.
Far North Deli – Claudia R.
The Black Sheep Sporting Goods – Valdie B.
Under the Sun – Denise W.
Mountain Mike’s – Darci P.
The Dressing Room – Sheila P.
Allie Fabrics – Evelyn D.
Dr. Moore – Janet A.
Carter Country Store – Alanna D.

The Auxiliary will personally notify all of the winners.

The Hospital Auxiliary meets the 2nd Tuesday of each month September-May at Chic-n-Chop.  New members are welcome! For more information, call 267-6912 or visit the Hospital website: www.boundarycommunityhospital.org/about-us/auxiliary

Time Sensitive Emergencies – STEMI

By Stu Willis, MD
Emergency Department Medical Director
STEMI Center Medical Director
Boundary Community Hospital

Thump-Thump, Thump …

Pain in the chest, down the left arm, shortness of breath, nausea, pale and clammy –  these are sure signs of a heart attack, right? Not always.  If you are female, have diabetes, or are elderly you may not have the “classic” signs when you have a heart attack.

Boundary Community Hospital has always held an essential role in meeting the healthcare needs of Bonners Ferry and Boundary County.  With the development of the Idaho Time Sensitive Emergency System, the hospital is working towards meeting the stringent criteria for official designation as a TSE Level II STEMI (Heart Attack) Center. This designation will ensure an organized, coordinated system of care along the complete journey of the heart attack patient – from the EMS ambulance paramedics, to the Emergency Department staff, and then transport by air (or by ground if the weather doesn’t allow flying) to the heart specialists at a large cardiac center capable of giving definitive treatment. The goal of the TSE System is to prevent deaths and improve patient outcomes by providing the rapid movement of patients to appropriate centers for their required treatment – it’s all about getting the RIGHT patient to the RIGHT place at the RIGHT time.

There are two types of heart attacks:  ST elevation attack (STEMI) – blockage of a large, major vessel; and Non-ST elevation attack (Non-STEMI) – blockage of a small, minor vessel. It takes an electrocardiogram (ECG) to tell the difference. While small, minor heart attacks are still important and require prompt attention, the blockage in a large, major heart attack requires extremely urgent, “time-sensitive” treatment to avoid long-term consequences and complications. So, time is of great importance – TIME IS MUSCLE !

Heart disease is the leading cause of death in the U.S and Idaho. About 635,000 new heart attacks occur each year in the U.S. – one every 44 seconds; and there are another 300,000 repeat heart attacks annually. And very worrisome is that around one in five are fairly “silent” in that they don’t have significant pain and few of the more classic signs. Some heart attacks are sudden and intense – these are not hard to mistake. But most heart attacks start slowly and with only mild or moderate discomfort.

CHEST DISCOMFORT – Most heart attacks involve some form of discomfort in the middle of the chest that lasts more than a few minutes, or that comes and goes, and then stays. It can feel like uncomfortable pressure, squeezing, fullness, tightness, or actual pain.

OTHER AREAS OF DISCOMFORT – Signs can also include discomfort of pain in one or both shoulders or arms, or the upper back, neck, jaw, or stomach region.

SHORTNESS OF BREATH – The shortness of breath of a heart attack may occur with or without pain or discomfort in the chest or another region.

OTHER SIGNS – Often other signs occur during a heart attack, and can include breaking out in a sweat, nausea or lightheadedness, and appearing pale.

Similar to men, most common heart attack sign in women, diabetics, and the elderly is pain or discomfort in the chest. However, this group is also more likely to exhibit other symptoms, particularly shortness of breath, vomiting, and back or jaw pain.

WHAT SHOULD I DO IF I SUSPECT A HEART ATTACK? Even if you’re not sure it is a heart attack, immediately call 9-1-1 and chew four baby aspirin or one adult aspirin unless you have a true allergy to aspirin. The EMS paramedics can begin other early essential treatment with an ECG and medications while you are on the way to the hospital.

WHY DON’T PEOPLE ACT FAST ENOUGH? Many people having a heart attack wait more than two hours before getting help. Some people feel it would be embarrassing to have a “false alarm.” Others are so afraid of having a heart attack that they tell themselves they aren’t having one. These feelings are easy to understand, but they are also very dangerous.


  • Don’t smoke, and avoid second-hand smoke
  • Treat high blood pressure if you have it
  • Eat foods low in saturated, trans fat, and sodium (salt)
  • Be physically active – exercise regularly
  • Reach and maintain a healthy weight
  • Take medicines as prescribed
  • Get regular medical check-ups
  • Control your blood sugar if you have diabetes

The Emergency Department staff of Boundary Community Hospital has coordinated with Boundary Ambulance, Life Flight Network, and the cardiology staff of Kootenai Health in developing a state-of-the-art process to quickly start the initial standardized treatment of heart attack victims and deliver them directly to the heart catherization lab to open the blockage…the faster, the better.

To introduce the community to the Idaho Time Sensitive Emergency Initiative, Dr. Willis is speaking with community and church groups about “What You Need to Know About Heart Attack, Stroke and Trauma.”  If you would like to have Dr. Willis speak with your group, call 267-6912 to get on the calendar.

Time Sensitive Emergency – Trauma

WaaahYah! WaaahYah! WaaaYah!…

By Dr. Stu Willis, Emergency Department Director

The sudden sound of a vehicle crash…the sight of a bloody leg from a chain saw encounter…the thump, thump, thump of granny pivoting down the stairs…these all produce instant fear, anxiety, and worry for an episode of serious injury.

As the first Pacific Northwest hospital to be awarded the Critical Access Hospital designation by the federal government, Boundary Community Hospital has always had an essential role in meeting the healthcare needs of Bonners Ferry and the surrounding county.  With the advent of the Idaho Time Sensitive Emergency System, the hospital is working towards official TSE Designations by meeting the stringent criteria as a Level IV Trauma, Level III Stroke, and Level II STEMI (Heart Attack) Center.

The 2014 Idaho Legislature approved and funded a plan to develop a statewide Time Sensitive Emergency System of care that includes three of the top five causes of death in Idaho: trauma, stroke, and heart attack.  Studies show that organized systems of care improve patient outcomes, reduce the frequency of preventable death, and improve the quality of life of the patient.  The goals of the TSE system are to decrease mortality and improve patient recovery by providing the rapid movement of patients to an appropriate center for definitive treatment.

Worldwide there are eleven deaths every minute due to trauma – that’s 5.8 million fatalities a year, and over one million are the result of motor vehicle crashes. Wearing seatbelts, not driving after drinking, and not driving while distracted (texting, etcetera) are major preventive efforts that have already shown to have a dramatic positive impact.

Trauma is the fourth leading cause of death in Idaho, and the third leading cause in Boundary County. It is estimated that by 2020, one out of every ten persons will die from an injury.

But short of death, other major disabilities result from trauma. For example, various degrees of brain injury, whether a concussion or a massive bleeding injury, occur in the U.S. some 1.7 million times per year. These injuries result in nearly 300,000 hospitalizations, over 52,000 deaths, and about 90,000 cases of severe disability each year. Protective headgear, such as helmets, help some, but preventing the injury in the first place is even more important.

Each year 10 million children visit U.S. emergency departments due to an injury – that’s one visit for every six children…and 10,000 are fatal. “Childproofing” the home and other areas children visit, and simple careful supervision are paramount to ensuring child safety.

For the lay person encountering an injury case, remember the A-B-Cs – Airway, Breathing and Circulation. Ensure the airway is open, but don’t move the neck around as there could be a major neck fracture. Assist with breathing, if necessary, and control ongoing bleeding with direct pressure.

According to Emergency Department Director, Stu Willis, MD, “As a rural community hospital, we have an obligation to provide services that improve survivability. However, we need the community to be aware of the signs and symptoms of time-sensitive emergencies so they can get help as fast as possible, whether it’s the paramedics with advanced life support training, the hospital emergency department staff, or Life Flight transporting a patient to a higher level of care facility such as a major trauma center. In addition, prevention education is a key and vital component of this, especially in regards to injuries and major trauma.”

“At Boundary Community Hospital, our goal is to provide the community with timely healthcare services that are second to none, whether it’s emergency services or long-term care, inpatient or outpatient,” says Hospital CEO Craig Johnson.

To introduce the community to the Idaho Time Sensitive Emergency Initiative, Dr. Willis is speaking with community and church groups about “What You Need to Know About Trauma, Stroke, and Heart Attack.”  If you would like to have Dr. Willis speak with your group, call 267-6912 to get on the calendar.

The TSE System could potentially save 244 lives annually in Idaho according to the Idaho Department of Health & Welfare.