QMR - Volume 15, Issue 3 (2022)

spring 2022

ISSUE 15.3

revolutions

QMR Battle scars How did battle scars left by wars lead to shifts in the surgical field?

turning point A personal reflection on navigating the discomfort of the clinical space as it undergoes revolutions in diversity and safety

dermatology Dermatological considerations in treating skin of colour and the evolutions in care needed to meet the needs of racialized patients

subtle revolutions Read about evolutionary narratives that history often overlooks

Revolutions in medicine 1

In This Issue Managing Team

Sigi Maho Mahshid Hosseini

Staff Contributors

Sarenna Lalani Jessica Nguyen Helen Lin Jehan Irfan Anna Tran Devyani Premkumar Meghan Jenkins Imran Syed Mili Milivojevic Colin Faulkner Amelia Boughn Annie Kang Kaitlyn Rourke Kassandra McFarlane

Design

Jessica Nguyen Fiona Raymond Tanya Narang Colin Faulkner Molly Cowls Kaitlyn Rourke Suffia Malik Joshua Lowe Andrew Lloyd—Kuzik Jehan Irfan Sarah Sloss Helen Lin Kiera Liblik

Editors

Amelia Boughn Sarenna Lalani Helen Lin Haya Abuzuluf Anna Tran Annie Kang Meghan Jenkins Mili Milivojevic Colin Faulkner

Cover Art

Opinion How to start a revolution Decarbonizing healthcare ketamine in the mainstream academic antibiotic stewardship battle scars Community revolution at the polls Chiaroscuro Art Auction reflection Their intense fragility The turning point Dermatological considerations in Treating Skin of Color Leave People Better Than You Found Them Love: The Ultimate Revolution Lifestyle Fresh summer recipes fun rising stars Art

Kendra Zheng 2

4 6 8 10 12 14 16 18 20 22 24 26 28 30 32

Letter From the Editors W

e are proud to introduce the final installment of this year’s Queen’s Medical Review Trilogy Volume 15.3: Revolutions in Medicine!

We started this year with our ‘Beginnings’ issue, ushering in a new year and exploring fresh starts. We then moved to ‘Movements’ which signaled a transition point and pathway to new norms and new opportunities to create history. And now, as we approach the end, we reflect on the important movements that have served as a launching pad for Revolutions. Revolutions are all about cycles of change. While our Queen’s Medicine world revolves around clerkship streams, OSCEs, and exams, a larger societal context revolves around us. We exist in a shifting landscape of innovative changes, revolutionary perspectives, and the rolling momentum of new ways of living and knowing.

In this issue, our contributors are bringing their revolutionary perspectives into QMed’s orbit. Fiza Javed writes a deeply personal and poignant story about the dermatological considerations in treating skin of colour and the evolutions in care needed to meet the needs of racialized patients.

Amelia Boughn brings you two compelling articles in this issue. Her first article discusses the ‘subtle’ revolutions that occur with shifts in paradigm, detailing revolutionary narratives that history often overlooks. Her second article describes revolutions that can take place at the polls, providing a critical perspective on the upcoming provincial June election. Kassandara McFarlane writes an important piece on the emergency department revolutions taking place to combat the evolution of antibiotic resistance and the barriers that make such revolutions a challenge. Kaitlyn Rourke writes a compelling piece on the impact of battle scars on soldiers and how these impacts led to shifts in the surgical field. Devyani Premkumar writes a deeply personal reflection on navigating the discomfort of the clinical space as it undergoes revolutions in diversity and safety. From personal evolutions to social resolutions, Revolutions in Medicine is an issue packed with thought-provoking discussions, deeply moving reflections, and innovative conversations.

Ivneet Garcha & Gabriele Jagelaviciute Editors-in-Chief

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As our last QMR issue as Editors-in-Chief, we have so many people to thank. First, to our incredible contributors that make QMR’s world go around. All of our work revolves around YOU and the incredibly raw and honest way you breathe life into every issue. There are truly no words to express how privileged we feel that you have shared so honestly and selflessly. Without you, there is no QMR. Second, to our hardworking production team. Even though you have made this year so easy for us, you have also made it so much harder to go. Throughout this year, you have put trust in our vision and we have put all of our trust in you.

Safe to say, you never once failed us. You have shown up and delivered every time, and we can’t wait to see what you do with QMR as we pass the torch. And last, but most certainly not least to our forever engaged, forever supportive readers. We cannot begin to thank you enough for all of the engagement, entertainment, and enthusiasm you have shown for this little piece of QMed. QMR is truly your repository, and we hope we have made you feel it as much yours as it is ours. Thank you.

And with that, we invite you to start ‘Revolutions’ - through this issue and in spaces beyond these pages. ⚚

How to start a revo Written by Amelia Boughn, Meds ‘25 Artwork by Kiera Liblik, Meds ‘23

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hen I think of revolutions, what initially comes to mind are the more loud and gruesome kind: the French Revolution (anti-aristocracy), the Algerian War of Independence (anti-colonial), or the American Revolution (anti-taxation), It’s no surprise that these revolutions are top of mind. The Merriam Webster dictionary’s top definition for “revolution” is “a change in the way a country is governed, usually to a different political system and often using violence or war.”1 Revolutions take other shapes and forms as well. They can be periods of rapid change and innovation. For example, we have had four industrial revolutions, those periods of turmoil and rapid change following the invention of steam power, mass production, digital technology, and big data.

think the world could be. Sometimes, these changes come about from large and bloody conflict, but often they are much more subtle and are accomplished through the courageous actions of the revolutionaries that history often overlooks. Their actions may serve as the first domino falling in much larger social or political movements.

Sometimes, the change is so gradual that the initial act of revolution, that first falling domino, goes completely unnoticed. Canadian medicine has many of these revolutionaries. The beauty of history is that we can look back and tell their stories.

Clement Ligoure

On the morning of December 6th, 1917, with the world in the grips of the First World War, two ships collided in the bustling Halifax Harbour. One of the ships, the French SS. Mont Blanc, was packed with high intensity explosives.

Twenty minutes after the collision, the Mont Blanc exploded. The powerful explosion destroyed the harbour and everything around it, causing the deadliest disaster in Canadian history.

Of course, revolutions cannot happen without revolutionary thinkers, the visionaries who rupture the boundaries of what is considered acceptable to change the status quo. Some of the most famous revolutionaries include Not far from the explosion, in his Thomas Jefferson, Robert Fulton, and private medical clinic on North Street, Dr. Clement Ligoure was preparing Steve Jobs.

However, I think we do a disservice to ourselves and to the histories we tell when we focus only on the most visible and famous periods of change.

When you keep reading down to the bottom line of the Merriam Webster “revolutions” page (because who wouldn’t want to spend Saturday night doing this), eventually you will get to a very different definition of the word: “a change in paradigm.”2 Changes in paradigm are subtle shifts in the way we see the world, or in what we

for a typical day. A member of the Queen’s Medicine class of 1916 (and one of the last Black medical students to graduate from Queen’s before the university implemented its Black student ban), Ligoure moved to Halifax after graduation hoping to practice medicine and enlist in the military.

When he arrived, however, racist military and hospital officials blocked him from doing either. Frustrated but undeterred, Ligoure advocated for the creation of the No. 2 Construction Battalion (composed entirely of men of African descent) and founded his own private medical clinic in the North end 4

of Halifax.

After the explosion, the city’s hospitals quickly filled up, and many injured people made their way to Ligoure’s clinic.

Ligoure treated everyone who came free of charge – 180 patients a day – for several days following the explosion.

At first aided only by his housekeeper and boarder, the city eventually sent nurses to assist, and his small private clinic became a makeshift hospital for those with non-life-threatening injuries. The young doctor, who less than a year before had been blocked from practicing at any of Halifax’s hospitals, saved hundreds of lives in the days following the catastrophe. Five years later, in 1922, Ligoure died from unknown causes. His actions during the disaster went largely uncelebrated.

Edith Monture

At around the same time as Ligoure’s heroic actions in Halifax, Edith Monture was working as a registered nurse at hospital in France. A Mohawk woman born on the Six Nations of the Grand River reserve, she faced an impossible choice after graduation from high school.

She dreamed of becoming a nurse, but the Indian Act forced compulsory enfranchisement on any Indigenous person who chose to pursue higher education in Canada. Enfranchisement was a racist policy of assimilation that stripped an Indigenous person of their legal and ancestral identity, essentially forcing young people to choose between education and community.

Monture, instead of picking between pursuing her dream and remaining part of her community, chose both. She left Canada and the racist Indian Act behind and moved to New York where she earned a nursing degree from the New Rochelle Nursing School. When the first World War started, she enlisted

opinion

olution

Rodriguez set out to change the law. She appealed first to the British Columbia Supreme Court, then later to the Supreme Court of Canada. She wanted the courts to rule that the section of the law prohibiting assisted suicide violated the Canadian Charter of Rights and Freedoms. Rodriguez spent the final two years of her life in the

References 1. Merriam Webster Dictionary, “Revolution,” https:// www.merriam-webster.com/dictionary/revolution.

2. ibid

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In 1992, Sue Rodriguez faced an incredibly difficult situation. The year prior, she had been diagnosed with ALS, a progressive degenerative neurological condition that gradually robs people of their ability to walk, move, speak, eat, and, eventually, breathe.

Rodriguez did not want to spend the end of her life hooked up to a ventilator, unable to move or breathe for herself. She wanted to die on her own terms via assisted suicide, but was prevented from doing so by Canada’s Criminal Code, under which the punishment for assisted suicide was up to 14 years in prison.

Revolutionaries are not always celebrated loudly. They can’t always be found on the TV or radio, or in our high school history books. Ligoure and Monture became revolutionaries through the tenacious act of serving their communities as healthcare providers in a racist and exclusionary system. Rodruiguez lived in a healthcare system that was not serving her needs, and though she lost her initial court battle, she planted a seed that twenty years later would grow into what is today known as MAID. The opportunities for revolution are all around us. If these stories tell us anything, it’s that you don’t need to be a cabinet minister or tech genius to start a revolution. Revolution can come from anybody who refuses to accept a system or situation that is unjust and steps up in the name of change, to fight for what the world could one day be. ⚚

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Sue Rodriguez

Twenty years later, the Supreme Court in Carter v Canada ruled unanimously in favour of what Rodriguez had fought so hard for: the law prohibiting assisted dying was in violation of the Charter of Rights and Freedoms. The ruling set the stage for the policy that is today known as Medical Assistance in Dying (MAID). When students in Canada learn about MAID, they learn about Marlene Carter and her instrumental role in fighting for MAID. They might not, however, learn about Rodriguez, the woman who fought ferociously until the end of her life for change she didn’t live to see realized.

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While the first part of Monture’s nursing career was defined by wartime heroism, the second was defined by dedication to community. In 1920 she returned home to the Six Nations reserve near Brantford, where she served her community as a nurse and midwife for the next forty years.

During this time, she also became the first Indigenous woman to be granted voting rights in Canadian elections (due to a provision in the Military Service Act) and was a fierce advocate for First Nations health until her death in 1996. Through her work, she provided reliable healthcare for a community that faced (and continues to face) inequitable access to safe healthcare services from both the federal and provincial governments.

public spotlight, fighting for the right to die by assisted suicide. In September of 1993, the Supreme Court held that the law did not violate the Charter and it was maintained.

Rodriguez died at home in 1994. Her friend and physician Svend Robinson was investigated for physician-assisted suicide.

Edit

in the US army corps and was deployed to 23rd Buffalo General Hospital in Vittel, France. There, she spent over a year treating critically injured soldiers, returning to the United States in February of 1919.

Decarbonizing Health Care Expanding the definition of patient safety Written by Colin Faulkner, Meds ‘24 Artwork by Kaitlyn Rourke, Meds ‘23

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hen we consider the ways in which we work towards patient safety, one often neglected reality is how carbon emissions contribute to early death and disability. In a year, this number is around 23,000 years of life lost just within Canada.

With ~5% of Canada’s greenhouse gas emissions coming from the health care sector, there is an impetus to reduce our footprint. Clinicians and future clinicians are uniquely positioned to both act on reducing emissions as well as communicate the health effects of climate change.

For many, climate change feels like an impossible challenge. However, within the field of medicine, there exist low-hanging fruit that if plucked, could yield significant benefits. In 1985, atmospheric scientists discovered a downward trend in ozone layer thickness.

In response, a worldwide effort began to ban the main culprit, chlorofluorocarbons (CFCs). CFCs were used in air conditioners, hairspray bottles, and importantly, asthma inhalers. For inhalers, the alternative became hydrofluorocarbons (HFCs). Solving a problem with another problem, it turns out that due to the gas’s

structure, the HFCs in one metered-dose inhaler (MDI) are equivalent to the CO2 emissions of a 290km road trip. With the increased rates of asthma due to pollution, inhaler HFCs equate to around 3.1% of all healthcare carbon emissions. The solution: dry powder inhalers. With few contraindications, the simple switch to dry powder inhalers from MDIs is one of our most accessible opportunities. So why have we not made this change? Placing the onus on already-overworked family physicians is less than ideal. In this case, it is vital to communicate how far-reaching these changes can be.

The COVID-19 pandemic has also precipitated some changes in medical standards that have reduced emissions. In the operating room, to reduce the aerosol of viral particles associated with general anesthesia, local anesthesia became more common. The use of anesthetic gas accounts for over half of all CO2 production in the OR; local anesthesia uses far less.

While some physicians have been switching back to old methods, local anesthesia can actually improve patient outcomes and reduce side effects like delirium, on top

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opinion

“By advocating for the expansion of patient safety to include reducing health care pollution, we can begin to prioritize emission reduction at all organization levels.”

of creating less pollution. Alternatively, switching from desflurane and nitrous oxide to sevoflurane can reduce gas-related emissions by 80%.

using renewable energy sources are a few of many potential improvements.

By advocating for the expansion of patient safety to include reducing health care pollution, we can begin to prioritize emission reduction at all organization levels.

Realistic targets, like dry powder inhalers and regional anesthesia, are a good start. Tackling the bulk of emissions will require us to pressure the supply chain and continue to practice prophylactic medicine. ⚚

Telehealth visits have also jumped over 110% since the start of the pandemic, and represent an additional opportunity to reduce emissions associated with transportation. The opportunity lies in the maintenance of these changes; challenging previous status quos while prioritizing patient outcomes will be an important next step.

Further Reading: - planetaryhealthlab.com/publications - “Pressurized metered-dose inhalers and their impact on climate change” by Fidler et al.

-rcoa.ac.uk/patient-information/about-anaesthesiaperioperative-care/your-anaesthetic-environment

At a policy level, the target for health care decarbonization should be the supply chain: production, transport, use, and disposal of goods and services; more specifically, the production. Due to the complexities of the global system of supply, and that of medical equipment, 90% of the CO2 associated with the average piece of medical waste is created before the item is even used. Medical facilities should consider this when reporting their emissions, but they need to also hold their suppliers accountable. Fewer virgin plastics, switching to continuous manufacturing, and

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Ketamine

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Written by Colin Faulkner, Meds ‘24 Artwork by Sigi Maho, Meds ‘24

K

etamine began as a veterinary anesthetic when it was first approved for use in Belgium, in 1963.

By 1970, it was approved for human use in the United States. It was favoured by the military during the Vietnam war for its wide margin of safety and rapid anesthesia. By 1999, enough accounts of its psychedelic effects, sometimes experienced at high recreational doses, landed ketamine as a Class III controlled substance. It wasn’t until researchers discovered that Ketamine was effective at reversing opioid-associated hyperalgesia, that ketamine began to be considered again for acute and chronic pain.

Acute Pain

In the emergency room, how pain is managed is now a quality of care indicator. In the midst of an opioid epidemic, considering alternatives is a priority. In this setting, a sub-anesthetic dose produces the same frequency of adverse events as a placebo – a counterargument to concerns about the sedation and disassociation associated with high doses. Ketamine also tends to reduce postoperative pain scores, and the time until the patients’ first analgesic request.

How does it work? For pain, ketamine inhibits the NMDA receptor, producing an analgesic effect at low doses.

Treatment-Resistant Depression

Depression is common, and varied are the treatments for it. So what happens if no treatments work? About 30% of those treated for Major Depressive Disorder (MDD) have no symptom resolution after taking 2

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in the Mainstream or more medications. In these individuals, we find another Health Canada-approved use of ketamine; if a person responds to ketamine, usually through an IV infusion, it can rapidly reduce suicidality and reduce other symptoms. In addition, it can be effective when the individual has severe depression with concurrent anxiety. Importantly, these effects are almost immediate, unlike the weeks that other medications, electroconvulsive therapy, or transcranial magnetic stimulation can take.

How does it work? In depression, sub-anesthetic doses are hypothesized to stimulate synaptogenesis, by increasing glutamate in the spaces between neurons.

It also appears to reduce inflammatory signaling, which has been linked to mood disorders.

It’s not a catch-all, however. Contraindications exist in two main groups. The first of these is in patients who have a history of schizophrenia, psychotic symptoms, or Post-Traumatic Stress Disorder (PTSD). The second is those with significant hepatic or cardiovascular disease.

With this revolution in psychiatric care, it now becomes a priority to study any long-term effects of chronic ketamine treatments. More thorough research is also required for the medical use of ketamine in older adults.

Depression is the second most common psychiatric disorder in older adults. Among this case prevalence, one-third are treatment-resistant. As ketamine can avoid the respiratory depression of opioids, it may have a role in geriatric acute pain management as well; ketamine also has a counteracting effect among those dealing with opioid-induced hyperalgesia.

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Harm Reduction with Ketamine

With an increase in ketamine for medical indications, the recreational use of illicit ketamine has also increased. While possession of ketamine is against the law in Canada, it is still important to approach its use with harm reduction in mind - for the safety of patients, and anyone you know who uses it.

A common dose of ketamine (often snorted) is around 3050mg, and looks like a whiteish crystalline powder, with no odour and a bitter taste. Illicit ketamine is frequently contaminated; drug testing kits like the Mandelin Test can help prevent consuming more dangerous drugs but are not 100% accurate. Desired effects usually include euphoria and dissociation (an out-of-body experience).

Side effects to observe include nausea/vomiting, loss of motor coordination, extreme dissociation (sometimes referred to as a K-hole), and complete loss of consciousness at higher doses. Serious risks are more likely when used with alcohol, benzodiazepines, or Gamma-hydroxybutyric acid(GHB), but can also occur with high doses alone: respiratory arrest, psychological dependency, and nephrological damage with chronic use.

Some Additional Tips:

- Never use ketamine alone. If you must, ask a friend to check up on you over the phone or in person.

- Avoid sharing any objects used for snorting, like straws or spoons. ⚚

Stop the Evolution, Join the Revolution: Challenges and Solutions for Antibiotic Stewardship in the Emergency Department Written by Kassandra McFarlane, Meds’ 23 Artwork by Fiona Raymond, Meds ‘23

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ntibiotic resistance has been and continues to be a threat to our health, with a growing number of bacterial species resistant to at least one antibiotic.1 Many bacterial infections are becoming increasingly difficult to treat, including Pseudomonas aeruginosa, Mycobacterium tuberculosis, and others, as a result of antibiotic resistance.2 In 2018, antibioticresistant organisms contributed to 26% of all infections in Canada and resulted in 14,000 deaths.3 Antibiotics are one of the most commonly prescribed medications in the emergency department (ED) and while antibiotic use can be lifesaving in the right circumstances, there is evidence that almost 33% of antibiotic prescriptions in the ED are inappropriate.4 Antibiotic stewardship programs are one of the ways to deal with the misuse of

antibiotics5, an important preventable cause of increasing resistance.6 As the interface between the community and the hospital, EDs are an ideal setting to address the inappropriate prescription of antibiotics.6

Challenges

The ED setting poses unique challenges for antibiotic stewardship by emergency physicians, one of which is maintaining a balance between efficiency and ensuring sufficient coverage for infections.7 Patients presenting for care require timely provision of treatment so as to prevent the worsening of their condition and the general goal of the ED is to improve patient flow to avoid overcrowding, morbidity, and mortality.8 Obtaining the data necessary to make decisions about 10

the appropriate antibiotic required, if at all, takes time. Tissue cultures are necessary and extended turnaround time for results can increase the length of stay a patient has in the ED and contribute to overcrowding.7 Concern for adequate coverage for an infection may lead to inappropriate selection of broad-spectrum antibiotics.7 In addition, patients or their parents may pressure the provider for antibiotics.9 This pressure from patients to prescribe antibiotics leads many doctors to acquiesce as it’s often less challenging than engaging in confrontation.9 As well, giving into a patient demand for medication is perceived to maintain rapport with the patient, though physicians remain aware of the irrational request by the patient.9 As a result, inappropriate antibiotic

ACADEMIC prescription rates increase, potentially worsening antibiotic resistance.6 While it is clear that emergency physicians face challenges when it comes to appropriately prescribing antibiotics in the ED, there are potential solutions available.

physicians in the ED towards optimal choices of antibiotics, accounting for local resistance patterns. This thereby eliminates unnecessary use of broadspectrum antibiotics, one of the contributors to the development of resistance.12

Solutions

Outpatient Parenteral Antimicrobial Therapy (OPAT) Clinics

4 Moments of Antibiotic Decision Making

Conceptual frameworks in medicine are developed to address problems in healthcare and provide useful guidance to physicians. Many are already integrated into practice, like those involved in patient handover.10 For emergency physicians, using a framework for decision making around antibiotic use could help reduce inappropriate prescribing.10 The “4 Moments of Antibiotic Decision Making” considers four significant points in the timeline of antibiotic prescribing and prompts the physician to reflect.10 The first moment seeks to clarify whether the patient requires antibiotics emphasizing that physicians remain mindful of diagnoses other than infection that could explain the presentation.10 The second moment highlights the importance of obtaining cultures prior to beginning antibiotics in order to confirm and specifically target an infection and to use the most appropriate empiric antibiotic in the interim; the use of a local antibiogram is helpful in this context.10 The third moment prompts a reflection on the plan for the course of treatment, ensuring that the treatment plan considers any new data obtained.10 Finally, the fourth moment regards the length of antibiotic treatment and supports adhering to evidence-based guidelines when administering antibiotic therapy.10

Antibiograms

An antibiogram is a summarized dataset comprising information on bacterial isolates in that institution.11 This clinical tool provides details on the prevalence and susceptibility of bacterial species within the community and hospital and aids the clinician in directing antimicrobial therapy.11 Proper use of an antibiogram can guide

Patients whose infections require intravenous (IV) antibiotics, but who are not sick enough to be admitted, require follow-up and management of their treatment in the community.

Outpatient parenteral antimicrobial therapy (OPAT) clinics provide a specialized service for these patients in an ambulatory setting,13 while simultaneously helping to offload volume from the ED.14 These clinics are staffed with infectious disease specialists familiar with and dedicated to the management of a variety of infections that require ongoing care in the community.13 OPAT clinics provide a safe and cost-effective alternative to hospitalization or follow-up in the ED and help to reduce antibiotic resistance through effective and specialized treatment.13

Conclusion

Although antibiotic resistance has become an increasing concern in healthcare, there are effective solutions that exist for emergency physicians to revolutionize antibiotic stewardship in the ED. Given thatBecause antibiotics are commonly prescribed in the ED and because the ED operates at the interface of the community and the hospital, it is a particularlyn important setting to implement changes in prescribing practice. While the challenges facing emergency physicians include balancing efficiency and flow with effective treatment while managing increasing pressure from patients, there are some potential solutions that may help with ensuring antibiotics are appropriately prescribed. Though this is not an exhaustive list, considering the “4 moments of antibiotic decision making”, using local antibiograms, and taking advantage of OPAT clinics where they are available will help reduce the 11

inappropriate use of antibiotics in the ED and potentially decrease the rate of antimicrobial resistance both in the hospital and within the community. ⚚ References 1. Chokshi A, Sifri Z, Cennimo D, Horng H. Global contributors to antibiotic resistance. Journal of global infectious diseases. 2019 Jan;11(1):36.

2. Tacconelli E, Carrara E, Savoldi A, Harbarth S, Mendelson M, Monnet DL, Pulcini C, Kahlmeter G, Kluytmans J, Carmeli Y, Ouellette M. Discovery, research, and development of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and tuberculosis. The Lancet Infectious Diseases.

2018 Mar 1;18(3):318-27.

3. Finlay BB, Conly J, Coyte PC, Dillon JA, Douglas G, Goddard E, Greco L, Nicolle LE, Patrick D, Prescott JF, Quesnel-Vallee A. When Antibiotics Fail: The Expert Panel on the Potential SocioEconomic Impacts of Antimicrobial Resistance in Canada. 2019.

4. Denny KJ, Gartside JG, Alcorn K, Cross JW, Maloney S, Keijzers G. Appropriateness of antibiotic prescribing in the emergency department.

Journal of Antimicrobial Chemotherapy. 2019 Feb 1;74(2):515-20.

5. Barr DA, Seaton RA. Outpatient parenteral antimicrobial therapy (OPAT) and the general physician. Clinical medicine. 2013 Oct;13(5):495.

6. May L, Cosgrove S, L’Archeveque M, Talan DA, Payne P, Jordan J, Rothman RE. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Annals of emergency medicine. 2013 Jul 1;62(1):69-77.

7. Jorgensen S, Zurayk M, Yeung S, Terry J, Dunn M, Nieberg P, Wong-Beringer A. Emergency department urinary antibiograms differ by specific patient group. Journal of clinical microbiology.

2017 Sep;55(9):2629-36.

8. Jarvis PR. Improving emergency department patient flow. Clinical and experimental emergency medicine. 2016 Jun;3(2):63.

9. Lewis PJ, Tully MP. The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers. Research in Social and Administrative Pharmacy. 2011 Mar 1;7(1):4-15.

10. Tamma PD, Miller MA, Cosgrove SE. Rethinking how antibiotics are prescribed: incorporating the 4 moments of antibiotic decision making into clinical practice. Jama. 2019 Jan 15;321(2):13940.

11. Joshi S. Hospital antibiogram: a necessity.

Indian journal of medical microbiology. 2010 Oct 1;28(4):277-80.

12. Cižman M, Srovin TP. Antibiotic consumption and resistance of gram-negative pathogens (collateral damage). GMS infectious diseases.

2018;6.

13. Seaton RA, Barr DA. Outpatient parenteral antibiotic therapy: principles and practice. uropean journal of internal medicine. 2013 Oct 1;24(7):617-23.

14. Mohammed A, Qadrie ZL, Nagavamsidhar M, Suman A, Saiteja D, Shivani P. Outpatient Intravenous Antibiotic Therapy: Reduces economic burden of patients. PharmaTutor. 2018 Sep 1;6(9):24-30.

Battle Scars How Wars Impac

Written by Kaitlyn Rourke, Meds ‘23

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ars of the past century have shaped our current world: national boundaries were redrawn, new nations were born, and great empires diminished. In parallel, the soldiers who fought in the wars were also greatly impacted.

Many soldiers were left severely wounded by “battle-scars” after the war, resulting in emotional and functional distress. Wartime surgeons were faced with a new problem: how could they reconstruct these defects and help soldiers with their recovery?

Facial battle scars were not such a big issue before World War I. 19th century wars were fought with swords and short-range firearms, resulting in stabbing, slashing, and punctures wounds to soldiers’ body rather than their faces. As such, the priority for wartime surgeons was to control bleeding and avoid infection. Furthermore, many soldiers would die from their wounds, thus there were fewer living with significant scars, reducing the need for medical care to include considerations for soldier’s appearance From 1914-1918, World War I (WW1) was fought with unprecedented intensity, with significant mortality and morbidity. Much of the damage was due to the new types of war weapons, including heavy artillery and machine guns. Shells were filled with shrapnel, designed to cause maximum damage.

They would explode and cause facial and head wounds, burning through flesh or ripping faces off entirely. Soldiers who survived would be left with

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severely disfigured faces, barely able to recognize themselves anymore. Some injuries to the jaw would leave men unable to eat or drink, requiring constant help. Others would be left with gaping holes where their nose used to be. Many of these soldiers were terrified of going back to society.

Surgeons had never seen this severity of injury before. Originally, they attempted to stitch together the jagged edges, without considering the chunks of missing flesh. This would result in grotesque scars and permanent disfigurement. One head and neck surgeon, Harold Gillies, wanted to find a new way to close these wounds. Gillies began experimenting with transferring skin from other places to reconstruct the defect. He was able to achieve success by keeping the blood supply of the donor tissue intact and moving the flap to close the hole. Maintaining the physical connection ensured that blood was supplied to the skin, increasing the chances of the graft being accepted by the body.

In 1918, Gillies opened The Queen’s Hospital, the first hospital dedicated to reconstructing facial injuries, so soldiers could hopefully lead a normal life. The first patient treated was a gunnery warrant officer named Walter Yeo. Yeo sustained severe facial injuries at the Battle of Jutland in 1916, including loss of his upper and lower eyelids. To reconstruct the area, Gilles took a flap from Yeo’s chest, keeping it connected to the blood vessel, and grafted it to Yeo’s face, producing a new eyelid!

Along with Yeo, more than 11,000 operations

ACADEMIC

s: cted Surgery

In modern war, weapons have evolved to cause even more destruction, corresponding to more complex wounds. High velocity missiles course through human flesh, producing extensive soft tissue and bone destruction along their path.

Explosive weapons, such as bombs, grenades, mines, and improvised explosive devices, produce extensive composite tissue damage due to blast effect. At the same time, there is also improved trauma care and emergency response, meaning critically ill patients can survive the immediate destruction,although requiring later reconstruction. Now having left the battlefield, reconstructive surgeons work at tertiary centers, providing delayed reconstruction using the same principles learned during the Great Wars.

Complex explosion-related wounds are also relevant to our current times, especially with the advent of the 2022 Russo-Ukrainian conflict.

Bombing victims have had a difficult time accessing adequate reconstructive care due to a lack of surgeons with enhanced traumabased reconstructive training within Ukraine.

As a response to this, a handful of Canadian reconstructive surgeons have set up emergency clinics on the Ukrainian-Poland border.

When looking back at past wars, “battle scars” resulted in the development of many modern techniques of reconstruction. Treatment of burns and the importance of rehabilitation are still used in plastic surgery. Wartime wounds continue to pose a complex reconstructive challenge, especially in the Russo-Ukrainian War. Furthermore, for the first time, the priority of surgery was aesthetic rather than strictly life-saving. The World Wars was the first time it was appreciated that physical wounds could affect emotional and psychosocial wellbeing. In modern plastic surgery, this principle continues to persist. ⚚

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Background image sourced from Fairbanks, Eugene F. (2011). Human Proportions for Artists. Bellingham, WA: Fairbanks Art and Books.

Sculture photographs by Alexander Van Steenberge on Unsplash.

were performed on more than 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds).

In 1930, Gillies’ cousin, Archibald McIndoe, joined the practice of reconstructive surgery. When World War II broke out, McIndoe joined the army as a military doctor, treating serious facial disfigurement. Once again, aesthetic injuries were just as important to treat as other life-threatening emergencies. McIndoe further expanded the field by developing new techniques for treating badly burned faces. He also recognized the importance of rehabilitation of casualties and social integration back to normal life. Interestingly, many of his techniques continue to be used in modern reconstructive surgery.

Kendra Zhang, Meds ‘24

Lora Stepanian, Meds ‘24

Chiaroscuro Art Auction Returns In-Person Written by Lora Stepanian, Meds ‘24

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pring 2022 saw the in-person return of the Chiaroscuro Queen’s Medicine Art Auction, an annual QMed tradition, which prepandemic, would customarily take place in-person every fall with the aim of raising funds for charity. For the week of April 17th, members of QMed and the local community engaged in online bidding wars over the many student-submitted artworks and talents.

These included paintings, drawings, works of pottery and sewing, plants, and talents including personal training and bartending. These all culminated on April 23rd with the in-person component of the auction in the School of Medicine Atrium. Attendees pooled in to see the wonderful contributions of our students, and to listen to special performances by our very own band of physicians, Old Docs New Tricks, and class of 2024 musician, Gena Zheng. Through the hard work and commitment of all our donors, patrons, and volunteers, the auction was able to raise around $1300 for the local charity, Almost Home. Almost Home is a home-away-from home for families of ill or injured children receiving medical treatment from Kingston area hospitals. It receives no ongoing government or agency support, relying on individual donors to keep its doors open. We feel incredibly fortunate to have been given the opportunity to support such a worthy cause and appreciate all of the help and support received along the way to make the auction a reality! ⚚ 14

Sigi Maho, Meds ‘24

community

Lora Stepanian, Meds ‘24

Janjulee Ellis, Meds ‘25

Janjulee Ellis, Meds ‘25 Old Docs New Tricks with Art in Medicine Executives Kendra Zhang, Sgi Maho, & Lora Stepanian

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Art in Medicine Executives Lora Stepanian & Sgi Maho

Revolution at the polls: It’s election season Written by Amelia Boughn, Meds ‘25 Artwork by Kiera Liblik, Meds ‘23

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n June 2, we are heading to the polls for the first provincial election in four years. While voting is just one of many forms of advocacy, it is an important one. In each federal election since 2011, the 18-24 year olds and 25-35 year olds had the two lowest voter turnouts of all age brackets. Governments see these statistics, and it helps them decide who to create their policies for. This is why, even if you’re frustrated with the limited options for candidates in your riding, or just burnt out in general by the

hyper-partisan nature of politics today, it’s still important to vote. The more young people who cast their ballots, the more power we will have between election years to advocate for things important to us. If parties know our vote can affect their chances of being re-elected, they are more likely to listen. So, here are your options for casting your ballot this June. Make a plan to vote early, and reach out to me at aboughn@qmed.ca or visit https://www.elections.on.ca/en/voting-inontario.html if you have any questions!

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Community

ways to vote 1

Cast your ballot in person in Kingston or in your home riding. If you plan to do this, make sure you visit https:// e r e g i s t ra t i o n . e l e c t i o n s . on.ca/en/home to check that you are registered as a voter in the riding you plan to vote in on election day. As long as you have a valid Kingston address, you should be able to vote in Kingston. Do this several weeks in advance so there is time for Elections Ontario to send you an updated voter card in the mail.

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Cast your ballot by mail. This is a great option if you’d like to vote in your home riding but will still be in Kingston on election day. For the upcoming election, you can apply to vote by mail starting on May 4. The deadline to apply is May 27. After you apply to vote by mail, Elections Ontario will send you a voting kit. Elections Ontario must receive your completed voting kit in the mail by election day (June 2).

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Vote by advanced polls in the electoral district you are registered to vote in. The polls are open 10am to 4pm on specific advanced voting dates still to be announced by elections Ontario. This is a great option if you’re like me and aren’t exactly sure where you’re going to be on election day, or just don’t want to deal with that long line outside the Leon’s Centre! ⚚

nothing which we are to perceive in this world equals the power of your intense fragility: whose texture

compels me with the colour of its countries,

rendering death and forever with each breathing

- E.E. Cummings

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Their intense fragility: the importance of storytelling

reflection

Written by Helen Lin, Meds ‘25 Artwork by Fiona Raymond, Meds ‘23

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was first introduced to the poem, somewhere I have never travelled, gladly beyond from the book, When Blood Breaks Down: Life Lessons from Leukemia by Dr. Mikkael A. Sekeres. He describes his patients having this intense fragility, as written by the great poet E.E. Cummings, that appears intangible yet powerful at the same time. Dr. Sekeres recounts an experience he had where he observed a patient of his being described as a “futile case” by residents.

Unfortunately, this patient, Mrs. Abrams, was suffering from ovarian cancer and was slowly dying from fluid filling her lungs. She chose to spend her final hours saying goodbye to her two children. Even after her children left, Dr. Sekeres saw her struggle to write out 3x5 greeting cards for future occasions for her two kids for the time after she passed. He wondered what was behind the power of Mrs. Abram’s intense fragility that pushed her past her limit to finish writing out the cards for her children. He wondered how strength and dignity came boundless in many of his patients. I too wonder the same.

Over the course of this semester, I am continuously awed by the vulnerability and courage of the patients that come back to speak with our class, to recount their experiences.

It is no easy task to remember some of the most challenging moments of your life. And for them to do it so willingly and so graciously only fuels my desire to learn. From the numerous and courageous leukemia and lymphoma patients in our Blood and Coagulation course to the brave parents in our Neonatology class, all of them have instilled an emotional core in our learning. They instruct us in ways the lecturers cannot, and in doing so have allowed us to perceive the humanity behind their ordeals. What a privilege to hear these stories.

I’m grateful for these stories. In an academic sense, they help us consolidate what we’ve learnt and add humanity to the cases. Studies have shown that the importance of storytelling can be powerful. As noted by Job et al., there is a disparity between theory and practice by what is taught in universities compared to what actually happens in practice settings [1]. They argue that this theory-practice gap is bridged by reflective dialogue, such as the use of patient stories in healthcare education [1]. In terms of our education, oftentimes the theoretical is not enough. We need the addition of aesthetic, personal, ethical and emancipatory knowledge [1]. These encourage us to engage in reflective thought. Also, a patient’s story shared in the classroom with students helps with the patient and student dialogue, which enables a problem-posing approach to education [1]. The problem-posing approach grounds students in the realities of the world and helps them challenge their assumptions, beliefs and attitudes [1]. Benner et al. argues that in order to 19

better prepare students for the messiness of clinical practice, patient stories are useful to foster learning and bringing the complexity of practice into the academic environment [2]

I can definitely see the benefits of patient stories on students, but what about the other way around? Do patients achieve a sense of closure or contentment from sharing their stories?

McWilliam et al. find that with older Canadian adults (65 years+), storytelling is a way of generating trust between patients and nurses as a method of empowering the elderly patients [3]. Many patients who participated in the Patient Voices Programme (www.patientvoices.org.uk) find that they have gained confidence through the process of sharing their stories in a digital format [4]. Therefore, storytelling in the healthcare setting can be helpful for patients in creating a space to share their experience and to be in contact with supportive networks [5].

These studies highlight the importance of personal narrative in our learning as well as the patient’s well-being. There is a revolution that has entered medical education over the past few decades, and I believe it revolves around patient care and knowledge becoming front and center. Long gone are the days when the physician makes most of the medical decisions for the patient. We have now adopted the model of shared decision making, which is for the better for both patients and physicians. But the learning continues, and the enrichment of our learning from patient stories will help us bring in a new wave of physicians. Hopefully, ones who can truly empathize and work together with patients.

I still have a long way to go before I become a licensed, practicing physician. I’m sure I’ll encounter many more patients whose stories will move me and inform my practice.

What still eludes me is where the patients get their gumption from to volunteer their stories to our class. What I am sure about is that it comes from a place deep within them that wishes to prevent mistakes, honour the correct choices, and delve into the emotional impact of those choices. I can’t put it better than E.E. Cumings. What intense fragility indeed. ⚚ 1. Job C, Yan Wong K, Anstey S. Patients’ stories in healthcare curricula: creating a reflective environment for the development of practice and professional knowledge. Journal of Further and Higher Education. 2019 May 28;43(5):722-8.

2. Benner, P., M. Sutphen, V. Leonard, L. Day, and J. Bass. 2009. Educating Nurses: A Call for Radical Transformation. San Francisco: John Wiley 3. McWilliam CL, Stewart M, Del Maestro N, Pittman BJ, Brown JB, McNair S, Desai K, Patterson ML. Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians. Health Promotion International. 1997 Jan 1;12(2):111-23.

4. O’Neill F, Hardy P. Designing patient-shaped healthcare: Hearing patient voices.

5. Haigh C, Hardy P. Tell me a story - a conceptual exploration of storytelling in healthcare education.

Nurse Education today. 2011 May 1;31(4):408-11.

The turning point Written by Devyani Premkumar, Meds ‘25 Artwork by Kaitlyn Rourke, Meds ‘23

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very day, I wake up and look at myself in the mirror. I think about how I present myself to others. Although I like to think I give all of me, sometimes, I reflect on how my identity is not “convenient” for some spaces. The looks I receive. The abrupt answers I am given. The change in tone. It frustrates me.

Some days I approach this with audaciousness. Some days, with silence.

I wonder, all the time; what will I endure in the clinical spaces?

We have these courses embedded into our curriculum; talking about accessibility, prejudice, all the “isms” and how to advocate for ourselves, for others and, of course, for our patients. While they show administrative effort, I often feel as though I’m sitting in a ‘let’s justify why I deserve rights’ seminar.

A lot of these discussions center around the journey we, as learners, must take to prepare for our careers. But what about our mentors? We talk about creating psychologically safe spaces; do our preceptors take these lessons about cultural safety with the same regard?

This piece was not meant to be just a list of questions. But they are important; and I am hoping I can find answers as I navigate through my training. We are taught to sit on the pedestals of “professionalism”, but why do I worry I may not get the support I require? Patients will come first, always, but would my supervisors look out for me too?

phots/TKlxnmieI ua.c htps:/ 20

reflection

“

By taking up space, we can transform the landscape of medicine, and redefine how representation and equity work together, for ourselves and for the ones we care for. That is, in itself, the start of a revolution.

I do not want to disregard the work that is being done. I am grateful to look across the sea of students in my class and see those that look like me and see those that are different. I am proud of all my classmates, coming from literally all walks of life, with their intersectional identities and perspectives. The unspoken allyship I feel when I walk into a room is something I will never take for granted.

Let’s take Medical Variety Night for example. I got to witness so many people come together, open-minded and eager to learn a Bollywood routine, something that is a big part of my identity. My parents, after watching the show and meeting some of my classmates, later sent me a text saying, “We are so happy we moved to this country, it was difficult, but watching you on stage with your friends today makes it all worth it”. This was a big moment for me because I hope the sense of belonging I felt on stage is one I am able to find across all platforms of my career.

I still aim to hold our supervisors accountable in advocating for us; but in the interim, it is comforting to see that we can be that support system for each other and for the next generation of learners. More and more, we look and feel like a group of future physicians that are representative of the patient populations we will treat. And therein lies the turning point.

By taking up space, we can transform the landscape of medicine, and redefine how representation and equity work together, for ourselves and for the ones we care for. That is, in itself, the start of a revolution. ⚚

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Diagnosis and Best Practices in treating Skin of Color: Reflections from a Case Study Dermatological considerations in detecting cancer in patients of color Written by Fiza Javed, Meds ‘24

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s we sit in the doctor’s office, waiting for the doctor to write a referral to a head and neck specialist, the family doctor says for the tenth time to my father: the spot on your face is “Nothing. probably a pimple”. A 60-year-old man with a black pimple on his nose which appeared to be growing inwards and detaching the crease of his nose (Refer to Figure 1). My father had brought this “weird spot” to the family doctor’s attention multiple times over the course of 5 years, before he received a referral to see an Otolaryngologist. As a person of color, how many times have I heard some variation of “That is not a real sunburn” or “You must not even get sunburnt”. Some even wonder if darker skinned people get skin cancer at all?

The doctor looks concerned upon mentioning that the cosmetic plastic surgeon he sent my father to suspects it could be melanoma or basal cell carcinoma. However, he reassures us it is likely just a benign lesion since he has had it for so long, likely “seborrheic keratoses”.

As I advocate to get a referral for a dermatologist or an otolaryngologist, the lack of urgency and unwillingness to take the lesion seriously is palpable.

After a few weeks we get to see a specialist. As the doctor inspects him, he calls in his residents as this is something new, a learning experience. He shares they haven’t seen this before, not in this location at least. Certainly surprised that something cancerous would be growing for 7 years at this point, could it really be cancer? As they take a closer look at the pigmented skin, the lesion growing into the crease of the nasolabial fold of the nose, slowly destroying the superficial tissue, the specialist is highly suspicious of malignancy.

For the first time in 7 years a doctor asks my father: What kind of sun exposure have you had? He replies candidly “My

favorite hobby was fishing; I went every weekend for 20 years”. Then the milliondollar question is finally asked “Did you ever use sunscreen?”

Figure 1 My father is a dark skinned, immigrant South-Asian man. Did anyone ever tell him he needed to wear sunscreen? Did he receive any education surrounding protecting his skin from the sun? Did he think he was ever going to get skin cancer? Did his doctor ever think to biopsy the lesion he kept bringing his attention to? Did his family doctor suspect it was skin cancer? Was he ever referred to a dermatologist for it?

Unfortunately, the answer to all these questions is no. We will explore why in this piece.

The pathology report comes back, it is a longstanding infiltrative pigmented basal cell carcinoma. Basal cell carcinoma (BCC) is the most commonly diagnosed skin cancer in Canada. There is a higher risk of incidence among men 60 years of age and older. Ultraviolet (UV) radiation is the most significant risk factor in the development of BCC, more specifically intense, episodic skin exposure in early years. It is usually slow 22

growing, originates in the epidermis and grows into the tissue. BCC rarely metastasizes; however, they can destroy local healthy skin nearby and the tissue beneath the lesion resulting in functional and cosmetic disfiguration (1). The most common sign of skin cancer in Asian skin appears to be a round, raised brown or black growth (2). With all these risk factors making the lesion on my father’s face worth an investigation, how did it take 7 years to get here?

It is true that darker skinned people are less likely–NOT unlikely – to get skin cancer, but when they do get it, they are more likely to be diagnosed at an advanced stage and die from it. Many studies report an average five-year melanoma survival rate of 90% in white people, compared to 70% in non-whites (3). Another study showed that latestage melanoma diagnoses are more common in Hispanic and Black patients than in non-Hispanic white patients (4).

Are we punishing dark skinned people for getting skin cancer?

I suspect it is a combination of lack of awareness, the inherent white skin bias in our medical textbooks and access to timely care. Dr. Andrew Alexis, MD, MPH, chair of the Department of Dermatology at Mount Sinai St. Luke’s, agrees. He posits that there is a less public awareness of overall risk of skin cancer in darker skin. He also notes that health care providers are less likely to suspect it because of lower prevalence.

Darker skinned patients are less likely to get regular, full-body skin exams. Lastly, the location of skin cancer in darker skin tends to be in the less sun-exposed and hidden areas making detection more difficult (5). The most common locations for melanoma and squamous cell carcinoma in patients of color are the lower extremities, the hips, toes, soles of the feet. Basal cell carcinoma, the most

reflection commonly diagnosed skin in cancer in Asian Americans and Latinos, is found on sun-exposed areas of the skin, such as the head and neck in all races (3, 6).

As a medical community how can we do better? Sunscreen use among white population is significantly higher than Blacks, Hispanics, and Asians. (7) “Many people of color mistakenly believe that they are not at risk, but skin cancer is color blind,” says board-certified dermatologist Henry W. Lim (6). We can increase awareness and educate our patients and colleagues about the need for sunscreen and protection against UV radiation from the sun or tanning beds, even for those who have a lot of melanin.

Dermatologists recommended the following: seek shade, wear protective clothing, use a wide-brimmed hat and sunglasses, do not use tanning beds, apply sunscreen with a sun protection factor (SPF) of at least 30 to all exposed areas of the skin 15 to 30 minutes before going outdoors. When outdoors, reapply sunscreen every two hours, and after swimming or sweating. POC should also consider taking a vitamin D supplement daily, due to higher risk of Vitamin D deficiency in darker skinned individuals (6,8) Many studies show gender, income and education are associated with sunscreen use (7). Maybe this means targeting groups of lower socioeconomic status and providing minority groups with sunscreen samples or finding other means of providing lower priced sunscreen. Creative solutions to

increasing sunscreen use are needed.

When prevention fails, how can we manage it better? There is a need for increased research on skin cancer in POC, so healthcare providers have access to resources when evaluating darkly pigmented lesions (8). Please refer to Figure 2 to view some images of what skin cancer looks like in dark skin (2). The kind of skin cancer my father had can be found as a pink, pearly, shiny growth on the internet and most educational materials only showing examples in fair skin.

It is nearly impossible to find an image like the one in Figure 1 for a presentation of BCC. Figure 3 shows what a BCC may look like in a POC, shared personally from one of the dermatologists, even though about 50% of BCCs in darker-skinned patients are brown, or pigmented, and thus harder to diagnose and easier to miss (5).

It is increasingly important that primary care physicians are educated and trained on visual differences in presentation, location, and high-risk sites for skin cancer in all races–more specifically POC – and that they refer patients to a dermatologist when suspicious (3). Dermatologists also recommend monthly skin self-exam closely looking at the palms of the hands, soles of the feet, the fingernails, toenails, mouth, groin, and buttocks for lesions that are changing, itching, or bleeding or any ulcers or wounds that won’t heal (6,8).

More specifically consider the “ABCDEF” of skin examination which traditionally focuses on asymmetry, border, color, diameter, and evolution of the mole in consideration. Now an F has been added to consider “funny looking”, which implies the lesion which does not look like the other is often the one we should be suspicious of for malignancy (9) Canadian demographics are changing. By 2036 people of colour are projected to be about a third (31% to 36%) of the population (10). It’s important that our medical

Figure 2 23

Figure 3 education, public education, and health care practices are also reflective of that.

It is unacceptable for POC to experience worse health outcomes solely due to them being a different skin color. I encourage everyone reflect on if you think the outcome of this case would be the same had I not encouraged my father to keep bringing up his concerns to the physician no matter how many times they had been previously dismissed.

This discussion also sheds light on the need for patient advocacy and its impact on health care outcomes, particularly its necessity for POC seeking care for conditions less recognized in darker skin. We need to revolutionize how we practice medicine as the landscape within which we practice changes around us. ⚚ References Zloty et al. Non-melanoma Skin Cancer in Canada Chapter 4: Management of Basal Cell Carcinoma. 2015 May. 19(3):239– 48.

Skin cancer in people of color. Aad.org. 2014. Available from: https://www.aad.org/public/diseases/skin-cancer/types/ common/melanoma/skin-color Gupta et al. Skin Cancer Concerns in People of Color: Risk Factors and Prevention. APJCP. 2016; 17(12):5257–64.

Hu et al. Comparison of Stage at Diagnosis of Melanoma Among Hispanic, Black, and White Patients in Miami-Dade County, Florida. Archives of Dermatology. 2006 Jun 1; 142(6).

Ask the Expert: Is There a Skin Cancer Crisis in People of Color? The Skin Cancer Foundation. 2020 American Dermatologists Provide Recommendations for Preventing and Detecting Skin Cancer in People of Color.

Newswise.com. 2014.

Calderón et al. Correlates of sun protection behaviors in racially and ethnically diverse U.S. adults. Preventive Medicine Reports. 2019 Mar. 13:346–53.

Agbai et al. Skin cancer and photoprotection in people of color: A review and recommendations for physicians and the public.

Journal of the American Academy of Dermatology. 2014 Apr 70(4):748–62.

Daniel Jensen J, Elewski BE. The ABCDEF Rule: Combining the “ABCDE Rule” and the “Ugly Duckling Sign” in an Effort to Improve Patient Self-Screening Examinations. The Journal of clinical and aesthetic dermatology. 2015;8(2):15.

Canada. Population Projections for Canada and its Regions, 2011 to 2036. Statcan.gc.ca. 2017

Leave People Better Than A Message for Future Clinicians

Written by Ethan Patterson, Meds ‘24 In February 2018, a group of dentists, optometrists, dental hygienists & assistants, and volunteers (like me), travelled to Guatemala to give free dental and vision care to people who lived in remote and impoverished areas who otherwise would not have access to this type of care. I know you might roll your eyes a bit as you think, “another voluntourist”, but this has been one of the most impactful experiences of my life and I felt I would share with you one of the biggest lessons I took away from it that I can apply as a healthcare provider.

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uring our time in Guatemala, we didn’t sleep in five-star hotels.

Admittedly, our accommodations were charming and much more comfortable than I expected, but one night I found myself unable to fall asleep.

I wasn’t sure if it was the humidity or outside noises, but something was keeping me awake the night before our first clinical experience. It certainly wasn’t the heat–even Guatemala doesn’t get overly hot in the middle of February. Because I could only sleep sporadically, in half-hour increments, and because we had hiked around a couple of mountains the day before, I felt very, very tired the next day.

While we ate breakfast, I almost choked on a tortilla that I simply forgot to chew. I was so tired that I forgot to chew my food. This is bad, I thought, downing my third cup of instant coffee. I gagged a bit. This was not the kind of Guatemalan coffee I had come to enjoy in my few days here. It tasted like topsoil. Is this even caffeinated?

I had made a promise to myself that I would do my best not to burden anyone, and that I would make my presence there helpful. There was not a chance I was going to complain about being tired. I packed up my things, and loaded onto our bus, ready for my first experience as a... well, I didn’t exactly know what my role would be. But even in my tired state, I was excited, albeit nervous.

Sometime in the middle of the day, I came to terms with my tired state. This is how it is, I told myself. There are worse things in

life than being tired. I worked in triage with my friend Dr. Jamal (a dentist on the trip) for a while, then after lunch he asked me to join him in one of the extraction rooms. We didn’t have fancy suction machines to suck the blood and saliva away like we do back home in Canada, so I spent most of my time acting as Blood-Wiper Extraordinaire in our extraction rooms, using wads of gauze to absorb the blood in patients’ mouths.

After we had set up the gauze and other supplies on a table near our “operating table” (two school desks, pushed together), a patient walked in. I remember her eyes.

Big, brown eyes stared up at me as I held her hand, and Dr. Jamal held a needle near her mouth, loaded with numbing agents.

It was the lesser of two evils: the needle, although shocking and unpleasant, far outweighed the pain of getting one’s tooth pulled out without any anesthetic.”Eres muy valiente,” I said to her. I was trying to say, you are very brave. My Spanish was, to say the least, abysmal, but I managed to translate this phrase with an Englishto-Spanish dictionary I purchased in an airport in Mexico during a flight layover a few days prior. Those eyes, I thought.

She didn’t deserve this pain. She wasn’t some privileged kid from back home, who ended up with a cavity after they refused to brush their teeth out of laziness. I would have bet anything at that moment that she didn’t even have a toothbrush. She doesn’t deserve this. It’s not fair. The needle pierced her gums. Her eyes welled up with tears, and she let out a small whimper.

I squeezed her hand a little tighter. She 24

You Found Them Our clinic setup. We kept a tally of how many teeth we extracted in that classroom. In a single day, we extracted 242 teeth. That’s 242 future (or current) infections and pain prevented.

Triage: The dentist I’m with (Dr. Nekky Jamal) inspects a patient and tell me, “5-3X.” I write, “5-3X” on her dental bib - this tells the dentist in the classroom we send her to that her upper right third tooth (5-3) is destined for extraction (X). It’s not that the dentist assigned to extractions can’t judge for himself which tooth to extract, but instead speeds up the process.

A patient ready for her extraction. It’s heartbreaking knowing that soon she may be crying from the new experience of having a tooth extracted, but when I see her tooth’s decay and the dentist next to me explains that this cavity could grow and cause more pain or deadly infection, I’m uplifted knowing this immediate pain will keep her healthier and safer in the future.

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reflection

You are a moment in someone else’s life, so make it a good one.

doesn’t deserve this. It’s not fair. A part of me thought I was being a little dramatic—it was just a tooth extraction. But it wasn’t the procedure we were doing that saddened me. It was that I knew if she could have kept her teeth healthy, she would have. She had a right to be healthy, and through poverty and unfortunate circumstances, she was never able to claim that right. It was taken from her. That’s what hurt. Thankfully, the freezing started to take effect and slowly the look of pain in her eyes drifted away.

Dr. Jamal quickly extracted her tooth, and said, “Terminado!” Finished. Our patient looked up, confused. In hindsight, it was probably our Spanish that confused her the most. Her hand shot to her mouth to cover it up and she looked up at me.

“Muy valiente,” I said again. I really need to work on my Spanish, I thought. But her big eyes crinkled in the corners and lit up– she was smiling from behind her hand. My heart skipped a beat. I managed to hold back the tear I could feel coming, but as I write this today, I let it finally fall. I’m not ashamed–it’s a very happy memory for me.

I led her to our “prize table”, where she chose a toy along with the toothbrush and toothpaste we gave her. I went in for a high-five, but her hands were fullI just gave her arm a squeeze. When she left, I realized that I hadn’t once thought about how tired or miserable I felt from my lack of sleep. Don’t get me wrong, I still would have jumped at the chance to fall asleep on one of those operating tables, but I no longer dwelled on my malaise. Instead, I 25

was excited for the next patient.

Likely, I will never see that girl again. I realized that I existed in a twenty-minute timespan of her life, and after those twenty minutes, she would never see me again. I owed it to her to give her the best version of myself that I could offer in those twenty minutes. She didn’t know I hadn’t slept the night before, nor did she deserve to be given anything less than the best standard of care because of it. It wasn’t my fault that I didn’t sleep, but it certainly wasn’t hers either. That realization struck me because I knew that I could carry it with me in all aspects of my life. I’m in medical school and will one day apply this to my patients, but you don’t have to be a healthcare provider to learn something from this. If you take nothing away from this story except one thing, then please take this: You are a moment in someone else’s life, so make it a good one. It is in your power to give others the best version of yourself that you can. Whoever you find in front of you, leave them better than you found them.

You have the capacity to leave someone feeling cared for, with a smile, and feeling just a little brighter. I learned that day that whether it’s a patient or a stranger on the sidewalk, we exist for only a moment in the lives of others, so it’s up to us to make that existence meaningful to them. We may not succeed every time, and sometimes our emotions may make this difficult, but it’s better to aim for that standard than not pursue it at all. ⚚

Love:

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The Ultimate Revolution

s a kid, fairytales were my absolute FAVOURITE. Every night, I would endlessly pester my mother to read the Serbian translations of all of the classics: Cinderella, Snow White and the 7 Dwarves, Rapunzel, and more. Obviously, I later realized some of the more questionable themes presented – Stockholm syndrome, anyone? Thus, this fixation remained but was reimagined as enthusiasm for horribly cheesy Hallmark movies and enemies to lovers smut novels.

I’m sure it comes as no surprise that I am a Hopeful Romantic – I’ve never personally resonated with “hopeless”, so this is my rebranding.

However, nothing beats a real love story.

Cue me asking anyone and everyone overly intimate questions – huge thank you to “We’re Not Really Strangers” for providing me a more socially acceptable mode of doing this. My favorite true story, to this day, isn’t one I’ve heard recounted. It is the love story of Caroline Hampton and William Halsted.

Written by Milana Milivojevic, Meds ‘24 Artwork by Tanya Narang, Meds ‘25

Caroline Hampton was a young woman born in South Carolina, orphaned at a young age by a mother who wasted away from tuberculosis and a father who died in the Battle of Brandy Station. Against all circumstances, she enrolled and later graduated as a nurse from New York Hospital in 1888. Just one year later, working at the now acclaimed Johns Hopkins Hospital, her life changed forever.

It was here, working as an OR scrub nurse, that she met and fell deeply in love with Dr. William Halsted.

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reflection

Known by many now as the “father of American surgery”, he was the first surgeon in chief of Johns Hopkins. She was the nurse in charge of his operating room. In what is now a very popular medical text, Doctors: The Biography of Medicine by Sherwin Nuland, he described her as “an unusually efficient woman” – charming, I know. William noticed that her sensitive hands were breaking out into horrible contact dermatitis (been there, lived that horror story). This was a result of the disinfectants being used in ORs at the time, namely mercuric chloride and carbolic acid. The pain this caused her moved him, and he took it upon himself to contact a local rubber company to fashion her the first ever pair of surgical gloves.

This is the story of how the first surgical gloves were invented – born out of love and necessity. They have since protected both patients and healthcare providers around the world.

Caroline and William married within the year and stayed together for over 30 years while being, by all accounts, endlessly devoted to each other.

So I leave you with this – maybe, just maybe, the greatest revolution is love. Seek it out, and let it inspire you. ⚚ Lathan S. R. (2010). Caroline Hampton Halsted: the first to use rubber gloves in the operating room. Proceedings (Baylor University. Medical Center), 23(4), 389–392. https://doi.org/10.1 080/08998280.2010.11928658

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Fresh Summer Recipes Written by Colin Faulkner, Meds ‘24

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n light of our revolutions issue, I thought it appropriate to offer two sustainable, healthy, and vegan recipes, along with a robust non-alcoholic cocktail. If you have any questions, feel free to message me on social media: @Colinraybrian

Orzo with Vegan Scallops

This recipe is awesome if you’re craving a fresh Mediterranean dish. Orzo is sometimes hard to find, but for Kingston, I get mine at Quattrocchi’s Specialty Foods.

Orzo: coat base of a medium pot or dutch oven with olive oil.

Heat to medium and add shallots, cook for 5 minutes until soft and translucent. Add the garlic and cook for a minute. Add the orzo and toast it for 2-3 minutes.

Deglaze with white wine, and stir as it evaporates, about a minute. Halal vinegar is also a great substitute for white wine.

Add vegetable stock, salt and pepper. Bring to a boil. Reduce heat and simmer for 10-15 minutes, or when all the stock is absorbed. Before removing from the heat, add the lemon juice, zest, and capers. Keep warm but off the direct heating element.

Vegan Scallops: Slice the king oyster mushrooms into 1.5 cm wide coins. Coat with oil, I prefer avocado oil because it has a high smoke point. Dry coat with salt, pepper, and sweet paprika (optional). On high heat, sear the mushrooms on both sides.

Squeeze a bit of lemon juice onto the pan if they are sticking.

Try not to move them while they cook, as that can prevent the crust from forming.

To plate: Add the orzo as the base, then the vegan scallops, then chopped parsley.

https://inspiralized.com/

Ingredients 3 Tbsp. olive oil or avocado oil 1 1/2 cups onion, chopped 2 cloves garlic, minced 1 cup orzo pasta 1/3 cup dry white wine 2 1/2 cups chicken broth 1/2 tsp. kosher salt 1/2 tsp. freshly ground black pepper 1 Tbsp. freshly squeezed lemon juice 1 tsp. lemon zest 1/4 cup capers fresh chopped parsley for garnish, if desired 28

https://sunkissedkitchen.com/

Lifestyle

Tom Kha

Chai Tonic

Originates from Thailand and Laos, this version is Thai style, as it doesn’t include dill. It’s an incredibly vibrant soup, and I love to dip veg potstickers in it.

A spicy chilled alternative to the classic Blueberry Tea, this is a great drink for the summer! This recipe makes 4 drinks.

Combine tea bags and 1 cup boiling water in a small bowl; cover and let sit 8–10 minutes. Add sugar, stir to dissolve.

Discard tea bags and let cool. Stir chai syrup and lime juice in a pitcher to combine. Divide among 4 rocks glasses filled with ice and add 2–3 oz. club soda to each. Garnish with anise pods and lemon twists.

Add the garlic, ginger, lemongrass, lime zest, red curry paste and vegetable broth to a large pot on the stove over high heat, bring to a boil.

Reduce heat and simmer for 5-7 minutes.

Remove the fresh ginger if you used it, as well as the garlic cloves and lemongrass. Add the soy sauce and rice vinegar, coconut milk, onions/shallots, and shiitake mushrooms.

Ingredients Chai Syrup: 2 chai tea bags ½ cup agave To finish: ½ cup fresh lime juice 1 can club soda 4 whole star anise pods 4 lemon twists ⚚

Cook for 8-10 minutes. Remove from heat. Stir in the lime juice and cilantro. Serve immediately.

Ingredients 1 tsp of ground ginger or 1 chunk of fresh ginger 2 cloves of garlic 2 stalks lemongrass, cut into 3 inch sections (replace with half a lemon if you can’t find) Zest and juice of one lime, separated 2 tbsp red curry paste (green is fine too) 1L of vegetable broth 1 tbsp soy sauce or temari 1 tbsp rice wine vinegar 2 cans coconut milk 1 cup shallots or onion, large dice 200-300g fresh shiitake mushrooms, sliced ¼ cup fresh chopped cilantro Optional Garnishes Thai chili peppers, thinly sliced Fresh cilantro leaves

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https://www.wideopeneats.com/

The soup is great as leftovers, just reheat in the microwave.

RISING STARS Written by Ivneet Garcha, Meds ‘24 Artwork by Sigi Maho, Meds ‘24

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t’s finally here, the last and final edition of Rising Stars. Issue 15.3 is all about Revolutions, and QMed, we really have come full circle. For the past two years, Rising Stars has started an astrological revolution and even though this might be the last instalment written by yours truly, I really hope this last one leaves you circling back for more in the future.

Revolutions are about change in established order.

Unbeknownst to all of you, here at Rising Stars, we’ve always talked about your orbital revolutions: the specialty you always cycle back to, who your world revolves around, which Drake song you have on repeat, etc. It has always been about movements and cycles, and the realizations that you need to bring into your orbit. In this issue,we are going to talk

about movement forward. I know I’ve been unkind to you in basically every single issue to date. I wouldn’t be an Aries if I didn’t give you a bit of tough love and a little roast to keep the fire lit underneath you. But Revolutions are about change, and so for a change in this issue, I’m going to be nice.

Medicine undoubtedly will evolve through revolution, and you will all have an important part to play in that. So in this edition, we’re detailing which Myers-Briggs personality type your astrological sign is and what role you will play in Revolutions to come.

If you don’t know your Myers-Briggs, check it out here: https://www.16personalities.com/personality-types

Aries: ENFJ (Protagonist)

Gemini: ENTP (Debater)

Taurus: ISFJ (Defender)

Leo: ENFP (Campaigner)

In a revolution Aries, you would be the charismatic, authentic source of inspiration leading the charge. As an ENFJ Aries, you are a born leader. You are extroverted with a tendency to fight for the underdog. You never shy away from doing the right thing, even when it’s not easy.

In a revolution, people turn to you to lead, but you will always ensure that it’s a team effort.

The ENTP Geminis aren’t afraid to go against the status quo. In a revolution which often finds its roots in disagreement, we need this group’s creativity, boldness, and gift of gab to help be the voice of change. INTPs can generate the necessary insightful thought with full confidence that the ENTPs will fearlessly disseminate the ideas crucial to revolt.

Taurus ISFJs are committed and always up to meeting their obligations. In a revolution that requires people who are in it for the long-haul and who can hold steadfast in their beliefs, Taurus ISFJ can lead the charge. When battles get hard, we can count on ISFJs to hold down the fort for themselves and for others.

As the ENFPs of the group, Leos are friendly and outgoing, They strive to get along with almost everyone, an underestimated asset in a revolution. While revolutions involve conflict, resolutions require harmony. As the dust settles, we can count on the ENFPs to bring everyone together as a new age of change is ushered in.

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Cancer: ESFJ (Consul)

While extroverted and Cancer seems like an inherent contradiction, people often forget that Cancers recharge from their community, are people-focused, and attentive to the needs of others. They are in every way ESFJs. In a revolution, they can be found creating community once the dust has settled and using their positive, nurturing energy to create a

Virgo: INTJ (Architect)

fun

sense of family.

The ultimate tacticians who have a love for perfecting the details, the contribution of the Virgo INTJs in a revolution would be obvious. Their minds are never at rest and only they could concoct a perfect strategic plan to ensure the revolution is even a success in the first place. They are the bridge between creative thought and inspired action, the crucial ingredient for which change would not be possible.

Libra: INFP (Mediator)

Scorpio: INFJ (Advocate)

Pisces: ISFP (Adventurer)

Capricorn: ISTJ (Logistician)

Aquarius: INTP (Logician)

Sagittarius: ESFP (Entertainer)

Fair and authentic, empathetic, and uplifting, the Libra INFPs are always interested in relationships and connections where wild dreams and hopes can be shared without judgement.

In a revolution, where values clash and ideologies don’t align, the Libra INFPs are crucial to ensuring everyone feels heard and all sides are considered and balanced.

Open minded and open to new experiences, Pisces ISFPs have a grounded warmth and artistry to their personalities that creates a safe space for self-expression.

ISFPs will be crucially important in the revolution, both opening dialogue between opposing sides and also inspiring others to embrace a more flexible approach that is conducive to change.

In a revolution, Aquarius are the INTPs generating thought provoking discussion and highlighting avenues for change.

For a revolution to take place, there must be original thinkers, ones who engage vigorously in intellectual debate so the ENFJs know what they’re fighting for.

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The introverted and intuitive Scorpio INFJs are idealistic and principled, seeking fulfilment from their desire to bring positive changes to the world, much like the ENFJs. As advocates, this group contributes to the revolution by fostering deep authentic relationships with others. They have an emotional honesty and insight that can help bridge differences, even when such coalition seems difficult.

In order for revolutions to happen, there must be willful, practical, and rational individuals to put big ideas into place. Capricorns are without a doubt the ISTJs who have the follow through needed to usher in change. They are grounded and reliable, and will be needed to stabilize new social paradigms as they are ushered in.

If there was ever a person to navigate a revolution with a sense of ease, it is the spontaneous spirits of the ESFP Sagittarius.

This group does not like to be boxed in so they naturally seek out original ideas. In a revolution, they would create a safe space for the more hesitant signs around them. ⚚

QMED ART Rare Disease Fiza Javed, Meds ‘24

Jasmine Ng, Meds ‘24

Jasmine Ng, Meds ‘24

Jasmine Ng, Meds ‘24

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ART

Depersonalization Anonymous

Jasmine Ng, Meds ‘24

Untitled Michele Zaman, Meds ‘25

Untitled Michele Zaman, Meds ‘25

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Photograph by Rachael Allen, Meds ‘24

“Revolution is not a one time event.”

— Audre Lorde

QMR 34