One morning each month, Sunnybrook’s trauma team receives an urgent emergency page about an incoming patient. It could be someone with a gunshot wound, a brain injury or a major pelvic fracture. They’ve been rushed to the largest trauma centre in Canada to receive life-saving treatment, and it’s all hands on deck. The team’s leader, surgeons, nurses, residents, respiratory therapists and others race to the trauma bay. But when they arrive, they’re not met with a person in serious distress.

Instead, there’s a high-fidelity mannequin on the stretcher. It looks human; however, it’s actually a prop used for simulation-based training. The mannequin can blink. Its pupils dilate. It is linked to a monitor showing its vital signs. It may even have a head wound to prompt the team that a head bleed may be present.

While simulated learning has been practiced for many years at Sunnybrook, the new “in situ” simulations are conducted in the actual trauma bay of the emergency department, rather than in a lab or SIM centre away from everyday equipment and where real trauma patients are treated.

“The element of surprise is important,” says Dr. Luis da Luz, a surgeon, head trauma team leader and a member of Sunnybrook’s trauma research group.

Although the simulation session is always in the morning, when real trauma cases are less common, no one except the simulation organizers know what to expect when they reach the bay. The lesson takes about 30 minutes and the team gathers immediately afterward to debrief and troubleshoot for another 30 minutes. For instance, during the simulation they might discover that their intraosseous insertion kit (for administering medication and fluids directly into bone marrow) was kept locked in a cabinet away from the trauma bed, creating a two-minute delay.

“Two minutes in a life-threatening situation is too long,” says Dr. da Luz. “We’re able to identify problems and resolve them, so the team is more prepared to act when a real trauma comes. That’s the beauty of the thing.”

The post Traumatic injury simulations lead to real-life learning for Sunnybrook trauma team appeared first on Your Health Matters.

On Thanksgiving weekend in 2019, a senior arrived at Sunnybrook’s emergency department with rib fractures after suffering a fall. She was in stable condition, but needed a new walker to get around. So, the woman was admitted.

The problem? No available beds.

“She spent the whole weekend with us in our hallway in emergency,” remembers Will Thomas-Boaz, advanced practice nurse for Sunnybrook’s emergency department and trauma program.

Fortunately, change was already in the works to address this all-too-common problem. Sunnybrook had begun developing a new team of emergency department healthcare workers with one main goal: helping seniors avoid long stays in the hospital by giving them the supports they need to go back home to the community safely.

On October 28, 2019, Sunnybrook launched the ED One Team. In its first five months, the team showed a decrease of 323 admissions, or 2.1 per day, compared to the same time period the previous year, says Thomas-Boaz, who develops quality improvement initiatives with ED One.

The ED One Team consists of both a hospital and community social worker, geriatric emergency medicine nurse, physiotherapist, occupational therapist, community care coordinator, psychogeriatric case manager, a community mental health specialist and staff from home-care service agencies. After a daily huddle to discuss cases, they usually work with an average of eight to 10 patients a day.

To further support seniors care, the ED One Team works together with the Slaight Senior Care Navigation Pilot, a project supported by the Slaight Family Foundation Seniors Fund. The pilot places a trained navigator from SPRINT Senior Care in Sunnybrook to help facilitate safe discharges into the community.

Natalie Coyle, the ED One Team coordinator, says using a holistic, team-based approach to patient care makes all the difference. She pulls up a letter from one patient, Terry, a senior living alone who arrived in emergency with a hip fracture. ED One Team members ordered his new walker, helped him learn how to use it, made sure he could easily return to his home in community housing and scheduled a home cleaning, too.

“I’m a very proud person and I’ve never accepted this kind of help before, but she really made me feel safe and was always pleasant and professional,” he wrote of his experiences with the ED One psychogeriatric case manager.

With a high number of seniors in the community, the ED One Team will be kept busy, but that’s precisely the point.

“Now that we have [ED One], I can’t imagine not having it,” says Coyle.

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In September 2019, Alice Lam was leading a busy life: reading, cooking, meditating, working on her photography skills and doing small projects around her Scarborough, Ont., home. Despite having Stage 4 breast cancer (meaning that the cancer has metastasized, or spread to other parts of the body), the 55-year-old was determined to live life to the fullest.

But that changed when, seemingly overnight, Alice went from working out at the gym to barely being able to walk. Weakness in her legs, back pain and numbness immobilized her. She found it impossible to even use the washroom.

“It happened so fast,” she says. “It didn’t take a month. It just took a few days.”

Believing it was a nerve issue, Alice’s family rushed her to a downtown Toronto hospital, where she received devastating news: a metastatic tumour had grown larger despite chemotherapy and was pushing on her spine – an exceptionally challenging area to treat. There was nothing they could do for her. Paralysis would be her new normal.

Fortunately, one of the doctors offered to get Alice a second opinion. He sent an e-mail with her MRI results and physician’s report to Dr. Jeremie Larouche, an orthopaedic surgeon at Sunnybrook. It was 3 a.m., and Alice was sent home.

She didn’t have to wait long. Within nine hours of receiving the e-mail, Dr. Larouche had not only read about Alice’s condition, but he had also coordinated a detailed treatment plan. She would have surgery the very next day. Alice says she was amazed by the speed of Dr. Larouche’s response.

“I’m a fast person, but he acts even faster!” she says, laughing.

The innovative surgery Alice was going to receive wasn’t meant to remove the entire tumour, however. Dr. Larouche would be performing “separation surgery,” a minimally invasive procedure that shears away a portion of the tumour from the spinal cord, potentially reducing recovery time, length of stay at the hospital and surgical complications.

“To see what we can offer [these patients] in their last years of life – it’s an unbelievably, intrinsically rewarding type of surgery.”
– Dr. Jeremie Larouche, orthopaedic surgeon at Sunnybrook

The surgery creates a two-to-four millimetre margin between the tumour and the spinal cord. That extra space is needed in order to protect the spinal cord from the second part of the procedure – radiation.

“Traditional radiation is limited in terms of the duration of benefit, so in select patients a new technique known as stereotactic body radiotherapy, or SBRT, is increasingly offered,” Dr. Larouche explains. “SBRT is an intense and targeted form of high-dose radiation, and for the spine, it is optimally delivered if there is some separation between the spinal cord and the cancer.”

Orthopaedic surgeon Dr. Jeremie Larouche performs separation surgery on a patient with metastatic spinal disease. (Photography by Doug Nicholson)

With SBRT, radiation therapists and oncologists pinpoint the cancer’s exact location and shape using sophisticated, 3D-imaging technology. Once mapped, numerous radiation beams are focused at the tumour from hundreds of different angles simultaneously.

While this combination of minimally invasive, debulking surgery and SBRT does not cure cancer, it does give an 80 per cent to 90 per cent chance that the tumour will stop growing and be controlled for the rest of the patient’s life. Furthermore, the combination of neurologic recovery and tumour control with SBRT can lead to better quality of life by maintaining mobility and decreasing pain.

Rather than spending their last few months bedridden with spinal-cord compression and nerve pain, many people are now able to walk, garden and even leave the house to visit friends.

But the technique has also required that surgeons and radiation oncologists at Sunnybrook develop a new mindset about how to best care for palliative cancer patients. In the past – and in many cancer centres to this day, as Alice discovered – Stage 4 patients have been considered too high risk for spinal surgery. Because of this perceived risk, and the fact that traditional radiation generally isn’t as effective when the disease is compressing the spinal cord for Stage 4 patients, many doctors wouldn’t consider surgical intervention an option.

“But now we have new tools and new techniques,” explains Dr. Larouche, who, along with Sunnybrook radiation oncologist Dr. Arjun Sahgal, has been leading the way for separation surgery, not just at Sunnybrook, but also in North America.

“Really, what I’m trying to bring is a change in mentality and attitude about surgical skills, such as less-invasive or minimally invasive surgery, to achieve our goals,” he says.

Dr. Sahgal, a recognized international leader who pioneered spine SBRT for Canada, adds that SBRT technology is often a very good “next step” for the right candidates, because it delivers extremely precise, very intense radiation doses aimed to destroy cancer cells while minimizing damage to healthy tissue.

“As early adopters, we and a few other centres globally have really promoted the idea that if you’re going to put somebody through a major operation, then why would we not follow it up with an equally aggressive radiation treatment?” Dr. Sahgal says.

In addition, rather than having to undergo five or even 10 radiation sessions, SBRT for the spine often requires only two sessions. For palliative patients, fewer trips to the hospital are a boon.

Dr. Sahgal notes that Sunnybrook leads the field internationally with respect to SBRT technique and outcomes, and he and his colleagues have published several studies in medical journals and led several clinical trials in this domain.

“In fact, we teach radiation oncologists and surgeons globally how to perform spine SBRT safely,” he says.

Alice says she’s incredibly grateful for Dr. Larouche and Dr. Sahgal’s commitment to helping patients like her get back on their feet again – literally.

Orthopaedic surgeon Dr. Tan Chen (foreground left) and Dr. Larouche (foreground right) during separation surgery. (Photography by Doug Nicholson)

One month after surgery, Alice was able to walk with minimal assistance. Soon after receiving her doses of radiation, she was able to walk quite naturally. That’s a far cry from how immobile she was before undergoing separation surgery and SBRT.

“Alice has just got this spirit. She’s indomitable and she’s done fantastically,” says Dr. Larouche. “This is a hard patient population to work with, because these awe-inspiring people are palliative. But to see what we can offer them in their last years of life – it’s an unbelievably, intrinsically rewarding type of surgery.”

While Alice knows the procedures were not meant to cure her, she says they have given her the next best thing – hope at a time when she felt hopeless.

“I prayed for experienced doctors, a proper diagnosis, and effective and timely treatment,” she says. “And I got all of those from Sunnybrook.”

The post Innovative approaches are providing an improved quality of life for palliative cancer patients appeared first on Your Health Matters.

(Photography by Kevin Van Paassen)

Sunnybrook researchers are investigating exciting new techniques to harness the power of ultrasound waves to treat depression

For as long as she can remember, Linda Bohnen has suffered from debilitating anxiety and depression. Despite trying talk therapy, numerous medications and even electroconvulsive therapy, nothing worked for long. Her feelings of hopelessness, overwhelming sadness and numbness always returned.

“It was really limiting my life. It was hard on my husband, on my daughter and on me,” says Linda.

The anxiety also made it difficult to leave the house. The only exception was taking her Siberian husky mix, Stoli, out for a walk.

Then Dr. Anthony Levitt, chief of Sunnybrook’s Hurvitz Brain Sciences Program and Linda’s psychiatrist for the past 30 years, told her about an intriguing new medical trial he was leading.

For the first time, Sunnybrook researchers were analyzing the safety and effectiveness of using MRI-guided focused ultrasound to help patients with treatment-resistant major depression.

As someone with highly resistant mood disorders – something that 2 per cent of the Canadian population suffers from – Linda seemed like a good candidate.

She would be the first-ever patient in North America to receive this game-changing procedure for treatment-resistant major depression – incision-free brain surgery done in real time (the only other case took place in South Korea).

“I felt that I had nothing to lose,” says Linda. “I had tried everything else, so why not?”

Same but different

The fundamentals of the procedure have actually been around for more than 50 years and have a long history of success.

“In the old days, it used to be done neurosurgically,” notes Dr. Levitt. Surgeons would create an incision in the scalp and skull, he explains, before drilling a hole in order to reach the area of the brain that would then be cauterized. Unfortunately, that meant destroying some healthy brain tissue along the way, too.

“And if you got it wrong, you’d have to go back and get it right,” he says. “There was no way of checking at the moment you were doing it.”

With MRI-guided focused ultrasound, however, a special helmet trains beams of ultrasound on one specific region of the brain called the anterior limb of the internal capsule – a pathway known to be active in depression. This “highway” connects the frontal lobes to the emotional centres of the brain, including the amygdala and hippocampus.

Fortunately, individual ultrasound waves pass through living tissue quite harmlessly. Where they converge, however, the beams create heat and form a lesion on a precisely targeted area of the brain.

“There’s no incision,” Dr. Levitt points out. “We don’t destroy healthy tissue on the way to the lesion because the beams of ultrasound don’t destroy anything except where they meet.”

Dr. Nir Lipsman – a neurosurgeon and principal investigator of the trial and director of the Harquail Centre for Neuromodulation at Sunnybrook – likens the technique to using a magnifying glass to concentrate light and create a pinprick point of heat “except we’re using this ultrasound system to concentrate sound energy,” he explains. “This is an old procedure done in a new way.”

Surgery at the click of a button

There are other benefits of guided ultrasound. Because the procedure is done inside an MRI scanner, Dr. Lipsman can see exactly where he wants to create the lesion, using computer-generated algorithms to create 3-D images in real time. He can even extend and change the shape of the lesion if needed, right then and there – all with the click of a button.

Or, as Dr. Levitt calls it, “surgery by mouse.”

What’s more, the risk of bleeding is quite low. Because the surgeons actually control the heat, they can test a specific area of the brain first at a lower heat to be sure only that portion is affected without any movement or sensation issues. “With ultrasound, we can do a test beforehand to make sure we have the right area,” says Dr. Levitt.

Once they have the all clear from the patient, the surgeons can go ahead and increase the temperature.

Two decades of development

This particular phase 1 trial was possible because of the work of Dr. Kullervo Hynynen, director of physical sciences at Sunnybrook Research Institute.

For almost two decades, Dr. Hynynen worked with industry partner INSIGHTEC to develop the technology.

On the day of her procedure, Linda wore Dr. Hynynen’s special focused ultrasound technology helmet, which looks a bit like an old-fashioned hairdryer. It actually contains 1,000 transducers, which convert electrical energy into sound energy. It also has a membrane that fits tightly against Linda’s now-shaved head, with a space where water circulates between the transducers and her skull to reduce the sensation of heat.

This isn’t the first time the game-changing helmet has been used.

Focused ultrasound was successfully tested in a world-first trial at Sunnybrook and other medical centres for patients with essential tremor, a nervous system disorder causing involuntary shaking. This success led to Health Canada and FDA approvals in 2016.

Dr. Hynynen recalls seeing a dramatic decrease inpatients’ tremors and shakes once the ultrasound hit the right location. Even so, his team of engineers and clinicians faced many obstacles on the way to success. “For about 50 years, people thought it was impossible to use ultrasound in the brain,” he says.

Tell that to Linda. Other than experiencing some heat in her head during the procedure, and minor headaches for several weeks following the procedure, she considers herself very lucky. Slowly, she noticed her mood was lifting.

“There have been more good days than bad,” explains Linda. Overall, she’s also noticed that she is more talkative and energetic. While Linda continues to take medication for her depression, some dosages have been reduced for the first time in decades.

“They had good experiences using ultrasound on patients with other [conditions],” she says. “I had a lot of hope.”

One piece of the puzzle

Dr. Levitt knows that addressing treatment-resistant depression – experienced by people who have been ill for at least five years and have had multiple treatments fail – is not as simple as flipping a switch on an ultrasound machine and hoping for the best.

Patients like Linda and the nine others who will be part of the trial will likely continue to take their medication even after the procedure. Some will also continue to get counselling.

In addition, trial participants will be assessed for the severity of depression and level of functioning at various checkpoints over the course of the year after treatment.

While the overall hope is for patients with depression to feel better, the goal is to make sure that the focused ultrasound procedure is safe and effective. Although researchers are in the early stages of the trial, they say focused ultrasound has the potential to be another treatment option for patients with major depression who aren’t responding to existing standard treatments, “It’s an adjunct. It’s an additional treatment,” he says, explaining that focused ultrasound is unlikely to control all symptoms but will make a difference for some, including extreme anxiety that keeps people like Linda housebound.

Besides, talk therapy will be needed for another reason after successful procedures: “These people have often had years where the symptoms have dominated their lives,” Dr. Levitt points out “Now they’ve got to figure out what they’re going to do with their lives,”

Dr. Lipsman agrees. In addition to follow-up appointments at the one-, three-, six- and twelve-month marks, patients who are part of the trial will be monitored for years, “This is a procedure where it’s incredibly important to maintain close contact and continue treating patients for the long run,” he says. That kind of commitment and moral support has helped Linda cope during recovery. Wearing scarves and turbans while her hair grows back, she’s now looking forward to hopping on a plane to see her daughter in Seattle, and hopefully feeling less anxious about travelling now than she has in the past.

As the first person in North America to undergo an innovative trial procedure to treat depression, she knows anything is possible, “I’m proud of myself for having done the procedure,” Linda says, “This past week, my mood has been very good. I’m just hoping that I continue to improve.”

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Last fall, a small group of scientists, clinicians and engineers – complete strangers to one another – spent four months together at Sunnybrook, all to solve a pressing medical problem. First they watched cardiologists perform heart procedures and talked to nurses, interventionists and technicians about the challenges they face in their work. Then they headed to a room down the hall to brainstorm.

The team – Ramtin Ardeshiri, Lindsey Di Bartolomeo, Ryan Tennant and Dr. Wael Abuzeid – wanted to address a conundrum that has long plagued cardiologists: how to better image and fix blocked blood vessels. If they could collectively devise a solution to make these life-saving procedures safer and more effective, it would result in improved patient outcomes and perhaps even save hospitals money.

The hard work paid off. Not only did the team build a prototype for a device that can get around hard blockages in blood vessels, they are now in the process of obtaining a patent.

These aspiring medical-technology (medtech) professionals were the first group to take part in the new hospital-based education program called Medventions. Launched by the Schulich Heart Program at Sunnybrook, Medventions gives multidisciplinary teams – undergraduate and graduate student interns as well as clinical fellows – the ability to work closely with expert academic and industry advisors who teach them how to create and commercialize innovative life-changing technology that directly answers clinical needs.

Sunnybrook has long been at the forefront of medical innovation and revolutionizing health care. Yet, according to Dr. Brian Courtney, director of Medventions, during this past decade – as health-care funding has been increasingly challenged – more emphasis has been placed on building Canada’s medtech industry from within the hospital’s own walls.

“We have great research in Canada,” says Dr. Courtney, also a cardiologist at Sunnybrook who earned his engineering degree before attending medical school. “We have a lot of people who are very knowledgeable and are world leaders on the scientific front. We have busy physicians who do high procedural volumes and fairly complex cases. And yet, when we go and use devices, they’re often sourced from elsewhere, not from [Canada]. Because a good chunk of our future depends on health-care technology, we have to participate more actively in developing and bringing new technologies to the market.”

From tongue depressors to hip implants, Canada has long depended on using medical devices from other places. According to Statistics Canada, in 2016 Canada imported $8.6-billion in medical devices while exporting $3.1-billion – a trade gap of $5.5-billion.

Developing more medtech innovations in our own backyard, however, could mean turning Canada into a world market leader in a rapidly growing and lucrative sector, expected to reach an estimated $342.9-billion (U.S.) globally by 2021, according to industry research data.

Culture shift

Encouraging an entrepreneurial culture at Sunnybrook to become a research and commercialization hub in Canada makes sense. Not only does Sunnybrook serve a large patient population, it also offers access to preclinical and clinical evaluation infrastructure – outstanding scientists, wellequipped labs, medical experts, financial support, patient participants, information systems and regulatory pathways.

On the top floor at Sunnybrook, there’s even a laboratory for developing medical devices and a machine shop where researchers can build prototypes in-house.

This vision has attracted donors who share Sunnybrook’s ambition to accelerate discovery and commercialization. Their support covers stipends for interns, prototype and equipment costs, networking and educational activities.

“At Sunnybrook, we are working to change the Canadian hospital environment with our vision of ‘inventing the future of health care.’ We need to move toward a culture with a stronger focus on how we can improve the patient experience and outcomes while making more effective use of finite health-care resources through innovation,” explains Graham Wright, research director of the Schulich Heart Research Program.

As a result of the technologies that have been developed at Sunnybrook – ranging from substances that soften plaque buildup in arteries to a worldfirst helmet-like device that uses focused ultrasound to non-invasively treat areas of the brain that were previously unreachable – more patients could eventually benefit from these kinds of targeted, less invasive treatments.

Dr. Courtney’s own research has led to the creation of an ultrasound catheter that takes pictures inside blood vessels and heart chambers – a device now approved in Canada and the U.S.

“What do patients want? They want minimal impact on their lives, ultimately. They want to get out of the hospital as fast as possible and they want to get better,” says Dr. Courtney. “So, would you prefer an open heart surgery or would you prefer a thin wire snaked up through your vessel, so you get out the next day, as opposed to seven or eight days later?”

The Medventions program brings together student interns and clinical fellows with academic and industry experts to create innovative medical technology. (Photograph by Doug Nicholson)

Inventors in training

Medventions is taking medical innovation even further by developing not just the technology, but also addressing Canada’s skills gap by providing the necessary training – a boot camp for inventors. After all, new technologies can’t reach the patient’s bedside unless there are trained inventors with the skills to bring them to market.

Immersive training is key. Because the program has medtech engineers and students with other skillsets working closely with doctors, nurses and technicians, they’re able to get a true sense of the challenges medical professionals face.

For instance, Medventions team members can see with their own eyes the challenges playing out during actual procedures instead of simply visiting the hospital, sitting down with a cardiologist and asking, “What are your challenges?”

“Without that engagement, without that kind of shoulder-to- shoulder way of looking at the problems, discussing and going back and forth, it’s really hard to get to the core of the trouble,” says Wright.

The program isn’t prescriptive either. While team members are given some general suggestions, guidelines and a research area – whether it is in musculoskeletal, orthopaedics, vascular surgery or an area of cardiology – it’s ultimately up to them to decide what to focus their problem-solving skills on.

“We don’t want the Medventions team to come in and say to them, ‘This is what you’re going to work on. Here’s the project and just implement it,’” says Dr. Courtney. “We want them to identify the need and a number of solutions.”

Having students from different professions looking at problems is a boon for the doctors as well.

By working with the Medventions team, health-care professionals, who are typically immersed in their day-to-day work, become more familiar with the innovation and commercialization process. They also begin to see their problem areas through a different lens – challenges that can be solved.

Ultimately, building Canada’s medtech industry takes time. Developing an innovative new medical device or technology and bringing it to market – whether it’s a new catheter, stent, balloon, pacemaker, heart valve, hip implant or a piece of ultrasound equipment – requires patience and determination.

The eureka moment is just the beginning, but the Medventions program prepares innovators for the reality.

“It’s a marathon, not a sprint,” notes Wright. “Everybody understands that it takes time to make this all work. You can’t just come in and have an hour’s interview and come out with an idea. It’s something that takes years overall.”

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