Use of IO for IV Rad Contrast

In ATLS we are taught that anything that can go through an IV can go through an IO. This was questioned when we were unable to obtain a large enough gauge IV to give a patient the contrast solution he needed. Would an IO be safer than a PICC line? Would one less ambulance trip make more sense? Would this cause unnecessary damage to the patient?

At our small hospital, we don't have access to much, but we can do IOs. When all you have is a hammer.....

I had a quick look at my PubMed On Tap app and found 3 case studies of others who have done this successfully. No side effects are noted.

These are case studies, certainly not case controlled research. Hopefully someone will pursue this.

IO access appears to be safe but I don't see any studies comparing safety to a PICC line, likely because IOs are only used in emergency situations.

So, would I use an IO for a patient needing radiocontrast? I would advocate for it if IV was unavailable, it could avoid an admission to City Hospital, I was able to convince the radiologist on call to let me do it. It's just as invasive as a PICC. Truly though, I'm not sure of a situation when this might be the right choice given my current practice. If a patient is unwell enough that they do not have IV access, chances are good they should go to the City anyway.

Pocket Blockers for Atrial Fibrillation

This week during rounds, a question was raised about whether or not "pocket blockers" as recommended by the CCS for symptomatic paroxysmal atrial fibrillation will actually work or if they take too long to work. Cardiology is NOT my strongest area of practice.

The patient was an elderly man who was having occasional, upsetting episodes of palpitations that were caused by paroxysmal atrial fibrillation that lasted for several hours, especially at night. During the day, his heart rate was often too low to consider a beta blocker. I don't want to be the cause of a fall in one of my elderly patients. I decided, on the advice of another doc, to give him a beta blocker (bisoprolol) at bedtime only. I still worry though that his heart rate may drop when he doesn't need it and cause a fall on the way to the washroom at night. Would it be worth considering a pocket blocker for this guy?

"The choice of rhythmcontrol relates to AF characteristics. For patients with a lowburden of infrequent paroxysmal AF, pill-in-pocket antiarrhythmictherapy might be reasonable. For more frequentparoxysmal AF, daily maintenance antiarrhythmic therapymight be tried, followed by consideration of catheter ablationif the response is not adequate."

It seems unlikely to me that the CCS would make this recommendation, and a pretty graphic to go with it, if it wasn't going to work.

Now, to determine which beta blocker to choose, because, damn, there are a lot of beta blockers.
Let's go alphabetically. I've taken my info from Up To Date because it's the easiest for me to search through the blockers. I'm just looking at the Canadian types and oral delivery because that's all I care about for the patient we were discussing.
acebutalol: onset 1-2 hours, 1/2 life 12-24 hours
atenolol: onset 2-4 hours, 1/2 life 12-24 hours
bisoprolol: onset 1-2 hours, 1/2 life 9-12 hours
carvedilol: onset 30 min - 1 hour, 1/2 life 7- 10 hours
labetalol: onset 20 min - 1 hour, peak effectiveness in 1-4 hours, 1/2 life 6-8 hours
metoprolol: onset 1-2 hours, 1/2 life 3-4 hours
nadolol: no onset info given, 1/2 life 20-24 hours
nevibolobol: peak onset 1.5 hours, 1/2 life 12 hours
penbutolol: peak onset 1.5 hours, 1/2 life 5 hours
pindolol: peak onset 1 hour, 1/2 life 3-4 hours (up to 15 hours in the elderly)
propranolol: onset 1-2 hours, 1/2 life 3-6 hours
sotalol: onset 1-2 hours (or sooner), 1/2 life 12 hours
timolol: onset 15-60 minutes, 1/2 life 2-2.7 hours

OK, so 3 of these are appealing based on onset less than an hour - carvedilol, timolol and labetalol. They also have half lives less than 12 hours with timolol definitely winning. Most of these though are active by 1 hour. For most patients that are symptomatic during the day, any of these might be great. But I worry about this elderly man with low blood pressure, low heart rate during the day, and multiple medications.

 I think finding a cardio selective drug might be most helpful and decrease the risk of side effects. Those are metoprolol, acebutalol, atenolol and bisoprolol.

Of these, metoprolol has the shortest half life. I have a winner, and since my patient has side effects on the bisoprolol, it's worth changing.

Using handheld devices in a patient centered way

Using handheld devices in a patient centered way

Why bother:

·       I’ve been told that patients don’t like when we use our smart phones in front of them, but my experience has been different. I tend to include the patient in my looking up resources and use the HHDs to teach my patients

What the lit review needs to show:

·       Appropriate size of focus groups

·       Survey methods for this type of study

·       How HHDs are being used in medicine

·       What do patients think about technology

·       Is there a difference in use of HHDs bw consultants and learners

What I’ve noticed in the literature so far:

·       All information on HHDs has come up in the past 2 years

·       It is all about what medical professionals think, there’s nothing about what patients think

·       We see lots of HHDs being used in the ER, that they are promoting patient safety and therefore are a technology we need to hang onto

Plan for the study

·       Start with parallel qualitative study on pts and providers

o   Patients:

§  What do patients think about learners with HHDs

§  What do patients think about consultants with HHDs

§  What do pts think HHDs are for

§  What aspects of use of HHDs do pts enjoy vs. wish we wouldn’t do

§  What do you use google for vs. what do you think your doc uses it for

§  Are you aware of resources accessible by hhds (google scholar, uptodate, apps)

o   Docs:

§  What do learners think about consultants using HHDs and vice versa

§  What do learners (consultants) think about their peers using HHDs

§  Do you use hhds with pts? How?

§  Are you comfortable suing HHds with pts, why? Why not?

§  What do you think that pts think of your HHDs

·       Follow up with large, multicentre surveys informed by qualitative results

o   Compare community, academic, rural settings

o   Survey patients and providers

                                   

Does Laughter Yoga provide benefit for participants with dementia?

Does Laughter Yoga provide benefit for participants with dementia?

A pilot study to test a method of quantifying benefit.

Why bother:

·       To this point, very little hard evidence for benefits of laughter yoga, mostly anecdotal

·       Those who run the program in MounForest have noted participants have increased engagement with staff and with each other through progression of the program, humour, remember staff, participants are happier and brighter and seem to be more playful

·       Laughter yoga is a program that is fairly easy to implement and low cost, if it is also beneficial to participants, we should increase the number of programs in rural Ontario.

·       The Day Out program offered by VON also provides welcome respite to caregivers. The majority of participants in the Mount Forest program live with family caregivers.

·       The percentage of elderly in rural Ontario is increasing, our FHT is looking for programs to serve them

Lit Review will include:

·       Has been shown to be useful for elderly depressed women when compared to another exercise program

·       Yoga decreases symptoms of anxiety depression, pain (poor evidence)

·       Yoga improves physical health but not mental health in patients with chronic disease

·       In patients waiting for organ transplant, laughter yoga shows immediate improvement in mood and heart rate variability

·       Some evidence for positive emotions having a positive effect on enhancement of well being

·       Humour therapy may be helpful for the treatment of patients with depression in late life

Lit Review highlights need for:

·       “a more convincing study would include mood measures before and after intervention”

·       Long term sustained research

·       Study of laughter yoga itself rather than humour or yoga separately

Purpose and Significance of this Study:

·       To prepare a testable and repeatable mixed methods review of Laughter Yoga to determine if the program provides benefit to the participants and their families with an eye on future Day Out programming at the VON.

·       To describe changes in wellbeing in participants of Laughter Yoga using validated measures pre and post intervention (MOCA, RAND vulnerable elders http://www.rand.org/content/dam/rand/www/external/health/projects/acove/docs/acove_ves13.pdf , functional testing performed at day out program by VON, GDS).

·       To describe impression of Laughter Yoga by the participants’ caregivers using open ended qualitative questions pre, during and post involvement in the LY program. To determine if those studying Laughter Yoga in demented participants are looking in the right places and inform future studies in this group.

Initial methodology proposed:

·       Prospective study on Laughter Yoga intervention in the Mount Forest Day Out program for those with dementia in the area.

·       Pre/post test study design of quantitative measures

o   MOCA, VES, Geriatric Depression score

o   VON functional testing

·       Qualitative parallel study of participants’ caregivers

o   Open ended questions about participants’ behaviours at home

o   Prompting questions about agitation, socialization, engagement in family activities

o   Phone interviews done pre intervention then q monthly following

How can the FHT in Mount Forest use technology and social media in a patient centred way: A Needs Assessment

How can the FHT in Mount Forest use technology and social media in a patient centred way:  A Needs Assessment

(A quick overview)

 Why bother

·       Very little in the literature about how rural residents access the internet and social media to answer their health related questions – to fill this gap for other rural practitioners

·       Believe that due to physical restraints on technology, many patients prefer data plans associated with mobile devices to desk top computers

·       The FHT wants to provide patients with appropriate educational materials, provide text or email reminders and/or coaching in a way that patients will want to use

·       To provide background for further research into implementation of a patient centred social media program in a rural FM team

Lit Review will include:

·       Info available on suburban vs urban social media, rural internet use in the USA 5 years ago

·       How social media helps patients (benefits of text coaching, blogs and online help groups)

·       Rural docs use tech, urban docs using social media with each other and implications for patients

·       List of usual social media associated w health information

·       How to survey patients about social media and technology

Lit Review is missing:

·       Social media use, lately, in Ontario

·       How to make our patient education resources online patient centred

Purpose and Significance of this study:

·       To direct the implementation of technology and social media into the Mount Forest FHT

·       To provide rural med community with information to improve patient care in their community

·       To discover what information patients want from their FM team to direct implementation of  evidence based info in a patient centred way (matching age, level of health, with tech and questions)

·       To propose a method of surveying a rural community about technology needs

·       To provide background information needed for a pilot study on using handheld devices in health care settings in a patient centred way

Initial Survey Questions

·       What type of technology does pt use to access the internet? (desktop computer, smart phone, tablet)

·       Location most often accesses internet

·       Does patient have privacy with accessing the  internet

·       Which social media does patient use? Which 3 of these do they use most often? (facebook, twitter, email, 4square, snapchat, skype, pinterest, vine, blogs, youtube, massive online gaming, linked in, google +, instagram, other)

·       Age? Level of health on most days?

·       What topics would you like information about from your FD?

·       Do you trust info from blogs etc.? Would you trust information you were directed to from your family doc?

·       Would you like to get email or text reminders of upcoming appointments?

·       How often do you search for information about your health on the internet?

a minimally invasive needs assessment on social determinants of health

Our LHIN is working on a project called Health Links. From what I understand, the idea is that we be looking at our health care system from the perspective of our patients with an eye on finding gaps that can be filled. I expect this to define which Social Determinants of Health are not being managed in our areas.

Social Determinants of Health are the economic and environmental factors in our lives that impact our health. Think poverty, healthy food, education, rewarding employment. There is a great resource put together by Mikkonen and Raphel in 2010 available here that explains The Canadian Facts of SDOH. Also look for ideas and a great conversation on Twitter by searching for #SDOH.

This weekend, I decided to have a good look around and see which resources are available to us as we start this new Health Links project. I came across this Ted Talk by Rebecca Onie:

Have a look. She's inspiring.

In short, Ms. Onie and her team have made it easy for doctors to prescribe things like heating, access to food, social groups. She has done this by putting volunteers armed with Google and agency information into the waiting rooms of city clinics. Doctors write a prescription for whichever socially powerful item would help their patients, the patients hand these to the volunteers. Rather than going with the culturally accepted and  She calls her volunteers her army of college students. I love this. Especially because those students are learning so much more than they could get in any sociology class.

But I'm in rural Ontario. I don't have legions of college students. If I did, which waiting room would get enough traffic to make the most use of their time? How could I possibly get resources to ALL my patients, spread all over our LHIN? And how do I make it easy for our docs to get this done? They are busy and have a huge spectrum of practice.

First, we are hopefully going to have funding to add a new outreach position to our team.

To figure out how to use this person to the greatest benefit for our patients, I'm suggesting Dear God letters (where GOD stands for Guardian Of Determinants of health). Every time one of our docs, nurses or nurse practitioner has an interaction with a patient where they find a SDOH need, they send an EMR message to the initials GOD with the patient's specific need. It's faster than writing a script, easier than a referral, and with our EMR it means that all these needs end up in one mailbox where we can figure out how best to serve both that individual patient and our patient population as a whole.

An example might be:
Dear GOD, this pt needs someone to help them fill out ODSP forms.

Or

Dear GOD, can we find a way to pay for this pt's gas to get to his referrals in Big City?

The success of this minimally invasive assessment will depend on:
1. the team's willingness to write Dear GOD letters
2. a guardian who has mad Google skills and is willing to think about things differently than we already do here in our LHIN
3. community resources sharing their information and being willing to let our guardian pick their brains
4. patients feeling that they can ask the health team for help for things they've never asked for help with before, and the health team reciprocating that feeling

Maybe patients should watch this video first to get an idea about what we are hoping they can open up to us about.

What do you think? Is this something we can do?