13 minute read
RESEARCH & INNOVATION
Dr. Geoff Porter (left), QEII surgical oncologist and head of general surgery; Brian Martell (centre), senior director, NSHA diagnostic imaging; and Dr. Rob Berry (right), head of interventional radiology, have been collaborating to bring four new interventional radiation suites to the QEII in 2020 to advance patient care. The QEII Foundation is fundraising to provide the latest technology and equipment — CT fluoroscopy and mobile C-arm. QEII Foundation
Full-focus patient care New interventional radiology suites opening at the QEII in 2020
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By Jon Tattrie
Interventional radiology (IR) is one of the fastest-growing fields of medicine and the QEII Health Sciences Centre is making a big leap forward for patients who need such care.
IR is a medical subspecialty of radiology that uses minimally invasive image-guided procedures to diagnose and treat diseases in nearly every organ system from head to toe. On any given day, the QEII’s IR team may use X-ray guidance to pass a small tube through an artery to remove a stroke-causing blood clot, use CT guidance to advance a needle into a small liver tumour to destroy it with heat, or use ultrasound and X-ray guidance to pass a balloon through a blocked artery to restore circulation in a patient’s leg to prevent the need for amputation.
The precision of IR procedures reduces the need for large incisions (open surgery) in the body and can often be done with local anesthetic, improving recovery for patients.
Brian Martell, senior director of diagnostic imaging for Nova Scotia Health Authority, says the current care journey for IR treatment is confusing and stressful for patients.
Patients register on the fourth floor of the QEII’s Halifax Infirmary, get assessed by a nurse, transfer to the fifth floor for another assessment, get the procedure done and then return to recover on the fourth floor.
Brian says the new IR suites opening at the QEII’s Halifax Infirmary building in 2020 will bring “full-focus patient care” and everything will happen in one area. “A patient will come in and be cared for in one space,” he says.
The smoother system will provide a more efficient IR service. “The whole experience will be less stressful and less confusing for the patient,” he says. “From start to finish, the interventional team will be taking care of the patient. The patient journey should improve dramatically.” Dr. Rob Berry, head of interventional radiology, says the idea for the new suite started in 2015.
“We consulted with interventional radiology departments across North America to determine the best possible, most efficient setup we could to advance care for our patients,” he says. “What we ultimately came up with is building four new IR suites to replace the two we had and an 11-bed pre- and post-procedure area just for the IR patients.”
The new IR area will also have its own CT fluoroscopy scanner for performing CT-guided procedures. This will further reduce patient movement and free up time on the diagnostic CT scanners. “It’s a huge improvement for our IR patients and it’s also expected to impact wait times for patients in the emergency department who need diagnostic CT scans,” Dr. Berry says.
The team plans to start opening the new suites in spring 2020 and have them fully running by fall.
The work is part of the QEII New Generation redevelopment. The QEII Foundation is fundraising to provide the latest technology and equipment — CT fluoroscopy and mobile C-arm — for two of the suites, while provincial government funding will cover the remainder.
CT Fluoroscopy relies on
A patient will come in and be cared for in one space. The whole experience will be less stressful and less confusing for the patient. From start to finish, the interventional team will be taking care of the patient. – Brian Martell
image guidance to conduct interventional procedures. It is vital in the diagnosis of some cancers through biopsies, and can be lifesaving in the treatment of cancer through ablation, which involves inserting a needle into a tumour and killing it. A mobile C-arm hosts simple but vital image-guided procedures. It is most commonly used for IV placement in cancer patients.
Dr. Geoff Porter, a QEII surgical oncologist and head of general surgery, says interventional radiology is a critical component of his work as a cancer surgeon. He says IR has been steadily moving forward over 30 years, allowing more and more patients to avoid surgeries.
“Initially, interventional radiology had a major focus on biopsies and dealing with complications after surgery that traditionally would have required a whole new operation,” Dr. Porter says. “Now, more and more IR-delivered primary treatments are available with great benefit to patients.”
He says surgeons, oncologists and interventional radiologists work as a team; the new IR suites will let them all play on the same field. Dr. Porter says it will be easier for medical professionals to talk about cases when they’re near each other and it will improve patient care by keeping everything in one place.
With the new IR suites on the horizon, Brian notes that a significant amount of planning was necessary. Vicki Sorhaindo, IR manager, along with many staff and physicians collaborated on the best plan to benefit patients today and into the future.
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Emma Price (right), DAMIT study research co-ordinator, takes a picture of a patient’s mole using a special camera that magnifies the mole by 20 times. The image is then analyzed by a computer to determine if it is safe or needs to be removed, detecting melanoma with a high level of accuracy. QEII Foundation
A.I. detecting skin cancer QEII’s DAMIT study targeting Nova Scotia melanoma epidemic
By Allison Lawlor
Concerned a new mole on her body might be cancerous, Jessica Howe immediately contacted a research study taking place at the QEII Health Sciences Centre.
Jessica, an administrative assistant at the QEII, spotted a bright yellow poster advertising the Direct Access to Melanoma Identification and Treatment (DAMIT) study in the elevator at work one day last fall. It called on people like her to take part in the study that detects melanoma, a life-threatening form of skin cancer, with a non-invasive machine that uses artificial intelligence.
“I had a new mole that came out of nowhere and I also had some soreness around it,” says Jessica. “I was concerned.” The DAMIT study, supported by the Dalhousie Medical Research Foundation’s Shaw Endowed Fellowship in Melanoma Research, is aimed at the early detection and treatment of melanoma. Dr. Peter Hull, the QEII’s head of dermatology and the physician leading the study, is calling on the public to contact his team about concerning moles. Finding melanoma early is crucial. The detection of thin, curable melanomas can save lives. In Nova Scotia, this is critical.
“We have the highest rates of melanoma across the country,” says Dr. Hull. “We have a real epidemic.” Each year in Nova Scotia, there are more than 18 cases of melanoma detected per 100,000 people. Dr. Hull attributes the province’s high rates to genetics, jobs and lifestyles. A large proportion of residents, like fishermen, work outdoors in the sun and outdoor recreational activities are growing in popularity.
Not wanting to wait and worry, Jessica called to find out more about the study. Emma Price, the study’s research co-ordinator, told her all she needed was to be 25 years or older and have a mole that was worrying her. She didn’t need a referral from a doctor. Jessica wasn’t sure what she should be looking for. She learned that the research team is particularly concerned about smooth moles.
“Moles rough on the surface are very unlikely to be melanoma,” says Dr. Hull. “We talk about the ugly duckling — a mole that looks different and is changing over a month. It doesn’t matter if it is a colour change or a size change. Those are all important.”
After expressing interest in the study and signing a consent form, Jessica was told patients are seen within one or two weeks.
During a typical meeting with a patient, Emma spends about 30 minutes with them. After learning about the history of the mole and what is concerning the patient, Emma then takes a dermoscopic image using a special camera that magnifies the mole 20 times and shines non-polarized light. This allows the team to see structures of the mole that can’t be seen with the naked eye. The dermoscopic image makes it easier for the artificial intelligence to diagnose melanoma. The image is then analyzed by a computer to determine if it is safe or needs to be removed. It detects melanoma with a high level of accuracy.
The research team also uses a special tape to sample the surface of the patient’s skin, analyzing the samples for genes only seen in melanoma.
Within 24 hours of taking the image of the mole, Dr. Hull examines it and determines whether the mole should be removed. Moles are never burned off, he explains. If removal is necessary, it will take place within two weeks.
Jessica learned her mole wasn’t cancerous, but it was removed just to be safe. “It was all completed within a three-week period,” she says. “It was very relieving to get in and get it dealt with so quickly.”
Taking part in the study allows patients to greatly reduce the amount of time they wait to see a specialist and have a mole removed, says Dr. Hull. Typically, it could take as much as six months to get an appointment with a dermatologist to check a mole.
Dr. Hull hopes his study will continue for at least two years and include 1,000 patients. Eventually, he would like to see the technology used to establish public centres in the province that would screen for cancerous moles, similar to breast-screening centres.
Dr. Ayman Hendy (left), anesthesiologist, Dr. Edgar Chedrawy (centre), head of cardiac surgery, and Dr. Hashem Aliter (right), cardiac surgeon, are part of a collaborative team at the QEII applying Enhanced Recovery After Surgery — or ERAS — a multidisciplinary care improvement approach to how patients recover from cardiac surgery. QEII Foundation
Enhanced recovery after surgery New cardiac surgery approach changing care for patients at the QEII
By David Pretty
A team of healthcare professionals at the QEII Health Sciences Centre is applying a comprehensive new strategy for cardiac surgery called ERAS — Enhanced Recovery After Surgery.
“ERAS is a multidisciplinary care improvement approach to how patients recover from surgery,” says Dr. Edgar Chedrawy, head of cardiac surgery at the QEII and an associate professor in the Department of Surgery at Dalhousie University.
As Dr. Chedrawy explains, ERAS is designed to prepare and guide cardiac patients through every stage of their procedure.
“Prior to surgery, we assess patients from a nutritional standpoint and we check the medications they’re currently taking,” he explains.
The ERAS team also performs a series of “engagement and pre-habilitation” measures, which are designed to improve the candidate’s functional capacity. “This helps patients to better deal with the stress of surgery,” says Dr. Chedrawy.
Another major part of ERAS is addressing the patient’s anxiety. As cardiac surgeon Dr. Hashem Aliter explains, this is accomplished by making social workers available for counselling and demystifying the process via an informational booklet, as well as a series of informative videos. “This allows the patient and their family to know the expectations, such as physiotherapy, nutrition and activity at home,” he says.
According to anesthesiologist Dr. Ayman Hendy, the tradition of fasting before surgery has also been challenged. “We now allow patients to drink clear fluids and consume specific carbohydrates,” he says. “The body can preserve it’s proteins for healing and other important functions.”
This level of care continues into the procedure itself.
“We implement different measures to help monitor the patient’s body temperature, control their blood sugar and reduce their chances of bleeding,” says Dr. Chedrawy.
With the stress of surgery elevating the patient’s glucose levels and, in turn, increasing their chance of infection, strict temperature and sugar controls are enacted.
“We also treat the patient’s pain and post-surgery delirium much more aggressively,” adds Dr. Chedrawy.
As Dr. Hendy points out, the historical use of powerful opioids for pain mitigation could be problematic, since they often render patients completely uncommunicative.
“By using shorter-acting pain medications, the patient’s mind is clearer faster after surgery,” he says. “Now, they can be given instructions and quantify their pain experience.”
Applying local anesthetics for targeted nerve blocks also helps to cut down on the use of debilitating painkillers. “This way, we can freeze the area and not give the patient something that makes their mind foggy,” says Dr. Hendy.
This cumulative level of care also gives the ERAS team a chance to liberate patients from the restrictive surgical tubing used to drain any blood accumulating after cardiac surgery, a lot sooner. Not only does this reduce pain and the threat of obstruction or infection, but it also gives patients back their mobility much sooner which, in turn, expedites their release from hospital.
“Almost a third of our patients will have some sort of kidney or lung injury, which is a potential side effect of the heart-lung machine used during surgery,” says Dr. Chedrawy. “While temporary and reversible, this injury prolongs their intubation time and their length of stay after surgery. But ERAS reduces that by almost 25 to 30 per cent.”
“We wait three or four hours and if the patient is stable, we remove the breathing tube and start with early mobilization if the patient’s condition permits,” says Dr. Aliter. Hydration and the early stabilization of body functions is another key component in the ERAS recovery process.
“We start with a clear fluid four to six hours after removing the breathing tube and we give them chewing gum if their condition permits,” says Dr. Aliter. “This will help normalize their gastrointestinal system after surgery and help prevent any further complications.”
As soon as it becomes feasible, light physical activity is encouraged.
“We get patients to use an incentive spirometer as soon as possible, even before surgery,” Dr. Aliter explains. “It’s a device designed to improve their lungs and respiratory function, so it’s easier for us to discharge them home.”
The QEII is the only medical site in Atlantic Canada to feature a cardiac surgery ERAS program. As such, it brings together a unique and talented pool of personnel from such diverse disciplines as anesthesia, nursing, social work, cardiology, pharmacy, nutrition and physiotherapy.
“It’s been shown many times to have an overall reduction in complication rates and length of stay, as well as an improvement in cost and the patient experience,” says Dr. Chedrawy.
“When the patient goes home, they’re in stable condition, they’re feeling well and everything is taken care of,” adds Dr. Aliter.
