INTOUCH JUNE 2014
'The whole hospital was involved' By Leslie Shepherd
They say it takes a village to raise a child, and it took nearly that many people recently to bring one child into the world under life-threatening conditions at St. Michael’s Hospital. In fact, it took four ob-gyns, one neonatologist, two pediatricians, two anesthesiologists, two hematologists, a radiologist and an interventional radiologist, a perfusionist, a trauma surgeon, a vascular surgeon, a urologist, a social worker, an ethicist, a chaplain, perioperative support assistants, unit service workers and respiratory therapists working together in two operating rooms, as well as nurses, clinical managers and educators in the OR, ICU, antepartum ward, postpartum ward, labour and delivery and the NICU, and the hospital’s expertise in blood management. Emerlinda Wania was pregnant with her fourth child when she developed a condition known as placenta percreta, where the placenta grows through the uterus, generally through a previous C-section scar, and can invade other organs such as the bladder. She started having some light vaginal bleeding and her water broke at 27 weeks into her pregnancy. She needed another C-section to deliver the baby, a hysterectomy to remove her uterus and additional surgery to repair her bladder and any other damage. Dr. Andrea Lausman, a specialist in high-risk pregnancies, said she was worried Wania would start bleeding heavily and require emergency surgery, so she assembled a team of two dozen health care specialists to prepare as if it Printed on 100 per cent recycled paper
Emerlinda Wania holds her baby Precious in the NICU. (Photos by Yuri Markarov, Medical Media Centre)
were an elective procedure. “I felt like we used all of the resources of our hospital to give her truly multidisciplinary care,” said Dr. Lausman. Adding to the complexity of the case was the fact that Wania is a Jehovah’s Witness and her religion forbids blood transfusions. The surgeries she was about
to undergo carry a high risk of serious bleeding. Doctors knew they could save her life and the baby’s if they could give her blood transfusions, but without that capacity, “we were very concerned she would die,” Dr. Lausman said. Well before the scheduled surgery date, Continued on page 2 JUNE 2014 | IN TOUCH | 1
OPEN MIKE with Dr. Arthur Slutsky Vice-President, Research
St. Michael’s launches new Centre for Critical Care Research One of the hospital’s 2014-15 corporate objectives is to accelerate research to practice. We are working to achieve this by creating cross-cutting “themes.” The first theme, the Neurosciences Research Program, was launched last year. The second theme will be in the area of critical care and will bridge clinical services and research in acute lung injury, sepsis and trauma. Critical care is a major clinical priority at St. Michael’s. As one of 11 trauma centres in the province, St. Michael’s has some of the most skilled and specially trained staff to care for the province’s most severely injured patients – those needing to be treated within the hour. In addition, we treat
many other extremely ill medical and surgical patients. Under the direction of Dr. Andrew Baker, our chief of critical care, the team admits about six to 10 new critically ill patients on any given night in our CVICU, MSICU or TNICU. Many of our gifted clinicians and scientists have research interests in acute lung injury, sepsis or mechanical ventilation. A star recruit in 2012, chief of anesthesia Dr. John Laffey’s research interests lie in cell- and gene-based therapies for acute respiratory distress syndrome. Dr. Wolfgang Kuebler is an internationally recognized leader in lung vascular biology and chair of the Section Advisory Committee of the American Physiological Society. These two individuals are spearheading our efforts in consolidating the hospital’s clinical and research strengths into the new Centre for Critical Care Research. It is comprised of close to 40 clinicians and researchers, organized into three research interest areas: lung, overseen
by Dr. Laurent Brochard, a world leader in mechanical ventilation research; sepsis, headed by Dr. John Marshall, another world leader in sepsis research and clinical trials; and trauma, led by Dr. Ori Rotstein, a world-renowned investigator in ischemia-reperfusion injury. These will link with the Keenan Research Centre for Biomedical Science activities of critical care investigators, led by Dr. Andras Kapus, the “floor lead.” The contingent of experts in this field – ranging from biomedical science to providing care – is substantial and likely unmatched anywhere else. The new program will strengthen collaborations among critical care clinicians and scientists at St. Michael’s and will set us up to be the pre-eminent centre for critical care in Canada and internationally. The formal launch of the new Centre for Critical Care Research will be on June 23.
Pregnancy story continued from page 1
Wania was under the care of the hospital’s blood management and conservation team who worked to raise her blood hemoglobin levels. They also created a comprehensive blood management plan for the surgery, which included using a big central IV line to ensure adequate fluid replacements and clotting factors, which are accepted by many Jehovah’s Witnesses. Importantly, the patient also agreed to use the cell salvage process in which her own blood lost during surgery was captured, washed and recirculated in a closed loop so it never left her body. Precious Jerylle Wania was born on April 1, just short of 30 weeks gestation but close enough that she was allowed to remain in the neo-natal intensive care unit, rather than be transferred to another hospital for more intense care. Both mother and daughter are doing well. “It was a very big decision for us,” said Emerlinda’s husband, Jerry. “Without blood, she might have died. We put our trust in God.”
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Dr. Bruce Gray stands in front of a CT scanner (Photo by Yuri Markarov, Medical Media Centre)
Using text to make CT scans safer By Greg Winson
Computed tomography, or CT, scans represent an important advancement in medical care, allowing doctors to non-invasively view detailed images of the body. However, since these diagnostic tests require the use of radiation, it is important to monitor whether the scans are necessary and that they use a radiation dose that is as low as reasonably achievable. Dr. Bruce Gray and Dr. Timothy Dowdell, radiologists in the Medical Imaging Department at St. Michael’s Hospital, hope to use image metadata— basically data about data--that is attached to each CT study to ensure that the process is safe and effective. “Image metadata, similar to metadata
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Did You Know? St. Michael's performs
for images in a digital camera, contains information on the type of CT scanner, type of study, who ordered it, when it was performed, by whom and the specific scanner settings used for the particular study,” said Dr. Gray. Little was done with this metadata until a Toronto-based company, Radimetrics, developed software to extract the information into a database for analysis. St. Michael’s was an early adopter of this dose-tracking software and now has a database containing metadata from St. Michael’s CT scans for the past four years. This has allowed for the development of a quality initiative that has seen radiation exposures for routine scans going down during this period. During the last 18 months, Drs. Gray and Dowdell have been working to expand
35,000 CT scans per year.
St. Michael’s is an RNAO Best Practice Spotlight Organization
this approach to data collection and analysis province-wide with the creation of the Medical Imaging Metadata Radiation Registry of Ontario, or MIMRRO. By analyzing the CT radiation data across institutions they will be able to determine the average radiation exposure for particular exams and identify centres that may be using more than necessary. “The fact that there are wide variations in radiation dose between sites is a concern,” said Dr. Gray. “Reducing average dose as well as identifying causes of variability and reducing them will significantly improve the care to our patients.” MIMRRO is focused on data from CT scans but ultimately could be applied to other types of medical imaging, such as interventional radiology, nuclear medicine and MRI.
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New MSICU to feature more space for families By Kendra Stephenson
The Medical Surgical Intensive Care Unit, or MSICU, of St. Michael’s 3.0 is being designed with patient- and family-centered care in mind. “There is sometimes great sadness in the MSICU, but it’s also touching to be trusted by families in such a vulnerable time,” said Dr. Antoine Pronovost, an anesthesiologist and medical director of the Trauma and Neurosurgery ICU, who was heavily involved in designing the new MSICU. “It’s very rewarding, having the opportunity to shape and improve that space. We can make a real difference in the lives of patients and their loved ones.” The new facility will address the challengers of the current location, where equipment, caregivers and families are all crowded into a small space around patient beds. When doctors need to speak with families – often difficult conversations – they often have to leave the unit and to have privacy or personal space.
The new facility will have all singlepatient rooms. Each room will have three zones – a patient area with 360-degree access for caregivers and equipment, a family zone next to the window and a health team space with bedside technology for electronic charting and monitoring patients. Families will also have access to support spaces on the unit, including a family lounge, private consultation rooms and team workroom. “Part of the major refocus for the new MSICU is bringing patients, families and the health team together,” said Dr. Pronovost, who has an interest in planning in addition to his critical care background. “We know that patients are at their most vulnerable when they are in the ICU and their families care deeply for
A conceptual rendering of what the future MSICU could look like. JUNE 2014 | IN TOUCH | 4
them and want to be at their bedside.” In addition to more privacy, singlepatient rooms have better sound insulation, making for a less stressful environment and better sleep cycles, Dr. Pronovost said. The rooms are also designed for better infection control and each one will have a patient lift, staff hand-washing sink and pair of articulating arms. The MISCU will occupy the fourth floor of the patient care tower and Cardinal Carter South, with 24 private rooms and three negative pressure isolation rooms. One of the private rooms and one of the negative pressure rooms will be capable of handling bariatric patients.
Dr. Simon Walsh, a guest faculty member; Dr. Christopher Buller, St. Michael’s director of cardiac catheterization and intervention; and Dr. Basem El-Barouni, an advanced trainee; treat a complex coronary artery blockage during an international course held at the Li Ka Shing Knowledge Institute last June. (Photo by Yuri Markarov, Medical Media Centre)
Unblock my heart By Kaylea Forde and Geoff Koehler
When coronary arteries are narrowed because of plaque buildup and blood flow to the heart is limited, cardiologists use a combination of medicine and stents to reopen them in a procedure called percutaneous coronary intervention. But when a coronary artery is completely blocked – known as a chronic total occlusion – percutaneous coronary interventions don’t typically work and patients are forced to choose between putting up with symptoms that limit activity or undergoing openheart surgery. Drs. Christopher Buller and John Graham lead a team at St. Michael’s that is changing this and developing a new set of advanced percutaneous coronary intervention techniques that may largely solve chronic total occlusions. The team develops and delivers advanced therapies for patients with
St. Michael’s is also heading a national trial that might make treating the more routine blockages easier. Dr. Buller is the principal investigator of the trial, which will assess the potential benefits of a new drug that may soften blockages over 24 hours. If the drug safely softens the plaque, it may make it easier and faster in some patients to reopen the artery and restore blood flow. the most complicated forms of coronary artery disease, especially for those who have been turned down for treatment at other centres. “St. Michael’s has built the largest program in Canada for advanced chronic total occlusion treatment,” said Dr. Buller, director of cardiac catheterization and intervention. “Delivering breakthrough percutaneous coronary intervention treatments for complicated blockages is a big part of our Heart and Vascular Program.” The most common technique at St. Michael’s for treating fully blocked arteries uses two catheters, each approaching the blockage from opposite
ends. This technique takes about twice as long as a routine percutaneous coronary intervention. St. Michael’s treats more than 160 patients with chronic total occlusions each year and is internationally recognized for its excellence and its contribution to the field. “Teaching is also crucial to our program,” said Dr. Buller. “Because we see so many cases, we’re able to offer a training course every June where we live stream six complex chronic total occlusion cases. Interventional cardiologists get an interactive, educational experience that can’t be conveyed through journal articles or text books.” JUNE 2014 | IN TOUCH | 5
The hospital’s Centre for Research on Inner City Health has launched a new research program focused on the health of people in prison. Dr. Flora Matheson is looking at the prevalence of TBI to improve screening and treatment. (Photo by Katie Cooper, Medical Media Centre)
Traumatic brain injury a health problem with serious impact for people in prisons By Evelyne Jhung
The hospital’s Centre for Research on Inner City Health has launched a new research program focused on the health of people in prison. A team of CRICH researchers – including Drs. Flora Matheson, Fiona Kouyoumdjian, Stephen Hwang, Diego Silva and others – have received a CIHR planning grant to identify health priorities in the prison population and build a network of researchers to work together to improve prisoner health. One branch of this research program will look at the prevalence of traumatic brain injuries and explore ways to improve screening and treatment. Despite evidence that suggests that people in prison have higher rates of traumatic brain injuries than those in the general population, there are no formal screening processes or tailored programs for people who have suffered a traumatic brain injury in prison. “When some people in prison exhibit behavioural issues, their actions may be a manifestation of a traumatic brain injury,” JUNE 2014 | IN TOUCH | 6
said Dr. Flora Matheson. “By examining the way TBI impacts people in Canadian prisons, we hope to improve screening and treatment for TBI in prison, and inform training initiatives for correctional staff so they are able to recognize and effectively interact with people with TBIs.” Improving treatment for TBI upon discharge from prison also helps to prevent re-incarceration. “We don’t want people to be re-incarcerated because of ‘bad behaviour’ because that’s
Correctional Service Canada already has an intake assessment that screens for mental health and substance abuse and the provincial Ministry of Community Safety and Correctional Services screens for mental health. Dr. Matheson sees the potential to incorporate TBI screening into the existing intake assessments. “The information will help correctional staff plan accordingly so that people with TBI can participate more effectively in programs aimed at rehabilitation. We
“We hope that by improving screening and treatment inside and outside the criminal justice system, we can keep more people suffering from TBI out of correctional facilities.” costly and not what’s going to help them,” Dr. Matheson said. “TBI is a health issue, one that often lands people in prison. We hope that by improving screening and treatment inside and outside the criminal justice system, we can keep more people suffering from TBI out of correctional facilities.”
know people who have suffered from a TBI have impaired cognition and personality disturbances. This means they may not be good at following their correctional program not because they’re trying to be difficult, but because they can’t follow the rules.”
New study aims to make personalized care a standard By Patricia Favre
With an aging population on the rise, hospitals are seeing more seniors living with mental health problems, cognitive impairments due to dementia, or other conditions that may be associated with responsive or challenging behaviours. A new interprofessional working group at St. Michael’s Hospital is studying the profiles of all patients, including seniors, receiving constant care with the intent to continuously improve care. “Patients under constant care are monitored around the clock and generally exhibit responsive behaviours, meaning they are likely to wander, resist care or act in a manner that could be seen as disruptive,” said Terri Irwin, one of the nurse professionals leading the study. “These behaviours are known as responsive because they’re usually due to something negative or frustrating in the patient’s environment that can be addressed and changed.” The working group is made up of a number of health professionals including nurses, physicians and occupational therapists. The group will work with three units in the hospital to collect patient data in the hopes of better understanding the characteristics of patients with responsive behaviours. The group will also consult with other health professionals and clinical assistants to learn about their experiences. “Once we’ve completed the study, we hope to equip our health
Lori Whelan (left) and Terri Irwin (right), leaders of the study, consult with a nurse on one of the units participating in the study. (Photo by Yuri Markarov, Medical Media Centre)
teams with a better understanding of what can cause this behaviour as well as standardized assessment tools and care plans,” explained Lori Whelan, an occupational therapist leading the study with Irwin. “All behaviour has meaning behind it. If we can better understand what triggers patient behaviours then we can adjust the way we provide care to meet the unique needs of each patient.” Irwin and Whelan explained that by standardizing the hospital’s approach to caring for these patients through care plans, more information would be shared among the patient’s health team.
Joanna Sim (left), a registered nurse, and Laura Shapiro (right), an occupational therapist, practice hand exercises with a patient. Shapiro and Sim work on one of the units that is collecting patient data for the study. (Photo by Yuri Markarov, Medical Media Centre)
“Every patient is different and it’s important for the entire team to be on the same page about patient experiences and triggers,” explained Irwin. “For example, if the patient happens to be a retired concert pianist, it’s likely that music would be included in the care plan as it could help to put the patient at ease.”
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Q&A
TIRUWORK (TERRI) TESSAMA,
MARKETERIA
By Kaylea Forde (Photo by Yuri Markarov, Medical Media Centre)
Tiruwork Tessama, better known as Terri, came to work at the Marketeria at St. Michael’s Hospital more than five years ago. One of three cashiers, Tessama is known for her contagious smile and her passion for helping people. The Marketeria, opened in 1997, seats up to 200 people and is one of three retail food outlets in the hospital whose proceeds support patient services.
Q. Tell us about your role – what do you do in the Marketeria? I provide general help; we have to work with everything. Most of the time I’m on cash, but if management asks me to do anything, if I can, I will do it. All of us will.
Q. What does a stressful/busy day look like? I try to make people happy, even if it is a stressful day. I enjoy everything about working here. I try to make anything possible, to make my customers happy. The people at St. Michael's hospital are great to serve, and I am happy to serve every department. I try my best to help everyone. We all try our best to provide nice things, with good service. Our staff
INTOUCH
JUNE 2014
In Touch is an employee newsletter published by Communications and Public Affairs. Please send story ideas to In Touch editor Leslie Shepherd at shepherdl@smh.ca. Design by Dermot Covel, Medical Media Centre
are all good helpers. And I look forward to helping, too.
Q. What brought you to St. Michael’s? What’s the most rewarding part of your job? I think that the environment is nice. The St. Michael's staff does a lot of things for other people, the doctors and nurses. And I am so happy to serve the other people, too. If I can make them happy, then I am happy. I like the logos too. Inspired care. I like that. I have to follow that at my workplace, too. I’ve been here for over five year and my favourite part is the customer service. I don’t have any problems at all. I love everybody here.
Q. What’s the most popular food item bought? You know, we have a lot of different stations here with many sections. Hot food, pizza, pasta, salad bar and coffee. But we sell everything the same. The salad bar is popular though, because everything we have here is fresh.
Q. What is your favourite thing to eat when you get home? Sweets. I like sweets. Fruit and sweets. But I like to cook spicy food at home. Traditional spicy food.