Printed on 100 per cent recycled paper SUMMER 2016 | IN TOUCH | 1

By Elizabeth Kosturik

Dr. Katerina Pavenski and Lesley Asiedu, a TTP patient, discuss platelet levels and treatment in the Medical Daycare Unit. (Photo by Katie Cooper, Medical Media Centre)

A new “virtual” clinic at St. Michael’s combines treatment and research for patients with thrombotic thrombocytopenic purpura, or TTP, an extremely rare blood disorder.

TTP is an acute disease that causes blood clots in the small blood vessels of the brain, heart and kidneys, which can cause permanent organ damage. TTP patients have low platelet counts and little or no ADAMTS13, a protein that prevents abnormal clotting. The most effective treatment is plasmapheresis,

a procedure that removes a patient’s “bad” plasma and replaces it with healthy plasma. Once a patient is in remission, his or her platelet levels must be checked regularly to monitor for possible relapse.

Coordinating follow-up appointments with different physicians, including hematologists and nephrologists, as well as plasmapheresis nurses, can be tricky. In the new clinic, a patient’s visit is tracked with a special code while he or she attends different appointments. He or she is able to keep in touch with the medial team through phone, email

Continued on page 2

INTOUCHSUMMER 2016

New ‘virtual’ clinic for rare blood disease a hybrid of patient care and research

or drop-in. The medical team can collect statistics and implement research and quality improvement initiatives.

“It’s extremely important to monitor patients so we can quickly treat them if they relapse,” said Dr. Katerina Pavenski, the head of the Transfusion Medicine division and medical director of the

TTP affects three per one million people. If it goes untreated, TTP can kill 80 per cent of patients within two days.

flash technology, which allows us to run Internet-based applications and view videos, is being used to deliver viruses or “ransom ware,” malicious software that blocks access to an institution’s computer system until a sum of money is paid. You may have read recently about four computers being infected by ransom ware at Ottawa Hospital.

We’ve taken several measures recently to strengthen our protection against viruses and other malicious software, including a campaign to raise awareness of what a suspicious email looks like and what to do if you receive one.

Our data centres have new backend processes to capture these malicious programs. We haven’t lost any corporate data but we have had to restore some local data on a couple of individual PCs.

In the past, anyone with “administrative rights” could download or remove software from their desktop or laptop. Hackers are now finding ways to use these user administrative rights so we’re having to tightening up on that. We are asking that anyone who wants or needs to load any additional software, call the Help Desk for assistance. Going forward, we may also need to limit access to some popular urls such as WIX.com if the

cyber criminals continue to embed their malware in these cloud-based platforms.

Everyone recently got a new screensaver on their desktops that encourages you to just “think before you click” on a link asking for personal or financial information – especially if the email comes from an unexpected source or at an unusual time. Hackers have begun scouring websites for the names of company executives and sending phony invoices in their name. So if Bob Howard sends you a bill demanding payment, call the Help Desk right away!

We want you to be our partner in helping us to identify suspicious emails. If you get one, call the Help Desk at 5751. Don’t click on the link. We’ll be happy to bring you a new computer so you can continue working if your machine gets infected.

SUMMER 2016 | IN TOUCH | 2

Surveys have found that nearly 20 per cent of people who receive an unexpected email from computer scammers click on the links they send or give them personal or financial information.

That doesn’t mean one in five of us are gullible. It’s a sign of how creative and sophisticated these people have become in creating computer viruses designed to fraudulently access our usernames, passwords, financial records and even our money.

Protecting patient records and other sensitive electronic data, while providing secure access to people entitled to this information, is the biggest challenge facing hospital Information Technology departments today, including here at St. Michael’s Hospital.

Software that was originally designed to make it easier to use our computers is now being used against us. For example,

Frank Garcea, Deputy Chief Information Officer

OPEN MIKE with

Follow St. Michael’s on Twitter: @StMikesHospital

Therapeutic Apheresis Service. “Since many of our patients live far away, we can act as a resource to local specialists and maintain therapeutic relationships with a patient.”

Lesley Asiedu, a TTP patient, said that knowing she will be able to keep in touch with her medical team will be a relief when she returns to school in August.

Asiedu was at school in Curaçao when she began feeling achy, short of breath and chest pain. She was airlifted to a hospital in Miami and diagnosed with TTP. The Brampton native was transferred to St. Michael’s to receive treatment.

“When I was diagnosed with TTP, my platelet level was six when it should have been between 140 and 300,” she said. “I should have had a huge fever and kidney failure. I believe I got through this because of God and I was lucky enough to get the right treatment at St. Michael’s.”

Asiedu was in and out of the hospital for about a month. She said that when she returns to her studies in August, she can get most of her blood work done in Curaçao, but it is a comfort to know she will be able to stay in touch with her care team virtually at St. Michael’s.

TTP story continued from page 1

SUMMER 2016 | IN TOUCH | 3St. Michael’s is an RNAO Best Practice Spotlight Organization

In the north elevator bay on the 15th floor of the Cardinal Carter Wing, a five-foot-tall statue of the Madonna and Child welcomes patients and staff to the Obstetrics and Gynecology Department.

The statue has been in the hospital for longer than staff can remember, possibly going back to when the nuns ran the hospital.

“You can’t just buy statues like this one anymore,” said Filomena Machado, the director of mission and values. “It’s become an icon for the floor.”

However, over the years the statue has received almost too much love, said Diana Potts, the administrative manager of Obstetrics, Gynecology and the Advanced Level 2 NICU. The statue holds significance to staff and patients, with many touching the statue for good fortune or praying to it.

“Whether people see the statue with religious significance, or as a mom and her baby, everybody takes at least some inspiration from this statue,” said Potts. “You can tell that it means a lot to the people on this floor.”

Between the age of the statue and the attention it receives, the plaster statue has had to be repaired and refurbished many times. The last repair occurred last fall to fix the extensive damage to the baby Jesus’ arm and hand. When Madonna and Child returned to the hospital, it was placed in a Plexiglas case as a proactive way of preserving the statue. The case was built by Tony Araujo and Daniel Travassos, a carpenter and painter in Engineering and Plant Services at St. Michael’s.

By Rebecca Goss

Madonna and Child statue repaired, refurbished and protected

(Photo by Yuri Markarov, Medical Media Centre)

SUMMER 2016 | IN TOUCH | 4

Simulated emergencies inspire real improvements

The trauma bay in St. Michael’s Hospital Emergency Department bustled with activity as a new patient was rolled in on a stretcher. With a possible leg fracture and significant blood loss, X-rays were quickly ordered and the Massive Transfusion Protocol went into effect. Everyone performed as if a life were at stake.

The difference this time? The patient was a mannequin.

The exercise was the seventh of 12 in-situ ED simulations planned by Drs. Chris Hicks and Andrew Petrosoniak, emergency physicians and trauma team leaders who are co-principal investigators of the TRUST (Trauma Resuscitation Using in-Situ simulation Team training) study, which seeks to augment lecture-based and traditional simulation learning by observing how staff interact both with themselves and the actual ED environment, as well as how smoothly the hospital’s processes and systems work.

The simulation scenarios last 15-20 minutes and include any on-shift staff in the ED, as required. Each is based on actual critical events that happened at the hospital, but spun differently.

“It’s not anecdote driving change anymore,” said Dr. Hicks. “We’re able to produce evidence that substantiates what people already know – and some stuff that they didn’t know.”

But it isn’t just these combined observations and analyses inspiring recommendations for improvement, it’s the 20-minute debriefs after each simulation that provide the “invaluable feedback that can lead to change,” said Dr. Petrosoniak. “People feel like they have a voice and see the benefits for themselves, to their work flow, to the department and to the patients’ safety.”

Initially, staff seemed hesitant about adding more work to already busy days, but after a few sessions Dr. Petrosoniak noticed a “culture shift” toward patient safety and how to improve it systemically. Showing staff how their ideas effected change aided the buy-in of making simulations just another part of the day’s routine, said Dr. Hicks.

Changes to the hospital’s Massive Transfusion Protocol – a way of rapidly moving blood across the hospital – showcase the study’s success. Dr. Hicks said that while the protocol looked good on paper, all sorts of unanticipated challenges arose in the real world. Simple things like which route to take while transporting the blood, waiting for elevators and where to stand in the trauma bay all added up to precious time lost. Through the study’s analysis, the average delivery time was cut in half to about eight to nine minutes. This improvement exemplifies the difference between design and user experience, thereby showing the value of continued in-situ ED sessions.

“This is a study, but we hope this training becomes something that happens as a matter of routine,” said Dr. Hicks. “You do this to make yourself and your team do patient care better.”

By James Wysotski

“I don't want this to be a 12-month study that just stops. What we do should carry forward and become a regular training exercise that happens at St. Michael’s Hospital and nowhere else, so that we can be leaders in that field.”

– Dr. Chris Hicks, Emergency Physician and Trauma Team Leader

A nurse and an X-ray technician position train together during a simulation. They practice just as they would perform if this were a real patient.

SUMMER 2016 | IN TOUCH | 5

The high-fidelity manikin used during each scenario following intubation. The manikin can be controlled remotely by the simulation team and it responds just like a real person including breathing, eye-opening and even speaking.

The trauma team reviews an ultrasound image during one of the simulation sessions in the trauma bay. (Photos by Yuri Markarov, Medical Media Centre)

SUMMER 2016 | IN TOUCH | 6

When the Sisters of St. Joseph’s founded St. Michael’s Hospital, it was to care for the sick and the poor—which shows that even in 1892, income and health went hand-in-hand.

In that tradition, the Urban Angel continues working to address the physical, mental and social needs of the disadvantaged patients St. Michael’s was founded to serve.

“The social determinants of health are the areas and aspects of our lives that clearly impact our health,” said Gordon Soplet, an income security health promoter with St. Michael’s Academic Family Health Team. “Food security, employment and housing are all examples—and are some of the areas we aim to address in the clinic.”

The Family Health Team is focused on improving income security for patients living in poverty. The team has two income security health promoters—Karen

Tomlinson and Soplet. Patients work with these promoters to navigate social services and improve their financial literacy.

Tomlinson and Soplet also help patients reduce expenses, complete their taxes, set up bank accounts, access free programs, budget and save for emergencies.

“Most primary care clinics aren’t as fortunate to have someone like Karen or Gordon, but that doesn’t mean we can’t help,” said Dr. Andrew Pinto, a member of the Family Health Team’s Social Determinants of Health Committee. “We want to address the root causes of poorer health for the disadvantaged everywhere, not only at our six Family Health Team sites.”

The Family Health Team partnered with Prosper Canada to build an online tool that screens individuals for low income and helps patients access benefits they may not be receiving. Dr. Pinto said he

hoped the tool would be particularly useful for people with mental illness, newcomers to Canada and those with language or education barriers.

Health-care provider and patient will go through the tool together because completing the questionnaire may involve discussing a patient’s clinical history. Some of the benefits this tool may identify, such as Ontario Disability Support Program, may require the action of the physician or another health-care provider.

“As a physician, I should know if my patient is struggling to put food on the table at the end of the month or is unable to afford the medication I’m prescribing,” said Dr. Pinto. “At St. Michael’s we aim to put this lived experience at the centre of our social determinants of health work. This online tool could help address similar income issues for patients at clinics across Canada.”

By Geoff Koehler

Spreading the wealth

Dr. Andrew Pinto, a family doctor with St. Michael’s Academic Family Health Team and a patient use a new online tool to help address income security. The tool was developed in a partnership with St. Michael’s and Prosper Canada. (Photo courtesy of Dr. Andrew Pinto)

SUMMER 2016 | IN TOUCH | 7

By Kendra Stephenson

Dr. Victoria Korley performs the second subcutaneous defibrillator procedure on a candidate patient at St. Michael’s Hospital. (Photo by Yuri Markarov, Medical Media Centre)

New implantable defibrillator device offers certain patients a safer alternative

Approximately 40,000 Canadians die of sudden cardiac arrest each year, often with little or no warning. Many are young, otherwise healthy individuals with undiagnosed heart conditions that are difficult to catch without extensive screening or genetic testing.

St. Michael’s cardiologist Dr. Victoria Korley treats patients who were able to be diagnosed with these types of conditions before a fatal event, usually with defibrillators, which are battery-powered devices placed under the skin to detect and correct potentially lethal irregular heart rhythms.

In April, she began placing a new device – the subcutaneous implantable cardioverter defibrillator, or S-ICD – in patients who aren’t good candidates for the standard defibrillator. The standard device, called a transvenous defibrillator, is smaller but sits just under the collarbone with the leads fed through the central vein and attached directly to the heart.

The presence of the transvenous leads within the heart tissue can sometimes cause serious complications, including lead displacement or fracture, as well as blood infections. These infrequent but serious complications could require removal of the leads or device, possibly causing hospital readmission or increased risk of death. “Although effective, the transvenous device is not ideal for

certain patients, especially those prone to infections, on dialysis or already using a central line for administering medications,” said Dr. Korley. “The new S-ICD has a much lower risk for infection and is easier to remove in case of an infection because it lives outside the chest cavity.”

The S-ICD leads sit by the left breast bone, under the skin but over the chest cavity and connected to the device located just under the left armpit. The device is larger than other defibrillators to deliver a strong-enough shock to be effective from outside the chest wall.

Patients are screened to identify their particular condition or arrhythmia and must fit specific criteria. For example, patients who have a condition requiring a pacemaker cannot receive the S-ICD as it does not have pacing capabilities.

“In addition to being equally effective in these patients, the S-ICD is well-received among younger patients because it is more aesthetically appealing,” said Dr. Korley. “Despite its bigger size, the outside scarring is minimal and the leads are not visible beneath the skin. The defibrillator itself also sits in a location that is usually covered by clothing or the patient’s left arm.”

Dr. Korley has performed two S-ICD procedures at St. Michael’s, and both patients are doing well.

In Ontario, 200 young people – between ages two and 40 – die from sudden cardiac arrest each year, many of which have an undiagnosed heart condition.

INTOUCH SUMMER 2016

In Touch is an employee newsletter published by Communications and Public Affairs. Please send story ideas to In Touch editor Leslie Shepherd at shepherdl@smh.ca.

Design by Lauren Gatti

(Photo by Yuri Markarov, Medical Media Centre).

By Kaitlyn Patterson

Dr. Gustavo Saposnik is a neurologist and researcher with St. Michael’s Hospital. In 2015, at the age of 50, he took a sabbatical to complete his PhD in neuroeconomics at the University of Zurich in Switzerland.

Q: Why did you decide to get your PhD at this point in your career?

After doing a master’s of public health degree in clinical effectiveness in 2001, I became interested in how clinicians and patients make decisions. But for the next 14 years, my time was spent developing the Stroke Outcomes Research Program and building my practice at St. Michael’s. When I finally had the opportunity to take a sabbatical, I thought it would be a joy to complete a PhD.

Q: What were the biggest challenges for you starting a PhD at 50?

One of the challenges was learning to be flexible and understanding the administrative bureaucracy of a university. Another challenge was organizing my medical practice. Thankfully I had wonderful colleagues who were willing to look after my patients in case of emergencies. I am indebted to Drs. Thomas Parker and Anthony Lang and colleagues for

supporting me taking the sabbatical, and Dr. Daniel Selchen and Mary Ann Willett for solving practical issues during my absence.

Q: What was it like stepping back into the classroom as a full-time student?

The last time I was a full-time student was 1990, when I completed my MD degree. This time, I was the “grandpa” of the group but was treated nicely by the other PhD candidates and got on well with my “grandkids.”

Q: What advice do you have for any established professionals considering a return to school?

Make sure you have the stamina and passion to do it. And do not underestimate the emotional and financial impact of your endeavour. Negotiate with your partner and family because their support is vital. I would not have been able to do it without the unconditional support of my loving wife, who took on the challenge of being a single parent for one year, and our wonderful daughters. Finally, don’t forget to relax and enjoy your time back at school!

Q & A DR. GUSTAVO SAPOSNIK