UTMJ
A student-run scientific publication since 1923
University of Toronto Medical Journal
Volume 95, Number 3, June 2018
www.utmj.org
A student-run scientific publication since 1923
University of Toronto Medical Journal
PREFACE
5 Preface from the Editors
NEWS & VIEWS
6 More HOCUS POCUS: Advocating for Point-of-Care Ultrasound Teaching in Medical School
Johnny-Wei Bai
9 Hypertension Pharmacotherapy: Practice Changing Updates in the Management of Hypertension Theunis van Zyl
12 Time to Get SMART About SALT in the ED? James R. Riggs
INTERVIEWS
14 Interview with Dr. Avery Nathens UTMJ Interview Team
19 Interview with Dr. Christopher Hicks UTMJ Interview Team
24 Interview with Dr. Allan Detsky UTMJ Interview Team
27 Interview with Dr. Karen Devon Dr. Sunit Das
PERSPECTIVES
32 Being Mortal: A Health Policy Perspective on Dying Well in Canada
Ayesha Tasneem
REVIEWS
36 Rejuvenating the Elderly – A Scientific Approach for Tackling Geriatric Intensive Care
Lukasz Wlodarek and Fievel Lim
41 The Need to Integrate Treatment Programs for Patients with Concurrent Eating Disorders and Substance Use Lewis Forward, Cathy Jiang, Kathy Ma, Lawrence Ma, Edward Ssebuliba, Chin-Vern Tan and J. Evan Zhou
43 End of Life Care in a Multicultural Framework: to Treat or Not to Treat
Mana Modares and Andreea C. Matei
HEALTH POLICY & ECONOMICS
45 The Sky’s the Limit When it Comes to Acute Care David Bobrowski and Adam Bobrowski
50 Hallway Healthcare: Solving Acute Care Overflow from the Community
David Bobrowski, Michael D. Elfassy and Adam Bobrowski
TRIBUTE TO PETER MUNK
54 Peter Munk Tribute
POETRY
56 Forever Always Dilshan I. Pieris
Table of Contents
Front cover illustration by Isabel Gordon.
A student-run scientific publication since 1923
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2017-2018 UTMJ Editorial Team
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Preface
Preface from the Editors
managing the largest tertiary trauma centre in Canada. In addition, we add to the understanding of geriatric intensive care, point-of-care ultrasound, and emergency mental health. We also share a tribute to the late Peter Munk, after whom the Cardiac Center at Toronto General Hospital is named.
It is in the spirit of advancement that the 2017-2018 UTMJ team has endeavoured to compile this issue. We would like to express our gratitude for the hard work and dedication of our diverse team of managing editors, associate editors, sec-tion reviewers, copy editors, the interview team, cover artist, and web developers. As always, we appreciate the generous sponsorships from our esteemed patrons. Last but not least, we would like to thank you, the reader – we hope you enjoy reading this issue as much as we enjoyed preparing it!
Sincerely yours,
Alexander Adibfar Brij Karmur
Editors-in-Chief, UTMJ
Dear Reader,
I
t is our utmost pleasure to share with you the third issue of the 95th volume of the UTMJ. While life-threatening conditions remain among the most harrowing experienc-es for patients, their familiexperienc-es, and even healthcare providers, the tireless work of multidisciplinary teams of critical care cli-nicians and researchers has saved countless lives and dramati-cally enhanced the care of critidramati-cally ill patients. This prog-ress has been the result of their commitment to tackling a number of complex problems, from ventilation and infection control to delirium and transplantation. In this Spring issue, the UTMJ would like to feature submissions that highlight re-search related to all aspects of trauma, emergency medicine, and critical care including but not limited to health policy, global health, mental health, clinical outcomes, basic scienc-es, and the social determinants of health.News & Views
More HOCUS POCUS: Advocating for Point-of-Care
Ultrasound Teaching in Medical School
sicians were credentialed to use bedside PoCUS, with lower rates in community compared to academic departments.3 In
another survey of mostly junior doctors, only 43.1% used Po-CUS in their practice and only 39.2% had received formal training in ultrasound. In this cohort, the top barriers to developing a PoCUS training program were availability and cost of ultrasound machines, lack of a formal curriculum, and time required to train faculty members and learners.4 Given
the growing importance of PoCUS, the current editorial aims to i) review the roles of PoCUS in critical and acute care set-tings; 2) describe the current state of PoCUS education; 3) advocate for increased PoCUS teaching in medical school.
Applications of PoCUS in Critical Care
The role of PoCUS is becoming as broad as it is essential. This was exemplified in rescue efforts after the devastating 2008 Wenchen earthquake, which led to mass casualty of over 69,000 deaths and hundreds of thousands injured. In a local hospital, PoCUS was used on 1207 wounded patients to guide interventions, triage injuries, and diagnose cases of hemo-peritoneum, pleural effusion, visceral organ damage, arterial tears, venous thrombosis, and soft tissue hematoma.5 Even
in a more controlled ICU setting, PoCUS has been shown to provide new diagnoses and changes to clinical management in 65.5% and 36.9% of cases, respectively.6 While there are
many uses of ultrasound, these are considered to be essential techniques based on the Canadian Point of Care Ultrasound Society and the critical care literature:2,6,7
Cardiac Ultrasound
Focused cardiac ultrasound (“FoCUS”) – the foundation for Critical Care Echocardiography (CCE) – classically in-volves five views of the heart: parasternal long axis, parasternal short axis, apical four-chamber, subcostal inferior vena cava, and subcostal four-chamber views. These allow evaluation of ventricular size and function (e.g., shock or heart failure), myocardial size and motion (e.g., cardiomyopathy or infarct), pericardial effusion, inferior vena cava size and mobility (e.g., volume status in the hypotensive patient), and aortic pathol-ogy (e.g., dissection or aneurysm). In hemodynamically un-stable patients, FoCUS is very valuable in providing diagnosis and guiding treatment.2,8,9
Lung Ultrasound
Through ultrasound, the lung can be visualized as the chest wall, pleura, and subpleural space, which are associated with various pathologies: pneumothorax, pleural effusion, in-Background
P
oint-of-Care Ultrasound (PoCUS) is hailed as the “stethoscope of the future”. While physical exams of-ten rely on an integration of maneuvers and ausculta-tion – all helpful for arriving at a diagnosis – the ultrasound now permits immediate and direct visualization of anatomy and physiology.1 Conceivably, this is a powerful tool inInten-sive Care Units (ICU), acute care, and trauma settings where patients require swift diagnoses at the bedside. For example, intensivists can use PoCUS to accurately assess for cardiac function, pneumothoraces, fluid status, and many other life-threatening conditions that previously required detailed ra-diographic studies.1,2
Despite the advantages of PoCUS, some argue that it is not being applied or taught to its full potential. In a survey of 101 American emergency departments, less than half of
phy-Johnny-Wei Bai, BHSc, MD (Cand.) 1
1 University of Toronto, Faculty of Medicine
Abstract
Point-of-Care Ultrasound (PoCUS) is hailed as the “stethoscope of the future”. Especially in acute and critical care settings, PoCUS has countless applica-tions and has been shown to improve diagnostic and procedural outcomes. Although residency pro-grams are starting to adopt ultrasound teaching, it seems that North American undergraduate medical programs have much room for improvement. For instance, a 2016 Canadian survey showed that only half of Canadian medical schools had integrated PoCUS into their curricula, with only 0-5 hours of teaching per year. Medical schools are constantly seeking to innovate education, and PoCUS should be no exception. This Review and Editorial will highlight the importance of PoCUS in acute and critical care, and advocate for increased ultrasound teaching in undergraduate medical programs.
More HOCUS POCUS: Advocating for Point-of-Care Ultrasound Teaching in Medical School
News & Views
CUS training into basic anatomy and physical exam courses, preclinical years, clerkship, or even throughout all years of medical school.16-19 Teaching usually involves a combination
of didactic lectures, hands-on training with patient-models or ultrasound simulators, clinical cases, and final projects or objective structured clinical examinations (OSCEs). Topics covered generally include systems anatomy, image acquisi-tion and interpretaacquisi-tion skills, abdominal FAST scans, cardiac scans, and lung ultrasound for pneumothorax sliding.20-22
While enthusiasm for PoCUS has “trickled” to the medical school level, there is room for improvement. In a 2014 survey of American undergraduate medical programs, only 62.2% reported some ultrasound training and 18.6% claimed it as an area of priority.23 Similarly, in the 2016 Canadian
medi-cal school survey, most schools reported only 0-5 hours of teaching per year.15 Top barriers to implementation included
lack of space in the established curriculum, lack of financial support and infrastructure, and lack of ultrasound machines. Given the ever-growing role of PoCUS, medical schools must leverage their ultrasound curricula to better prepare the fu-ture generation of doctors. Some strategies might include dedicating more curricular time for PoCUS teaching, part-nering with hospitals to access ultrasound equipment, rely-ing on free online resources and videos for teachrely-ing, and re-cruiting residents or senior medical students to teach junior trainees. On a national scale, as was recently done by Ameri-can programs, Canadian medical faculties should also define minimum standards for PoCUS skills before students move on to residency.24
Conclusion
PoCUS is an essential skill in a physician’s diagnostic and interventional toolbox. While residencies such as Emergency Medicine, Anesthesiology, Critical Care, and Obstetrics/Gy-necology have eagerly adopted ultrasound teaching, medi-cal schools should play their part by providing increased and early exposure to PoCUS. Future work should aim to establish a feasible and effective PoCUS curriculum, determine ways to assess competency at a medical school level, and set a national standard for ultrasound teaching in medical school.
References
1. Abu-Zidan FM. Point-of-care ultrasound in critically ill patients: Where do we stand? Journal of Emergencies, Trauma, and Shock. 2012;5(1):70-71. doi:10.4103/0974-2700.93120.
2. Arntfield RT, Millington SJ. Point of Care Cardiac Ultrasound Applications in the Emergency Department and Intensive Care Unit - A Review. Current Cardiology Reviews. 2012;8(2):98-108. doi:10.2174/157340312801784952. 3. Stein JC, River G, Kalika I, Hebig A, Price D, Jacoby VL, Filly R. A survey of
bedside ultrasound use by emergency physicians in California. J Ultrasound Med. 2009 Jun;28(6):757-63.
4. Peh WM, Kang ML. A pilot survey on an understanding of point of care bedside ultrasound (POCUS) among medical doctors in internal medi-cine: Exposure, perceptions, interest and barriers to training. Proceedings of Singapore Healthcare. 2017 Sep.
5. Dan D, Mingsong L, Jie T, Xiaobo W, Zhong C, Yan L, Xiaojin L, Ming C. Ultrasonographic applications after mass casualty incident caused by Wen-chuan earthquake. J Trauma. 2010 Jun;68(6):1417-20.
6. Killu K, Coba V, Mendez M, et al. Model Point-of-Care Ultrasound Cur-riculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management. Critical Care Research and Practice. 2014. 7. Canadian Point of Care Ultrasound Society. Core POCUS Applications.
Accessed 2018 Feb 13. Retrieved from https://www.cpocus.ca/about-ultra-sound-society/uses-ed-us/
terstitial disease, edema or consolidation, etc. Over the years, several imaging signs and decision-tools have been validated. For instance, lung sliding at the pleural line can rule out pneumothorax even more accurately than supine chest x-ray. PoCUS in the acutely dyspneic or hypoxic patient can guide life-saving diagnosis and treatment.10,11
Abdominal Ultrasound
Some abdominal pathologies can be identified on PoCUS, such as cholecystitis, abdominal aortic aneurysm or rupture, bowel perforation, renal perfusion or obstruction, or uro-gynecological disease. Specific to trauma, the Focused As-sessment with Sonography for Trauma (FAST) scan helps to identify free fluid in the abdomen as a sign of intraperitoneal bleeding. Thus, the abdominal ultrasound serves as an effi-cient and radiation-free alternative to CT-scans.11,12
Procedural Guidance
By providing direct visualization of anatomy, ultrasound has become the standard for various procedures including regional anesthetic blocks, central venous catheter or arterial line placement, para- and thoracenteses, and percutaneous tracheostomy. Being able to perform these techniques ef-ficiently with ultrasound is key when patients have difficult vascular or airway access following trauma or critical illness.11
Airway Management
While still primarily an academic interest, PoCUS can be used to guide airway and ventilation management in critical care. In a small study, diaphragm thickening fraction on ultra-sound demonstrated high sensitivity and specificity in predict-ing successful ventilator weanpredict-ing. There is also growpredict-ing body of literature on PoCUS in guiding endotracheal and trache-ostomy tube size, confirming tube positioning, localizing air-way structures for emergency access, and predicting difficult airways.13,14
Other
More specific applications PoCUS include vascular scan-ning for deep vein thrombosis, optic nerve assessment for in-creased intracranial pressure (i.e., in neurotrauma or stroke), and transcranial doppler for vasospasm or cerebral ischemia. However, these are not standardly performed or taught in Po-CUS curricula.11
Current PoCUS Teaching
Recognizing the importance of PoCUS, some faculties have been enthusiastic to test and adopt formal curricula. In a 2016 survey of 13 Canadian medical schools, around half of respondents (6/13) had implemented ultrasound education since 2013; commonly, this was taught in clerkship through emergency medicine, internal medicine, or anes-thesia rotations by non-radiologist physicians. There was also an emphasis on practical, hands-on teaching with a clinical problem-based approach, with the help of online resources and textbooks.15 In addition, several reports by American
Po-More HOCUS POCUS: Advocating for Point-of-Care Ultrasound Teaching in Medical School
News & Views
8. Saranteas T, Mavrogenis AF, Mandila C, Poularas J, Panou F. Ultrasound in cardiac trauma. J Crit Care. 2017 Apr;38:144-151.
9. Mok KL. Make it SIMPLE: enhanced shock management by focused car-diac ultrasound. J Intensive Care. 2016 Aug; 4(51).
10. Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accu-racy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos. 2014; 13(4): p29-40.
11. Wilson S, Mackay A. Ultrasound in critical care. Continuing Education in Anaesthesia Critical Care & Pain. 2012 Aug; 12(4): p190-194.
12. Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016 Aug; 4(53). 13. Samanta S, Singh RK, Baronia AK, Poddar B, Azim A, Gurjar M. Diaphragm
thickening fraction to predict weaning—a prospective exploratory study. Journal of Intensive Care. 2017;5:62. doi:10.1186/s40560-017-0258-4. 14. You-Ten KE, Siddiqui N, Teoh WH, Kristensen MS. Point-of-care ultrasound
(POCUS) of the upper airway. Can J Anaesth. 2018 Jan 18.
15. Steinmetz P, Dobrescu O, Oleskevich S, Lewis J. Bedside ultrasound edu-cation in Canadian medical schools: A national survey. Canadian Medical Education Journal. 2016;7(1):e78-e86.
16. Rempell JS, Saldana F, DiSalvo D, et al. Pilot Point-of-Care Ultrasound Cur-riculum at Harvard Medical School: Early Experience. Western Journal of Emergency Medicine. 2016;17(6):734-740.
17. Bahner DP, Royall NA. Advanced ultrasound training for fourth-year medi-cal students: a novel training program at The Ohio State University College of Medicine. Acad Med. 2013 Feb;88(2):206-13.
18. Syperda VA, Trivedi PN, Melo LC, Freeman ML, Ledermann EJ, Smith TM, Alben JO. Ultrasonography in preclinical education: a pilot study. J Am Osteopath Assoc. 2008 Oct;108(10):601-5
19. Hoppmann RA, Rao VV, Bell F, et al. The evolution of an integrated ultra-sound curriculum (iUSC) for medical students: 9-year experience. Critical Ultrasound Journal. 2015;7:18
20. Ang J, Doyle B, Allen P, Cheek C. Teaching bedside ultrasound to medical students. Clin Teach. 2017 Aug;
20. Strnad M, Zadel S, Klemenc-Ketis Z, Prosten G. Identification of lung slid-ing: a basic ultrasound technique with a steep learning curve. Signa Vitae. 2013; 8(1): p31-35.
21. Ang J, Doyle B, Allen P, Cheek C. Teaching bedside ultrasound to medical students. Clin Teach. 2017 Aug.
22. Gogalniceanu P, Sheena Y, Kashef E, Purkayastha S, Darzi A, Paraskeva P. Is basic emergency ultrasound training feasible as part of standard under-graduate medical education? J Surg Educ. 2010 May-Jun;67(3):152-6. 23. Bahner DP, Goldman E, Way D, et al. The state of ultrasound education in
U.S. medical schools: results of a national survey. Acad Med. 2014;89:181–6. 24. Dinh VA, Lakoff D, Hess J, Bahner DP, Hoppmann R, Blaivas M, Pellerito
JS, Abuhamad A, Khandelwal S. Medical Student Core Clinical Ultrasound Milestones: A Consensus Among Directors in the United States. J Ultra-sound Med. 2016 Feb;35(2):421-34.
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Hypertension Pharmacotherapy: Practice Changing Updates
in the Management of Hypertension
Thiazides, Are They All The Same?
Most providers assume all thiazide diuretics are, if not identical, very substitutable. However, there are two types of thiazide diuretics: thiazide-type diuretics, such as HCTZ, which are shorter acting with 12-hour efficacy, and thiazide-like diuretics, such as chlorthalidone and indapamide, which are longer acting with 24-hour efficacy.5 While similar, they
are far from identical. When examining physician prescrib-ing habits, thiazide-type HCTZ is significantly favoured over longer acting, thiazide-like chlorthalidone, likely secondary to cost and familiarity.6 Twenty-two percent of all patients
treated for hypertension in the United States receive HCTZ, while only 1% receive chlorthalidone.6
As mentioned earlier, however, thiazide diuretics are not all identical and differ in their length of action.(5) The rec-ommendation of thiazides as first-line treatment for hyper-tension was based on the ALLHAT trial, which specifically studied chlorthalidone and not HCTZ.(4) When read closely, CHEP guidelines specifically recommend thiazide-like di-uretics (chlorthalidone) as first line and not thiazide-type (HCTZ).(3) If this is the case, then why are so many physi-cians overwhelmingly prescribing HCTZ? Is there even a clin-ically significant difference between the two thiazides?
HCTZ vs. Chlorthalidone
The HCTZ vs. chlorthalidone question was recently ad-dressed in a meta-analysis of 21 RCTs by Engberink et al.7
While both decreased adverse cardiac events compared to placebo, only chlorthalidone was superior to other anti-hy-pertensives (HCTZ, CCB, ACE-I) in decreasing adverse car-diac events.7 Even with similar BP reductions between
treat-ment groups, Chlorthalidone resulted in a 12% reduction in adverse cardiac events and a 21% reduction in heart failure compared to HCTZ.7 Chlorthalidone was found to have
su-perior 24 hour BP control, likely due to its longer length of action, which was theorized to account for the lower rates of adverse cardiac events and heart failure.7 Both HCTZ and
chlorthalidone had similar rates of side effects compared to each other and other anti-hypertensives.7
The CHEP guidelines specifically recommends thiazide-like diuretics (chlorthalidone) as first line and not thiazide-type (HCTZ).3 Based on literature, starting new hypertensive
pa-tients on HCTZ as a first line is an inferior treatment.7 As
men-tioned earlier, chlorthalidone has lower rates of adverse cardiac events, similar rates of side effects, and, while more expensive than HCTZ, it is still a relatively affordable medication.7 If a Background
Hypertension affects approximately 23% of Canadians, with prevalence estimated to continue increasing.1,2 A third
of patients with hypertension are uncontrolled, having blood pressures (BP) above 140/90 due to either lack of treatment or undertreatment.2 This is important as hypertension is a
major burden on the healthcare system, consuming $13.9 bil-lion CAD dollars or 10.2% of Canada’s healthcare budget.1
Given these trends, proper treatment and control of hyper-tension is paramount.
In an effort to combat the disease, Hypertension Canada releases annual guidelines (CHEP) on the diagnosis, preven-tion, and treatment of hypertension, with the most recent up-date in 2017 recommending numerous changes to the man-agement of hypertension.3
Thiazide Diuretics: Why Do We Use What We Use? In hypertension pharmacotherapy, few drugs are more well-known than thiazide diuretics, with hydrochlorothia-zide (HCTZ) being a staple for primary care providers. The 2017 Canada Hypertension guidelines update recommends multiple first-line treatments, including ACE-inhibitors (ACE-I), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide-like diuretics.3 It recommends
that the preferred first-line treatment should be a thiazide-like diuretic.3 This is hardly news to most primary care
pro-viders.
The recommendation of thiazide-like diuretics as first choice is based on the ALLHAT trial. This double-blind, randomized control trial (RCT) of over 33,000 patients with hypertension compared treatment with chlorthalidone, a thiazide-like diuretic, to amlodipine, a CCB, or lisinopril, an ACE-I.4 The trial followed patients for 4-8 years and compared
adverse cardiac events and mortality.4 ALLHAT found that
thiazide-like diuretics resulted in a 25% lower risk of heart failure and better BP control compared to CCB and ACE-I.4
Given these results and the lower price of thiazides, ALLHAT and the CHEP guidelines concluded that thiazide-like diuret-ics should be the preferred first line treatment of hyperten-sion.3,4
Theunis van Zyl, MD Candidate (2018) 1
1 Schulich School of Medicine and Dentistry, Western University, London, ON
News & Views
Hypertension Pharmacotherapy: Practice Changing Updates in the Management of Hypertension
patient is currently well controlled on HCTZ, the CHEP guide-lines recommends continuing with the treatment.3 However,
next time you consider starting a patient on a thiazide diuretic for hypertension, remember to use chlorthalidone.
Combination Therapy
Another major addition in the 2017 update to the CHEP guidelines is the recommendation for single-pill combina-tion (SPC) therapy as a first line treatment for hypertension.3
Combination therapy is the combination of two anti-hyper-tensives, such as an ACE-I and CCB, also available in a single pill formulation. Evidence suggests lower doses of two anti-hypertensives results in better BP control and fewer side ef-fects than a larger dose of one anti-hypertensives.8
One recent meta-analysis examined 42 RCTs comparing doubling doses of monotherapy vs adding a second anti-hy-pertensive at initial doses (combo therapy) in management of hypertension.8 The study reported significantly larger
de-creases in BP and fewer side effects for combo therapy com-pared to higher doses of monotherapy.8 Compared to
place-bos, the respective reduction of systolic BP was 5 mmHg with monotherapy, 6 mmHg with double dose monotherapy, and 9 mmHg with combo therapy of two anti-hypertensives at initial monotherapy dose levels.8 This was true across all classes of
anti-hypertensives.8
Combo therapy was also significantly more effective at pre-venting strokes and adverse cardiac events than double dose monotherapy when treating hypertension.8 Compared to
pla-cebos, the respective reduction in cardiac events and stroke was 25% and 35% with monotherapy, 29% and 40% with dou-ble dose monotherapy, and 40% and 54% with combo thera-py. The evidence suggests that patients who fail monotherapy be trialed on combination therapy of two anti-hypertensives at initial doses, and not on increased doses of monotherapy given the preventative benefits and lower rate of side effects.
Initial Combo Therapy vs. Step-Up Therapy
While it is well known that combo therapy can improve control after stepping up from monotherapy, recent evidence has led the 2017 CHEP guidelines to recommend initial treat-ment with combo therapy.3 Two studies compared initial
combo therapy to step-up therapy and found that patients initially treated with combo therapy were more likely to reach BP control at 6 months. Furthermore, these patients had a 34% relative risk reduction (RRR) in adverse cardiac events or death.9,10 In fact, patients treated with monotherapy who
stepped up to combo therapy were found to have no differ-ence in inciddiffer-ence of adverse cardiac events compare to treat-ing solely with monotherapy.10
The study suggested that initial combo therapy is supe-rior as BP reduction is achieved faster resulting in reduced rates of cardiac events.10 Also, initial combo therapy reduced
healthcare resource use, with patients requiring fewer emer-gency room visits, hospitalizations, and outpatient visits per year.10 While these data are only observational, initial combo
therapy is a reasonable choice supported by the CHEP 2017 guideline update.3
Single Pill Combo Or Two Separate Pills?
When considering starting a hypertensive patient on initial combo therapy, a provider may wonder if is a SPC is neces-sary given their often prohibitive cost? Why not give two anti-hypertensives at once?
With hypertension being asymptomatic, treatment adher-ence is poor at 67%, and decreases with increasing number of pills and doses.11,12 The effect of SPC therapy on adherence in
hypertension was evaluated in two meta-analyses by Sherrill et al and Gupta et al.13,14 SPC was compared to dual pill therapy
for hypertension and was found to increase adherence by 8 to 29%, as well as increase persistence with therapy by 29%.13,14
Better adherence should improve health and SPCs were asso-ciated with $2000 lower healthcare costs annually compared to dual pill therapy when treating hypertension.13
Keeping in mind that treating hypertension with initial combo therapy is superior to both monotherapy and step-ping-up therapy (from mono to combo therapy),10 consider
the added benefits in adherence when using a single pill treat-ment.13 If a patient can afford it, physicians should prescribe
SPC therapy as initial, first-line treatment for hypertension.
Which Single Pill Combo To Choose?
With multiple SPC options, including ACE-I/CCBs and ACE-I/diuretics, it may not be clear with which medication to start. However, ACCOMPLISH, a large multi-center RCT of over 11,500 patients was conducted to partially answer this question.15 It compared treatment of hypertension with an
ACE-I/CCB to ACE-I/diuretic, looking specifically at bena-zepril/amlodipine vs. benazepril/HCTZ.15 In the study, the
ACE-I/CCB combo had a 17% RRR and 1.7% absolute risk reduction (ARR) in adverse cardiac events, and a 21% RRR and 1.3% ARR in death from cardiac causes compared to an ACE-I/diuretic.15
Based on this data, a good choice for initial combo therapy in hypertension would be an ACE-I/CCB combo. The 2017 CHEP guideline update also recommends starting with an ACE-I/CCB when choosing a combo therapy.3
Summary
In summary, there are two major updates to take away from the 2017 CHEP guidelines with regards to pharmacotherapy for hypertension. First, chlorthalidone should be the first line treatment when considering diuretics, not HCTZ. Chlortha-lidone has demonstrated superior BP control and lower rates of adverse cardiac events compared to HCTZ. If patients still have difficulty controlling their BP after treatment with a thi-azide-like diuretic, it is recommended to change their medi-cation to an ACE-I/CCB combo rather than simply increas-ing their chlorthalidone dose. Combo therapy is significantly more effective at reducing BP and preventing strokes and adverse cardiac events than increasing the dose of a single anti-hypertensive medication.
Finally, initial ACE-I/CCB single pill combo therapy is now also considered a first-line treatment, as it results in better rates of compliance and BP control and lower rates of adverse cardiac events compared to initial monotherapy stepped up to combo therapy. Initial ACE-I/CCB combo therapy is an
Hypertension Pharmacotherapy: Practice Changing Updates in the Management of Hypertension
8. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination ther-apy versus monotherther-apy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med [Internet]. Elsevier Inc.; 2009;122(3):290–300. Available from: http://www.amjmed.com/article/ S0002-9343(08)00992-3/abstract
9. Corrao G, Nicotra F, Parodi A, Zambon A, Heiman F, Merlino L, et al. Cardiovascular protection by initial and subsequent combination of antihypertensive drugs in daily life practice. Hypertension [Internet]. 2011;58(4):566–72. Available from: http://hyper.ahajournals.org/user/ logout?current=node/250932
10. Gradman AH, Parisé H, Lefebvre P, Falvey H, Lafeuille MH, Duh MS. Initial combination therapy reduces the risk of cardiovascular events in hypertensive patients: A matched cohort study. Hypertension [Internet]. 2013;61(2):309–18. Available from: http://hyper.ahajournals.org/con-tent/61/2/309.short
11. Claxton AJ, Cramer J, Pierce C. A systematic review of the association be-tween dose regimens and medication compliances. Clin Ther [Internet]. 2001;23(8):1296–310. Available from: http://www.clinicaltherapeutics. com/article/S0149-2918(01)80109-0/abstract
12. Cramer JA, Benedict A, Muszbek N, Keskinaslan A, Khan ZM. The sig-nificance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. Int J Clin Pract [Internet]. 2008;62(1):76–87. Available from: https://onlinelibrary.wiley.com/doi/ full/10.1111/j.1742-1241.2007.01630.x
13. Sherrill B, Halpern M, Khan S, Zhang J, Panjabi S. Single-pill vs free-equiva-lent combination therapies for hypertension: a meta-analysis of health care costs and adherence. J Clin Hypertens [Internet]. 2011;13(12):898–909. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1751-7176.2011.00550.x
14. Gupta AK, Arshad S, Poulter NR. Compliance, safety, and effectiveness of fixed-dose combinations of antihypertensive agents: a meta-analysis. Hy-pertension [Internet]. 2010;55(2):399–407. Available from: http://hyper. ahajournals.org/content/55/2/399.short
15. Jamerson K, Weber MA, Bakris GL, Dahlöf B, Pitt B, Shi V, et al. Benaz-epril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med [Internet]. 2008;359(23):2417–28. Available from: http://www.nejm.org/doi/full/10.1056/nejmoa0806182
cellent choice in patients unlikely to get adequate BP reduc-tion with a single medicareduc-tion.
References
1. Weaver CG, Clement FM, Campbell NRC, James MT, Klarenbach SW, Hem-melgarn BR, et al. Healthcare costs attributable to hypertension: Canadian population-based cohort study. Hypertension [Internet]. 2015;66(3):502– 8. Available from: http://hyper.ahajournals.org/content/66/3/502.short 2. Padwal RS, Bienek A, McAlister FA, Campbell NRC. Epidemiology of
hyper-tension in Canada: an update. Can J Cardiol [Internet]. Canadian Cardio-vascular Society; 2016;32(5):687–94. Available from: http://www.onlinecjc. ca/article/S0828-282X(15)01306-9/abstract
3. Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk assess-ment, prevention, and treatment of hypertension in adults. Can J Cardiol [Internet]. 2017;33(5):557–76. Available from: http://www.onlinecjc.ca/ article/S0828-282X(17)30110-1/fulltext
4. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients ran-domized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). J Am Med Assoc [Internet]. 2002;288(23):2981–97. Available from: https://jamanetwork.com/jour-nals/jama/fullarticle/195626
5. Carter BL, Ernst ME, Cohen JD. Hydrochlorothiazide versus chlorthali-done: evidence supporting their interchangeability. Hypertension [Inter-net]. 2004;43(1):4–9. Available from: http://hyper.ahajournals.org/con-tent/43/1/4
6. Shah SJ, Stafford RS. Current trends of hypertension treatment in the United States. Am J Hypertens [Internet]. 2017;30(10):1008–14. Available from: https://academic.oup.com/ajh/article/30/10/1008/3844728 7. Engberink RHGO, Frenkel WJ, Bogaard B van den, Brewster LM, Vogt
L, van den Born B-JH. Effects of thiazide-type and thiazide-like diuretics on cardiovascular events and mortality: systematic review and meta-anal-ysis [Internet]. Hypertension. 2015. 622-628 p. Available from: http:// hyper.ahajournals.org/content/early/2015/03/02/HYPERTENSIO-NAHA.114.05122.short
Time to Get SMART About SALT in the ED?
News & Views
renal replacement therapy or a doubling in measured cre-atinine. Ultimately, there was no difference in hospital free days, but the group receiving BC had significantly lower rates of MAKE30 outcomes, with a number needed to treat (NNT) of 111.4
The Isotonic Solutions and Major Adverse Renal Events (SMART) trial5 was published alongside SALT-ED in the same
issue of the NEJM. This trial compared NS with BC in ICU patients admitted to one of five ICUs at a single academic centre. Each ICU was randomized to utilize either NS or BC for one month at a time, switching every month. A total of 15,802 adults were randomized, 7942 in the BC group and 7860 in the NS group. Each group received similar volumes of fluid on average, although the range was large (0-3500ml). The primary outcome used the same MAKE30 composite cri-teria as in SALT-ED. Similarly to SALT-ED, this trial showed a significant decrease in MAKE30 in the BC group, with a NNT of 91. Within the subset of patients admitted with sepsis, the BC group had significantly less mortality at 30 days, as well as significantly less MAKE30.5
While both trials showed that patients receiving BC had significantly lower rates of adverse events as defined by the MAKE30 outcome,4,5 it is worth considering that as a
com-posite outcome comprising death, need for initiation of renal replacement therapy, and a doubling of serum creati-nine, critical thought should be applied regarding its valid-ity. These component outcomes are not clinically equivalent, but were treated equivalently in the analysis. In SALT-ED, the differences observed were driven largely by differences in renal failure, and showed that even low to moderate doses of saline may be particularly harmful for patients with pre-existing renal injury.4 By contrast, the harmful effects of NS
in SMART were driven largely by a difference in mortality (11.1% vs. 10.3%, p=0.06). Subgroup analysis revealed even greater differences in mortality for patients receiving NS with sepsis (29.4% vs. 25.2%, p=0.020) or who were already receiv-ing chronic dialysis (18.4% vs. 12.2%, p=0.015).5 Although
not the primary goal of this trial, these analyses of the compo-nents of the MAKE30 outcome suggest that these populations may be particularly sensitive to crystalloid selection and that further study is needed.
The SMART and SALT-ED trials represent the most sig-nificant efforts yet undertaken to discern whether NS or BC solutions are superior for crystalloid fluid therapy. The significant sample sizes meant that both trials were powered to detect small differences in outcomes, an important factor when considering the ubiquity of crystalloid fluid resuscita-tion. The SMART trial is also exceptional among ICU trials
I
ntravenous fluid resuscitation with crystalloids is one ofthe most common interventions performed in the emer-gency department and intensive care unit (ICU).1
Nor-mal saline (NS) and balanced crystalloids (BC) are often used interchangeably for this purpose, with considerable variation depending on physician preference and practice location. NS, the most widely used resuscitation fluid globally,2
con-tains 154mmol/L of both sodium and chloride, and is iso-tonic to extracellular fluid. However, the high chloride con-centration of NS has been shown to induce hyperchloremic metabolic acidosis.1 In BC solutions other ions, such as lactate
or bicarbonate, replace a proportion of the chloride found in NS, resulting in a more physiologic chloride concentration.1
In 2015, the 0.9% Saline vs Plasma-Lyte 148 (PL-148) for ICU fluid Therapy (SPLIT) trial was published showing no differ-ence in the rate of acute kidney injury in 2278 patients admit-ted to four ICUs in New Zealand who received either NS or BC3. This trial was not powered to detect small differences in mortality and did not control for the type of fluids received prior to arriving in the ICU. Given the ubiquity of fluid resus-citation and the potential for small differences in mortality to affect large numbers of patients, more evidence was required before declaring NS and BC equivalent or interchangeable. This article will review two recently published randomized controlled trials that compared NS to BC, and will consider how these and other ongoing trials may affect resuscitation fluid choices in the future.
The Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT-ED) trial compared NS with BC solutions in a prospective sample of adults treated with IV fluids in the emergency department and subsequently admit-ted to the hospital outside of the ICU.4 The BC arm included
both lactated Ringer’s and Plasma-Lyte, two commonly used BC solutions. To be eligible, patients had to receive at least 500ml of fluid in the ED and be admitted to the hospital out-side the ICU. 6708 patients were randomized to receive BC and 6639 to receive NS. The median volume of crystalloid received was 1079ml, and 88.3% of patients received their as-signed fluids exclusively. The primary outcome was Hospital-Free Days, defined as the number of days alive and out of hos-pital between their initial presentation to the ED and the end of follow up after 28 days. Secondary outcomes included the number of major adverse kidney events at 30 days (MAKE30), a composite outcome composed of death in hospital, new
James R. Riggs 1
1 Schulich School of Medicine and Dentistry, Western University, London, ON
Time to Get SMART About SALT in the ED?
ted to the hospital outside of the ICU, SALT-ED suggests that the choice of crystalloid did not affect hospital-free days, while secondary analysis points towards a possible advantage for BC in avoiding kidney dysfunction.4 In patients admitted to the
ICU, SMART showed that BC significantly reduced adverse MAKE30 outcomes, with a particular benefit in those with sep-sis.5 Ultimately for patients not requiring ICU admission,
clini-cians must still rely on their clinical judgment when choosing a crystalloid fluid. For clinicians attending to patients in the ICU, the findings of SMART suggest a move towards BC over NS for most patients requiring fluid resuscitation.
References
1. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013 Sep;369(13):1243-51.
2. Finfer S, Liu B, Taylor C, Bellomo R, Billot L, Cook D, et al. Resuscitation fluid use in critically ill adults: an international cross-sectional study in 391 intensive care units. Crit Care. 2010 Oct;14(5):R185.
3. Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, et al. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: The SPLIT randomized clinical trial. JAMA. 2015 Oct;314(16):1701–10.
4. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018 Mar;378(9):819-28.
5. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al. Balanced crystalloids versus saline in critically ill adults. New Engl J Med. 2018 Mar;378(9):829-39.
6. Hammond NE, Bellomo R, Gallagher M, Gattas D, Glass P, Mackle D, et al. The Plasma-Lyte 148 v saline (PLUS) study protocol: A multicentre, ran-domised controlled trial of the effect of intensive care fluid therapy on mortality. Crit Care Resusc. 2017 Oct;19(3):239.
7. Zampieri FG, Azevedo LC, Correa TD, Falavigna M, Machado FR, de As-suncao MS, et al. Study protocol for the balanced solution versus saline in intensive care study (BaSICS): a factorial randomised trial. Crit Care Resusc. 2017 Jun;19(2):175.
8. ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medi-cine (US). 2017 May 3. Identifier NCT02721485 Crystalloid FLUID choices for Resuscitation of Hospitalized Patients. 2016 March 29. Available from https://clinicaltrials.gov/ct2/show/NCT02721485
for randomizing patients within the ED, allowing for the as-signed fluid to be delivered early.5 However, there are
identifi-able limitations in each trial. Both trials included only a single academic centre, and neither blinded clinicians to group as-signment. This has the potential to affect decisions such as the initiation of renal replacement therapy and could intro-duce an element of treatment bias. Plasma-Lyte and lactated Ringer’s were also considered together in both trials, mean-ing that clinicians will have to await further investigations to inform the choice between these two options. An additional drawback in the SMART trial is in regards to its study popula-tion, which included ICU patients. The need for continuous IV fluid administration in ICU patients meant that those who remained in the ICU at the end of one calendar month may have been exposed to both NS and BC without a washout pe-riod. According to the authors, this occurred in only 4.4% of NS group and 5.4% of the BC group,5 however it is
conceiv-able that this switch could affect the results. Finally, SMART did not have a patient-centred primary outcome. While sub-group analysis did reveal possible signals towards reduced mortality in certain patient subgroups receiving BC, more evidence is needed before drawing conclusions about fluid choice and mortality.
There are currently two large multicenter randomized con-trolled trials in progress in Australia6 and Brazil7 comparing
Plasma-Lyte to NS in ICU patients. Neither trial plans to re-cruit as many patients as SMART or SALT-ED, but both list 90-day all cause mortality as a primary outcome.6,7 Additionally
a very large trial (planned N=65,000) currently underway in Canada will compare NS to lactated Ringer’s in all hospital-ized patients.8 Clinicians will eagerly await the results of these
trials, but in the meantime SMART and SALT-ED provide the best evidence to guide crystalloid therapy. For patients
Interview with Dr. Avery Nathens
Interviews
Interview with Dr. Avery Nathens
UTMJ Interview Team
way it has evolved. In Canada, it has evolved in a dif-ferent way because a lot of trauma is non-surgical, and it makes sense for others to be involved as well. In Canada, there is a mix of emergency room doctors, anesthetists, general surgeons, etc. We understand that each of the specialties bring something unique to the environment. To say that it only has to be a sur-geon as the TTL is probably not necessarily the right way to go in this environment. In Europe, they have a different model: trauma surgeons are orthopedic surgeons. So, there are different models, and each of them evolved just because of peoples’ interests and how the environment is structured – there is no right way to do it.
When you look at our performance as a trauma center in terms of mortality outcomes, we do fairly well as compared to other centers in North Ameri-ca – pretty much generally the Ameri-case for most trauma centers in Canada – we provide high quality care. Al-though everyone writes about challenges with access to care in Canada regarding waiting lists, that is not a problem in trauma at all: people get the care they need when they need it.
UTMJ: Can you describe your research in Quality Improve-ment and Trauma Systems?
AN: Quality Improvement
I run a program that was first developed in 2010 through the American College of Surgeons called the Trauma Quality Improvement Program (TQIP). For years before that, the way trauma centers were veri-fied or accredited was entirely based on what resourc-es they had and what structurresourc-es they had. However, there are 3 domains to quality improvement: struc-tures (having the right people and the right OR), processes (having the right protocols) and outcomes (what we are trying to achieve). The American Col-lege of Surgeons verification program, which accred-its centers, only looked at structures and processes and ignored outcomes. Then, based on success in elective surgery, we developed a program that would allow “trauma centre A” to compare itself to “trauma centre B” and would allow further improvements in care. What that means is that you have a spectrum of 500 trauma centers: some are high performing, and some are not so high performing. All of them have the same structures and processes. So, if we could identify the ones that are high performing, they are doing something different than other centres, who
A
very Nathens, MD, MPH, PhD,FRCSC, FACS is a trauma sur-geon, senior scientist, and Sur-geon-in-Chief at Sunnybrook Health Sciences Centre, Canada’s largest level I trauma centre. He is a Profes-sor of Surgery at the University of Toronto and holds graduate appoint-ments at the Institute of Medical Sci-ence as well as the Institute of Health Policy, Management, and Evaluation. He is also a Senior Adjunct Scientist at the Institute for Clinical Evaluative Sciences. Dr. Nathens is a Canada Research Chair in Systems of Trauma Care, Chair of the Ontario Trauma Advisory Com-mittee, and Director of the American College of Surgeons Trauma Quality Improvement Program. He has published over 400 peer-reviewed papers including over 250 that focus on trauma system design and implementation.
UTMJ: Can you tell us a bit about your educational back-ground and what led you to trauma surgery?
AN: I went to Queen’s Medical School and wanted to go into surgery because I enjoyed the relatively quick feedback – do something and get a pretty instant re-sponse. I started in general surgery because I liked the fact that you care for the whole patient, and then early on as an intern, I did an elective at Sunnybrook and was very impressed. I specifically remember a patient coming in who was hypotensive after a car crash, and an immediate laparotomy and splenec-tomy made the patient better. In an instant we identi-fied the problem, fixed the problem, and the patient around. I really found it rewarding and enjoyed the excitement around that.
Also, as a result of the fact that you don’t really have a lot of data to act on, you have to rely on a number of algorithms and to some extent you need to play the odds to make the right decision. I liked that feeling of working on the fly, and it was excit-ing to see patients get better so quickly. That is how I ended up in trauma: exposure to a few cases early on in internship and residency.
UTMJ: Can you speak to the different models of a Trauma Team Leader (TTL)?
AN: In the US, it is predominantly the trauma surgeons that run the trauma resuscitations. That is just the
Interviews
should be using and learning from that information. Without showing them their data, we would never know where they stand – now we make it clear so that centres will learn and can improve their care.
This led to a lot of research into determining what protocols and procedures are used by the centres that have better outcomes. We survey centres, look at the data, try to understand how they provide care, and then we publish our findings. If the high ing centres are doing X, then the lower perform-ing centres need to adopt that. This is, in essence, where comparative effectiveness studies meet qual-ity improvement. We now have 750 hospitals in that program and use survey research combined with out-come data to get at the answers we need. If we want to understand why people with brain injuries do better in some hospitals, we survey all hospitals and ask (as an example), “How is your neurosurgical critical care structured,” and that helps us gain insights, which we publish and share with other centres.
Trauma Systems
Trauma systems are really designed to get the right person to the right place at the right time. Now, that might be easy in an urban environment, but it is not so easy in rural Ontario, where you have significant distances and geographic impediments. The further north you go, there are fewer roads, fewer hospitals, and you are more likely to rely on air transport, which might be impacted by weather and other issues. For years, we have been studying access to trauma care in Ontario and have shown that there are opportu-nities for improvement. We started evaluating this in 08/09: if you were injured in a remote area, you were looking at 9-10 hours to get to definitive care. Over the years, we have developed better protocols to al-low EMS to transport patients to trauma centres. We are also supporting smaller, non-trauma centres in their identification of patients who need to be trans-ferred quickly, and that has helped. Overall, we have improved access to care to the point that many of the trauma centres, particularly in the Toronto area, are now overwhelmed with the volume of patients as protocols have changed. More patients are coming directly from longer distances – that saves lives – but we already have an occupancy problem here at Sun-nybrook, with occupancy typically around 110%.
UTMJ: What is the biggest barrier to different centres imple-menting recommendations?
AN: The biggest challenge centres have is that once they identify an opportunity for improvement, they tend to know what they need to do, but the implementa-tion piece is very challenging. What we have set up are collaboratives – for example, a number of collab-oratives in TQIP where small groups of centres get together and share ideas and experiences. All QI is
local, so it has to be adapted to the specific environ-ment. The more we get people talking to each other and saying, for example, “I did X here. My specialists didn’t want to do this, but we found that if we create this standardized order set, our care improved sub-stantially.” Simple things like that, where those con-versations happen, lead to the collaborative model of QI. It’s rarely the money, rarely the number of people. It is usually the commitment and willingness to change. It is all about understanding how to effect change in your environment – changing people’s be-haviour is 99% of it.
UTMJ: You mentioned that Sunnybrook is operating at 110%. What are the biggest contributors to the back-log?
AN: People aren’t being cared for in the right environ-ment. Patients with alternate level of care (ALC) needs don’t need a hospital setting, but there are no other facilities for them to go to. We need either a skilled nursing facility, which is common in the US and provides a place for patients to go that is not quite a hospital and offers more support than avail-able through CCAC (home care). They get the care they need but don’t occupy a hospital bed. Also, ac-cess to rehab is very different. People can wait several days for rehab, and that means patients are ALC wait-ing for rehab, whereas in other settwait-ings, they are dis-charged to rehab when they are ready to go. We also have fewer beds than anybody else per population, reflecting a lack of investment in the hospital system.
UTMJ: Can you tell us a bit about your “Stop the Bleed” Ini-tiative?
AN: There was a consensus conference called The Hart-ford Consensus that was held in the wake of the San-dy Hook shooting, where 26 people were shot at an elementary school in Connecticut. As a result of that, Hartford, Connecticut was the site at which a group of people who represented trauma surgeons, EMS, Department of Homeland Security, FBI, etc. got to-gether and asked how they can improve the probabil-ity of survival after an incident like this. The group came up with several recommendations. One was an understanding that it takes about 8-10 minutes for police/EMS to arrive. That means no one gets care for a critical few minutes, yet there might be many people who are not injured, who, if they had the right skills might be able to control active bleeding. If you look at the Boston Marathon incident, there are a lot of pictures of people with exsanguinating lower ex-tremity hemorrhages and people next to them who are actually stopping bleeding with pressure and tourniquets.
Interview with Dr. Avery Nathens
bleeding – that is, just putting pressure on wounds and putting tourniquets on. This came out the Hart-ford consensus in response to an active shooter in-cident but was designed really for any sort of injury where there is bleeding. It is a little like teaching the public how to do CPR – but with a focus on bleeding. We know that in the Yonge and Finch van incident, some tourniquet use probably made a difference.
We elected to send a team down to Chicago at the ACS headquarters to get trained in teaching the course, which has led to us training a number of peo-ple here in Toronto. We do know that the course is now spreading across Canada. In major venues now, just like you have AED, we are now seeing bleeding control kits (tourniquets, gauze, gloves).
UTMJ: Can you talk about Sunnybrook’s response to the Code Orange event you recently had?
AN: We are very thankful that we had been rehearsing. We made a decision about a year ago that we are com-mitting to practicing in anticipation for an event. You could imagine that when everyone is so busy, this is not a top priority, particularly given that we are at 110% occupancy. Nonetheless, we learned how to create OR capacity; who needs to be in the emergen-cy department (ED) triaging patients; and how best to communicate. We also identified some real practi-cal issues, like an insufficient number of stretchers or chest tubes.
When this happened at 2 PM that afternoon, there was a Code Orange minor on the overhead. I heard this and went downstairs to the ED and quickly had a sense of what we had to do. I understood what was happening with the OR. I put the ORs on hold, so no more elective surgery would take place until we knew what was coming. I also set up a group of doc-tors, each of whom would form a team around each of the sickest patients. For the less sick patients, they were distributed throughout the ED and had emer-gency doctors and other folks taking care of them without the whole team. Everybody got care very quickly, and we learned a lot about what our capacity was with all hands on deck. We learned more about how we can use people to the extent that their skills allow. We had medical students, residents, and other individuals stepping up. Altogether, the response and the team was excellent.
UTMJ: What was your biggest challenge and things you hope to improve for the future?
AN: There were challenges with identification – most peo-ple were unidentified and distributed all over the ED. However, the triage of patients (sick versus not sick) was done fairly effectively. The triaging of patients in terms of deciding who gets to the OR first, who gets CT first – that was all pretty straightforward. We were
fortunate because it was middle of the day on a Mon-day, and we had all the resources and people avail-able. This might have been a little more challenging in the middle of the night.
We had another drill last week that was a table-top exercise with a big blast injury and a large number of patients, which provided further learnings regarding how we can put in place processes to identify patients. We are coming up with strategies pertaining to how we can quickly register patients, as the usual process takes too long when there are multiple casualties.
UTMJ: In the wake of the tragic Orlando nightclub shooting, you hosted the trauma team that was directly involved in caring for the patients to describe their experienc-es. What lessons did you learn from them?
AN: I heard the Orlando team speak twice: once at TQIP and then when we brought them to Toronto last year. They told us about issues with supplies – like chest tubes – things like that you don’t think about. It is helpful to us – now, we have supplied ourselves with the right equipment just in case. It is a small com-munity of trauma centres that have been through this and that community talks to each other. Just like we have these collaboratives where people learn QI, it is no problem to talk to people in Las Vegas and Or-lando and ask, “How do you identify patients? What is your strategy?” For example, they told us that they will have 100 patients who are pre-registered with a medi-cal record number and name. As patients come in, they just get the armband because there is no need register them. They are already pre-registered, and you can add exact dates and times. Everyone talks and shares ideas, and Sunnybrook has joined that community.
UTMJ: What advice do you have for medical students who want to get involved in trauma?
AN: Each surgical specialty (and critical care) has a ma component. Depending on where you work, trau-ma might only be a strau-mall fraction of your activity, and you have to like the other 90%. For example, if you’re interested in orthopedics, there are dedicated fellow-ships that focus on orthopedic trauma. These doctors really learn how to work in the context of multiple teams, so an orthopedic trauma surgeon speaks the same language as the other surgeons involved in trau-ma care. There is a lot of coordination of care and working as part of a team is so critical. Many who take care of trauma patients understand the principals of damage control – do what you need to do to imme-diately save a life or limb; resuscitate the patient, and then return to the operating room for definitive care. The term “damage control” is actually derived from the US Navy, where they focused on strategies to re-pair a shift sufficiently just to get back to port.
Interview with Dr. Avery Nathens
Interviews
did a research study looking at trauma resuscitations outside of the mass casualty incident piece and cre-ated different levels of stressful trauma scenarios. We measured the cortisol response in the residents go-ing through the trauma simulation in the simulation centre. There was no question that there were corti-sol and heart rate responses. In a mass causality inci-dent simulation, if doing it with moulage patients and stretchers moving, there could be a response there as well.
We are also trying to improve team performance in the trauma bay. We have created a far more struc-tured environment. Now, we have a support zone, ob-server zone, active team zone, etc., and it is pretty well organized. This led to a little more control in that en-vironment. We are looking at developing a program (either going to be video debriefing or black box) where people will be able to capture the environment and really QI the activity that occurs in the trauma bay. This will lead to better ergonomics and better communication. This is a big focus of ours.
UTMJ: You hold many involved positions. What do you like to do in spare time and how do you balance work and life?
AN: I spend a lot of time outdoors. I did triathlons for a while, but now I just run and do a lot of hiking. I lived in Seattle for a while and fell in love with the outdoors. I also do a lot of cycling up north around the Caledon/Orangeville area, and about a year ago, I got into photography and enjoy it. Photography is a combination of art and technical skill, which is the perfect blend for me. If I can’t get up north, I go to Leslie Street Spit and could walk 5 km out in the middle of Lake Ontario and take great bird pictures, great sunsets, sunrises, etc. It is amazing what Toron-to has Toron-to offer if we look for it.
I work in two countries. I have a visa that allows work in US, and activities with the American College of Surgeons are so different than what I do here – I enjoy both of my positions, but there is no question that working in two countries is challenging!
What allows me to continue is that I think what I do makes a difference, and it is enjoyable. I can im-pact patients’ lives day-to-day at Sunnybrook, and I can impact thousands through policy-related work. Small policy decisions in Ontario and the develop-ment of TQIP has probably saved thousands of lives. My work has a broad reach and I work with a great community of surgeons. I have been in trauma since being at Harborview in Seattle, and I’ve slowly made my mark in a variety of things: trauma centre access is a big one, and QI is another. I did a lot of work re-lated to emergency general surgery and QI programs around that. I’ve backed off that now because trauma has been my number focus. Blending all that with family life is hard, but I try to protect weekends. For general surgery, you have to like and be
com-fortable operating in the neck, chest and abdomen – as well as the lack of planning that comes with the spe-ciality. The surgical oncologist has the opportunity to review CT scans and spends time at multidisciplinary tumour boards discussing what the best plan might be for a particular patient. Trauma is very different from a general surgical perspective – there is none of that – but we have to work as part of a team and have to be able to prioritize all of the patients’ injuries. To become a trauma surgeon, many do a fellowship in trauma surgery, often combined with critical care. This provides a good perspective on these patients’ needs and makes you a better trauma surgeon.
If you want to focus on trauma but prefer anaes-thesia or emergency medicine as your core specialty, many ensure they get additional trauma exposure at a trauma centre and often have additional areas of fo-cus like critical care. This gives a better sense of how to prioritize patients and the full spectrum of trauma care – from resuscitation to rehabilitation.
If you’re interested in this big picture, you should probably do surgical or ICU training. If you’re inter-ested primarily in the resuscitation phase, then emer-gency medicine might be the right specialty.
UTMJ: What do you think of getting a PhD in a surgical field?
AN: The Department of Surgery has a Surgeon Scientist Program. It is very well supported. There is also the MD/PhD program. In terms of the clinical context, it is probably more helpful if you do a PhD later in your residency training. Granted, it depends on what you are doing for your MD/PhD. If you’re an engineer, it probably doesn’t matter, but if you’re doing health services research, which a lot of trauma surgeons do, the clinical context is pretty important. It is nice to have lived it a little bit and then study it. Incorporat-ing a PhD in a residency program is great – the pro-gram is still heavily invested in your success because you are still a resident. The only people I know who have pursued their PhD during medical school are engineers or basic scientists. For the most part, peo-ple tend to do it as part of their surgical training.
UTMJ: Going back to the Code Orange and training these multidisciplinary teams – how do you go about train-ing in trauma simulation and elicittrain-ing a real-life re-sponse?
Interview with Dr. Avery Nathens
Interviews
Most doctors work five days a week. Trauma sur-gery is different. We have one week where we’re very busy, and then we hand over the service to the oth-er doctor. We work Friday to Friday typically once a month. It is a very busy week and we take in all com-ers: all the trauma patients and usually all the emer-gency general surgery patients. But we know on Fri-day morning, we can hand those patients over. That model, which is common for trauma centres, allows us to do clinical work in a concentrated way – patients get good care because they are our only focus for that week – and then we do a bit of research on the side.
UTMJ: Do you think there is room for a two-tiered health-care system?
AN: There is room for two-tier model. Rigid adherence to the Canada Health Act has probably ensured higher level of care for all Canadians. In Canada, people coming to the ED are just at a higher level of health, and as a result, outcomes are typically better. In Seattle, patients would come in with no care for 20 years – morbidly obese, uncontrolled diabetes. We don’t see that here. So, I think we have got pretty far with the model that we have. But with the complexity of health care and increasing demands for services, we need new funds in the system, and the only way is through private sources.
People are concerned that there will be truly a two-tiered system where you have private and public, but we could probably come up with hybrid model that better serves out population… no politician has yet to make this decision, but someone has to at some point.
UTMJ: What can we look to in the next decade in terms of advances in trauma?
AN: We are very good at controlling hemorrhage right now. If a patient makes it to hospital, we are almost al-ways going to stop the bleeding. People are still dying from head injuries, and we don’t really effective ap-proaches for the management of patients with severe traumatic brain injuries. We need advances there and that might be cerebral protection, whereby we do something with the brain so that it can recover.
The other thing we haven’t addressed as well is functional recovery after injury. While everyone fo-cuses on trauma survival, the fact is, 93% of patients survive and probably 25 to 40% of those patients are significantly impaired with anxiety, depression, PTSD, chronic pain. We haven’t come up with good approaches to identifying and managing high-risk patients. That is a big focus of many organizations now for improving functional outcomes. We actually received funding to build a multidisciplinary trauma clinic, which is probably opening next year, to try to address this issue.
