Specialist Physicians Realize the Future Lives in Surrey

Mayor Dianne Watts talks to media outside the Jim Pattison Outpatient Care and Surgery Centre in Surrey on June 8, 2011.

Mayor Dianne Watts talks to media outside the Jim Pattison Outpatient Care and Surgery Centre in Surrey on June 8, 2011.

If you talk to people who work in, or alongside, the healthcare industry, you will no doubt pick up a common theme related to physician resources — they are scarce and recruiting them is a veritable challenge. The situation is so serious that attracting specialist physicians is often identified as one of the major threats to success when opening a new hospital or adding additional beds to an existing facility.

It is precisely this contextual backdrop that makes what is happening in Surrey so intriguing.

Physicians are realizing that Surrey has the necessary ingredients to be one of the best places to practice the craft of medicine. Indeed, the historic trend that has seen Vancouver be the bigger draw when compared to communities such as Surrey is reversing as I write.

But, why Surrey? Quite simply, it is the patients. Canadians have made Surrey one of the fastest growing communities in Canada. The population growth has accelerated a healthcare infrastructure investment of over $750 million just in the last few years. Leading the way has been visionary Mayor Dianne Watts and her team, who are helping physicians, like many other Canadians, realize that, per the city slogan, “the future lives here.”

The specific appeal for physicians, in my opinion, is the combination of a unique patient population mix and the following characteristics:

1. A focus on culture

The major driving force bringing physicians to Surrey is the concerted effort to promote a new culture of healthcare innovation and excellence. A significant shift is now underway which is seeing Surrey positioning itself firmly among the traditional major players such as Vancouver General, St. Paul’s and Royal Columbian Hospitals.

This shift from its traditional role as a community hospital will see Surrey become a leading academic centre of excellence with enhanced research, academic and educational opportunities. This shift is attracting not only practicing physicians but also more and more physician learners who, once their training is completed, will plan to set up practice in Surrey.

2. The practice opportunities at the Pattison centre

jim pattison outpatient care and surgery centre

Many physicians have been afforded the unique opportunity to practice in the Jim Pattison Outpatient Care and Surgery Centre, the first stand-alone dedicated outpatient facility of its kind in Western Canada. What is making physicians so enthusiastic about the Jim Pattison centre? Well like the name implies, only outpatients are seen.

Here physicians can focus directly on the patients at hand without the constant interruptions for emergency and urgent cases that comes when clinics are located within hospitals. This allows a cardiologist, radiologist, or orthopedic surgeon to be highly efficient in the delivery of their care. The design of the Jim Pattison centre was heavily influenced by LEAN methodology, which reduces the inefficiencies in patient flow and maximizes the effectiveness of care delivery. In short more order, less chaos.

3. The Surrey redevelopment and expansion project

A major redevelopment and expansion effort is underway in Surrey including the building of an eight-storey Critical Care Tower on the Surrey Hospital campus. This state of the art facility will add 120 beds to the Surrey campus including much-needed emergency department capacity as well as both adult and neonatal critical care beds. This development is bringing some of the latest technology, equipment and care models to Surrey and the physicians are anxiously awaiting the opening of this new facility.

With the population mix that it has, and the traits outlined above, it is no wonder that Surrey has managed to attract some of the best physicians to the city.

And this certainly bodes well for the future, as in my experience, once doctors begin to practice in Surrey, they often remain committed to the region for their career. With an opportunity to raise their kids in a thriving and vibrant community and to practice great medicine, why would they move?

So while many people from within and around the healthcare industry will make commentary about the challenges associated with securing quality physicians, it is refreshing to have a story like Surrey’s to brighten the picture ever so slightly.

Dr. Allan Holmes grew up in Surrey and has spent the last 20 years working within the Fraser Health Authority in a variety of capacities. Recently he served as the hospital medical co-ordinator of the Jim Pattison Outpatient Care and Surgery Center and his current role is the physician resource planning consultant for the Surrey Memorial Hospital Redevelopment and Expansion Project. Dr. Holmes is also the founder of Iridia Medical, a continuing medical education provider and regional distributor of automated external defibrillators.

Automated External Defibrillators and Children

Automated External Defibrillators

An automatic external defibrillator is used to restart a heart that is pumping with an ineffective rhythm that does not adequately circulate blood. In most cases AEDs come equipped with defibrillator electrode pads made just for children, but not always.

To address a few concerns, the following is a recent statement to our first-responders on the use of Automated External Defibrillators (AEDs) for children.

Automated External Defibrillators and Children

Position Statement

Iridia supports the use of Automated External Defibrillators (AED) in the pediatric population.

The following recommendations are provided for First-Responder Services with AED programs and are consistent with the current Heart and Stroke Foundation guidelines:

  • AEDs equipped with pediatric dose attenuator and pads should be used on children (aged 1-8) and infants (less than 1 year) with no signs of life
  • Pads should be placed in the standard anterior-apex position or in the anterior-posterior position
  • Should pediatric dose attenuator and pads not be immediately available, adult pads may be used on both children and infants with no signs of life.

For more information on AEDs  and their use, please visit our website.

Best Regards,
Dr. Allan Holmes
Medical Director, Iridia

Medical Director Update – BC Ambulance AEDs reconfiguration

BC Ambulance AEDs

A recent memo was circulated by the Director of First Responder Services Randy Shaw regarding the reconfiguration of the BC Ambulance AEDs. In part this memo outlines the following. The BCAS AEDs are being reset to eliminate the “charge‐up whine” when a shockable rhythm is detected and instead prompt the responders to resume CPR – See appendix 1 for the complete memo.

This AED reconfiguration is being done to encourage crews to continue chest compressions during the charge‐up phase of the AED and is one more step in maximizing time on the chest.

Although I am in agreement in principle with this initiative, it has come to my attention that there may be a considerable cost for some Fire Service AEDs to be reconfigured. This cost depends on the software version installed in the AED. In discussions with BCAS and the Emergency Health Services Commission, the following is recommended based on the model of AED and the software version:

lp500/1000

1. LP 1000s with software version 2.42
Recommend – reconfigure as these units contain the same software as BCAS AEDS (no costs incurred)

2. LP 1000’s with software versions older than version 2.42
Recommend – reconfigure not required ‐ The cost to upgrade ($700.00 per unit) does not justify the benefit

3. LP 500
Recommend – reconfigure not required ‐ The cost to upgrade ($300.00 per unit)does not justify the benefit

For those units where there is a recommendation not to reconfigure, the same benefit (chest compressions during charge‐up) can be obtained by reminding crews that chest compressions should continue throughout the “charge‐up whine”.

Best regards,
Allan Holmes
Medical Director, Iridia Medical

Appendix 1

TO ALL FIRST RESPONDER AGENCIES, SENT ON BEHALF OF RANDY SHAW, DIRECTOR, FIRST RESPONDER SERVICES

This note is to advise you that effective this week BC Ambulance Service (BCAS) AEDs will begin to undergo a minor reconfiguration. The AEDs are being reset to eliminate the “charge‐up whine” when a shockable rhythm is detected and instead prompt the responders to resume CPR.

If a shockable rhythm was detected on analysis, the AED will begin to charge and a 15 second timer will show in the display window. At 12 seconds, the AED will warn the responders that a shock is advised and at 15 seconds, prompt the responders to stand clear and to push the shock button.

There is no change in the procedures for CPR.

As you know, we teach that chest compressions are to resume during the charge‐up phase. This change in AED configuration is purely intended to support the re‐establishment of chest compressions during that phase. Please notify your first responder agencies accordingly both so that they are aware of the BCAS AED change and so that first responder agency medical oversight may consider the change with their own AEDs if similarly configurable.

Bath Salts – Medical Director Update

Dr. Allan Holmes & Dr. Erik Vu
Clinical Snapshot: Bath Salts
Subject: Synthetic cathinones
Street name: “Bath Salts”, “Plant Food”, “Cloud Nine”, “Rave”.

What are “Bath Salts”?

Psychoactive drugs containing MDPV1 have entered the recreational drug market, with a recent surge in the United States (US) and Canada. These products are often labeled as “bath salts” or “plant food,” and have been used legally for decades in parts of the US and Europe. These products are also available for online purchase and may be sold under such names as “Cloud Nine” or “Rave.”

What do “Bath Salts” look like?

MDPV and other analogues (e.g. Mephedrone) are often supplied as white powders. Users can snort or ingest these white or brown amorphous or crystalline powders, but since they are soluble in water, these substances can also be injected.

Bath Salts

What are the effects of “Bath Salts”?

MDPV has a chemical structure similar to MDMA2 or “Ecstasy”. The intended effects are improved attention, energy, and euphoria. Clinical features include altered mental status, agitation, delusions, hallucinations, psychosis, fast heart rate, high blood pressure, chest pain and elevated core body temperature, amongst others.

Why are “Bath Salts” dangerous?

MDPV is used as substitute for other stimulants such as amphetamines, cocaine or ecstasy because it can produce the same effects on the brain. MDPV toxicity can present as excited or agitated delirium. Mainstream media have reported bizarre suicides and homicides. Drug-induced psychosis and aggression appear to be more severe than with other amphetamine-like stimulants.

How do you manage patients high on “Bath Salts”?

Agitated patients require urgent medical assessment. Caution should be used when restraining these patients due to the potential of cardiac arrest in patients with excited delirium.

Summary of Key Points

  • MDPV (i.e. “Bath Salts”), has strong stimulant effects similar to cocaine and amphetamines. This compound can be considered an emerging designer drug of abuse.
  • The psychoactive profile of these drugs has gained popularity with widespread use of this compound as recreational drug, particularly among young people.
  • The marketing of MDPV as “bath salts” or “plants fertilizer” provided false assurances on the safety of this substance as drug of abuse.
  • Current case reports show the potential for severe cardiovascular and central nervous system toxicity.
  • Excited delirium is characterized by delirium with agitation, elevated temperature, elevated heart rate and breathing pattern, and can be followed by a period of “giving up,” or cessation of struggle, followed by cardiac arrest.
  • Use caution when engaging a patient exhibiting these signs or symptoms. Use caution if/when restraining these patients.
  • Considering the limited information about the clinical, pharmacological and toxicological effects of this substance in combination with the potential health risks, the alertness of the medical and law-enforcement community is of great importance in order to mitigate the downstream effects of MDPV use.

Best Regards,

Allan Holmes

Medical Director, Iridia

13,4-methylenedioxypyrovalerone, or MDPV
2methylenedioxymethamphetamine, or MDMA

Headaches, are They All Created Equal?

Clayton Tobin is a BCAS paramedic who also works for us in northern BC. To help his fellow Iridia paramedics out, he put together a summary on assessing and diagnosing headaches. For the benefit of other paramedics and first-aid attendants who read the blog, we decided to share an abridged version of it here.

Industrial Paramedics are in a unique situation where we are assessing patients in remote locations.  A common presenting complaint for these patients is of a headache.  Fortunately, most headaches are benign, but a small percentage of them can be serious. They are cannot-miss headaches, though they may initially have only mild symptoms.

HeadachesThere are two main classifications of headache: primary and secondary. Primary headaches are defined as existing independently from any other medical condition, and account for 90% of all headaches that present for medical assessment.  They’re usually migraines, tension headaches, and cluster headaches. Although they can be severe and debilitating, they are benign. Patients with primary headaches will almost always have a history of similar headaches. If the headache is different from their “normal” headaches or they are having a new onset of a primary headache, you’ll have to consider the possibility of a secondary headache. A secondary headache is one that results from an underlying medical condition. That condition can be something as benign as sinusitis or muscle strain or it can be life threatening.

Carbon monoxide (CO) poisoning, meningitis and subarachnoid hemorrhage (SAH) (bleeding between the membranes that cover the brain) are among the most worrying of serious headaches. A good history is important in catching the CO poisoned patient. It is important to keep this possibility in the back of your mind when you are assessing the headache patient in an industrial setting.

Meningitis is an inflammation of the membranes that cover the central nervous system and is almost always associated with a headache and fever. A stiff neck, confusion and photophobia (light hurts the eyes) are common accompaniments. Patients suspected of meningitis will require assessment by a physician as they can get very sick quickly. Pay special attention to any headache patient with a fever.

SAH presents as a severe, “thunderclap” (sudden onset) headache. Patients will often say things like, “this is by far the worst headache of my life”. They come usually during physical exertion or other activity that increases pressure in the head. Two thirds of all SAH are caused by the rupturing of an aneurysm Loss of consciousness or buckling of the knees is not uncommon, and they can often develop neck stiffness, low back pain, bilateral leg pain or increased intracranial pressure leading to confusion or coma. Sentinel headaches will warn of SAH 30%-50% of the time. These warning headaches can present as more mild or benign ones and are often misdiagnosed. Patients will often ignore these headaches as over-the-counter analgesia can relieve the pain. Sentinel headaches are characterized by a sudden severe pain often brought on by bending, lifting or even coughing as increased blood pressure in the cerebral artery causes a small leak in the aneurysm. A full-blown SAH can occur a few hours to a few months after a sentinel headache (2 weeks is the median time span). A patient suspected of having a sentinel headache or SAH will need a diagnostic CT scan or lumbar puncture to determine if there is blood in their cerebral spinal fluid.

Because some causes of secondary headaches are catastrophic, a thorough assessment must be done for all headache patients. This includes a complete set of vital signs including blood pressure and especially a temperature and a neurological assessment. It is important to obtain a good history including the onset (sudden?), severity (“worst headache in my life”?) and quality (“different from normal headache”?) of the pain and its precipitating events. Palpate the face and head. The location of the pain (i.e. unilateral or bilateral) may also be useful. Note whether or not anything makes the pain worse (tenderness over the temples as in temporal arteritis) or better (lying down as in spontaneous intracranial hypotension). Is there a stiff neck? What are the associated symptoms?

Headaches are most often benign and can easily be dismissed, but a limited few of them are caused by a cannot-miss condition. In the setting of industry we often get the worker coming in who is just looking for a Tylenol. With a thorough assessment we can significantly reduce our chances of missing the rare, cannot-miss headaches.