That was the message of the inaugural Emergency Room (ER) Discovery Day held at Sunnybrook Health Sciences Centre last week. Hosted in partnership with the University of Toronto (U of T) Temerty Faculty of Medicine’s MedLinx program, Sunnybrook’s President’s Anti-Racism Taskforce and Emergency Medicine faculty, residents and fellows, 30 students from high schools across the Greater Toronto Area spent their PA Day learning about different career paths and professions that serve the hospital’s emergency department (ED).

For Dr. Saswata Deb, a Sunnybrook emergency physician and lead organizer of the event, the event was years in the making and the motivation behind the ER Discovery Day was personal.

Dr. Saswata Deb (centre) with ER Discovery Day facilitators and emergency medicine physicians Dr. Gerhard Dashi and Dr. Nicole Kester

“My family immigrated to Canada when I was 10, and we faced various challenges. Things like language barriers, racism and financial hardship,” he explains. “Organizing an event like this has been a long-standing goal of mine since becoming a physician, and I am thrilled to see it come it life.”

The ER Discovery Day students came to Sunnybrook through MedLinx, a U of T outreach program specifically designed to offer high school students who come from underrepresented communities or who experience socio-economic challenges hands-on opportunities and mentorship to explore careers in health care.

The students started the day with a tour of Sunnybrook’s ED and trauma bay before hearing from a panel of interdisciplinary health-care professionals about their journeys to working in health care. In the afternoon, they got the chance to learn some hands-on, life-saving skills.

Dr. Deb shares some of what students got to learn, the stories and experiences that were shared, and what’s next for ER Discovery Day:

Did the students hear from people who work in Sunnybrook’s emergency department?

We brought together representatives from various fields within and beyond the emergency department who work collaboratively to care for patients every day, including physicians, nurses, physiotherapists, social workers, occupational therapists and hospital administrators. Many of the speakers come from backgrounds similar to the students, including those who are immigrants or children of immigrants, from racialized groups or who grew up with socio-economic challenges. The goal was that the students could be inspired and motivated by people working in health care who look like them, and who went through similar experiences to get to where they are.

What kinds of hands-on activities did the students try out?

There were five stations the students got to rotate through: CPR, which is a skill that can actually save a life; suturing, to learn how to sew cuts and wounds; Stop the Bleed, which is another life-saving skill if someone has massive bleeding; ultrasound, where they got to see what the heart looks like on an ultrasound which I always found fascinating; and intubation, which is how to insert a tube into someone’s throat to keep them breathing. Hopefully they came away from those inspired from having learned something new or a life-saving skill.

Students participate in a Stop the Bleed demonstration.

What do you hope the students got out of the event?

I’m hoping that the students see that, one, health care is not just about doctors or nurses. There are lots of different professions and lots of opportunities. Two, the stories that were shared by people today will inspire them that they can still be successful despite systemic barriers. And three, from these different hands-on sessions, they can walk away with some life-saving skills.

Was anyone else involved in organizing the day?

To see this come to fruition is a testament of the work of so many who have been involved in bringing this day to life. There’s Sunnybrook staff and leadership; physicians from internal medicine, surgery and the ED; members of the Sunnybrook’s Presidential Anti-Racism Taskforce; U of T’s Office of Inclusion and Diversity; Emergency Medicine residents and Emergency Medical Services. They all came together to collaborate and volunteer their time. It’s very exciting for me to see this come alive after a vision that I’ve had for almost 20 years.

What’s next for ER Discovery Day?

We want to do this regularly, and we want to grow this program even bigger. We want more students to participate. Demand is quite high, so our vision is to expand this, and we can only do this with all the support from all my colleagues and all the partners that are involved. And we hope that in the future there will be even more support and more resources for us to continue to grow.

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At Sunnybrook Health Sciences Centre, Registered Nurse Marley Gimblett was set to be in charge of the Emergency Department (ED) that weekend. Marley worked with colleagues on Sunnybrook’s Emergency Preparedness team to run through every potential scenario that could arise, part of the hospital’s ongoing imperative to be ready for any emergency event. However, as the weekend approached, there was a sense of unease among ED staff.

“In the ED, we’re ready for anything,” Marley says. “But for this, staff said they felt underprepared, especially to respond to large numbers of patients coming in who may be teargassed or pepper sprayed, and how they would protect staff and other patients from being exposed.”

Though a large-scale emergency in Toronto never materialized, Marley seized the opportunity to enhance emergency preparedness training in the Sunnybrook ED to help staff feel more confident and prepared in making critical decisions during a mass emergency – and to ensure proper procedures are in place to protect patients and staff from dangerous contaminants.

In September 2023, Marley enrolled in Sunnybrook’s Practice-Based Research and Innovation (PBRI) TAHSN fellowship, specifically to focus on improving preparedness among ED staff responding to chemical, biological, radiological, nuclear and explosive (CBRNE) events. The fellowship provides point-of-care health professionals such as Marley the opportunity to lead practice-based quality improvement projects that enhance patient care.

“My motivation for pursuing this came out of wanting to be a resource for staff, and wanting to have more knowledge about this topic,” Marley says. “When you’re getting involved in a fellowship project like this, you have to love your topic.”

Since completing the initial fellowship, Marley is now the inaugural PBRI advanced fellow at Sunnybrook, allowing her to continue her work. As an advanced fellow, Marley will support the implementation of a formal CBRNE response procedure, with a focus on training and education for clinical staff in the ED.

Among the initial training topics that Marley put together, and inspired by the convoy in Ottawa, was decontamination procedures for patients arriving in the ED with injuries or exposure to pepper spray and teargas.

“The focus was on Registered Nurses, as they’re typically the most hands-on in the ED,” Marley explains. “We trained staff on basic principles on CBRNE response and how to set up the decontamination room to prevent further staff and patient exposure to chemical substances like teargas and pepper spray,” adding that this protocol could be applied to other CBRNE exposures.

“For biological threats, that might be like having a patient with Ebola come in. For radiological or nuclear, it might be if someone has radiation poisoning or if there was an event at a nearby nuclear plant. Responding to explosives would be similar to a trauma, but on a different scale.”

Surveys following the training showed significant improvement in how confident and prepared ED staff felt about responding to CBRNE events.

Through the advanced fellowship, the project will continue and expand to support the implementation of dedicated CBRNE response training for Registered Nurses and Charge Nurses in the ED. Marley’s goal is to keep working with the Emergency Preparedness team to educate ED staff and have more ongoing training sessions. She says that would include further CBRNE preparedness education, proper personal protective equipment training, running a CBRNE simulation and further evaluating preparedness across the hospital as possible outcomes of her work.

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Within the arsenal of interventions is buprenorphine, a synthetic opioid that is among the recommended standards of care for people with untreated opioid disorder. However, despite evidence of its efficacy in both mitigating overdose and managing opioid use disorder and opioid addiction, uptake of buprenorphine in emergency departments (ED) widely across hospitals has been limited.

Dr. Kalocsai, alongside a team of scientists, clinicians – including Dr. Nikki Bozinoff, an associate scientist and physician at the Centre for Addiction and Mental Health (CAMH) and Dr. Dominick Shelton, an emergency physician at Sunnybrook – librarians and people with lived experience of opioid use, recently led a scoping review to find out why.

The findings, published this month in The Lancet Regional Health, point to a health system that is grappling with the intricacies of structural and social barriers that contribute to a worsening opioid crisis, but also an opportunity to enhance teaching and education for clinicians who work with people who use drugs through what Dr. Kalocsai calls structural competency training.

“We found that some of the barriers that limit uptake is the failure to recognize and address structural stigma, poorly equipped services to manage patients’ medical and psychosocial complexity, and difficulties adapting to the increasingly toxic drug supply,” Dr. Kalocsai says.

As an education scientist, she adds, “this research shows where there are opportunities to educate clinicians to better serve marginalized communities and think about the structures of power, health disparities and equity.”

Dr. Kalocsai explains the significance of the findings of this scoping review, and the ways that they can contribute to a body of knowledge around the opioid toxicity crisis.

What do people need to know about the social and structural barriers that exist in addressing opioid use and overdose?

We know that the overdose crisis has disproportionately affected racialized and marginalized people, but the research on buprenorphine initiation in the ED rarely reports on patient characteristics that can contribute to marginalization. In that sense, much of the existing research actually fails to consider how intersecting structural barriers influence the inequitable access to buprenorphine in the ED. Most of the articles, for example, refer to stigma as a barrier, but usually define stigma as a negative attitude rooted in the individual, without diving deeper into how it might be structurally embedded through laws, policies, norms and processes at the level of the organization and society.

What is structural competency training, and how could it help support health care providers’ decision-making in the ED?

Structural competency training is education that enables people to recognize and respond to various social and structural factors – such as racism, colonialism, sexism, heteronormativity, houselessness and poverty – that people who use opioids often navigate, and which produce persistent health disparities and marginalization.

When it comes to buprenorphine initiation, what we’ve seen in the literature is a lack of comfort with buprenorphine and substance use care generally in the ED, and consequently increasing biomedical buprenorphine training as a solution. But the research also suggests that biomedical training is insufficient in and of itself to bring about behaviour change among health care providers. We recommend including structural competency training – in addition to training on motivational interviewing, harm reduction approaches co-created with patients, as well as ongoing provider supports such as mentorship, communities of practice and just-in-time training – so health care providers can recognize the social and structural factors that impact the opioid crisis.

An as education scientist, what can you tell us about the role that this kind of research can play in fostering health care providers’ ability to recognize and respond to different systemic barriers?

I hope our findings will lead to changes in how health professions are trained to provide care for people with opioid use challenges and support the optimization of ED-based buprenorphine and opioid-agonist treatment initiation as both a treatment and harm reduction strategy. I also hope that the study will contribute to increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways across Canada and the United States.

What message do you have for front-line clinicians who are treating patients in the ED affected by substance use and overdose?

Our results point to innovations that deliver high-quality care: multi-disciplinary addiction consult teams, low-barrier harm reduction-informed services that support transition to outpatient care, and adaptations to introducing buprenorphine that address the toxicity of the drug supply. Taken together, these changes could lead to the normalization of opioid use disorder care in the ED and a shift in understanding opioid use disorder as a condition is amenable to treatment in the ED.

Education science is a niche area of health research, and this study is especially unique. Can you tell me about that, and what the added value is of this research?

This is the first comprehensive review of the complex web of factors that facilitate and challenge the implementation of buprenorphine initiation in the ED. We wedded two research frameworks — the Consolidated Framework for Implementation Research (CFIR), which is a popular implementation science framework, and critical theory to understand how relations and structures of power undergird buprenorphine implementation in the ED. Our analysis also sheds light to the limits of CFIR, which does not easily lend itself to the examination of power. It suggests that by adapting CFIR to incorporate a critical lens, for example, an intersectional approach could help us understand how structures of power and oppression influence the inequitable access to the implementation of buprenorphine in the ED.

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Nearly 10 years later, the same group of researchers is once again approaching a new breakthrough, this time with the potential to bring the technology to more patients and more clinics, and to revolutionize the treatment options for many neurological and brain diseases.

The team, led by Dr. Kullervo Hynynen, vice president of research and innovation and senior scientist at SRI, as well as the Temerty Chair in Focused Ultrasound Research, has developed a powerful new ultrasound device specifically designed to open the blood-brain barrier to allow helpful agents — such as chemotherapy, antibodies, stem cells or gene therapy to reach the brain. However, unlike the current focused ultrasound device, the new technology operates without the need for real-time MR imaging – a costly hurdle for delivering focused ultrasound to the brain.

At Sunnybrook, focused ultrasound is most commonly used to treat essential tremor, a neurological disease that causes tremors which can severely affect a person’s quality of life. Dr. Nir Lipsman, chief of the Hurvitz Brain Sciences Program, Harquail Chair in Neuromodulation and senior scientist at SRI, explains that the technology used for this indication is called high-intensity focused ultrasound, which uses ultrasound waves to target tissue and create lesions deep within the brain, without the need for a scalpel or incisions.

The new technology in development, meanwhile, is low-intensity focused ultrasound, which Lipsman says, “is used to open the blood-brain barrier and deliver all kinds of therapeutics to the brain.”

The technology behind the low-intensity focused ultrasound is currently undergoing clinical trials at Sunnybrook’s Harquail Centre for Neuromodulation – to be housed within the new Garry Hurvitz Brain Science Centre – and has the potential to provide new treatments and therapies for brain cancers, Alzheimer’s disease, Parkinson’s disease and Amyotrophic Lateral Sclerosis (ALS).

Drs. Hynynen and Lipsman shared some of the latest developments and most promising potential of the next-generation helmet.

Drs. Kullervo Hynynen and Nir Lipsman

How could this next-generation helmet change the way focused ultrasound is used to treat brain diseases?

Lipsman: One of the conditions we are most interested in is brain cancer. Currently, the entire procedure across all of our trials is done inside the MRI for real-time imaging. There are some indications where that’s very important, but there are other indications where real-time imaging may not be as critical. The next-generation helmet means we may be able to do the procedure outside of the MRI environment, saving time and money, and making the procedure more comfortable for patients. The idea is over time to develop a safer, more streamlined, and effective procedures for accessing critical brain circuits, and that’s where the new technology will really shine.

Hynynen: Taking the procedure out of the MRI would make it a more accessible form of treatment. We would do an initial scan of the patient’s head to be able to create a rapid prototype of the helmet that is customized to the patient, and subsequent treatments could be done without real-time imaging. Being out of the MRI means no associated costs, and by bringing costs down it increases capacity significantly.

How is the next-generation helmet different from the existing technology?

Hynynen: The current focused ultrasound technology works really well for precise single ‘dose’ treatments, like treating tremors or what you might think of as ‘surgery’ treatments. But for treating brain cancer or Alzheimer’s, which require multiple treatments, it becomes prohibitive in its current state using real-time MRI. By taking the treatment out of the MRI, we can perform any number of treatments. It’s taking it to the next level – it becomes a real treatment for things like brain cancer and Alzheimer’s.

What would a treatment visit look like for someone using this new technology?

Hynynen: The patient would get the initial MRI scan, and from that a customized helmet would be created. Then, the patient would come in for treatment, get the helmet and transducers on. We would infuse drug and infuse the microbubbles that help us open the blood-brain barrier, and with very controlled modulation we would open the blood-brain barrier to deliver the therapy. The treatment can be precisely customized for each patient to the area of the disease while the intact blood-brain barrier is protecting the rest of the brain.

Lipsman: An aspirational goal would be to do with focused ultrasound what we do in a chemotherapy clinic or a dialysis centre. It would be an outpatient procedure where patients come in, get the procedure, and leave in a more streamlined, comfortable process. Ultimately, we hope to use focused ultrasound at every stage of the brain cancer treatment journey. This can include immediately after surgery, when patients undergo chemotherapy and radiation or it might be at the time of a recurrence, and in order to enhance the effect of other treatments. The idea is to match, as much as possible, novel treatments to our patient’s specific conditions.

This technology development is generously supported by the Weston Family FUS Initiative and our incredible donor community.

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Students in the Focused Ultrasound High School Summer Research Program, Summer Student Research Program and the Sunnybrook Program to Access Research Knowledge (SPARK) for Black and Indigenous Medical Students work alongside renowned SRI scientists on research projects that span the expertise found across Sunnybrook.

This summer, SRI welcomed more than 200 learners into these programs. Meet three of this year’s summer students.

Aidan Wang, Summer Student in Dr. Meaghan O’Reilly’s Lab

Focused Ultrasound High School Summer Research Program

Not yet out of high school, Aidan Wang is already carving out his path in neuroscience. He is one of 25 students who made it into Sunnybrook’s highly competitive Focused Ultrasound High School Summer Research Program.

Honing his interest in machine learning and computational research, Aidan is working with Dr. Meaghan O’Reilly, a scientist in Physical Sciences at SRI, to develop models that will help apply focused ultrasound techniques to deliver therapies to the spinal cord. Much in the same way that focused ultrasound is used to open the blood-brain barrier to deliver treatments to the brain, Aidan says, Dr. O’Reilly’s lab is exploring how it can also be used to breach the blood-spinal cord barrier.

“The shape of the bones in your spine are a lot more complicated than the skull, so what I’m working on is using machine learning to create a better way to turn CT scans of the spine into a 3D model. We can create individual images of every single piece of vertebrae, and then we can run simulations on it.”

Although he hasn’t yet decided what he wants to do after high school, his experience at Sunnybrook this summer has opened his eyes to what a career in neurosciences could look like for him.

“I always wanted to work in research, but before this summer that was just a concept in my mind,” Aidan says.

“This program has really put me in the shoes of someone working in research, whether it’s diving into the literature and always learning about new developments in your field, or even waiting two days for the code for your model to run. In that case, it’s a lot of waiting, but it’s still fun.”

Alessia Apa, Summer Student in Dr. Isabelle Aubert’s Lab

Undergraduate Summer Research Program

Inspired by her own family history with Alzheimer’s disease, Alessia first reached out to Dr. Isabelle Aubert, a senior scientist in Biological Sciences whose work focuses on neurodegenerative disorders, for a co-op placement last fall. Alessia made such an impression on the team, she was invited back to the lab for a position in the SRI’s Summer Research Program.

This summer, she’s working on a project that uses focused ultrasound to deliver gene therapies to the brain, which would otherwise be inaccessible due to their large size and the presence of the blood brain barrier.

“I’m using two different strategies to confirm that our gene therapy has successfully entered the brain,” Alessia says.

“We’re able to visualize where we target the focused ultrasound and can confirm where in the brain the therapy is produced as well as measure how much therapy is being produced.”

Working in Dr. Aubert’s lab, Alessia is acutely aware of the toll neurodegenerative diseases can take on the brain. Only a few years ago, Alessia’s grandfather received care for his Alzheimer’s disease at Sunnybrook and now, she says, she’s coming back to where it all started.

“I’ve been exposed to Alzheimer’s disease from a pretty young age,” Alessia explains. “Getting to come into the lab, seeing the advances that Dr. Aubert and our entire group are making towards developing potential therapeutics for Alzheimer’s disease, is really fulfilling.”

“I feel like I get to contribute to the overall improvement of the disease, bringing hope to families like mine.”

Jada Roach, Summer Student with Dr. Donald Redelmeier

Sunnybrook Program to Access Research Knowledge (SPARK) for Black and Indigenous Medical Students

Physician apologies can be a fraught subject, whether apologizing for being late to an appointment or even for a medical error. But for Jada Roach, saying, ‘I’m sorry,’ could lead to better relationships between clinicians and patients.

Jada is a medical school student with SPARK, a Sunnybrook-led program that provides Black and Indigenous medical students with mentorship and opportunities to engage in research.

This year, Jada is one of seven medical school students exploring different career paths in research and academic medicine through the program. Under the mentorship of Dr. Donald Redelmeier, senior scientist in Evaluative Clinical Sciences, she has been researching clinician apologies with the goal of creating a resource that will help clinicians apologize better and enhance person-centred care.

Even though she hasn’t yet narrowed down which medical speciality she wants to pursue, she says SPARK has given her an enormous breadth of exposure to different fields.

“SPARK offers us three different mentors over the summer and then through the rest of the year. It’s such an amazing opportunity to get to interact with different specialties,” Jada says.

“I’m such a champion of equity work and giving people different opportunities that they might not have had. Being in SPARK, there’s a range of projects that I never would have had the opportunity to choose.”

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