A 'Furst' in Protecting Feet
The numbers are startling. Half of all limb amputations in Ontario are directly related to diabetes. Of those, 85 per cent are a result of a foot ulcer (breakdown of the skin) that won’t heal.
The impact is devastating, even deadly. Nearly 70 per cent of limb amputees with diabetes will not survive past five years.
St. Joseph’s Primary Care Diabetes Support Program (PCDSP) is working to reduce that toll. The team, in collaboration with the South West Regional Wound Care Program (SWRWCP), has developed a standardized screening, assessment and referral tool now being shared across the region. Called “St. Joseph’s FURST” (Foot Ulcer Risk Stratification Tool), the tool is fast, simple and reliable. It allows clinicians to quickly look for red flags before foot ulcers develop so that referrals can be made for preventative care, education can be provided to the patient, and close monitoring can be initiated.
The end game is early identification and effective intervention of those at risk of diabetes-related foot ulcers, says Betty Harvey, nurse practitioner and clinical nurse specialist with the PCDSP.
Once a person has a foot ulcer, it becomes a significant concern requiring much care and a great expense to the health care system. We know that close monitoring can reduce amputee rates by 40 to 85 per cent.
With the tool, clinicians systematically check for any numbness in the feet in 10 spots, and for deformities such as calluses, bunions, hammer toes etc. to pick up any danger signs, explains Betty. For example, in patients with diabetes, 60 per cent of calluses develop into ulcers.
The tool, developed through the support of St. Joseph’s Health Care Foundation and the SWRWCP, is now being disseminated to clinicians across the region.
A One-Two-Punch in Rehabilitation Success
When you walk past the Geriatric Day Hospital at St. Joseph’s Parkwood Institute, you might do a double-take when you see Diane Jamieson, 78, donning her boxing gloves to throw a double jab.
This past winter, after undergoing surgery for a broken hip, Diane arrived at Parkwood Institute as an inpatient discouraged with her rate of recovery.
I thought this was it. I was never going home and I’d have to move into long term care, says Diane.
One thing she missed most was her non-contact boxing class, part of her regular fitness regime to help with Parkinson’s disease.
When physiotherapist Danielle Sinclair heard of Diane’s passion for boxing, she enlisted avid boxer and Parkwood Institute volunteer Greg Overend. Together with Diane, they built a unique therapy program.
Working with what patients love and connecting with their interests motivates them, says Danielle.
It increases enjoyment and moves therapy along.
As an inpatient, Diane’s team of practitioners in the Rehabilitation Program documented her progress in her CARE Binder. This individualized tool engages patients and family caregivers as partners in care, helping to track names of their health care providers and personalizing information about nutrition, exercise, discharge planning and more.
As Diane transitioned back home and began outpatient care at the Geriatric Day Hospital, her CARE Binder has been essential to her ongoing progress. She is able to share and update the information as needed.
Every one of my care providers truly listened to what was working and not working, says Diane.
My care wasn’t based on their assumptions. They attended to my specific needs, like adding boxing to my rehab. I really feel like I’m part of this team and appreciate how they’ve gone out of their way to make my treatment my own. We all want to have our own voice – not just in healing but in this world.
Listening to what matters most
St. Joseph's is committed to involving patients, residents, and family caregivers as partners in care, program planning and quality improvement. Through the Care Partnership initiative, St. Joseph's is drawing on the wisdom and lived experience of patients, residents and families to achieve the best care possible.
The Best Person for the Job – Hands Down
Expertise in hand therapy and a “handy” Indian accent creates the perfect formula for teaching in South Asia.
In a recent trip to India and Sri Lanka, Shrikant Chinchalkar, a renowned leader in hand therapy, challenged old practices and shared his vast knowledge in treating hand fractures and other injuries through lectures and clinics.
In the past, the practice of keeping a cast on for three to six weeks was typical, says Shrikant.
Often surgeons felt the stiffer the injury was held in place the better. But based on knowledge of wound healing we know there is a better way.
Shrikant, a long-time hand therapist at St. Joseph's Roth|McFarlane Hand and Upper Limb Centre who couldn't sit still in retirement and returned to casual practice at St. Joseph's, imparted his wisdom to eager clinicians.
It is more beneficial to cast for three to seven days, then splint the break and start a controlled movement program, he explains.
Otherwise hand therapists will struggle with stiffness, often resulting in slower recoveries and additional surgeries.
The Education Committee of the International Federation of Societies for Hand Therapy initiated the trip by Shrikant, who jokingly declares the request wasn’t purely about expertise.
When teachers are from Australia or the United Kingdom, accents pose a problem. I think I was chosen not only because of my experience but because of my Indian accent, he smiles.
After two successful trips this year, Shrikant will be returning to both countries again next year.
Beyond the Classroom
Hockey sticks and shin guards have become part of the weekly routine for residents at Mount Hope Centre for Long Term Care, along with several energetic medical students.
In a collaborative initiative with Schulich School of Medicine & Dentistry, 13 students volunteer at Mount Hope – visiting with residents and assisting with recreational programs such as music, floor hockey, shuffleboard and resident pub nights. While enjoyable for all, the experience will shape the kind of doctor the students will become.
The students are enrolled in a new social medicine course at Western designed to enhance communication skills, provide an opportunity to work with different populations, and improve understanding of how a patient’s life situation may affect health. The students choose a demographic population to study and are encouraged to contribute to the well-being of the community by participating in a community placement.
There's more to being a doctor than recognizing and treating an illness," says Dr. Teresa Van Deven, Curriculum Coordinator for Schulich Medicine & Dentistry. "It's about teaching our physicians about the whole patient and the whole community in which they live.
Every week, Jeff Lovell, who hopes to become an oral and maxillofacial surgeon, engages with residents and participates in floor hockey events, while learning more about his chosen demographic.
Being aware of social health issues is just one part of the course," says Jeff. "Many of the residents at Mount Hope don't have many visitors or family. For me, it's also been about working on establishing connections, developing empathy and becoming more familiar with a population that I serve. It's been an eye-opening experience.
Breathing in the Benefits of Fitness
Not long ago, Jim Kenny, 74 described himself as fragile and "in desperate shape." He couldn't walk to the end of his lane, was depressed with no social life and dwindling independence.
For Byron Ducharme, 76, taking a shower and putting on socks and shoes were herculean feats that would leave him exhausted.
And at only 52, Dawn Kennedy's extreme low energy had taken a toll on her mental health.
For each of these individuals, chronic obstructive pulmonary disease (COPD) had slowly imprisoned them in their homes and bodies. Battling for every breath and needing increasing help and medical care, many of life's pleasures had slowly slipped out of reach. But on a warm sunny day in Gibbons Park, Jim, Byron, Dawn and about 45 others tossed a ball around and played games in the shade of a pavilion. Jim was up on his feet with a walker, foregoing his usual wheelchair. There were smiles, laughter, camaraderie, and an undeniable sense of confidence and hope.
All are participants in St. Joseph’s COPD and Pulmonary Rehabilitation Program, which includes medical care, education, pulmonary fitness training and an exercise maintenance program. While many thought exercise was impossible, all are now rediscovering joys that had eluded them for years.
Beyond medication, there is a lot we can do, explains respirologist Dr. Don Farquhar, Medical Director of the COPD program.
With exercise training, we are optimizing the patient’s general fitness and conditioning, and thus their ability to manage the ventilatory burden that COPD imposes on their muscles. The predominant symptom of COPD is breathlessness, which leads to a downward spiral of inactivity, deconditioning, and more breathlessness. Exercising and improving their level of fitness helps patients break out of that spiral and become active again.
Breaking down silos
At St. Joseph’s Hospital, a robust focus on chronic disease management brings programs together in new ways to address the needs of patients living with multiple chronic conditions. For example, the Diabetes Education Centre, Cardiac Rehabilitation and Secondary Prevention Program, Heart Failure Clinic and COPD and Pulmonary Rehabilitation Program together provide expertise at the right time for the right patient.
Looking at each patient and their multiple needs, care is integrated to improve quality of life, says respirologist Dr. Don Farquhar, Medical Director of the COPD program.
There’s a fluidity of programs so that we can find the care pathway that best suits the patient.
It's Okay to Ask for Help
Struggling with persistent thoughts of suicide, a young woman in the care of psychiatrist Dr. Sandra Northcott was at risk of harming herself. She had been hospitalized multiple times for prolonged periods due to mental illness and was struggling to cope.
We will keep you safe, Dr. Northcott told her.
We will look after you until you are able to look after yourself. I know you're not feeling strong right now and that is okay. I just need you to be brave.
One of the leading causes of death in Canada, suicide is often intertwined with mental illness. In fact, many individuals struggling with suicidal thoughts often reach out for help from a mental health care provider before ultimately deciding to end their lives.
That tells us there are gaps we need to fill across our health care system, says Dr. Northcott, Site Chief of St. Joseph's mental health care program.
We had to become part of the solution.
Stepping up to the plate, St. Joseph’s mental health program has become the first in Canada to implement the Zero Suicide initiative. Underway at Parkwood Institute and Southwest Centre for Forensic Mental Health Care, the program standardizes how often patients are asked about thoughts of suicide, educates staff on how to have those meaningful conversations, helps patients make coping plans, and generally wraps care around the individual so that fewer people fall through gaps in their care journey, says Jodi Younger, Vice President of patient care and quality at St. Joseph’s.
Today, the young woman Dr. Northcott cared for during a difficult phase of her life is in a much better place. As a gesture of appreciation, the grateful patient painted two art pieces that hang in Dr. Northcott’s treatment office to provide hope and assurance to others. Both paintings reflect the physician’s gentle words of encouragement when she needed them most.
You will not always be strong, but you can always be brave,” and “It’s okay to ask for help.
Setting a bold goal in suicide prevention
The Zero Suicide program at St. Joseph’s sets a bold goal of reducing suicides and attempted suicides. Through Zero Suicide, every individual is offered tailored suicide prevention strategies, a full risk assessment that looks at the patient’s lifetime history of suicidal thoughts or actions, and, if needed, a safety plan. With their health care provider, each patient identifies situations that might cause stress, healthy behaviours to help them cope, and who they can call or where to go when in need of support.
In addition, within 24 hours of discharge from an inpatient stay, each patient receives a caring call from the outpatient team to schedule a follow-up appointment and every outpatient is asked about their risk of suicide at every visit.
Redefining the End-of-Life Journey
When Doug Del Net was nearing the end of his life in December 2017, he and his wife Barbara made a decision. His final days would be spent at Parkwood Institute with the support and compassionate care provided by the Palliative Care Unit.
On December 6, 2018, one year after Doug’s death, St. Joseph’s unveiled the new Palliative Care Unit (PCU) at Parkwood Institute. Designed in consultation with patients and families, it offers a home-away-from-home for families like the Del Nets during their most vulnerable times.
A media room allows families to video-chat with relatives or watch a movie together, and a comfortable living room with a fireplace is available for quiet gatherings. In the Douglas Del Net Family Room, named in recognition of a generous donation from the family prior to Doug’s death, families can share a meal, enjoy a cup of coffee or relax together while a loved one is receiving medical care.
In each of the 18 private patient rooms are many special touches such as soft floor lighting so clinical staff can enter at night without disturbing anyone. A couch converts to a bed for overnight family visits and above each resident’s bed is a high resolution photo light featuring a calming image chosen by patients such as clouds or trees.
Our role as health care providers is to help our patients find comfort at the end of their life and be at peace, says Robert VanderHeyden, Coordinator of the Palliative Care Unit.
We help them live the best quality of life possible and support their families throughout the palliative care journey.
In the new Palliative Care Unit at Parkwood Institute, many of the home-like features were made possible through the support of the community, with St. Joseph’s Health Care Foundation contributing $1.2 million in donations toward the $2.8 million renovation.
Transformative Surgery Saves Breasts, Improves Survivorship
Stephanie Wilds was 45 when diagnosed with invasive breast cancer in both breasts. In the past, she would have endured a double mastectomy. Instead surgical oncologist Dr. Muriel Brackstone was able to remove the cancer, and save her breasts.
When I was diagnosed I didn't have hope that I would be here in five years, says the mom of two young girls.
I was blown away when I learned that I didn't have to lose my breasts and that I would be around a lot longer than five years.
Dr. Brackstone, Medical Director of St. Joseph's Breast Care Program, is leading a shift across Canada to new breast surgery techniques that are dramatically changing the outcome and quality of life for women diagnosed with breast cancer.
About 80 per cent of women with breast cancer undergo a lumpectomy - surgery in which only the tumor and some surrounding tissue is removed. While much less drastic than a mastectomy, a large lumpectomy often leaves women with a significantly distorted breast.
What’s exciting is we can now perform surgery in a way that can not only reduce the risk of the cancer returning but also drastically improves the cosmetic outcome, says Dr. Brackstone.
Oncoplastic surgery, combines the latest plastic surgery techniques with breast surgical oncology. When a large lumpectomy is required, the remaining tissue is sculpted and molded to restore natural appearance. It also includes a breast lift and reduction. The opposite breast may also be modified to create symmetry. As co-founder of Canada’s first hands-on oncoplastic surgery course, Dr. Brackstone is teaching the technique to practicing surgeons across the country.
While Stephanie lost about half of each breast, she is thrilled with the reduction and reshaping of her breasts. She is also cancer free.
I look better than I did before. They are beautiful. They are perfect.
Game changers in breast imaging
New breast cancer surgery techniques at St. Joseph’s Hospital are propelled by the latest wave in breast imaging technology.
Contrast-enhanced mammography and tomosynthesis (three-dimensional mammography), are cutting-edge imaging tools resulting in more accurate diagnoses, reducing the need for follow-up visits, decreasing unnecessary biopsies, enhancing critical information required by breast surgeons, and speeding up the overall diagnostic process.
With contrast-enhanced mammography, the area of concern is highlighted in much more detail, pinpointing cancers that can’t be seen with standard mammography. It’s particularly effective in assessing dense breasts. Tomosynthesis, meanwhile, creates three-dimensional images of the breast, providing radiologists with many more views than a standard mammogram.
Change has arrived, and it’s here, says Dr. Anat Kornecki, Breast Radiology Lead at St. Joseph’s.
It shifts the entire paradigm of how we think when it comes to assessing breast abnormalities.