One of the biggest risks of delirium hip fracture patients is pain management.
And we usually treat that pain with narcotics and sedatives.
And of course, too much narcotics and too much sedatives also leads to delirium.
So it's a real fine line between our treatment and the disease itself.
An elderly family member or friend has just had hip surgery and you've come to the
hospital for a visit.
But instead of the tired but smiling face you expect to see,
You're greeted by a stranger.
This person looks like someone you know well, but their behavior is completely different.
They seem agitated, irritable, and belligerent, or perhaps lethargic and confused.
This is post-operative delirium, and while this condition may have a number of causes,
One of the most common is from the use of narcotic painkillers, a necessary measure to
counteract the often excruciating pain associated with hip fractures.
But there's a quiet revolution in anesthesiology taking place in a handful of operating
rooms in BC's lower mainland, and it's improving fracture patient outcomes while
substantially reducing their opioid intake and possible risk of delirium.
And one of its greatest proponents is right here at Peace Arch Hospital.
This is the power to heal.
In this series of podcasts, we'll focus on the many innovative ways Peace Arch Hospital,
located in White Rock, British Columbia, Canada, has been an integral part of its
community.
We'll take you behind the scenes of the hospital's dynamic fundraising arm and talk to
those who are instrumental in creating new initiatives to help this important healthcare
facility grow and evolve along with the town it serves.
A new laptop-sized portable ultrasound is revolutionizing the care provided by
anesthesiologists at PeaceArch Hospital.
With direction provided by the ultrasound's probe, this technology's real-time imaging
capabilities allow for precise needle guidance and anesthetic delivery that safely targets
and blocks nerves, enhancing the effectiveness of pain management techniques and reducing
the risk of complications.
The result is significantly less post-operative pain following hip surgery, as well as a
reduction in opioid consumption and related side effects.
Here to tell us how a small community hospital like PeaceArch became an early adopter of
these leading edge portable ultrasounds is one of the technology's greatest advocates, Dr.
Marshall Cheng, Department Head of Anesthesiology at PeaceArch Hospital.
And joining us to share another remarkable aspect of this episode's story, in which one
couple's generous donation made acquisition of the ultrasound device possible, is Sean
Kenney, the Hospital Foundation's Philanthropy Officer for Leadership Giving.
Dr.
Chang and Sean Kenney spoke with the Power to Heal host Lance Peverly, a journalist and
former editor of the PeaceArch News, and a longtime resident of the White Rock, South
Surrey area.
Dr.
Chang, let's start by addressing what I believe is a popular misconception.
That an anesthesiologist is someone who just sits beside the operating table monitoring
the amount of drugs being used to keep a patient asleep while a medical procedure is
performed.
How do you see your role?
Well, there's some truth in that and there's some falsity in that.
We are in the operating room.
Yes, you are.
So for those who don't know, anesthesiologists, yeah, we do operate in the operating room.
We take care of patients around surgery, including pre and after surgery.
And that's our role.
That's our primary role, but we're also in other parts of the hospital, especially in
Peace Arch.
We help out in the ICU sometimes.
We help out in Emerge.
We help out on the wards.
In other hospitals, they run a chronic pain clinic.
So we're in other areas also.
And what's your background, Dr.
Ching?
Why did you choose anesthesiology as your medical specialty?
I have an interesting course of how I entered in medicine.
I entered
I entered university thinking I would become a journalist.
This is way back when...
I hear that's a popular profession.
I grew up with Walter Cronkite.
I wanted to be Walter Cronkite.
But after almost failing English, decided a second career path would be better.
So after about five or six years, I entered medicine and I was really attracted to
anesthesia because of, so this acute medicine, you get to deal with sick patients, you
know, almost every day.
You get to see...
good results almost right away.
Amazing.
I was interested in physiology and pharmacology.
So I finished my medical degree at UBC and went off to Toronto to do five years of
anesthesia and a year of critical care and then moved back to BC and moved back to the
hospital by the sea, which I love.
Before we go much further, I do need to ask
Anesthesiologist versus anesthetist.
Are they the same?
it a regional thing?
that's a good question.
I get that asked that a lot.
Actually, it's a hot topic now because it's American versus Canadian, right?
I didn't realize that.
did not realize that.
Yeah.
So yeah, an anesthesiologist, it comes from Britain.
So because we're educated in the British system and we follow the British system closely,
we're called anesthesiologists.
OK.
And Americans, of course, they want to be different.
So they're anesthetists.
I do find that easier to say.
That's right.
Now, before I ask you about this new technology that is revolutionizing the care you
provide, what exactly is it replacing?
Talk us through the pain management techniques that were usually applied for patients
with, for example, hip fractures.
That's a very, very good question, Lance.
And it's a question and a topic that's really dear to my heart.
One of the most common complication of surgery is delirium, and it's more so
in patients with hip fractures.
Patients with hip fractures get around 30 to 50 percent rate of delirium, post-op
delirium.
And why that's important is not just because it's very common in those patients, but it's
linked to worse outcomes.
It's linked to more infections, more pneumonias, more heart attacks, more strokes while in
hospital, and of course, more deaths.
So it's very, very important that we get to treat delirium.
prevent delirium in hip fracture patients.
One of the biggest risks of delirium in hip fracture patients is pain management.
I see.
Right.
If they have too much pain, they're prone to delirium.
And so we try to treat that pain.
And we usually treat that pain with narcotics and sedatives.
And of course, too much narcotics and too much sedatives also leads to delirium.
So it's a real fine line between our treatment and the disease itself.
And sometimes, of course, we get it wrong and we put patients in delirium.
Right?
How we're approaching this now is trying to avoid narcotics while trying to treat pain.
And we're tending now at PeaceArch, and you talked about this revolutionary technique, is
we're providing hip blocks, hip fracture blocks where we inject local anesthetics around
the hip capsule that's fractured.
And the local anesthetic will numb that hip and provide probably about a day, 16 to 24
hours of...
pain relief, which is important when you're moving a patient around in bed with a hip
fracture where they've got to use the commode or you've got to provide care for them.
So this is a revolutionary technique.
It's a revolution techniques for Fraser Health, but it's been around for a bit in the
world.
Where, for example, where, where?
yeah.
It actually started off in Toronto.
yeah.
Of all places in Toronto.
And it's used in other parts of the world.
So prolifically.
that it's in Australia, it's become a standard of care for infractural patients, a
national standard of care.
I think Britain also has this as a national standard of care, meaning every patient in
Australia and Britain that comes into hospital gets this sort of pain management.
We haven't got that in Canada yet, but I'm hoping that it starts at research.
Postoperative delirium is a common complication stemming from hip fracture surgery with
the number of patients affected ranging between 30 to 50 percent.
The elderly are particularly susceptible to this condition resulting in longer hospital
stays and increased risk of heart attacks, strokes and infections.
Pain is a contributing factor for delirium, with the body going into a kind of fight or
flight mode as even the most simple movements can produce excruciating agony.
The narcotics and sedatives generally administered to alleviate this pain could also
contribute to patient delirium, with a fine line existing between prescribing too much or
just enough anesthetics.
Narcotics is used, sorry, I'm trying to figure out where this is.
Is mainly hip fractures where the delirium comes in or is it all sorts of procedures?
You're correct, Lance.
Delirium is the most common surgical complication in the general surgical population.
The incidence usually ranges between three to five percent, but it multiplies almost
tenfold in hip fracture patients going up to 30 to 50 percent, which means that half of
our hip fracture patients will experience delirium.
And that's a big thing because the delirium is associated with a lot of bad complications.
So I would say hip fracture patients are probably one of the most high risk patients and
even more so in my opinion, more so than even cardiac patients.
Now, I hope I don't get too personal here, but I'm told your own father's experience with
delirium and cognitive difficulties after surgery, it must have been very difficult for
you to watch.
Can you tell us what happened and how this inspired you to seek?
pain management alternatives?
Yeah, thank you for that.
Yeah, this happened probably about eight or nine years ago.
My father fractured his hip visiting a friend in hospital.
He actually fractured it going up the hospital steps.
So, so lucky for him, he got the right care right away at the right time.
He had surgery and then probably about two days after surgery, he started getting
delirious.
hallucinating, a bit of disorientation.
And he recovered, luckily, within five to seven days.
I went home.
But to his surprise, after that, he found it very difficult to read and to follow
conversations.
And prior to that, I must mention that my dad was very sharp.
was an avid reader, loved socialization, just on the ball.
So he noticed an overnight change.
He noticed a...
very sudden.
You notice overnight change and it continued for months and we now know that delirium
though short-lived can have long lasting impact on cognitive function.
We call it post-operative cognitive decline and it's related to delirium.
Some patients with intention can overcome it so you really have to really focus on
techniques to recover from it.
I had a bit of an experience.
One of my children at age four was having the tube placed in his eardrums.
I don't know if this is related.
I remember taking him to Surin Memorial.
The doctor had told them that he did not need a general anesthetic.
The younger children generally do, but he could have a local anesthetic.
And then we discovered when we came into the desk, they told us that the anesthesiologist
said, no, he needs the general anesthetic.
They put him under and within
seconds he started screaming and kicking.
And they put me in a room with him where I held him tight and he was deliriously kicking
and scratching me and screaming.
And about a half hour later, didn't know anything that had just happened.
It was like waking up.
And I assume this is a rare reaction.
Is there any relation between this and what you're talking about?
Or is it the drug itself that would cause something like that?
In children, it could be the drug.
In children, it's more likely the drug.
It's called emergence delirium in children.
And it's usually short-lived and doesn't have long-term effects as the delirium in elderly
patients.
They're not really related then.
They said it was an allergy at the time.
Yeah, it's usually related to the drugs.
The pathophysiology, the alterations in the brain are not related between children and
older patients.
Like clinically, with children, it usually will last a few hours and then...
they're fine, but with older patients, they tend to last days to sometimes even weeks and
then have longer, longer complications on top of that.
Now, getting back to the newer system now, sorry, did you call it not nerve blocks?
called it?
Yeah, we call it the acronym is PENG, P-E-N-G.
And funny enough, it's invented by Dr.
Peng in Toronto.
Did he have something to do with the naming then?
I wonder, I wonder.
And does it just sort of dull the feeling then rather than?
completely dulls the feeling.
If it works, we are able to move that hip, that fractured hip, without any discomfort.
We've seen patients within 20 minutes of the block where we can lift that leg up and twist
it and turn it and they have no sensation of what we're doing with their fractured hip.
Now, I'm guessing portability is a big factor in the effectiveness of these new ultrasound
devices.
Is there more to it than just convenience?
That is one of the biggest things actually.
You know, what happened before is that logistically, it was very hard to do these blocks.
To provide care, you need, you know, the right time, the right personnel, and you need the
right equipment.
And the right equipment can mean the logistics of it all.
Right?
So let me explain.
Prior to having this new portable ultrasound,
We would have to bring patients into the operating room or into our recovery room to have
our blocks done because our machine was quite big and not portable.
So we would have to bring the patient to the machine instead of bringing the machine to
the patient.
So what does that mean to the patient?
It means that we've got to move the patient with a fractured hip, painful.
It would involve nursing to help us coordinate the move and it would involve us going, you
know, coordinating with this big lumpy machine.
and coordinating a whole time.
So logistically, it was very difficult.
So once we had this new portable machine, and I have to explain the portability of it.
It's a machine which is the size of a laptop.
So the screen itself and the computer and everything, you can just tuck it underneath your
arm like a laptop or like a book and start walking out.
And the probe, the ultrasound probe where you actually put on the patient is the size of
your iPhone.
So you slip that into your back pocket,
pick this book up, this laptop up, and you walk down the hallway to where the patient is
at.
Sounds like it could be taken to smaller hospitals everywhere.
It doesn't need the large operating room for these kind of procedures.
You're right.
The other one is huge and bulky.
It's almost like four feet, you know, and it's on wheels and it's got cables hanging out
and you got to plug it in.
It's a chore.
Whereas this is, it's pure and simple.
You just slip it into your pocket, pick it up like a book and walk over to the bedside and
there you are, you're ready to go.
And the patient doesn't have to move.
The nurses don't have to be involved.
So logistically, it made things a whole lot easier.
And not as expensive it's sounding like, am I jumped to conclusions there?
You you asked a very difficult question.
I'm fortunate enough not to be involved in the money.
You don't do the personal billing for the patient?
I don't do the personal billing.
No, no.
I just sit around and play with my toys.
And I'm so lucky that that is so fortunate the foundation takes care of all the money and
all that headache.
Well, I was going to say, why don't we bring Sean Kenny from the Peace Arch Hospital
Foundation into the discussion here since he does deal with money.
Sean, your job title includes leadership giving.
What does that refer to?
Yes, thank you, Lance.
So leadership giving refers to our major gifts program.
So any one organization or business that makes an annual gift to the foundation of twenty
five thousand dollars or more.
as included in that leadership giving group.
And to be very clear, we're very, very grateful for any and all gifts, no matter the size.
They all touch our hearts and make for life saving impact.
However, donors who make these profound leadership gifts are able to transform healthcare
here at PeaceArch.
So one avenue for impactful giving is to capital projects like the recently completed
medical imaging campaign, where the community came together to fund $10 million to replace
imaging equipment, such as X-ray.
mammography and MRI machines with new state-of-the-art equipment that can help our
radiologists detect serious ailments like cancer more accurately.
So newer technologies can produce faster scans too, leading to seeing more patients each
day and ultimately reducing wait times.
Another really top priority for us is critically needed equipment such as the portable
ultrasound that was funded through that process here at PeaceArch.
So every year
departments come together to identify their urgent equipment needs and we select $2
million in items to support in addition to the items that Fraser Health already funds.
So not only does this save lives, but having the most up-to-date equipment really helps in
physician recruitment and retention and it gives our patients and families peace of mind
that we have the best equipment available to our medical teams when they need it most.
We've had many wonderful individual and organizations support critical equipment over the
years like TB Vets Terrible Foundation.
funding a Hamilton C6 ventilator or the Tsu Chi Foundation, funding an arthroscopic
surgery set for shoulders.
Sean, the Foundation funded the purchase of the portable ultrasound we're talking about
today.
What was the impetus for acquiring this device specifically?
Yes, so as you've heard from Dr.
Chang, there was a clear and urgent need for this portable ultrasound.
So when physicians and departments identify these critically needed pieces of equipment,
the Foundation partners with them to ask for the public support in bringing these pieces
to PeaceArch.
equipment that the hospital otherwise wouldn't have.
So Dr.
Chang and the OR department made a compelling case for the portable ultrasound to be on
our annual $2 million capital equipment list.
understand one couple's generous donations made acquisition of this new technology
possible.
Yeah, that's right.
How does that work?
Take us through the steps that started with thoughtful donors through to the purchase of
this amazing piece of technology.
So after hearing about the vital need of this portable ultrasound from Dr.
Chang,
From a visit to the hospital from our wonderful donors, Ed and Johanna Campshire, they
decided to make a really inspiring decision to fund that piece of equipment.
We are so humbled by Ed and Johanna's generosity and longstanding commitment to making an
impact at PeaceArch Hospital.
It's such an inspiration.
They and donors like them really take pride in choosing a particular piece of equipment
and then hearing about it after it arrives.
Our doctors and medical teams love being able to explain the impact of the equipment and
thank the donors directly.
Is there a list or something?
Do you ever post items online where you say this is what we would love to have some of
maybe the smaller items that aren't going to be the major campaigns for that year?
The more common route to getting involved and giving to critical equipment like the
portable ultrasound is through our website, pahfoundation.ca, where you can find the
current catalog of our medical equipment in need and how to support it.
On the list, you'll find equipment that can be supported for, say,
$2,500 and all the way up to $200,000 and everywhere in between.
Not to mention, you can always give a gift of any amount to be designated to a piece of
equipment of your choosing.
We've had many donors and organizations that have combined their gifts to make that piece
of equipment a reality at PeaceArch.
You can always reach out to myself or any of our staff if you're interested in supporting
medical equipment and we'd be honored to help you through the process.
In order to avoid the use of narcotics, nerve blocks targeted with the aid of the portable
ultrasound are applied as early as possible before hip surgery.
The blocks are effective for a period typically lasting between 16 to 20 hours, taking the
patient through the operation and into post-surgery.
However, with the bones now repaired and not coming into contact with each other, pain is
usually decreased and reliance on narcotic medications reduced.
And in terms of usage of pain blocks assisted by the portable ultrasound, Peace Arch
Hospital is a clear leader utilizing this technique in approximately 90 % of hip fracture
procedures.
Dr.
Cheng, let's go back to how common is the usage of these portable ultrasounds for pain
management after surgery?
Are you helping break new ground here in Western Canada?
That's a good question.
know, there's three parts of quality care.
One is providing at the right time and having the right personnel and having the right
equipment.
And having this equipment, having this portable ultrasound puts us onto a different
sphere.
Having this equipment has actually made this possible.
Without this new equipment, we would not have had this block.
program or been able to reach these patients and prevent delirium.
When did you get this device?
We probably got it about two years ago.
Would you happen to know how many procedures for hip surgery have been carried out at
PSARCH?
this is a good question.
So, PSARCH being such a small hospital, we do the highest amount of hip fractures in
Fraser Health.
we're hitting...
idea.
Yeah, most people don't.
So we are treating the majority of hip fracture patients in Fraser Health.
with this program and with these blocks.
We're making a big impact, I believe.
Certainly I've been privy to some of the data on delirium in Fraser Health.
And I think about two years ago, they showed a reduction in delirium in Fraser Health in
elderly patients.
I have to tease out the data a bit more, but I'm wondering if it could be linked to this
new equipment and our use of this new equipment and providing these blocks.
How many hip surgeries does PeaceArch do in a year then?
Oh, that I don't really know.
We probably do, I would say one or two a day.
Oh, wow.
Yep.
That's a lot.
That is a lot, especially for a hospital size of P-Search.
That small.
Now I'd like to ask you, does having access to cutting edge donor supported equipment like
this at P-Search help attract top medical talents such as yourself?
100%.
100%.
Having the right equipment.
and having the support of the community and the foundation.
I'm half kidding when I say I don't worry about the cost because the medical community at
Peace Arch, if they want something, they just approach the foundation and it's always yes.
It's never how much will this cost?
I don't get that from the foundation and it's such a blessing as a medical profession just
to concentrate on medicine and know that Peace Arch and the community has your back on
everything else.
you
In the future, do you see more applications of this nerve blocking technique to improve
patient outcomes and reduce the need for strong pain medications?
I do.
I do.
I know that Langley is trying to copy us.
I know that Surrey Memorial is trying to copy us.
I know that Royal Columbian is trying to copy us.
I'm just hoping they have a foundation like we do.
Yes, yes.
It's supportive.
In addition to hip replacement though, what sort of procedures could this be used for?
So what we use it for now is providing nerve blocks for after
Knee replacement surgery is quite painful and we have to move the knee after surgery
otherwise patient develop contractures and immobility so they have to move through pain.
So what we do now is we do nerve blocks to target the knee so these patients can be
comfortable after surgery and be able to mobilize and walk around after surgery.
We also use these blocks for hip replacement surgeries.
So it's the same sort of thing, same sort of concept and we use that for that.
We use it for
Shoulder surgeries, which are very, very painful.
can imagine we have to move that shoulder after surgery, otherwise you're frozen.
So we inject local anesthetic around the big structures here.
There's a lot of arteries and nerves.
We use the ultrasound to perform it safely so we don't hit the big arteries.
It sounds like anything with a joint in the body could be used in that area or is that too
general?
Almost every joint.
Yeah, almost every joint.
And we use these ultrasounds to perform the block safely because usually the nerve is
around a big blood vessel.
and is around other structures.
So we try to, we just try to pinpoint the nerve instead of hitting other structures as we
use a needle in there.
This will be life-changing, life-changing for people having these procedures.
Definitely, definitely.
There's a big difference.
We've noticed a big difference in mobility after using these techniques and patient
satisfaction.
Well, Sean Kenny, just to wrap up, what does this say about our community of White Rock
South Surrey when generous donors step forward to help fund important equipment like the
portable ultrasound?
Yeah, know, Lance, simply put it, saves lives.
I'm just continually in awe of the openhearted generosity in White Rock and South Surrey.
I've made connections with so many incredible people who are so passionate about having
the best community hospital in the world, making astonishingly heartfelt gifts because
they want better health outcomes, not only for their families, but for their neighbors'
families as well.
Having state of the art equipment means staff are able to perform more in-depth procedures
and perform routine procedures faster.
What does that mean?
Well, it means they can perform more procedures for patients here in our own backyard and
reduce wait times with faster procedures.
I'm really honored to say that we've had Peace Arch Hospital staff, physicians,
technologists, and nurses' faces just light up with joy when they see a donor-sponsored
piece of equipment like the portable ultrasound come in.
We also see that when the latest technology comes in, there's a greater breadth of
equipment to use that attracts staff to Peace Arch Hospital.
We know the community's support has saved countless lives with their generosity and on
behalf of the entire team at Peace Arch Hospital Foundation, we're just so grateful for
you.
I truly can't say enough.
My thanks to Dr.
Cheng and Sean Kenny from Peace Arch Hospital for speaking with me today.
And thank you to all the donors who help keep our hospital on the leading edge of
community health care.
Thank you, Lance.
Thank you very much.
The Power to Heal podcast presented by Peace Arch Hospital Foundation in White Rock,
British Columbia, takes you behind the scenes of an innovative hospital foundation and
introduces you to the team who find new and sometimes surprising ways to engage with the
local community and help fund the best healthcare possible in the region.
Since 1988, the foundation has raised over $250 million for capital projects.
medical equipment, and community health programs.
Their passionate and caring team's number one priority is the prudent stewardship of your
gifts and the resulting positive impact on patients and medical staff at Peace Arch
Hospital and the entire White Rock South Surrey community.
Peace Arch Hospital Foundation, where innovation comes to life in so many ways.
The simple act of giving is truly transformational.
Every dollar we receive is enhancing health care in this community, whether it's
supporting our capital infrastructure, the purchase of essential medical equipment, or
funding a wellness program like stroke recovery or a children's club to encourage healthy
habits and active play.
Our wide range of giving options includes monthly donations, an increasingly popular and
convenient choice that makes the greatest impact on your community hospital.
You just sign up once and the rest is automatic.
And that includes receiving a consolidated tax receipt at the end of the year.
But no matter what giving option you choose, it all matters and it all makes a difference.
Be sure to subscribe to Power to Heal wherever you get your favorite podcasts.
Each episode brings you inspiring stories about the Peace Arch Hospital Foundation and its
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Thanks for listening.
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