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The Round Up Podcast

The Round Up Podcast

Episodes dropped fortnightly

The Round Up Podcast

Welcome to The Roundup, a north Queensland-based medical podcast offering local content for local clinicians. Listeners will hear from passionate and knowledgeable clinicians discussing the approach and management of a diverse range of medical topics of significance to our communities.

Join Dr Elissa Hatherly, a local GP based in Mackay, family planning clinician and Head of James Cook University’s clinical school in Mackay on Yuwi Country. Elissa has 20 years' experience as a doctor in the Mackay region. With clinical work spanning both general practice and the hospital environment, Elissa is particularly interested in preventative health care and improving health literacy in the community. Elissa is also a member of the Mackay Hospital and Health Service Board.

This podcast is currently focused on the region of Mackay and is a collaborative project between the Mackay Hospital and Health Service, local clinicians and JCU where they discuss a range of popular health topics with local experts in each episode. We would like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander peoples of this nation, their contribution to health care and the Traditional Owners of the lands on which we practise.  

Episode 1: Trouble-shooting IUDs

Intrauterine Contraceptive devices: when to use them, common concerns and how to best manage our patients.

Transcript

Episode 1 IUD The Roundup

Thu, 9/8 10:45AM • 33:55

SPEAKERS

Dr Elissa Hatherly, Dr Stephen Lambert

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In this episode, Dr. Steven Lambert talks to me Elissa Hatherly about some common pitfalls with intrauterine devices and answering some common questions.

Dr Stephen Lambert  00:52

Good morning, Elissa. Just in general, in terms of women's health, I know as a male GP, it's probably an area where I'm probably giving okay care, maybe a standard of care but good quality health care, what's been your experience of, of good quality health care, particularly when it comes to sexual health, contraception, womens health?

Dr Elissa Hatherly  01:16

Yeah, we are really behind the eight ball. Unfortunately, we don't have quality sex education in the schools. We don't have good, respectful relationships, counseling, a lot of schools don't have any respectful relationships, counseling, or a lot of sex education at all, maybe as part of a health class. So the general health literacy in the area is poor. And when I talk to young people, particularly they are getting poor advice from their parents, even if they are bold enough to ask their mums and dads, because the mums and dads didn't have good quality advice. So if we can do better, that would be great for the community. Sex Education, contraception, counseling, emergency contraception, counseling, all of those things are not rocket science. But I certainly don't expect every GP to be as good at every aspect of medicine as every other. And certainly for the junior doctors who might be seeing women in emergency with an unplanned pregnancy or threatened miscarriage, or who I've just popped an IUD in, having a good idea about some of those skills that are needed with those patients is really important. It makes it easier for the doctor, and much nicer for the patient.

Dr Stephen Lambert  02:28

I think today we're going to be talking about contraception. I'm imagining contraception is an area where, you know, we're talking about the public in Mackay probably feel like they've got a lot of information about you know, you would have talked to your mom, you would have got stuff in schools, that kind of thing. What I'm hearing you sort of say is there's there's an opportunity for doctors across the board, you may not be practicing this type of medicine every day, in the same way that you are, but there's a role for all health practitioners, doctors, you know, GPS, interns, Junior Doc's to be where the opportunity presents itself to be increasing the literacy, health literacy. Yeah, that's

Dr Elissa Hatherly  03:14

right. So for example, I just saw a young woman for an intrauterine device insertion on Friday, she had a six week old baby. The last time I saw this young woman, I inserted an IUD, and I said to her what happened to the IUD that I put in and she said, my GP took it out because I have endometriosis and PCOS and the GP reassured me that I wouldn't fall pregnant. And that GP I'm sure, wasn't doing what they thought was wrong but it has made an enormous impact on this young woman's life that can't be underestimated. And

Dr Stephen Lambert  03:49

maybe that'd be helpful for today's conversation is exploring some scenarios and common scenarios, particularly in the general practice environment, probably the patients I'm seeing where I'm not doing Woman's Health everyday or providing contraceptive advice, but I guess there is a body of knowledge that I would need to deliver a high standard of safe quality care. Certainly when I was in medical school, oral contraceptive pool was what we focus most of the time on. Copper IUDs were around. It was kind of like oh yeah, there's this thing. That that there was a little bit of knowledge. And then I think, you know, long acting reversible contraceptives (our LARCS) have probably come to the fore in the last sort of 5-10 years

 

Dr Elissa Hatherly  04:34

or so women doctors  like me have been banging on about LARCS for a long time. So hopefully that message is really starting to filter out into the medical community. A long acting reversible contraceptive is our focus for all women of all age groups because they are much more effective at preventing a pregnancy. The contraceptive pill is an easy one for any doctor to prescribe, but it is not an easy one for women to use and use reliably. And even if it is being used reliably, we can only expect it to prevent a pregnancy in 98 times out of 100. And if you don't want a pregnancy 98 times out of 100 is not good enough. We want a LARC where we are getting contraceptive efficacy, almost 100% of the time. So we use the numbers of about 99.9% effective, statistically a LARC is a more reliable contraceptive method than sterilization.

Dr Stephen Lambert  05:33

With that sort of context, do you want to give us just a bit of an understanding of particularly in terms of intrauterine devices, so in terms of LARCS, yeah, different products there and then I guess even within the class of intrauterine devices, the various products with their pros and cons, so it'd be great to just get your thinking about when you would use which of those.

Dr Elissa Hatherly  05:57

So in terms of LARCS, we have the implanon etonogestrel rod that sits in the upper arm that lasts for three years and provides really good contraception. It can give some unpredictable bleeding in a small number of women, but it's a great starting point, particularly for young women and women who maybe are not sexually active. That's an easy one to learn to insert and to do regularly in your practice, and is a great starting point. They cost about $30 for anyone, which is great. Financially effective, economically viable contraception for young women. When we look at  uterine devices, we have two types. We have those containing a progesterone likely Levonorgestrel, so we have the Mirena which lasts for five years, and delivers a higher dose of progesterone and now we have the Kyleena, which is a fractionally smaller device, again, lasting five years delivering a smaller dose of progesterone every day. And then we have the copper IUDs which irritate the lining of the uterus and are equally effective at contraception. We have the Multiload, the T 375 and the TT 380, that last one will last for 10 years. The smaller IUDs containing 375 millimeters of copper will last for five years for contraception. The copper IUDs can also be used for emergency contraception if inserted within five days of unprotected sexual intercourse. So they are fantastic. For women who don't want any hormone they can go for a copper IUD. For women who don't want any hormone, they might actually benefit from an intrauterine device containing progesterone. Because the progesterone is really only being delivered into the uterus, it's not going into the rest of the bloodstream, it is unlikely to impact on their mood or their weight. The fantastic thing with those progesterone delivering IUDs is that they are quickly reversible, like the copper IUD. So if you try a progesterone containing IUD and don't like it, we can take it out and you go back to normal almost immediately.

Dr Stephen Lambert  08:09

So in terms of IUDs, we've got the those impregnated with Levonorgestrel and the copper IUDs. And in terms of choosing one or the other, am I hearing you say that's kind of patient choice? Or is there? How would you go about selecting?

Dr Elissa Hatherly  08:30

So the progesterone containing IUD's cost about $42 each, which is very different to the copper IUDs, which we can access for around $100, which is still really cost effective when they're used for five to 10 years. Unfortunately, a lot of pharmacies in our region don't stock the copper IUD. And so the women who want a copper IUD might have to ask for it to be ordered in so access is a little bit slower, but not inaccessible at all. The copper IUD as I said, irritates the lining of the uterus, so it does increase the heaviness and the crampiness of a period. That might just be for the first few months it might be for the lifetime of the copper IUD, but you wouldn't know unless you tried it. A lot of women who use copper IUDs are super happy with them. For the progesterone containing the Levonorgestrel containing IUDs, they thin the lining of the uterus, which tends to give women a much lighter, shorter, less crampy period than they might experience any day of the week. So they are a fantastic option for women who need contraception. They are also a fantastic option for women who have an unmanageable period or a period that's interfering with their lives, which can be really variable. I have women all the time who tell me that changing two pads a day is unacceptable for them and that's fine. I have women who are changing two pads every hour, which I think we can all agree is unacceptable. But it's down to the woman whichever way she wants to manage her period and IUD can be there to help.

Dr Stephen Lambert  10:09

So in terms of the progesterone containing IUD, it seems like there are two basic clinical indications that that you could use this for. So ones contraception, the other related to menorrhagia. Yes. We may as well start with sort of contraception and then maybe move to sort of menorrhagia. So I've got a 27 year old, so the lady who's come to get a prescription for the pill, shes got two children doesn't want any children anytime soon. Part of my usual practice, with a request for the oral contraceptive would be to do sexual health screen, obviously, rule out contraindications, but I've been trying to get better at going have you explored other alternatives for sort of contraception? Have you had that conversation in terms of making people aware of IUDs, the benefits, and then helping them weigh up the pros and cons?

Dr Elissa Hatherly  11:07

Yep. So for anyone who comes in, regardless of their age, or where they are in their family planning, I would talk about long acting reversible contraceptives, we know that intrauterine devices, for example, are perfectly acceptable for nulliparous women, so women who have not yet had a baby. And even I will insert them in women who have not become sexually active, if that's the right contraceptive for them. So if someone comes in for contraceptive advice, I will actually just hand write a list of all of the different classes of contraceptives available to them. Also talking about the cost, because that's important, talking about patient input, because that's important. If you can't remember to brush your teeth every day, then you probably shouldn't be remembering to take a contraceptive pill every day, we talk about whether or not people do shift work, whether or not they have multiple sexual partners, and then maybe shouldn't have an intrauterine device. We talk about other things that might be bothering them, like their weight, or their mood, and help walk through the different options to work out what is going to be most acceptable for that woman.

Dr Stephen Lambert  12:15

And so what I'm hearing you sort of say is as part of the counseling, particularly, you know, not just for the LARCS, but particularly with the IUDs, a good set of sexual health history would be sort of really sort of important as part of that consult. It's

Dr Elissa Hatherly  12:35

tricky, isn't it? It's hard to do that in a sensitive fashion without being too interested in the nitty gritty of someone's sex life. But we do recognize that women who are not looking after their sexual health are at higher risk of contracting chlamydia and gonorrhea, which are both really prevalent in our community at the moment. If you pick up chlamydia or gonorrhea, and you have no symptoms, then you might end up with tubal occlusion, and primary infertility or secondary infertility. And that is devastating for those women. So in women who I'm talking about intrauterine devices with,  I say to them, you know, it's incredibly important that we screen you for chlamydia, make sure you don't have an undiagnosed infection. And of course, use condoms with new partners. And that's a conversation I have with everybody, when talking about contraception, regardless of their marital history, or their occupation, or however many children they have, that reminder that condoms are always important with new partners cannot be overstated.

Dr Stephen Lambert  13:35

So in terms of, I guess, myself, I wouldn't be inserting sort of IUDs. Just I haven't had the training to do that. But I've got a young lady in front of me, and we're talking about contraception. I'd like your input, I guess, into I guess, a potential approach for others listening, who may not be in the position where they've had the training to insert IUDs. So I guess the one thing in the back of my mind, if I'm going to refer someone for an IUD, this is the right form of contraception for them, there's a potential of a gap where they might not be covered with contraception before from my consult to seeing you, and some, you know, some patients or a lot of patients just need time to sort of think through the pros and cons I've given them information I've printed information. So my practice would be to give them the pill, so they keep going, give them the referral, I'll often give them a script as well, to perhaps collect that and then come sort of see you knowing that they won't have it inserted on the first consult. Do you have some things or just in your experience? Just nuancing that approach a little bit what would be the best way in approaching that sort of consult where there is potentially a gap in contraceptive cover?

Dr Elissa Hatherly  14:56

so we don't ever want a gap in contraceptive cover, even if women promise that they'll use condoms, I'm always a little bit nervous because condoms require two dedicated partners to use condoms correctly. So we often prescribe what we call bridging contraception. So that might be using the contraceptive pill for a short time, you would want to start it on an active pill, so that it's into their system as soon as possible. Or you could use a depo provera injection, for example, or you could use a nova ring if that was most appropriate or a progesterone only contraceptive pill. We always encourage people to use condoms, as I said, but that bridging contraception is incredibly important. If someone is already using something like the contraceptive pill and has been using it for a long time, don't ask them to stop their pill, I would always want them to continue with that contraceptive pill for seven days after the insertion of the IUD. Because a levonorgestrel progesterone containing IUD will take seven days to become effective. We know that those those IUDs are effective straightaway as contraception if they are inserted at the time of the period as long as it's a true menstrual period. If someone's had a medical termination of pregnancy, for example, we're not 100% sure what recent bleeding might mean whether they have had a true period and whether that IUD insertion is going to be effective straightaway. And of course, if you send someone in for insertion of an IUD and something pops up in that history that we need to investigate a little bit further, or we think a different form of contraception might be nice for that woman, then we don't proceed with that IUD insertion, we might further delay that contraceptive commencement and have a need for further bridging contraception. So if someone's coming from outside, I would ideally like them to still be on active contraception. So when women are coming into family planning clinic, for example, they don't need a referral because we are GPs who run that clinic women can self refer and they don't need a paper referral from the hospital. And we will ask them to have a little bit of pain relief about half an hour before that appointment time to bring the device with them on the day, to bring a pad and maybe, particularly if they're young women who haven't had a pregnancy, we'd suggest they have a driver to take them home afterwards, because they can be super crampy and maybe even feel a little bit faint. But for the vast majority of women, even women who've only had caeserian section births, the difficulty or the discomfort with insertion is really short lived. And I don't think people appreciate that adequately, you might be really uncomfortable for a minute or two but women leave our rooms with some mild period pain and can happily go back to work or go about their business. It's not perhaps as big a deal as some people might consider.

Dr Stephen Lambert  17:59

That's awesome. That's good to understand, I guess the process from the family planning side so that, you know, I guess we can adequately plan.  Would you what would your approach be? So that let's assume this young lady's had her IUD, she comes back five, six months later. She's concerned that she's put on a little bit of weight. She's concerned that her moods have changed, and it may be related to the progesterone. I'm assuming this is not  infrequent.

Dr Elissa Hatherly  18:36

Everyone blames their contraception.

Dr Stephen Lambert  18:39

How do you approach that consult in the sense that I think a lot of us or hopefully know that that's fairly sort of rare, and that this is working locally. But at the same time, you know, patients do come with, it's in their mind that there was an event and this is cause and effect relationship. How do you approach that? Yeah.

Dr Elissa Hatherly  19:04

So we actually see all of our patients six weeks after insertion to make sure that the bleedings settling down that there's no evidence of infection or expulsion of the IUD, and that the unpredictable bleeding that you would normally get at the initiation of the progesterone containing IUD has pretty much settled down. We know that for the first three months or so with a progesterone containing IUD, you might get a higher dose of progesterone released, which might actually get into the systemic circulation so could potentially make women feel a little bit bloated. They might complain of headache mastalgia, their mood or they might be a bit more tearful than usual. Some of those PMT symptoms might be there in a mild in a mild they you know some of those symptoms might be mild. But, you know, I reassure people that if it is related to the IUD, but that that effect would be gone by the three month mark. If we're at six months and women are concerned that their bodies are substantially changing, then an important thing to do is look at what contraception they have used previously. So if people have used a contraceptive pill, for example, that has really suppressed ovulation, when they have their IUD, they might notice more cyclical mood changes as their ovary kicks back into gear, they might notice more ovulation pain at mid cycle, they may not know where they are in their cycle, because the Mirena has suppressed their period, but they might notice cyclical ovulation pain, they might notice that they have gained a little bit of weight or their mood is a little bit poor, because they've actually benefited from the contraceptive pill. Whereas now all we've done is not necessarily to introduce a mirena. But we have removed a contraceptive pill that they had a lot of benefit from, aside from the contraceptive effect. We call those the beneficial side effects of the pill, they are substantial.

Dr Stephen Lambert  21:08

That's really helpful for me in the sense that thinking through what a patient's presenting with, you know, we lump these contraceptives under contraceptive, without thinking that the different modes of action, there's there's actually substantial differences in physiology and how you're getting the contraceptive effect. But there are also other beneficial side effects  to these different forms. Once again, this comes down to the counseling side of

Dr Elissa Hatherly  21:36

Yeah, but keeping our patients engaged is incredibly important. So we need to acknowledge that that patient has those symptoms that they're experiencing, they may not be the side effect of the mirena they not may not be because we've withdrawn the contraceptive pill. But it's also important to ask about other things that are going on in their life have they recently had a baby have they recently returned to work, have they commenced some other medications like an SSRI. So as I said, we can always remove the IUD and give them a period of time without their IUD to see if their symptoms improve. More often than not, I will also give them a prescription for another IUD at that same consult and say look, I'll take out your IUD, if you find that things don't magically change without your IUD, then we can always pop another one in and you can with your GP explore causes for your other symptoms down the track.

Dr Stephen Lambert  22:30

So what I'm hearing is the key point here is the patients come in thinking, you know, they're focused on the IUD. Really important to take a biopsychosocial approach, not have that anchoring bias, where the patients come in this is the problem but rather to zoom out and do a thorough history examination for for other biological causes or their symptoms, all while acknowledging that what they're experiencing is valid and reliable. I think sometimes the message we give is not your IUD keep the IUD in sort of.

Dr Elissa Hatherly  23:02

That's the message I'm going through inside my head, but out of my mouth comes a much more compassionate approach. And of course, it's going to depend on how much sleep I've had the night before how many patients I have waiting in the waiting room, how hungry I am, did I bother to eat lunch today? Probably not. So you're only as good at counselling your patients as you are at managing all of those other things in your workplace from day to day as well.

 

Dr Stephen Lambert  23:31

We might sort of finish off with just one more scenario around IUDs, and then to  summarize some of the key points. So I guess the second scenario is a 45 year old lady who still requires sort of contraception, but in terms of your history, you've uncovered that their periods getting heavier and longer and it's actually impacting sort of life. What would your approach be to that sort of scenario?

Dr Elissa Hatherly  24:01

So it's incredibly important that we offer women at midlife contraception up until we are sure that they have passed through menopause. So women who have their last period before the age of 50, we need to provide them with contraception for two years, just in case they have an unexpected ovulation in that time. For women over the age of 50, we want to provide them with contraception for at least 12 months after their final period. So if someone is using a contraceptive, like the pill, for example, then they are going to be having a reliable withdrawal bleed every month. And we may not know when they are going to go through their last period. We might need to stop their contraception and ask them just to use condoms for a period of time so we can assess what's going on with menopause. So for most women at the age of 45, the average age of menopause being 51 in this country, so women at 45 will not infrequently have a heavier period, that doesn't necessarily mean there's anything nasty going on. And we often use the nice criteria to just establish whether or not we need to investigate that heavier bleeding more enthusiastically or not. For those women who have no concerning pathology on the radar at all the ones who are not making the hairs on your back of the back of your neck stand up, we would look at a contraceptive that's going to provide reliable contraception, but also help to make their life a little bit easier with a lighter, less crampy and maybe even shorter period and that's really where the progesterone containing IUDs come into their home. So when we are over the age of 45, we can provide women with a progesterone containing contraception for what we use extended what we term extended use, so we don't leave that IUD for five years. We actually leave it for seven years, as long as we've removed it by the age of 55. So anyone over the age of 45 would get their last IUD their last progesterone containing IUD and that would be removed 12 months after we are sure they've passed through menopause. With a mirena or a Kyleena, we can be sure they've gone through menopause just by measuring the FSH because that is not interfered with by that contraception. So if you have an elevated FSH in a patient, you would wait another 12 months before removing her IUD. If that FSH is particularly high, like 80, then you don't need to repeat the level. If the FSH is only marginally elevated, you would repeat it six to 12 weeks later to be sure that it was still elevated, and that that woman was in menopause. But it's important that we leave that contraception for 12 months after we suspect their last period so that we capture those women who might have an extra ovulation down the track.

Dr Stephen Lambert  27:02

So in terms of our history, we're suspecting a fibroid uterus in this particular patient and we're able to sort of confirm that with further investigation. Do you want to talk a little bit about the role of IUDs and managing.

Dr Elissa Hatherly  27:18

So when IUDs first became more popular in Australia, it was a common misconception that women who'd only had caesarians were inappropriate for an IUD, that women who had a fibroid uterus were inappropriate for an IUD, that women who were nulliparous were inappropriate for an IUD and we just know that that is not the case. So many women will have fibroids in the uterus. Many women will have small fibroids. A large fibroid might increase the risk of spontaneous expulsion of that IUD, but I will always suggest it to women as an option to try or women who have an IUD would be encouraged to examine themselves for the string of the IUD to be sure that their IUD is in the correct place. If you or your partner can feel the string, then you are reassured that your IUD is in the right place providing contraception. If that IUD improves that woman's period substantially, or insubstantially even, it's up to the woman to know whether that IUD is affecting her period adequately or not. So if we try an IUD for six months, and that woman finds her period is much improved, then we would leave that IUD. If we use that IUD and the woman's period isn't very much changed, or they are crampy, or the IUD is pushed a bit low in the uterus, then we might say, Okay, we've tried the mirena, it's not going to work for you for your period and look at other options for that woman. I'll always give Mirena a go.

Dr Stephen Lambert  28:55

So just to summarize the discussion today, some of the take home points that I've taken and feel free to add any in terms of your long acting reversible contraceptives. I've heard you say that they're more effective than sterilization. So very effective form of contraception. Yeah. Second thing is they're appropriate for any woman basically of any age or previous obstetrical gynecological history. There are some contraindications obviously to it. But in terms of when they initially were introduced, there were ladies excluded, that would no longer be excluded. So the IUD can be considered for anyone wishing to use it as a form of contraception, definitely. In terms of your copper IUDs versus your progesterone impregnated IUDs the mirena and Kyleena are the most available and accessible to ladies here in Mackay.

Dr Elissa Hatherly  29:56

That's right. They're the ones that we have in Australia and all pharmacies stock them, they are a similar cost, they are really cost effective for women of all ages, and really have made an enormous impact on women's quality of life.

Dr Stephen Lambert  30:10

In terms of good medical care around advice around contraception, or providing sort of options, like my takeaway from this is always to take a good biopsychosocial approach to these conversations, there are lots of factors that come into determining an appropriate form of sort of contraception or beneficial side effects from different forms of contraception. And once again, just I guess, good communication skills when counseling prior to, you know, insertion of an IUD, but also the follow up down the track where a patient may come in and go I think it might be my IUD causing these symptoms, just taking a really sort of thorough history and examination and balancing the science at the back of your head going unlikey, but let's let's explore this a bit further.

Dr Elissa Hatherly  31:07

That's right. So of course, the pelvis is a complex anatomical area, it's easy to write off a woman's pelvic discomfort or symptoms as related to an IUD. Often women are also constipated, or might have an appendix that's playing out or suffer with irritable bowel syndrome. There are lots of other things going on. Whilst you might have an IUD in place, that is not the axis of evil. There are other things at play always.

Dr Stephen Lambert  31:35

So once again, thorough history examination, investigation, don't, don't don't let your anchoring bias necessarily get in the way.

Dr Elissa Hatherly  31:45

That's right. And at the end of the day, we just need to do what is best for that particular patient.

Dr Stephen Lambert  31:50

Any final thoughts? If there was one take home that the listeners today needed to take home from this, what would it be?

Dr Elissa Hatherly  31:58

Use condoms. And remember, an IUD for all of your female patients, they can be really helpful, we're so lucky in Mackay to have an easy access pathway for women. But of course, they can always see one of the gynecologists either publicly or privately. And there are lots of GPS in town who are trained to do IUDs you need to be doing them frequently to be proficient, and I would encourage every doctor to consider IUDs in their counseling of their patients.

Dr Stephen Lambert  32:30

Fantastic. Thank you. Thanks for your time, and hope to catch up with the next topic sometime soon

Dr Elissa Hatherly  32:36

Thanks Steven. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 2: Burnout: in yourself and your colleagues

Hear from Psychiatrist Dr Paul Henderson about his personal experiences and tips for recognising burnout in ourselves and our co-workers. Take the time to test your level of burnout, and learn about ways to manage psychological pressure.

Sources

Burnout: In yourself and your colleagues podcast resources

The Burnout Scale (theburnoutproject.com.au)

Self report scale that can provide some guidance on whether you are burning out and if so how severely it is affecting you.

Burnout: A guide to identifying burnout and pathways to recovery by Gordon Parker | Goodreads

An excellent book on Burn out by teg Australian Psychiatrist who was one of the founders of the black dog institute.

TEN – The Essential Network for Health Professionals - Black Dog Institute

The online TEN Navigating Burnout program has been developed specifically for health professionals to reduce the impact of burnout in a way that is sensitive to the unique challenges they face.

The Thriving Doctor: How to be more balanced and fulfilled, working in medicine by Sharee Johnson | Goodreads

This is a book written by an Australian Psychologist who specialises in treating Doctors. It concentrates on the psychological aspects of self care and complements Gordon Parkers book. It isn’t a replacement for it as it doesn’t cover the really important aspect of how to approach your workplace to discuss a position that is burning you out.

Crucial Conversations: Tools for Talking When Stakes Are High by Kerry Patterson | Goodreads

This is a great book that can help guide you in how to maximise the likelihood that any negotiations with your managers/supervisors result in appropriate adaptations to a role that is burning you out.

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth by Amy C. Edmondson | Goodreads

Psychological safety is a really important aspect of organisational culture that can protect against burn out. This book is by one of the pre eminent researchers in the field.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework - Kathryn Turner, Nicolas JC Stapelberg, Jerneja Sveticic, Sidney WA Dekker, 2020 (sagepub.com)

Restorative just culture and its relation to critical incident analysis is another approach that can protect clinicians in an organisation against burn out. This paper describes its implementation specifically in relation to suicide but if you exchange suicide for any critical incident you will see it actually provides a generic template that is applicable across the board.

Clinician health - Caring for Colleagues

Transcript

Burnout in yourself and your colleagues

Thu, 9/8 10:32AM • 12:29

SPEAKERS

Dr Elissa Hatherly, Dr Paul Henderson

 

Dr Elissa Hatherly  00:02

Welcome to the roundup and North Queensland based medical podcast offering local content for local clinicians. I'm your host, Alisa hatherly. I'm a local GP and family planning clinician and head of James Cook University is Clinical School here in Mackay on Nui country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. Welcome to today's episode on burnout in clinicians with Dr. Paul Henderson. Paul, thanks so much for joining us, you are so experienced in this area as a local psychiatrist here in Mackay. And burnout in doctors is something you're really passionate about. When we think about burnout from trauma. Of course, the type one trauma where there's a particular event or type two where there's repeated long term exposure to a traumatic event, or vicarious trauma. Burnout is something that is incredibly prevalent, isn't it? I think

 

Dr Paul Henderson  01:17

yes, absolutely. Because of vicarious trauma. You know, in ourselves in first responders, we not only witness a great deal of direct trauma, so to speak, but we also bear witness to a great deal of trauma in other people's lives, we, unfortunately are in the position of having to give a lot of bad news, which is very traumatic. We're also in the position of treating people with conditions that we we can't find a treatment for that works, which is which is also very traumatic. So So yes, so you know, everything that applies for PTSD, and our patients apply to PTSD and us. But I think if I suppose I would, I would open it up to something which in my mind is much more prevalent, and in many ways, much more significant, which is burnout. And this is something close to my heart. Because I've written myself like twice in my career. So far, you didn't get to learn after the first time. And you think as a psychiatrist, I would have learned to learn to recognize the signs growing in me. But the last time was only about 18 months ago, and it was what it was what triggered my transition from public health into into private health to be honest. So you know, when you look at surveys that look at prevalence rates, it's it can be absolutely enormous and really astoundingly enormous, you know, usually the lowest figure that is reported is 30%. And the highest figure that I've seen is up to 70% in surgical residents in America. And that, you know, that is enormous because it is it can be such a devastating experience to be burnt out. And I suppose the things to be aware of is that, you know, the core symptom is fatigue, absolute exhaustion, and I suppose that's generally what we don't recognize, because we all work so hard, that we just expect to be fatigued. But when that fatigue stops lifting over the weekend, and becomes a permanent part of our day to day working life, you know, that's a sign that you're starting to creep into burnout, distance, you know, having a sense of distance from your job, or cynicism about your job, or distance from your patients. So compassion, fatigue, those are all common parts of burnout. And also having a having an increasing self doubt about your effectiveness as a doctor is a common part of burnout. And, you know, sleep disturbance is a really common potent part of burnout. Because of the exhaustion, distance feeling from your family and friends is a really common part of burnout, anxiety, you know, particularly anticipatory anxiety going into work, having really low mood and work. And unfortunately, it becomes a self perpetuating cycle, because you're so exhausted. And you know, it's hard to say, but you start to lose the ability to care about what you're doing, that really starts to constantly promote that self doubt.

 

Dr Paul Henderson  03:57

And, you know, I'm no longer practicing with my value set. Because when I came into medicine, I was highly conscientious, I was highly compassionate, I was trying my best for my patients. And now I just don't seem to care anymore. And that is such a source of shame. For doctors, that is a massive barrier for us seeking any help, because you have a sense that I can't reveal to anybody that I don't feel like I'm the doctor that I should be. And I know I experienced that. And you know, and I find it hard to reach out for help as well. But I think, you know, once you recognize that yourself, there's many different ways that you can go about trying to address it. But if you don't recognize it in yourself, it can continue to build and it's, you know, once you have enough doctors in the system or enough professionals in a system where burnout is common, then the whole system starts to burn out. And you know, once you understand the the impacts and symptoms of burnout, you know, you start to recognize that the you know, the person that you work with who just doesn't seem to care anymore. It's not because they're a bad person. It's because they're burnt out but you We'll also see that when there's a number of people that are sort of affected by that, and they're starting to engage in what would commonly be termed as presenteeism, so they're present in work, but nonetheless, they're still absent from work, because they're just doing the bare minimum, because they don't have the mental reserves to go any further, then it means works get shifted to other people, that that increases the chance that they will burnt out, or burn out, that increases the risk of their risk of resentment, it causes tension with in teams. And so it really, you know, it really sort of spreads across teams, unfortunately. So I think, you know, for our own well being, it's really important to recognize, but also for our patients, because, you know, sadly, the research shows that a burnt out doctor is not a doctor, that's that is that is working at their highest level of productivity, or efficiency, or compassion, or conscientiousness. And that, you know, we all want to be that doctor that is functioning in that way. But sadly, the system and it's not a reflection of us on the whole, it's a reflection of the system that we work in is massively overloaded, constant time pressure. And I think, you know, something that's really become apparent in COVID is moral injury and moral injury can be a significant cause of burnout, it can be a significant cause of PTSD as well, actually. And moral injury is when you are behaving away in a way or that when you witness behaviour, that is inconsistent with your value set. And, you know, you'll probably recognize and what I just described about burnout, that you start to experience increasing motor and injury, about your own behaviour, or potentially start to have increasing moral injury about your own behaviour as you burn out. Because you, you just simply can no longer practice in a way that is consistent with your value set, because you're so absolutely exhausted and emotionally numb.

 

Dr Elissa Hatherly  06:43

Gosh, okay, so we need to be a lot more aware of burnout in our colleagues and in ourselves, study percent of our colleagues up to 70% is a massive number. And as you say, in the light of COVID, that moral injury is enormous.

 

Dr Paul Henderson  07:01

Absolutely. And in the show notes, I've included a really fantastic book by a is an Australian psychiatrist called Gordon Parker, literally called burnout. And he is one of the psychiatrists was one of the founders of the Black Dog Institute. And that is a really fantastic exploration of how burnout affects people, particularly within the medical profession. I've also actually included a link to a self reported burnout scale, if anybody is concerned that there may be burning out and just want to have a sense of if that is the case. And it's a spectrum, you know, from subtle symptoms of feeling exhausted, but nonetheless, really recovering over the weekend, to absolute exhaustion, all the other symptoms, and simply not being able to turn up to work. And at the extreme end of this spectrum, because burnout, there's a lot of similarities to depression, but it's not depression. But at the extreme end of the expected spectrum, up to 30%, of people with burnout would go on to develop depression as well.

 

Dr Elissa Hatherly  07:55

Okay, so for doctors who are experiencing burnout, or other mental health concerns, like depression, they can always access the doctors for doctors, peers, or the peer support work through the hand in hand Foundation, can't they?

 

Dr Paul Henderson  08:12

Absolutely. And the black dog Institute also has something called 10, the essential network for professionals. And that is for any medical professional, who is concerned, they may have burnout or other mental health conditions. And it's, I suppose, a professional group that can signpost them or provide support. There's lots of sort of psycho educational material on in that part of the website, and more generally, in the Black Dog Institute website, and I'll put a link in the show notes to that aspect for them as well. And there's also a good book by an a, an Australian psychologist whose name escapes me now but who, who now solely devoted time to coaching doctors, particularly with burnout. And her book is, I think, called the thriving doctor, which I've put in the show notes as well. And that's a really in depth, sort of self help book for how you can concentrate on the psychological aspects of self care, I suppose, you know, to you know, self care work life balance is really important to try and limit the impacts of burnout. But there's two other aspects and these are really well documented in the book called burnout is you really have to, and this is really hard, you really have to think, hard and deep about the role that you're in. Because even with all the self care in the world, if you're in an unworkable role, and sadly, there are many other workable roles in health at the moment, the chances of you being able to stave off burnout, even with all the best self care in the world, are quite low. So you need to you need to think long and hard about the role you're in. And that doesn't necessarily mean that I'm going to change role. But at the very least, it means you have to understand why the role is having such an effect on you, and be able to hopefully talk to a manager that will listen to you and that isn't always the case or a supervisor that will listen to you about the impact of the role on you And what can be done to change the world. And the last thing is a personality characteristic that is that is highly correlated with burnout. And it's related to conscientiousness, which is perfectionism. So when we come into medicine, the more conscientious we are, the more we get praised, essentially. And that can for people that aren't already perfectionist, that can provoke perfectionism. And even in a role that is actually genuinely doable. If you're a perfectionist, you can simply drive yourself into burnout. So you know, sort of the three areas you know, when you're thinking about burnout, self care, thinking about the role you're in what can be done to change it, but also specifically thinking about if you have perfectionist qualities to yourself, and what can be done to address those as well.

 

Dr Elissa Hatherly  10:42

Oh, Dr. Paul Henderson, thank you so much for your time today. Burnout is something that we all need to be thinking about. In the lead up to are you a K day in September, recognizing in ourselves and in our colleagues that we are not okay is incredibly important. Dr. Henderson, thank you so much for your time, we really appreciate it and look forward to seeing the great work that you're doing in our community. Thanks, Paul. For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqth.edu.au forward slash roundup hyphen podcast, or contact us at nqth.mci@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 3: Neonatal Jaundice

Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, making it a very common condition. Around 3% to 9% of the total neonatal population, may need treatment. Tune in to hear from Mackay Base Hospital Paediatrician, Dr Gopakumar Hariharan who talks to Dr Elissa Hatherly about the common causes of physiological neonatal jaundice, and how to manage this in the community or in a hospital setting.

Sources

 

Table 1. The differential diagnosis for neonatal jaundice1,2

 

Early jaundice

(Within 48hours of life)

Pathological

Intermediate jaundice

(Day 3-10 of life)

Common and mostly benign

Prolonged jaundice

(Beyond Day 14 of life)

 

●       Haemolysis

-          Rhesus/ABO incompatibility

-          G6PD deficiency

-          Hereditary spherocytosis

-          Alpha thalassemia

 

●     Intrauterine Infection

 

●     Sepsis

●   Physiological jaundice which may be exacerbated by/associated with:

-          Prematurity

-          Bruising

-          Cephalohematoma

-          Polycythemia

-          Delayed passage of meconium

-          Breastfeeding

-          Dehydration

-          Asian ethnicity

-          Infant of diabetic mother

 

●    Haemolytic causes

●     Breast milk jaundice

 

●       Sepsis

 

●       Hypothyroidism

 

●     Inherited deficiencies of glucuronyl transferase enzymes - very rare

 

●     Conjugated jaundice  Biliary atresia, neonatal hepatitis

 

Guideline: Neonatal jaundice (health.qld.gov.au)

 

 

Table 2. Pertinent questions on the history of a jaundiced neonate2

History

Risk factors for jaundice

Day of onset of jaundice

-    Always pathological if <24 hours of life

Antenatal  factors

-    TORCH infections (Toxoplasmosis; Other(Syphilis, Hepatitis B); Rubella; Cytomegalovirus; Herpesviridae)

-    Maternal diabetes

Maternal blood group

-    Blood group O and baby group A or B (ABO incompatibility);

-    RhD negative for rhesus related haemolytic jaundice

Birth history

-    Prematurity

-    Traumatic delivery: cephalohematoma, bruising

Neonatal feeding

-    Exclusive breastfeeding

-    Dehydration

Family history

-    Siblings with neonatal jaundice

-    Gastrointestinal disorders

-    Haemolysis

Stool and urine colour

-    Acholic stool and dark urine are concerning features of conjugated jaundice

RACGP - Prolonged hyperbilirubinaemia in a neonate

Transcript

SPEAKERS

Dr Elissa Hatherly, Dr Gopakumar Hariharan

 

Dr Elissa Hatherly  00:02

Welcome to the roundup a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Hi, and welcome to our podcast today with Dr. Gopan Hariharan. He's one of the neonatologist's at Mackay Base Hospital. We wanted to talk about neonatal jaundice today one of the most common conditions that requires medical attention in newborn babies, super common in general practice and we need to be confident managing these babies. Gopans also a senior lecturer with me at James Cook University here in Mackay. Welcome Gopan.

 

Dr Gopakumar Hariharan  01:09

Thank you for having me today.

 

Dr Elissa Hatherly  01:10

Oh, well, thanks for coming along. Let's start off with a really common case that GPs may encounter. I see these babies all the time. We had a little baby who was one week old, a little girl presenting for her routine seven day baby check. Her birth was pretty uneventful at term and uncomplicated vaginal delivery and the antenatal period was pretty unremarkable. Everything during the pregnancy had been fine. She had a normal morphology scan and maternal serology was all negative, there was nothing concerning there and her clinical examination from the paeds department prior to discharge was also normal. From memory, she was about 3.6 kilos when she was born, so that makes her a nice big baby. But on examination at day seven, she was quite jaundiced. She was otherwise fine, but the jaundice was quite remarkable. So I wanted to ask you today Gopan, just how common is jaundice?

 

Dr Gopakumar Hariharan  02:09

So approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life. So it's very common for babies to have jaundice. The question is, whether that requires treatment or not. Around 3% to 9% of total neonatal population, may need phototherapy as a treatment. There are a couple of reasons why babies are predisposed to jaundice. Firstly, the neonates have a larger red cell mass and a shorter lifespan. And we know that the bilirubin is a breakdown product of haem, and with a larger red cell mass, and a shorter red cell lifespan, a greater release of bilirubin occurs into the circulation. Therefore, predisposing to hyperbilirubinemia. Neonates also tend to have an immature liver function, and that can lead to slower metabolism of bilirubin. Another factor is delayed passage of meconium. Thereby there is increased reabsorption of bilirubin from the intestines. So these are the reasons why jaundice is relatively common in babies.

 

Dr Elissa Hatherly  03:30

Right that meconium isn't a factor I often think about So are there any groups of babies who are at higher risk of jaundice?

 

Dr Gopakumar Hariharan  03:38

Apart from the babies being predisposed to jaundice by their nature itself, there are some maternal and neonatal risk factors that predispose some babies for exaggerated jaundice. The maternal risk factors would include blood group incompatibility related to ABO or rhesus blood types. There are occasions when we come across minor red cell antibodies in a mother and that can also result in exaggerated jaundice but they would be predominantly pathologic jaundice which appear generally within first 24 hours of life. Babies born to families from particular ethnicity, for example, East Asian or Mediterranean tend to have a greater degree of jaundice. In a family if there is a previous jaundiced baby who required phototherapy, then the subsequent siblings are at higher risk. And it's very important to note this when taking a history, maternal gestational diabetes is a very important risk factor and that is attributed to the polycythemia that these babies have. A larger degree of red cell mass can result in a greater release of bilirubin into the circulation, thereby predisposing to hyperbilirubinemia. From a neonatal perspective, feeding is probably the most common condition that we see. Breast feeding itself puts babies at risk of increased jaundice and we refer to them as breast milk jaundice. Reduced intake can predispose babies to jaundice because of dehydration and increased enterohepatic circulation. If the baby have hematoma or bruising, probably from birth trauma, these sites can release bilirubin resulting in exaggerated jaundice. As you already mentioned, the polycythemia in an infant of diabetic mother is a significant risk factor. Then there are factors causing haemolysis example this expediate efficiency. Again that can lead on to the pathologic jaundice. They could present in first 24 hours of life, or they could present with prolonged jaundice. Bowel obstruction, infection, and prematurity are all other risk factors for jaundice. So it's an exhaustive list of causes and predisposing factors. It is important to recognize that late preterm babies are at particularly elevated risk of jaundice, and we have several admissions to the paediatric ward. The late preterm babies are found to have difficulties with feeding and related dehydration can cause them to have severe jaundice and getting re admitted. So it is important that we shouldn't be reassured that these babies are born closer to term. They are at risk. And it's important to remember that these babies are at risk of high jaundice levels.

 

Dr Elissa Hatherly  04:03

Right. And of course, those late preterm babies that would be at around 36, 37 weeks gestation when they're born. Is that right Gopan?

 

Dr Gopakumar Hariharan  07:17

Yeah, absolutely. So 35 to 37 weeks those will be the late preterm babies,

 

Dr Elissa Hatherly  07:24

okay. So, when would jaundice be considered pathological then from your point of view?

 

Dr Gopakumar Hariharan  07:30

the jaundice is considered pathological if it's onset is less than 24 hours. And as I already mentioned, conditions which can cause hemolysis, such as ABO or rhesus incompatibility can result in pathologic jaundice. Pathologic jaundice can also occur if it persists more than two weeks of life when we refer to them as prolonged jaundice. The other factors which raises possibility of pathologic jaundice include, if the baby is unwell raising the suspicion of sepsis or has an elevated conjugated bilirubin component or has pale colored stools. These require prompt investigation and management.

 

Dr Elissa Hatherly  08:15

Right. So what would those key components of the assessment of that jaundiced neonate be then Gopan?

 

Dr Gopakumar Hariharan  08:22

When we encounter a baby who appears jaundiced the relevant factors that needs to be taken into consideration are the age of onset, if the jaundice has manifested less than 24 hours, or if the jaundice has persisted more than two weeks, then they are considered pathological and needs further evaluation. Antenatal course is important, the presence of maternal antibodies, or intra uterine infections can predispose to babies having jaundice, presence of birth trauma from instrumental delivery, these babies could have cephalohematoma, or significant bruising and these could be sites where bilirubin is released into the circulation. Feeding is very important to look for. Breastfed babies have an increased risk of jaundice and referred to as breast milk jaundice. And if the feeding is inadequate, then it can lead on to dehydration and increased enterohepatic circulation leading on to significant jaundice. It's important to ask parents whether the baby has been passing dark urine that stains nappies or history of pale colored stools and that could suggest significant pathologies like biliary obstruction, which needs urgent attention. Presence of a setting for ABO rhesus or any other hemolytic condition also needs prompt attention. If the baby is unwell or febrile child then that could suggest a septic child, septic baby and needs further evaluation along those lines and urgent treatment.

 

Dr Elissa Hatherly  10:17

Yeah, okay. So we've assessed the baby now and so, as part of the examination, what particular things will we be looking at in the jaundiced neonate then Gopan?

 

Dr Gopakumar Hariharan  10:29

The key components important in evaluating a baby with jaundice would include a general examination, a general examination, looking at general tone and neurological examination. The idea is to detect whether the jaundice is highly elevated resulting in complications like kernicterus. So, that will be very important and if the baby has a shrill cry or abnormal tone, then that needs immediate attention and treatment. Hydration status will be very important, looking at capillary refill time, and also looking at mucous membranes. And that will give us an idea whether the breast milk is sufficient in the first place. Plethora from polycytemia would be an indicator that the baby has allowed the red cell mass, releasing greater bilirubin into the circulation. Looking for bruising and cephalohematoma would be important and hepatosplenomegaly in the abdominal examination would allow us to think differential diagnosis pertaining to primary liver conditions.

 

Dr Elissa Hatherly  11:43

Sure, so what's been the initial approach when we're investigating the baby with jaundice?

 

Dr Gopakumar Hariharan  11:50

Any baby who visibly looks jaundiced needs a serum bilirubin done. And what we're looking for is both the unconjugated fraction and the conjugated fraction of bilirubin. If there is high bilirubin, or once we once we get the serum bilirubin done, it's important to plot it on the gestation based specific nomogram that's freely available from the Queensland or statewide guidelines. And this is to determine whether a baby crosses the threshold for treatment with phototherapy or exchange transfusion. If the condition warrants, then further testing, like full blown examination and Coombs test, would be necessary if there is a suspicion of hemolysis.

 

Dr Elissa Hatherly  12:46

Right so, of course, it's really the GP then who's most likely to come across these babies between 24 hours of life and 14 days of life when they're most likely to get jaundice, what would be the most common causes, and then the relevant investigations needed for this group of normal jaundice in the neonates?

 

Dr Gopakumar Hariharan  13:08

Jaundice that occurs between 24 hours and 14 days of life is probably the most common presentation to the general practitioners, as you rightly say, because if it was pathologic jaundice, generally it gets managed within the hospital itself within the first 24 hours. The common differential diagnosis considered will include physiologic jaundice, which is the most common, breastfeeding jaundice, sepsis, hemolysis, breast milk jaundice or bruising from birth trauma. So the investigations will be targeted to rule out these possibilities. For example, if dehydration is a possibility from breastfeeding jaundice, then a serum sodium would be very important, because it will be quite elevated in case of dehydration. A blood sugar would be useful in order to detect hypoglycemia if the feeding has been grossly inadequate. CRP blood culture, urine culture, lumbar puncture as per sepsis protocol may be necessary for a baby who looks unwell and the suspicion is sepsis. In case of probable hemolysis then a full blood examination blood film, reticulocytes, neonatal blood group and typing, direct Coombs test would be important. A G6PD screen may be undertaken in certain high risk group for example, those coming from Asian ethnicity and further workup for hemolysis may be necessary depending on the clinical situation. If we are confident that it is physiological jaundice, then no further testing is necessary. No testing is necessary if we are confident that it is breast milk jaundice, or jaundice secondary to bruising.

 

Dr Elissa Hatherly  15:07

Good. Okay, so then for those babies in whom we think it is simply that physiological jaundice that you mentioned, what's the treatment then?

 

Dr Gopakumar Hariharan  15:18

The initial step in the treatment of hyperbilirubinemia is to establish that we are dealing with an unconjugated hyperbilirubinemia or are we dealing with a conjugated hyperbilirubinemia. In order to determine this, it's important to look at the conjugated fraction of the bilirubin and that should be less than 20 micromoles per liter, and the conjugated fraction is less than 20% of the total bilirubin. As I already mentioned, once we get the serum bilirubin, it is plotted into the bilirubin chart available from the statewide jaundice guidelines and if the baby's bilirubin level is above a threshold for phototherapy, then baby may require admission for that. It's also important to treat underlying condition if we can find anything. For example, if the baby is breastfeeding, and has lost weight, dehydration is a possibility and that might be contributing to exaggerated jaundice. In these situations, we generally involve maternal and child health lactation consultant, and sometimes speech pathologist to help mother with breastfeeding. Speech pathologist is particularly useful in late preterm babies where sucking and swallowing may not be entirely mature. And it's useful for speech pathologists to get involved in these cases. So also, if there is a consideration of significant tongue tie affecting breastfeeding, in these situations we also sometimes suggest formula feeds while the mother is having breastfeeding supported. That's that's not uncommon that sometimes we do recommend formula feeding if the mother is struggling with breastfeeding. If sepsis is a possibility, then we follow the statewide sepsis guidelines, investigate accordingly and treat with antibiotics. If hemolysis is a possible, possible underlying cause, then we get full blood examination G6PD, Coombs test, reticulocyte count, osmotic fragility, if hereditary spherocytosis is a possible possibility. And in some cases, we do seek hematology opinion in managing these babies. We also review maternal blood group for ABO and rhesus incompatibility. Probably that's the most common thing that we look in the first instance as I already mentioned, breast milk itself can cause significant jaundice, and that is due to factors which are transferred across breast milk, and which can inhibit the metabolism of bilirubin by the liver. It can also lead on to break down of conjugated bilirubin in the intestine and handle releasing excess and conjugated bilirubin into the circulation. These babies are generally well looking with adequate weight gain. If we find that the conjugated fraction is high, alongside having pale stools and dark urine that stains nappies then biliary atresia should be considered and urgent gastroenterology opinion should be sought.

 

Dr Elissa Hatherly  18:55

Right? Gopan can I just ask you to go back to the breastfeeding jaundice? If you could just clarify for me please the difference between the breastfeeding jaundice and the breast milk jaundice. What's the difference?

 

Dr Gopakumar Hariharan  19:11

So breastfeeding jaundice generally occurs in the first week of life when breastfeeding is just being established. Inadequate feeding can result in dehydration and increased reabsorption of bilirubin from the intestines resulting in hyperbilirubinemia. Inadequate intake sometimes also result in delay in passage of meconium which contains large quantities of bilirubin that is then reabsorbed into the infants circulation. Treatment is through supporting breastfeeding by involving lactation consultants, and child health nurse as needed. And at times, as I already mentioned, sometimes we do suggest formula feeding if the parents wish while breastfeeding is being established. This is a temporary measure. We are advocates for breastfeeding, but this is just to tide over that that phase when breastfeeding is being established. Some babies could have tongue tie which needs assessment by speech pathologist and lactation consultant and we facilitate that in the hospital. In addition to our clinical review, breast milk jaundice on the other hand, generally occurs in the second or later weeks of life and continues for several weeks. It's postulated that factors such as beta glucuronidase in breast milk, increases the breakdown of conjugated bilirubin in the intestines to unconjugated bilirubin. There are other factors such as lack of protein lipase and non esterified fatty acids in breast milk, which inhibit normal bilirubin metabolism. And these can predispose to breast milk jaundice. The only way to establish the diagnosis is by temporary cessation of breastfeeding for 12 to 48 hours. And if we can establish that there is a dramatic decrease in serum bilirubin with stopping breastfeeding, then the breast milk jaundice can be diagnosed. It is also important to remember that we have to investigate thoroughly and make sure that we are not missing any substantial diagnosis before coming to the diagnosis of breast milk jaundice. And these babies continue to be a bit jaundiced to around six weeks and and that is acceptable.

 

Dr Elissa Hatherly  21:49

Okay, so there's a lot of information here Gopan, I might just try and summarize that if I can. Our approach to jaundice between 24 hours of life and two weeks of life starts with that detailed history and clinical examination, particularly checking for the dark urine and pale stools of biliary obstruction. And the other things that we're looking at would be checking the total serum bilirubin and looking at the fraction of the conjugated bilirubin, which should be less than 20%. We need to check the maternal blood group for ABO and rhesus type, and any other minor blood group abnormalities that might pop up plus the full blood count, the direct Coombs test, the reticulocytes and the blood film in suspected hemolysis. And then the other things will depend on that clinical picture like the urea and electrolytes and liver function test, other things that might contribute to a high rate of hemolysis like G6PD deficiency and hereditary spherocytosis, there was a sepsis workup as well, looking for congenital infections. So that would be the torch screen, of course, and screening for inborn errors of metabolism, and things like that we will probably leave to the pediatricians as well as the thyroid function test, and other inborn errors of metabolism, like urine reducing substances and things like that. There's a lot to be thinking about Gopan. Are there any groups of babies who we should be particularly monitoring and really keeping under close surveillance when they're first discharged?

 

Dr Gopakumar Hariharan  23:39

There are a subset of babies that we do close surveillance, especially those babies who had pathologic jaundice, for example, from ABO incompatibility or rhesus incompatibility. They are at risk of continuing to have hemolysis and continue to be jaundiced. So they require very close surveillance. The other group would be those who had cephalohematoma. They are at risk of jaundice, and so are some babies who have bruising from the birthing process itself. So in a nutshell, babies who have predisposing factors for exaggerated jaundice, we do a very close surveillance and it's important to have a very close follow up.

 

Dr Elissa Hatherly  24:29

Okay, so the follow up required for babies who have received phototherapy. What should we be looking out for in those babies?

 

Dr Gopakumar Hariharan  24:38

So babies coming off phototherapy should have a repeat bilirubin after 18 to 24 hours to ensure that there is no rebound hyperbilirubinemia. A safe limit for stopping phototherapy is when the serum bilirubin has fallen less than 50 micromoles per liter from the threshold line for further therapy. In order to happen in order for this to happen, the baby necessarily doesn't have to stay in the hospital. Once the babies are discharged from the hospital, we have child health nurses who visit the family and make clinical assessments and decide on further testing. Those from private facilities may have their own processes. And in many of these cases, we find that the general practitioner will be very closely involved in following up these babies. At the time of discharge, we give a detailed verbal and written information on neonatal jaundice so that they are aware of what to look for. The statewide neonatal jaundice guideline is a great resource to refer while managing these cases.

 

Dr Elissa Hatherly  25:50

Yes, of course. So, what's the risk Gopan if babies are not identified promptly, who in fact need treatment?

 

Dr Gopakumar Hariharan  25:59

babies with the exceedingly high unconjugated bilirubin heart rate or increased risk of kernicterus and the kernicterus is a condition where excess unconjugated fraction of bilirubin crosses the blood brain barrier and get deposited in various areas of the brain, especially the basal ganglia. In significant cases, this could result in dystonic cerebral palsy and other morbidities could be hearing deficits and neurodevelopmental delays. And that is the risk posed by significant jaundice and if there is delay in treatment, and that risk is caused by any of the pathologic causes that can result in jaundice, for example, ABO incompatibility. A rapid rise in bilirubin example, more than 8.5 micromoles per liter per hour also puts a baby at particular risk. So it's it's not only the absolute bilirubin value, it's also the rate of rise, which is important to look at in case of evaluating a baby with jaundice.

 

Dr Elissa Hatherly  27:12

Okay, so now Gopan, let's go back to the baby that I was talking about at the beginning of this chat. You know, this baby too. When we looked at this baby born at term who was jaundiced at one week of age, when I examined her she was clinically well, but we sent her off to have her serum bilirubin check. And when you looked at it, and I suppose you would have plotted it on the age specific bilirubin chart, you found that the level was high enough for the baby to warrant phototherapy. What happened next?

 

Dr Gopakumar Hariharan  27:48

this baby got admitted to the pediatric ward because as you just mentioned, the the levels were quite high, above the threshold for phototherapy. We also noted that baby has had lost more than 10% of birth weight. And at that point in time, we did a serum sodium which was 148, which was elevated and that suggested dehydration. So in addition to the phototherapy, we involved the lactation consultant in the hospital to help the mother with breastfeeding. And the parents were open to trial some formula feeds at that point in time while the mother was establishing breastfeeding. We talked about other possibilities as well. At that point in time, there was no setting for hemolysis as mother's blood group was A positive and baby didn't have any particular features of sepsis. Baby was active otherwise, therefore no further blood tests were needed. With adequate feeding established, the bilirubin steadily dropped to safe limits, and we discharged the baby from the hospital after 72 hours. We ensured that the baby and the family was linked with a child health service in the community and a repeat bilirubin, which was done in 24 hours after discharge was in safe limit and baby had demonstrated good weight gain.

 

Dr Elissa Hatherly  29:21

That's a really reassuring end to the story, isn't it Gopan. So yeah, what would be your key take home messages from this story on neonatal jaundice?

 

Dr Gopakumar Hariharan  29:33

So the key points would be to ensure taking a thorough history, performing a physical examination to rule out any significant underlying pathologies and relevant investigations as necessary to treat a jaundiced neonate. It's important to pay particular attention to late preterm babies because of the risks that I already mentioned. It's also important to consider a wide range of differential diagnosis in babies presenting with jaundice even though physiologic jaundice is the most common cause. Pediatric referral is indicated for cases of early jaundice, that's jaundice appearing within 24 hours of life, conjugated hyperbilirubinemia, babies with pale colored stools, prolonged jaundice, or any other additional concerns.

 

Dr Elissa Hatherly  30:30

Oh look thank you so much for your time Gopan, we really appreciate you sitting down to talk through neonatal jaundice. I think next time we'll have to talk about prolonged hyperbilirubinemia where it's a little bit different, but thank you so much for your time. Thank you. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 4: Asthma in the post-COVID world

Take a look at how asthma is being managed in the post-COVID world. Hear from Dr Pranav Kumar, who talks to Dr Elissa Hatherly about new treatments for asthma patients and provides his tips and tricks on how to manage asthma in this new era.

Dr Pranav Kumar is a Consultant Respiratory Physician at Mackay Private Hospital and an expert with a broad array of experience in lung conditions. He has published research in major peer-reviewed journals and is a highly skilled clinician and proceduralist.

Sources

Since the COVID-19 pandemic there were concerns that asthma patients could be at increased risk for SARS-CoV-2 infection and disease severity, it appears that asthma is not an independent risk factor for both. Asthma is not over-represented in hospitalised patients with severe pneumonia due to SARS-CoV-2 infection and there has been no increased risk of asthma exacerbations triggered by SARS-CoV-2 in that setting.  

There is accumulating evidence that asthma phenotypes are important factors in evaluating the risk for SARS-CoV-2 infection and disease severity, as findings suggest that Th2-high inflammation may reduce the risk of SARS-Cov-2 infection and disease severity in contrast to increased risk in patients with Th2-low asthma.

Regarding asthma medications, the use of ICS, despite early concern about immunosuppression, is safe. Furthermore, ICS do not increase infectivity or disease severity. In contrast, chronic or recurrent use of SCS before SARS-CoV-2 infection is a major risk factor for poor outcomes and worst survival. Biological therapy for severe allergic and eosinophilic asthma does not increase the risk of being infected with SARS-CoV-2 or having worse COVID-19 severity. These data emphasise the need for optimised management of asthma patients in order to achieve asthma control and avoid whenever possible the need for chronic or recurrent use of SCS. However, further studies are needed to answer still unresolved questions such as the relation between different asthma phenotypes and SARS-CoV-2 infection.

Busse WW, Lemanske Jr RF, Gern JE. Role of viral respiratory infections in asthma and asthma exacerbations. Lancet 2010; 376: 826–834

Branco ACCC, Sato MN, Alberca RW. The possible dual role of the ACE2 receptor in asthma and coronavirus (SARS-CoV2) infection. Front Cell Infect Microbiol 2020; 10: 550571

Zhu Z, Hasegawa K, Ma B, et al. Association of asthma and its genetic predisposition with the risk of severe COVID-19. J Allergy Clin Immunol 2020; 146: 327–329.e4

Yamaya M, Nishimura H, Deng X. Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells. Respir Investig 2020; 58: 155–168

Yu LM, Bafadhel M, Dorward J, et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021; 398: 843–855

RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. 2021; 384: 693–704

Transcript

SPEAKERS

Dr Elissa Hatherly, Dr Pranav Kumar

 

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Welcome to today's episode where I'm joined by Dr. Pranav Kumar, one of our respiratory physicians at the base hospital. Pranav has qualifications in respiratory medicine from not only Australia, but India, America and the UK. Thank you so much for joining us today.

 

Dr Pranav Kumar  01:00

Thanks, Dr. Hatherly. It's really nice. I'm really excited to sort of come to join this podcast.

 

Dr Elissa Hatherly  01:07

We wanted to talk a bit about asthma today and I suppose it's a particularly important topic in light of COVID. How big a problem has asthma been in the COVID era?.

 

Dr Pranav Kumar  01:19

 So, basically, we see that as is never been sort of a lesser problem. Prior to the COVID era, if you see, really, if we estimate the percentage of cases throughout Australia, so nearly 10% of the population which sort of diagnosed or sort of latent or cough variant the asthma is present, it is one of the top 10 diagnoses presenting to our emergency department. And overall, if we compare the whole degree of severe asthma in the post COVID era, it normally consumed about three to 5% of the total cases of asthma. So if you look at the whole, this whole data is Lex there got quite a mammoth problem at this moment. And what actually, we see is with the COVID-19, although there was a misconception that normally, as after COVID, we get more cases of asthma or exacerbation. It is partly true and partly untrue, which I'm going to explain you in a later discussion of the time. What I really want to put in here is it has intensified the stigma we had around the asthma cough. And we see that there was a very interesting survey which said that nearly 43% of Australians who  saw someone coughing and they, they, they thought it to be contagious, though they are, you know, just a mild cough, small cough-variant asthma. So overall, if you look at the whole data, I think the problem has gone and there has been more unmasking of the silent or cough-variant asthma to sort of become very persistent and see their form of asthma post COVID era.

 

Dr Elissa Hatherly  03:31

Right. So COVID is helping to unmask those patients who have silent asthma. Getting that reactive airways as a response to that inflammatory process. And yeah, that stigma around cough is really prevalent in our community. We've certainly noticed that in general practice, but three to 5% of the community is a big number. With asthma, then what increases the risk with COVID-19 in our patients, what are the sorts of things we need to be mindful of?

 

Dr Pranav Kumar  04:06

Well, you know, that doctor Hatherly we had this notion that was you know, the major drivers for all our, you know, asthma exacerbations, are the respiratory viruses and that holds true for time immemorial like every asthma exacerbation, if you look at the most of the data as we see nearly 80% or more of the cases from the all the respiratory viruses. And since after the COVID it was thought that look, this is one of the Coronavirus is going to be no different and then we're going to more and more number of increased severity or increased number of cases or exacerbations through the years. What normally we have seen that you know how the COVID they viruses they basically uses more angiotensin converting enzyme 2 expression. And that has also been contributed that, that they will be more severity of infection, there will be more infectivity, as is one of the viruses. But all the epidemiological data or studies, which we have so far has said that the incidence of these cases are pretty low, that there is no asthma doesn't sort of, you know, in these people cases hasn't gone up. And it has shown that the incidence of COVID 19, in people with asthma was pretty low. And the current evidence also supports that the notion that asthma does not increase the risk of COVID 19 was also true. But it all saying this, you know, the other aspect of it was severe COVID, which, which normally, we seen the people who had asthma, and has got an old age, or they had different comorbidities in form of cardiovascular disease, or diabetes, or obesity, they are the ones who are the most sufferers. And I also think that the there are two, or the two data, which I like to sort of mention here is one from the Belgian asthma registry or Sani which has got, they did a severe asthma network in Italy. They, they they said that and they found out through their you know, course of the disease, that severe asthma is not an independent risk factor for COVID-19. So, if you look at the whole picture, I think, what we thought initially, that, you know, we are going to have more and more, because it's one of the respiratory viruses, and then we're going to get more ACE2 inhibitor expression and increased infection and increased severity, which wasn't the case, but only the people who had severe COVID and asthma were the people who belong to the old age group or the people who had comorbidities in the form of obesity, cardiovascular and diabetes, who were the worst sufferers.

 

Dr Elissa Hatherly  07:32

Yeah, certainly, we learnt a lot in that first twelve months about COVID and respiratory disease. So with some asthma, I wonder if you could take us through some of the different phenotypes and relate that to disease severity, then please.

 

Dr Pranav Kumar  07:48

Yeah, that's a very interesting question and Dr. Hatherly, I recently had the European respiratory Congress, where they had a long debate about these phenotypes and the treatment part and that was really interesting. And they know the what we know till date is we got type two or Th2. So, there are two types Th2 high or Th2 low these are the two phenotypes, which normally we use and the difference between them is Th2 high is mostly the 50% of the formal asthma diagnostic diagnosis patients will have it and type two, before I sort of go further, I just say that they have this interleukin manifestation like IL4, IL5, 13 eosinophils pheno epithelioid barrier dysfunction, all these can cause a protective effect on the size of COVID-19 infectivity and severity Yes. So, this was very interesting that despite of the you know, there is expression of these they have poor risk, protective effect. And mostly if you see there was also some studies which has shown if you've got more eosinophils, they are more protective for this COVID 19 infection and severity, in comparison with Th2 type or more they will call Th2 low they have more neutrophilic infiltration and they are more mostly pauci-granulocytic inflammation where this is mostly non allergic type and they had common association with people who had obesity related or smoking related or other comorbidities related in there. The you know, as we know there was more severity there was more infectivity and much more mortality. Compared to IL 4, 5 they have if you see the biomarker, there were IL6 which was predominant. And as is noted in one of the studies, these obese people will have increased leptins, and the increased leptin will cause more Th1 pathway, and they will cause more severity and more infectivity.

 

Dr Elissa Hatherly  10:24

Right. So the higher the eosinophils, the more protective toward COVID. That's fantastic. And of course, would include a lot of our patients that we have here in our region. In terms of asthma medications, then do we need to be tailoring those a little bit more to those different phenotypes to better address that risk of COVID-19 and the disease severity?

 

Dr Pranav Kumar  10:51

That's a really interesting question. And that's really sort of generating a lot of interest in I think there will be a lot of a lot of studies has still to be carried out. But when we talk about the predominant as we know that inhaled corticosteroid (ICS) is one of the which, which is mainly used for the prevention and our protection as a as a preventer in asthma medication. If we think ICS per se, it says that it confirms some of the protections against the COVID. So there was initial when we had COVID, when we started to have COVID. And there was concerns that using people on a high dose corticosteroid or inhaled corticosteroid will give them instead of more mortality and more chances of severity of infection didn't come through on this study, we say that they causes a decreased expression of ACE2 although you know the where these, these viruses are binding. So they will be less a less than of their, you know, binding and less severity of infection. They also had some sort of biochemically protein seronase in the lung, they were also reduced and they helped in overall modify the risk or confers a kind of protection against the COVID. As we also know, Dr. Hatherly that all these ICS causes decrease inflammation. That's the main main job and, and in some studies, if you see there's very interesting that some of the anti inhaled corticosteroid in form of ciclesonide or Mometasone, they, they sort of suppress this virus per se as well. So there's still study going on. So but that was very interesting finding that some of these inhaled corticosteroid also suppress the SAR school or COVID-19 infections. And as you know, in our at the moment, when we're treating we're treating a lot of people with, with the when we say some sort of severity of the COVID, we do use, inhale budesonide drugs, which is a very common to give them like at least, you know, 12- to 16-hundred micrograms of budesonide. And that was based on a trial, which was the principal trial, and we say that the more inhale Budesonide you use, and they will decrease the symptom burden, and also helps us in the time of recovery, and also reducing the total hospital admission. So that was a really, really, very good trial. And that has prompted us to help us to sort of designed this, putting this budesonide as a routine kind of management for this COVID, which is not that severe, to decrease their symptom burden, as well as recover and reducing in the hospital admissions.

 

Dr Elissa Hatherly  14:13

Right. So those ACE inhibitors have that anti inflammatory effect as do the inhaled corticosteroids, which we've known for many, many years. Now. That's, that's interesting.

 

Dr Pranav Kumar  14:24

Yeah. There's another one, which was really sort of, we always thought that if you use systemic steroid in this group of patients, like if you use, they will have more severity of the disease, isn't it that will cause more while to sort of replicate. And there was a recent recovery trial, which did say that, if you've used the dexamethasone of like nearly six milligram per day, for nearly 10 days in those group of patients, it was found that 28 day mortality was very less, and also the rate of the decrease like rate of intubation in those group of patients. So that was really interesting finding and sort of still sort of worked out for all the severity cases in the what we get in the ICU.

 

Dr Elissa Hatherly  15:20

Yes, certainly important information for you to have before the COVID patients started to appear in our part of the world. Dr. Kumar can we ask about the biologics then too, so we know the ACE inhibitors, the inhaled steroids and the oral steroids are really effective. What about some of those newer biologics that we've been prescribing in the last few years?

 

Dr Pranav Kumar  15:41

Yeah, and that's very, very, I mean I'm really particularly very interested in like, biologics. Since we have biologics, it is really sort of I have patients here who, on a lot of them, like at least I know, five of them, who are my patients and on non-biologics, they most of the time, they presented to the hospital, got intubated and went to the ICU. And since they've been on biologics, they've been doing pretty well and sort of out of the hospital for most of the time. So that really sort of made me very interested. And I post COVID I've seen that we did have sort of a lot number of cases which has come up with increased severity and there was a sort of they being labeled as a long COVID. But in fact, they were the COVID, they were the asthma with a sort of gone into a severe kind of asthma which was not responding to any treatment. And in a couple of them, I recently put them on biologics, and they they are recovered on their, on the pathway of them. And so, if you see the types of biologics, we have, like anti-IGE, IL5 and IL5  receptor antagonist, we are mainly using here anti IL5 and anti IL5 receptor. And they normally they do is they blocked the type two, inflammation and confers a degree of protection against COVID as well, only thing, which was sort of contradictory that in one stage, we know that eosinophils are protective. These drugs basically they got, they have concerns of decreasing the tissue and the blood eosinophils. So, we thought that we will get more disease severity or increased severity in these cases. And there was a study which all eyes I think have done this in our talk earlier, that eosinophils are kind of more than 150 they normally give you a decrease mortality. But you said this was a contradictory finding at one at one stage, we were saying that if you've got a more eosinophils they are protective to overall confirms that I have you know less risk from the COVID. At the same time that we are using biologics, we say that they are providing a protection, though they are decreasing your eosinophil counts to a very significant level or even to the normal and there has been clinically evidence with so that this use of biologics are pretty safe. It is it has found that during the course of the follow up that they are not associated with increased severity or mortality. So, so since when this study has come up, I think we have instead of as soon as the patients are diagnosed and they are being they're being put on the biologics without any much of you know, risk of that, you know, you're using biologics in this group of patients. We don't we previously thought it to be very, very cautious and nowadays these study coming up, even though they have found out that they treat the severity cases and more morbidity and mortality are less though, it is quite safe to use the biologics

 

Dr Elissa Hatherly  19:17

Right. So particularly as you said, for some of those patients who might be experiencing what we thought was a long COVID symptom like persistent breathlessness. You think sometimes it can be undertreated breathlessness and the patient's need to be more fully worked up and more comprehensively treated then.

 

Dr Pranav Kumar  19:39

Yeah, and that's that's very important point as you said, in the post COVID They will have more like an array of symptoms in the form of shortness of breath, to chest pain to palpitation, and all so many kinds of symptoms. And most of the time if the people had COVID, and it persisted for nearly four weeks or more, we just term it as a long COVID. But if we sort of sticks seriously, because you know, if you see this group of patients, in some of them, if you do a lung function, if they got a very serious sort of airflow limitation in people who got a persistent sort of shadowing versus a perioheral area of consolidation, like organizing kind of pneumonia on the CT scan, they need to be treated, rather than labelling. So it's basically if the symptoms persist, there is nothing harm in doing some tests to confirm that we are not dealing with something which has been unmasked by the COVID, or is still the COVID long effect, because in there was recently a case with us, who has been labeled as a long COVID has a lung fibrosis that that chap, I think he left, he was in Indonesia. And then he when he came in and half of the lung was fibrosed, so he's finally getting lung transplant done. But it was initially labeled as a long as long COVID. So that does a few of the things which really sort of makes you wonder that you know, that of course, the long COVID will present with lots of issues and lots of somatic problems and health problems. But doing some investigation, before we label them will be a perfect way to deal with deal with this situation.

 

Dr Elissa Hatherly  21:41

Right. Okay, so for patients with persistent symptoms after COVID or worsening symptoms, it might be long COVID. But we need to be carefully ruling out other comorbidities like lung fibrosis, as you said, Is there anything else we should be looking for? Do you think?

 

Dr Pranav Kumar  21:59

I think it's, you know, if the patient has got, like, you know, the long COVID will have a array of symptoms. For the lung point of view, I would say that doing the chest X ray and doing a CT scan or lung function test, wont harm us, but actually help us to rule out the other causes which can sort of mimic and as a long COVID.

 

Dr Elissa Hatherly  22:27

Right, look Dr. Kumar, thank you so much for your time and your expertise today talking about asthma and the post COVID world I had no idea it was so incredibly prevalent, as you said, usually in the top 10 of our Emergency Department presentations and with severe asthma. Of course, in primary practice we can we can cope with that a little bit more enthusiastically, I suppose by making sure those patients are having their inhaled corticosteroids at maximum dose. And as you said, just ruling out other conditions with a chest X ray, a lung function test and maybe even a CT chest. Dr. Kumar, thank you so much for your time. We really appreciate it.

 

Dr Pranav Kumar  23:11

Thank you so much. I really do indeed a pleasure for me. Thank you so much.

 

Dr Elissa Hatherly  23:18

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 5: PTSD and Trauma

Want to know more about treating PTSD and trauma?

Tune in to the latest episode of The Round Up: A Medical Podcast and join your host Dr Elissa Hatherly who talks to guest speaker Dr Paul Henderson about who is affected by trauma, tips on starting a conversation with those affected by trauma and how to get patients started on their treatment journey.

Sources

Trauma, PTSD and burnout in our patients and ourselves podcast resources

Australian PTSD Guidelines - Phoenix Australia

Phoenix Australia is a not-for-profit public company, affiliated with the Department of Psychiatry at the University of Melbourne. As well as having Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD it also has a lot of easy to read psychoeducation material for people who have ben traumatised. The only negative, in my opinion, is they take an overly narrow view of the definition of trauma (limiting it to the DSM V definition)

A Practical Guide for the Provision of Behavioral Health Services - Trauma-Informed Care in Behavioral Health Services - NCBI Bookshelf (nih.gov)

Free and excellent online book on all aspects of trauma informed care. It takes a broader view of trauma than Phoenix and includes a lot of practical guidance on how you go about asking trauma related questions.

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) - PTSD: National Center for PTSD (va.gov)

5 question screen for PTSD

Life events checklist – self report

Self report trauma screening checklists have been shown to have higher rates or true positive responses than clinician interviews.

Life events checklist clinician interview

This interview adds some important questions about the quality of parental/carer relationships in childhood. Not only does this allow access to the potential trauma of emotional abuse or neglect but it also adds important information about the increased vulnerability people can have before an adult trauma occurs which is likely to have some prognostic value when thinking about the potential and times scales of recovery from later life trauma.

Dissociative experiences scale

Although it is unlikely that most GP’s or none mental health specialists would administer this scale it none the less gives a very helpful overview of the many different ways in which dissociation can impact people.

Dissociation FAQs - ISSTD (isst-d.org)

This web page has more detailed information about the different ways dissociation can impact someone.

Recovery orientated language guide

This is a guide produced by the Mental Health Coordinating Council and although at first glace it could be seen as overly PC its actually a really helpful resource to reflect on. People who are traumatised can be extremely sensitive to have they perceive they are being treated so a thoughtless use of words could be mean the difference between someone engaging enough to enter into treatment or not.

Blue Knot Foundation

BNF are the National Centre of Excellence for Complex Trauma. Their website includes resources and support materials for people who have experiences of complex trauma, and those who support them, personally and professionally. They have a support line and a referral service than can link people with therapists specially trained in providing trauma informed therapy.

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults - American Journal of Preventive Medicine (ajpmonline.org)

A good summary of the data from the seminal study of the impact of childhood adverse experiences on adult physical and mental health outcomes.

Grounding Techniques: Exercises for Anxiety, PTSD, & More (healthline.com)

This provides straight forward instructions on how people can engage in a number of different grounding exercises.

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk | Goodreads

This a fantastic book the details our understanding of how trauma impact our neurobiology and physiology in general and clearly links these impacts to how we see trauma affecting patients in theire day to day lives.

 

Transcript

Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, we're talking about PTSD and trauma with local psychiatrist Dr. Paul Henderson. Paul, thanks for meeting with us today.

 

Paul Henderson  00:50

It's a pleasure. Thanks for inviting me Elissa.

 

Elissa Hatherly  00:53

We understand that trauma is something you're particularly interested in. What do we need to know about trauma in general terms as doctors in the community?

 

Dr Paul Henderson  01:04

I think sort of overarching is the concept of trauma informed care. And I suppose I hope by the end of this discussion, your listeners will have more of a sense of what that is, and how they can improve and enhance that aspect of their own practice. And I suppose most importantly, feel more confident when they are confronted by a person that has had trauma in their own life and also be more confident about how to address trauma in their lives as well.

 

Elissa Hatherly  01:35

So when you talk about trauma, it might be different to what I think of as trauma. What's the traumas that we need to be asking our patients about or more alert to in our practice?

 

Dr Paul Henderson  01:48

I think the most sort of general definition of trauma in my mind is any event that overwhelms a person's coping mechanisms, and has a lasting adverse effect upon them. Because to me, that that encompasses all aspects of trauma. And I suppose importantly, it distinguishes the quite narrow types of trauma that are part of the diagnostic criteria for PTSD. And I think in general, day to day practice, if you just think about the diagnostic criteria for PTSD, you'll actually be overlooking a lot of traumas that people experience. So if we, if we sort of drill down a little bit further in that definition, there's a number of different ways you can categorize trauma. But possibly the most helpful is thinking about type one, trauma type two, trauma and vicarious trauma. The type one trauma is what we would probably all classically recognize as trauma, as distinct individual events, whether that's a car crash, or an injury, or a near death experience. A one off event that is that is in keeping with the diagnostic criteria for PTSD. Type Two trauma is repeated and chronic trauma, it's it can be repeated type one trauma, so they're not entirely distinct. And it's more commonly occurs in younger people, although it can occur in older people. And more commonly, it's much more interpersonal in nature. So something that is done by someone to you and would tend to be of higher rates of psychopathology following it. And then there's vicarious trauma. So witnessing other people's trauma, hearing about other people's trauma, and that's something that is obviously particularly relevant to us as doctors.

 

Elissa Hatherly  03:32

Ok so what are the sorts of things you mentioned with type one, a distinct event might be a car crash? What are the things that might fit into the type two category?

 

Dr Paul Henderson  03:44

So things that would fit into type two are childhood sexual abuse, domestic violence, war, genocide, you know, anything that refugees, asylum seekers often go through people in domestic violence, violent relationships, severe and chronic racism would also fit into type two traumas. So anything that is ongoing and traumatic, and as I say, generally done by one person to another,

 

Elissa Hatherly  04:13

Right. So with trauma being an overwhelming experience impacting or overwhelming a person's coping mechanisms and affecting their function. What are the first steps that we as clinicians should take with patients who we feel have experienced trauma type one or two or vicarious?

 

Dr Paul Henderson  04:35

I suppose the first step is understanding potentially how prevalent it is and understanding that it may not be the first thought in mind that this person has experienced trauma, but nonetheless, there's a high chance that a lot of people that are walking through your doors, whether you're in primary care, or within hospital setting, have experienced trauma, and that may be impacting their presentation with you at that moment in time. So if we think about prevalence, you know, the type one traumas estimates are up to about 50% of people in their life will experience a significant one off incident of trauma. And when it comes to type two traumas, possibly up to about 25%, of which the rates of childhood sexual abuse are, unfortunately, very high, up to one to one, sorry, one or two out of every 10 girls will have experienced childhood sexual abuse of some form or another, and potentially up to one in 20 boys will have experienced it. And that's, as I say, just one type of sort of type two trauma that that is prevalent. So it's, the prevalence rates are very high. And though we were going to go on to talk about PTSD, trauma can present in a multitude of ways. So after a type one event, probably only about 15% of people will continue to have PTSD symptoms after about 12 months after the event. So actually, for most people, the outcome is resilience. Though we're talking about the negative effects of trauma, actually, we should understand that for most people, the outcome is resilience, and they will process it and they will get through it.

 

Elissa Hatherly  06:09

Wow, I had no idea that type one traumas were so prevalent about 50% of our community, that's incredible. Of course, we all know that sexual abuse is much more prevalent than we've ever really understood before. But those statistics are still really frightening.

 

Dr Paul Henderson  06:24

Right. So if we were meeting a patient for the first time, or even someone who we knew quite well, and we suspected trauma might be at the heart of their presenting complaint, is it appropriate for us in general practice, for example, or seeing a patient in the emergency department to flag whether or not trauma might be behind some of their presenting complaint? Or is it better to refer them on to a psychiatrist or a psychologist so that they can explore that potential in a safe space?

 

Dr Paul Henderson  06:24

Yeah, and if we if we think about other aspects of PTSD, maybe 15% of people would develop it, but with with thinking mental health outcomes, depression, anxiety disorders, substance use disorders, psychotic disorders, adjustment disorders, somatization disorders, abnormal grief reactions, and even at times OCD. Those are these are all mental health disorders that can be triggered by a traumatic experience. And as well, also, we need to think about physical health disorders. There's a seminal study called the Adverse Childhood Experiences Study, which was done in the late 90s in the States, and it recruited about 17,000 people in two cohorts. And they looked at 10 different adverse childhood experiences, all the way from parental divorce, to somebody in the household having mental health problems, through to poverty, domestic violence, childhood sexual abuse. And really, when you look across almost all physical health outcomes, cardiovascular disease, cancer, autoimmune disease, the more of those events that you've had in your childhood, the more chance that you have of experiencing that sort of negative physical health outcome in the future. And once you get over four, four events, the rates of all those physical health problems significantly increase. So somebody, somebody doesn't even have to be presenting to you with a mental health problem. If somebody is chronically physically unwell at an early age, it's also just worthwhile having in the back of your mind has this stemmed in some form of childhood trauma,

 

Dr Paul Henderson  08:36

I think it's absolutely appropriate to screen for trauma, in primary care or in ED. Because, you know, in a step care model, there's a number of things that can be done in those settings, before onward, ongoing referral, that can really help a person at the time of presentation. And just simply the question of, you know, and which, depending on how you state the question, but most simply, have you been traumatized in your life that on its own can be massively important because actually much of the time that aspect of a person's care is avoided for for many reasons that we can come on to talk about both within our system but also within the person themselves. And so just indicating that you're interested to understand if somebody has had a traumatic event in their life can actually really open the doors to them wanting to engage and access treatment with you. There are certainly you know, challenges in doing it in primary care or within the ED or within general hospital settings. That you know, the first of which is we are constantly time pressured, and constantly overloaded. And actually when somebody discloses trauma, what you need to do is to be able to give them some time to be able to say whatever it is they need to say about it. But yeah, the way that you can you can, you know, start the conversation is you know, you're telling me this, you know, when whatever this presenting complaint is and a number of people that I've seen that have similar problems have also experienced some trauma in their life. I'm just wondering, you know, have you ever experienced any traumatic events that you think are continuing to, you know, have an impact on you just now.

 

Elissa Hatherly  10:14

Right. So then for patients who self-declare that they have experienced traumatic events, or in whom your suspecting what would be our next steps, once we have started to uncover some of those concerns?

 

Dr Paul Henderson  10:28

Well, I suppose if we start with people who you're suspecting and maybe with that open question, they haven't felt confident enough to say something. But nonetheless, if you still have a sense that the there's something that they're ashamed about that they're a little bit reluctant to talk about, then a different way of going about it and actually, the evidence shows that going about it this way is probably gives more reports more elicits more reports of trauma than just asking questions, is to provide a screening questionnaire to them that they can do on their own. And there's a number of screening questionnaire that's out there. But I've in the show notes, I've included a one called the life experience questionnaire, which is a simple page of A4, I think it covers somewhere between 10 and 50, different types of trauma. And it's something that somebody can go away, and sort of in their own time and dispassionately just tick a box as you go as they go down the list. And the next time that you see them in whatever setting that is, that may then allow you to start exploring it more fully.

 

Elissa Hatherly  11:26

So Paul, if someone discloses trauma to me as a clinician, how do I go about discussing it with them? And what are those next steps?

 

Dr Paul Henderson  11:35

Yeah, I think this is, you know, this is a really important part, because I think this is the part that, understandably, a lot of people, clinicians don't feel confident about. And that's what can lead to, you know, avoidance of asking questions, you know, the fear that they will not be able to handle this discussion in a sensitive way, you know, the fear that they may be may re traumatize the person, which actually, if you just have time to listen, you're non-judgmental, and you're compassionate, the chances of re traumatizing somebody is very small. And it's also not mistaking the fact that yes, people may be getting distressed when talking about their trauma, but that doesn't equate to being re traumatized. And actually, you know, you would often expect people to get distressed by talking about their trauma, but that's fine, as long as you have the confidence to be able to contain that with them, and continue the discussion with them. So I suppose, you know, just in situations where we're unsure, I think it's always good just to go back to basics. So what are the outcomes that you wanted from the discussion? So really, you know, at its most basic, you want to know how the trauma is affecting somebody, it's not important to really know the details of the trauma and anyway, so you know, have confidence that you're not going to be exploring the trauma in a detailed way. And actually, that is something that you probably do want to avoid, to some extent, because doing that, within an unskilled way, can be where, where people get really traumatized. And then also, you know, so understanding how it's affecting the person, and then by the end of the discussion, how can we start the process of maximizing the chance of recovery? So within that, you know, you're, you know, it's about understanding the barriers to the conversations, yeah, the person's own shame, the person's previous negative experience of, of trauma, your own experiences of trauma. So these are sort of things that you may want to reflect on beforehand, when you're thinking just impacting a trauma informed condition, understanding what the person's expectations are for treatment, understanding what can be done in the immediate term, you know, what you can do in that discussion with them that from that point on which you can be helping them. And also, then we'll be talking about what can be done in the longer term from a formal treatment point of view. And so if we're thinking about the structure of the conversation, again, it's back to basics. So it's the presenting complaint. And in that, you know, you're really starting up front by reassuring them that, you know, I don't need you to tell me everything about the trauma that you've been through, what's most important for this discussion is that I understand how the trauma is affecting you. So please feel free to tell me as much or as little as you want about the trauma. So already, that you're starting to overcome a barrier there about the person's fear about what they're going to say. You'd probably also want to be talking about confidentiality, because another barrier is what's going to happen with this information. And that's particularly relevant if somebody is still in a traumatizing situation. So in a domestic violence relationship, you know, if they think you're going to take the information and report it to the police immediately, and that's going to actually mean more trauma for them, then the chances of them talking to you are pretty slim. But you also do need to sort of caveat the confidential discussions, you know, along the lines of well, but, you know, although what we say is confidential, I have to say if you do tell me something that makes me fear that anyone is still significantly at risk it may be that we that I can't keep what you told me confidential and that allows that you know, that's honesty but it also allows the person to couch the conversation in a way that they can still have it. But if there's things that they want to hold back, because of that, and they can, and that's not ideal, but it still allows the conversation to be had in a way that can then lead into further conversations. You may also want to ask, you know, have you told anybody before, because often people will previously have disclosed and had a negative response. So classically, particularly with a childhood, childhood sexual abuse, children will have disclosed, and their disclosure will be minimized, or they'll be told you're lying, or you're imagining things. And you can imagine that, if that's been their experience, the chances of them wanting to explore things, again, is much, much lower. So if you understand they've already had a bad experience, you know, say so what was it that was difficult about that? And then that can understand how, you know, let you understand how you can specifically couch your conversation to try and be the opposite of what their previous negative experience was. And also, you know, if they said, if they say that they haven't told anybody before, you know, thank them, I really appreciate that you put enough trust in me, that you've been able to tell me this today. And I hope that by the end of the discussion, that we can start understanding how we can help you move forward from this. I suppose the one sort of special case within the presenting complaint is children disclosing trauma, because that's something that, you know, essentially has to be reported to child safety. So if we think you're moving on to the history, because then the complaint is, then how is it you know, how is this affecting you? And, you know, just as with any history, you're starting with open questions. So, you know, how do you think what happened is affecting you now? So just nice and open. And then, you know, slightly drilling down into slightly more closed questions: has it made you think differently about yourself?, because a lot of trauma really affects a person's self-worth their sense of their self, that causes them develop to develop a lot of shame. And you can start getting that sense with that open question. Has it affected your, your beliefs about other people has it affected your trust in other people? Now, you know, if it's a natural disaster, or a car crash, or something like that, it's not an interpersonal trauma, probably not. But if it isn't interpersonal trauma, and they're massively distrusting, then you need to understand that that's going to be a significant barrier to doing a lot of self-care things, but also accessing more formalized sort of treatment going forward. Thinking about shame, a lot of people will believe that, that what has happened, has happened because they deserve it to happen. And that is a massively corrosive self-belief. So you know, if you're feeling confident enough in the area, this area, you may actually want to ask that question, do you think you deserve it, because you really want to right from the outset, be countering, and gently challenging those beliefs, you know, there's nothing that you've told me so far, that would suggest that you deserve this. And really, for me, it sounds like this, this, the responsibility lies with the person that did this to you. Because if you believe you deserved it, then you there's also a good chance that you don't, you don't deserve to access treatment, and you don't deserve to feel better. So you know, trying to expose that belief early on, will be quite important as well. And then drilling down into more sort of closed and symptom specific questions. So, you know, are you feeling more anxious since this happened? Is it affecting your mood? Is it affecting your sleep? Are you feeling more irritable? Are you feeling emotionally numb, and people can have this horrible situation in which they go between anxiety and anger and numbness. So they don't feel any positive emotions and the only emotions they do feel are really horrible. And that's, that's not an uncommon in people that have been traumatized. Is it impacting any of the important relationships in your life, particularly if people are feeling emotionally numb, they will also feel quite distant in their relationships. And also, quite importantly, are you avoiding anything? Are you avoiding doing anything because of the way you feel at the moment, because it's important to understand that are there, have they started to avoid all the positive things in life or many of the positive things in life, that could actually be helping them get through this in the short to medium term, then you sort of move on just very briefly into drug and alcohol history, you know, since this has happened, have, you know, you know, there might be drinking has that changed, have you know, the amount of cannabis you're using has that changed? Because, you know, it's a very common coping mechanism to use drugs or alcohol to, to numb the negative emotions you're feeling or numb the shame that you're feeling. And clearly, if that's the case, you're giving yourself a much higher chance of not processing the trauma. So again, that will give you an idea if that's an area that you're going to need to work on when you're thinking about treatment plan. Obviously, with this sort of thing, it's thinking about the immediate treatment, it's important to then move on to think about risk. You know, since this has happened to you, have you ever felt that it's not worth living anymore? Or have you ever felt that you know, you've ever thought about harming yourself? Have you thought about suicide? So because obviously, if that is the case, you may need to be thinking about sort of safety plans in the short term and immediate ongoing referral. If somebody's telling you yeah I really don't know how I can cope with this anymore, then, you know, referral to the acute care team is something that you may have to do there. And then lastly, sort of, you know, once you've sort of concentrated on the more pathological side of things, you know, starting to think about what are the more positive things, what are the things that you can draw on? So what are your social circumstances at the moment? Who's important in your life? Who can you rely on? Who can you connect with? And even if you've withdrawn from the moment who is potentially there that could help you through this? And then we can moving on to think about more specifics, specifically about immediate treating plan, it's really important to ask the person, so how do you want this to go? You know, they may say, yeah actually say, to you actually, I'm just really happy, I've told somebody, and I don't want anything else at the moment, I'm not prepared, I don't feel like I'm in the right place to deal with this in the moment and that's absolutely fine. If trauma is ongoing, or if the symptoms of trauma are ongoing, the person really needs to be in the right place in their own minds to start addressing them. Because if you start addressing them too early, or you try to start sort of forcing somebody to address them too early, they're just going to withdraw and avoid and actually, you're going to get the opposite outcome to what you want. And in that case, you know, for you know, for a general practitioner, it's a sort of holding pattern, you know, you're talking, you're going to be giving them advice that will go on to talk about the generally healthy things in life, and then bring them back and just see how they're going, you know, are you ready to start addressing it or, you know, as we mentioned before, the a lot of people have these traumas, symptoms will naturally start to improve anyway. And so you get an understanding that we don't have to do anything more formal. So once you once you know, what the person's expectations are, you know, all the,you know, thinking about all the generic things you do. So psychoeducation is enormous, you know, explaining, well, you know, because the links between trauma, and all the different ways it can affect us, there not a lot of common, you know, anxiety, obviously sleep to some extent, but a lot of them are not sort of common sense. And so it's going to sit down with the person and say look these are all the common ways that that trauma affects you. But also what's really common that after a matter of weeks, or a matter of months, these will gradually lift if you just do the right things for yourself in life. And you shouldn't, you know, even though it feels absolutely horrific now, you know, for most people, you shouldn't have to worry that it's going to continue feeling like this, you're going to continue feeling like this. And if you do continue feeling like this, then there's a number of things, different things that we can do at that point. But at the moment, these are probably the, you know, the basic things you need to be doing for yourself. And before gets sort of necessarily going on to the generic basic things, you can also, you know, take a strength based approach by asking the person so you've been through this really tough event, you know, it's common for tough events to happen in life, how have you coped with in the past? You know, what have you done that's been really helpful for you in the past? And actually, they may say, well, I haven't been through any hard events. And you can say, well, what do you think, you know, what do you think of what do you think are your strengths? What do you think are the aspects about you, that you might be able to bring into play here that you can help yourself so so that, you know, allows you to obviously talk about the generic stuff, the person said, look, I really love playing my guitar, I haven't picked it up since this happened, you know, you may start encouraging, Well, Julie, you could start doing that again because if that's something that gives you a bit of pleasure, a bit of joy, a bit of meaning, then doing that, again, something like that, that's just a wonderful natural counter to the effects that the trauma is having on you. So when we're thinking about the more generic stuff, you know, as you know, sleep is so important. Maintaining social contact is really important, but often a real challenge for many of the people we see, and often they haven't really had much social contact before the trauma anyway, minimizing avoidance is enormously important. You know, because that becomes a self-compounding situation and your anxiety about going into the situations that you're avoiding, would just keep building and building over time, minimizing your drug and alcohol use, if that's a particular issue, maximizing your nutrition, maximizing your exercise, and, you know, potentially doing something like breathing exercises, that's a lot, and you're not going to throw all that at somebody at once. So, you know, if somebody just isn't sleeping well, you know, maybe concentrating on their sleep, concentrating on trying to maintain social contact, concentrating on minimizing drug and alcohol use, and concentrating on trying to minimize avoidance and, you know, employing any of the strengths that that that a person has already reported to you and sort of sort of bringing them into action. And I suppose, then, that sort of can be where the conversation concludes. So, you know, I've understood how this has impacted you. I've had a discussion with you, to help you understand more fully about how it's impacting you. We understand what strengths that you could be bringing into the situation at the moment, we understand what are the things you probably shouldn't be doing that could make things worse, and we understand things that you ideally you could be doing to help you process and recover more quickly. So I suppose the last thing that comes to mind is what happens in the situation that we fear the most, and somebody just gets really, really emotionally distressed during the discussion. And I suppose for somebody that is traumatized, that probably means they're being in their mind, they've been taken back into the traumatic situation. And they are either sort of having a flashback potentially, or just lots of, you know, the memories which are just flooding through their mind, or they're experiencing all the emotions that that were there at the time of the trauma. And if that's the case, you know, you would you would be explicit about that. You know, I can see you know, the discussion, you know, understandably, is, really upsetting you. So let's stop talking about it now and we can maybe come back to it the next time we meet. But I think at the moment, let's try and just help you feel a little bit less distressed at the moment, and just changing the topic may be enough for somebody else. So if you know somebody reasonably well, and you know, that they have a really positive relationship in their life, so you know, you know, whether that's their husband, their wife, their child, their grandchild, you could just ask them to talk about that person, because naturally that will bring them their mind away from the trauma or, often will. And it will. And because that person is associated with a lot of positive emotion, hopefully, that that will allow the positive emotion associated with them to replace the negative emotion that is associated with the trauma. So I know you have a really good relationship with your grandson Johnny, tell me about, you know, tell me more about what he's up to at the moment. And that can be enough of a change of direction to, you know, to minimize the distress and just take the person out of the mindset that they've got into. If that's not enough, then you can just be a little bit more sort of start to sort of introduce some basic psychological first aid. And so what you can say, there's a number of different ways you can go about it. But you know, if they're breathing very quickly, you could say ok, you know, it looks like you're probably reading a bit too fast and that's making you a bit more anxious so why don't we just sit and do some slow breaths for a minute, and you will do that with them. And the important thing, when with any breathing exercise, is that the out breath is longer than the in breath, because that's how the, that's where the parasympathetic nervous system is stimulated. So you could sit down and go, Okay, we're going to breathe in through our nose for four, take a little pause, and then we're going to breathe out through our nose for six. And you can just do that with them. And you're counting in for four, and counting out for six. And if you do that for a minute, a lot of people will start to be able to calm down or feel less emotionally distressed. And lastly, you know, if somebody is really sort of stuck in a flashback, or the memories, it's about grounding them in the moment, and the breathing can be enough because you can get them to actually concentrate, concentrate on the sensations of the breath, not just slowing the breath, but say to them, okay, well, why don't you feel actually how that breath is when as it goes in and out of your nostrils? Or can you feel your breath in your belly, and that is taking their focus away from the trauma and into the here and now. Or you could say, how about we just do a little bit of grounding exercise, and I've put some grounding exercises on the show notes. And what this is about is just bringing your focus to the here and now. So why don't you tell me five different things that you can see in the room? Because grounding exercises, use any of your senses. So that's obviously a visual one. Or you're sitting in the chair at the moment, why don't you put the hand your hands on the arms of the chair, and just tell me what the arms of the chair feel like. So anything that really activates any of your senses, and classically, actually smell is the best one. But often, we don't have anything that's really strongly smelling about. But if you're if you happen to be sitting with a woman, and you might say, tell me, have you got any perfume in your bag? Do you want to bring it out, and do you want to smell the perfume and tell me what it smells like? Because classically speaking, those, those can be the strongest and most profound, grounding exercises that can really bring somebody out of a lot of emotional distress quite quickly, if done well.

 

Elissa Hatherly  28:15

So if they do score highly in terms of trauma, do they, are they best served by seeing a trauma specialist? Or would any psychologist have the skills then to help those patients work through those traumatic events?

 

Dr Paul Henderson  28:30

I suppose I hope in this day and age where trauma informed care has been much more prevalent, particularly within psychological circles for you know, probably the last 10, 15, 20 years that any psychologist should be in a position to be able to provide trauma informed care, now there’s lots of different psychological approaches to trauma informed care. And, and in particular, psychologists may be more skilled in one approach compared to another. But equally, having said that, you know, the research base, which suggests that whatever trauma informed approach you use, will generally be as beneficial as another, although for individual people, you know, no doubt one particular approach may be more beneficial than another. So yeah, so you shouldn't necessarily have to refer to somebody who specializes in trauma informed care, but if you know if somebody is very highly traumatized and very complex, the Blue Knots Foundation, which is the sort of peak body, in non sort of non-governmental organization within Australia, for people that have experienced complex trauma, so that type 2 trauma, they do have a referral service where they can identify, they can they can provide information on on psychologists around the country that can provide very high levels of trauma informed care, and that's also a link that I will include in the in the show notes for you.

 

Elissa Hatherly  29:50

Fantastic.

 

Elissa Hatherly  29:51

So you did mention that resilience is incredibly important in recovery from trauma and what are some of those factors, those protective factors in our patients that make them more likely to experience that resilience and have a less negative outcome from their trauma.

 

Dr Paul Henderson  30:13

That's an interesting one, because a number of them are not having a number of negative experiences already in life. So you know, less experience of trauma, less experience of social isolation, less substance use less preexisting mental health problems. I suppose when you flick around, all those other things give you a higher chance of having a negative outcome with trauma. If you're if you're thinking more sort of from positive basis, I suppose, having enough emotional intelligence to some extent, to recognize the impacts of trauma on you to be able to reach out to your natural friends and family and support systems to be able to discuss and process it within the relationships that are closest to you, without necessarily having to rely on professional relationships to help process it, doing the all the sort of self-care, things that we know are generally helpful for mental well-being you know, whether that be nutrition exercise, sleep is a massive one, if you're not getting enough sleep right from the outside, from the outset, whatever you're doing, everything else is going to be so much harder. So yes, there's a number of sort of different factors. And I suppose, you know, going back to childhood, the quality of your relationship with your parents is a really important one, the better, the more supportive, the more nurturing, the more loving a relationship you have with your parents, the more likely you will be able to, you'll have developed the skills of emotional regulation yourself of emotional intelligence, that will set you up to be more resilient if you experience trauma later. And conversely, you know, unloving, critical, cold, judgmental parents or relationships will leave you at much higher vulnerability for having negative impact on your mental health if you experience trauma in life. And to be honest, you know, having a negative or cold or critical relationship with your parents is traumatic in and of itself. And that's a really good example of a type of trauma that can have massive consequences in later life. But nonetheless, it's completely missed when we think about purely the very type definitions around PTSD.

 

Elissa Hatherly  32:18

Right. So moving on to PTSD, then Paul, how do we diagnose it you mentioned earlier, it has really narrow criteria for the definition as a as it appears in the DSM.

 

Dr Paul Henderson  32:32

Yeah, so in DSM, they have what is called criterion A, which is the criterion that you must satisfy before considering all the rest of the criteria to have a diagnosis of PTSD. And their wording is exposure to actual or threatened death, serious injury or sexual violence in one of them or one or more of the following ways. And that's including direct experience within yourself, witnessing it in another person, or learning about it from another person. And that's that latter bit is where vicarious trauma comes in, into play.

 

Elissa Hatherly  33:02

Right. And so then the current best management, that's with psychological therapies, isn't it?

 

Dr Paul Henderson  33:09

So it usually would be with the probably with a combination of psychologically psychologic therapy and pharmacological therapy. And which is not to say that everybody has to have pharmacological therapy or psychological therapy, you know, a lot of it will come down to personal choice, because if you put no stock in pharmacology, then in pharmacological or psychological therapy, the chances of it, you know, really being helpful for you are fairly small. So if we think about sort of psychological therapies, just a general trauma informed approach is important. Trauma focused CBT is a well recognized approach. Narrative exposure therapy would be a well recognized approach. EMDR would be a well recognized approach, cognitive processing therapy would be well recognized approach. But there's probably another 10 or 15 therapies that other psychologists could engage in. If we think about sort of more complex trauma, things like EMT, sorry not EMT, DBT, would be a really appropriate way to sort of start approaching that with the person as well.

 

Elissa Hatherly  34:15

So that's a lot of options for management in terms of psychological therapies. That's reassuring, but as you say, you really have to have buy in from your patient to engage in either the psychological or pharmacological therapies. So developing that sound and positive therapeutic relationship is the key to all management for all conditions across the vast variety that we see, isn't it?

 

Dr Paul Henderson  34:39

Absolutely. And actually, the evidence base in psychology shows that probably 80 to 85% of the benefits of a psychological approach is nothing to do with the type of psychological approaches that has been taken and everything to do with the nature and the quality of the relationship you have with your psychologist. And I think that would expand to the nature and you know, you know, outside psychological approaches You know, the nature of relationship you have with your treating doctor as well, whatever, whether it's primary care or within a specialty. So what I always sort of coach patients is that, you know, you've got your mental health care plan, you've been referred to a psychologist, if in the first couple of sessions, you're sitting down with them, and you don't feel that you gel with them, you have a sense of, they don't quite understand where you're coming from, or even if they do the treatment approach that they're taking, you know, doesn't necessarily gel with you, you know, if you feel assertive enough, have that conversation with them. But otherwise, just understand that you need to gel with your, with your psychologist or psychiatrist. And if it's not working, then have the confidence to say, Okay, I think I'm going to go and try and meet somebody else that that I do gel with. And that's really hard, because it goes against sort of general kind of social rules of not wanting to upset people not wanting to disappoint people, but it's also really hard, because the chances are that you'll have waited on a waiting list for 2,3,4 months and then if you get there and all of a sudden, it doesn't seem to be what you need you think oh really I have to go through this again, maybe I'll just stick with this. But to be honest, going somewhere else, if you know, because just sticking with it. If you're not gelling with a person, it's probably not going to get you very far, unfortunately.

 

Elissa Hatherly  36:06

Okay, so troubleshooting with the patients, if they're not achieving a really good therapeutic alliance with their treating psychologist or psychiatrist, have the confidence to make a change. And we say that to our general practice patients too all the time, don't we, not all GPs are right for all patients. What are the best pharmacological therapies? You mentioned there are a few. Can you talk about those in broad classes, please?

 

Dr Paul Henderson  36:35

Yeah, so really, the place to start is with an SSRI. And the also in the show notes, there's the Phoenix, Phoenix, Australia, PTSD guidelines. And that really, you know, details everything to do with the treatment of PTSD and the most up to date, evidence base, and they refer to Sertraline, Fluoxetine or Paroxetine as a good starting point. And I suppose I would have, although Paroxetine can be a wonderful antidepressant, I would have a little bit of caution about it with anybody that you fear won't be really consistently compliant, because it has really significant rates of withdrawal, even after just missing one dose for some people can actually be a pretty aversive reaction for somebody who is not able to take it day in day out. Fluoxetine, on the other hand, is absolutely the opposite. You know, if you take it for two weeks, and you stop, it'll still be in your system for 10 days. So that's a medication that can actually be pretty good for people that are struggling with compliance, obviously, you know, the less compliant you are, the less chance it's going to be beneficial, but at least you won't be getting withdrawal effects. Sometimes it can be a bit stimulating. And so for people that are very agitated as part of the trauma response, you may want to think twice about Fluoxetine, and then something like Sertraline can be pretty, pretty helpful from that point of view, because it tends to be better tolerated than almost any other antidepressant.

 

Elissa Hatherly  38:02

Okay, so any other tips and tricks or troubleshooting go to's for us please?

 

Dr Paul Henderson  38:11

I think, as I mentioned before, sleep is really important as a foundational foundation stone of any form of recovery. And so trying to get sleep right is really a necessity in whatever you're doing. And, you know, and that starts from just all the basic sleep hygiene stuff, you know, how much caffeine your having in the day, you know, what are the distractions or noises or light levels within your, within your bedroom? How much screen time just running up to bed, you know, are you working late and your brains really busy before going to bed. So just, you know, all the general sort of sleep hygiene rules apply. And but I suppose in my mind that if there, if there's a trauma response that is causing sleep problems, the sleep hygiene stuff will stop it getting worse, probably you will stop, it'll stop you doing things that make it worse, but whether it will then actually help it improve that's, I suppose a different thing. And then, you know, so then you're thinking, well, if somebody is having a lot of nightmares, Prazosin can be really good as a direct treatment for trauma related nightmares. And in that case, I would usually start at somewhere between 0.5 and two milligrams depending on the person. So you know, a reasonable size adult, reasonably aged adult that doesn't have any problems with low blood pressure, I'd be happy to start them at two milligrams. But somebody who's frail and elderly possibly has problems with low blood pressure I'd start them with 0.5. And you can work up in a stepwise manner to potentially up to 10 milligrams. And my experience is you often see a gradual stepwise improvement as you do work up the dose. And I would give somebody you know, probably a couple of weeks on a single dose before deciding whether to take the next step up or not. If nightmares are not a particular concern then some augmenting with something like Mirtazapine to whatever other antidepressant you may choose, or, you know, simply using Mirtazapine on its own, though, it's actually interesting it's not in the guidelines, but nonetheless, you know, starting Mirtazapine at 15 milligram grams at night can be very helpful for sleep. A lot of people, you know, respond well to Phenergan between 10 and 75 milligrams, and remembering with whatever you're doing with a sort of sedative medication, that for people that are experiencing hangovers in the morning, that can be really off putting, as long as it doesn't knock them out as soon as they're taking it then you can bring it early and earlier in the evening, and some people will even just take these medications after dinner, they will you know, will not be sedated enough that it makes them go to bed at half by seven. But it does relax them enough that they can get off to sleep reasonably without having too much of a hangover in the morning.

 

Elissa Hatherly  40:46

Thanks so much for joining us today Paul to talk about trauma and PTSD. Of course with PTSD, there's more than one criterion for the diagnosis. We've only really touched on criterion A today, but we'll add the additional diagnostic criteria to our podcast notes. So we've talked about so many things. Particularly I think, for me the importance to remember that the outcome of trauma for the vast majority of patients and friends and coworkers is of course resilience, and that we shouldn't be shy when we're starting a conversation about trauma with our patients, or with anyone else for that matter and the importance of good social supports and self-care as part of that resilience piece, and part of recovery from traumatic events. Thank you so much for your time. For more information about the roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 6: Voluntary Assisted Dying

From 1 January 2023, Voluntary Assisted Dying (VAD) will be made legal in Queensland. It means eligible Queenslanders will be given the option to request medical assistance to end their lives in a manner that is safe, accessible and compassionate.

It’s a sensitive and important topic for us to be discussing as a medical community. So join your host, Dr Elissa Hatherly, as she chats with FACRRM GP and JCU MBBS Alumnus Dr Max Ryder about VAD, the legislation changes, and how we care for our terminally-ill patients in regional, rural and remote communities.

Resources

QLD Health Voluntary Assisted Dying in Queensland

https://www.health.qld.gov.au/system-governance/legislation/voluntary-assisted-dying-act

Link to register to join the QLD Voluntary Assisted Dying Implementation Conference

https://www.health.qld.gov.au/news-events/events/qh-events/queensland-voluntary-assisted-dying-conference

Transcript

SPEAKERS

Dr Elissa Hatherly, Dr Max Ryder

 

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Welcome to this podcast on voluntary assisted dying. I'm joined by Dr. Max Ryder, who's a doctor in Proserpine and working in the community in palliative care. Is that right Max?

 

Dr Max Ryder  00:52

Yes, somewhat correct. I'm employed by Queensland Health through Proserpine as a rural generalist obstetrician. And I've started working privately through a GP practice here locally, to provide end of life, palliative care for people in their home.

 

Dr Elissa Hatherly  01:07

So you must have been really excited when the voluntary assisted dying legislation first passed at the end of 2021 to give your patients some more options.

 

Dr Max Ryder  01:18

Yeah, it's been a big landmark release from the Queensland Government, we're catching up with Victoria, and WA at the moment. And we're now developing our own pathway to support people who inevitably suffering with a terminal illness and they're wanting to exercise their right and the option to request medical assistance for the end of their lives.

 

Dr Elissa Hatherly  01:44

Okay, so with that new legislation introduced at the end of last year, I imagine 2022 has been a really busy year, for everyone involved with voluntary assisted dying to engage with the stakeholders and develop those pathways. Is that what you've been involved with?

 

Dr Max Ryder  02:00

Yeah, so I've come about halfway through that development process. It all started with setting up the voluntary assisted dying unit, the VAD unit down in Brisbane, and there are a group of people that have been working on developing a lot of the policy structure, protocols, navigating all of the all of the issues that they've they've found from Victoria and WA, and trying to put a package together that could be presented to the health care services. And so I've joined as a representative for our Mackay health service alongside Melissa Harris, who is a palliative care support CN in Mackay Base Hospital. And we're now taking it forward to try and implement that locally to make sure it meets the the very demands of very diverse, geographically spread out healthcare service, such as our region here.

 

Dr Elissa Hatherly  02:56

Yeah, you're right, diverse is an understatement for our HHS, that's for sure. So for the patients who are coming to end of life, I imagine there are quite strict eligibility criteria that they would have to meet before they can go down the voluntary assisted dying path. Can you talk us through that, please?

 

Dr Max Ryder  03:14

Yeah, that's right. So there's, I suppose two ways to look at it. There's eligibility criteria for the patients, but also eligibility criteria that clinicians and that includes doctors and nurses need to have in order to assess, discuss and help implement the process of voluntary assisted dying. So for patients, our criteria are a little bit different to Victoria and WA ,they have somewhat been refined. And they've done that in a way to try and ensure that a very general level of medical training is required, and not relying upon specialties to help get people through this process. So people need to have an advanced progressive illness that will cause death, and is expected to cause death within 12 months to the best of the clinicians understanding and it must be causing suffering that the person considers to be intolerable. And I guess that's a really important part because we need to make sure that people are having a full assessment in terms of their current symptoms, and if they can be better managed. And that includes ensuring good palliative care, which is a different chapter to voluntary assisted dying. And this is, this is an end of life option, as opposed to a management of symptoms potentially, like palliative care is. They need to have decision making capacity and acting voluntarily without coercion and they need to be at least 18 years of age and fulfill residency requirements. So that's the five point checklist of eligibility that gets assessed by two different clinicians on two separate occasions. And we'll put a flowchart up for people to see hopefully that the title for these clinicians is either a coordinating practitioner so someone who is the is the key person responsible for helping to support someone through the process. And then a consulting practitioner, which is a doctor that double checks the eligibility criteria to make sure they're met. And then, together with those two people signing off, then they are supported with the voluntary assisted dying unit in Brisbane to make sure that all the checks and balances have been met before an administration decision can be made. And then a plan can be enacted to support that person should they wish to go through with the voluntary assisted dying administration.

 

Dr Elissa Hatherly  05:40

All right. So that's a really important point, isn't it about the difference between voluntary assisted dying and palliative care. I think a lot of people in the community think of voluntary assisted dying as a requirement. Where as from a clinical point of view, it's really palliative care that the vast majority of our patients really need assistance with, and that voluntary assisted dying is only for a very small subset of those patients. Would that be your experience?

 

Dr Max Ryder  06:04

Yeah, that's exactly right. And and when we talk about voluntary assisted dying, there's two, two categories, I suppose we've found in the other states that there's a large percentage of people that will go through an eligibility assessment through this rigorous process and get their authorization to be eligible and be able to undertake a voluntary assisted dying administration, however, they don't actually go through with with that administration. And what we've found is that people find that comfort knowing that they have an alternative option. And a lot of these people who are still having decision making capacity, and still potentially 12 months away from death, just like to have the option available, should their symptoms become intolerable and deteriorate quickly. Because obviously, this process is going to take a matter of weeks to potentially a month or so depending on how streamlined that process can be for that patient.

 

Dr Elissa Hatherly  07:00

Sure. And of course, locking in their option before they potentially lose that decision making capacity would be incredibly important for those patients.

 

Dr Max Ryder  07:07

Yeah, that's, that's correct. It's all part of good, good medical counseling about their condition, their symptoms and their progression at a very early stage rather than people coming in necessarily just to talk about voluntary assisted dying, I think.

 

Dr Elissa Hatherly  07:20

Right. And you mentioned also in the eligibility criteria, the importance of fulfilling residency requirements. So to the voluntary assisted dying, patients in Queensland need to have been Queensland residents for a certain period of time?

 

Dr Max Ryder  07:35

Look, I'm not quite sure on the exact details of the residency requirements, I would suspect that that they would need to be Queensland residents and have a Queensland address would be my assumption is what that does refer to,

 

Dr Elissa Hatherly  07:49

Certainly by the end of this consultation period before those final plans and processes come into place, I imagine the government will make a decision about that for sure. So we've talked a bit about the eligibility for the patient. Can you talk to us a bit more about the eligibility for the clinicians? And you were saying there are two clinicians that need to be involved?

 

Dr Max Ryder  08:14

Yeah, so I think the first thing over arching is the clinician, whether it be doctor or nurse being involved or any any practitioner for that matter whether it's speech therapist, social worker, they have a right to conscientious objection as an individual practitioner, it's important that if they do object to discuss, be involved in in that process, so they do inform the patients early, and they do offer them support to access the service, either through the Central Support Service or an actual clinician they're aware of. The important thing to make note of is that entities have been protected in this legislation. That means that all Queensland health facilities will be required to ensure people have access and entities won't have the right to withhold or deny people access to these this process, which is a little bit different to what has been experienced particularly in our health service with regards to medical and surgical termination of pregnancy, which has been in our health service been objected to, since my involvement in the HHS, but when we talk about the role of the medical practitioner, there's a few criteria the the most general term is that a general registration must be held for at least five years. So that's looking at roughly a PGY 6 trainee who's not on a specialty, has not had reached a specialty level or they may hold a specialty registration for at least one year. And that could be general practice. You know, physician training, whatever it may be. There's no specific requirement to have a field of expertise. You must have an expected level of medical training and then go on to conduct the appropriate online training to make sure that you, you are able to be one of these practitioners involved in the voluntary assisted dying process.

 

Dr Elissa Hatherly  10:08

Right. So you need to have gone through the process as a patient looking to achieve the voluntary assisted dying requirements, you need to go through a process with two different people, one of whom must be a medical practitioner of at least five or six years standing who has completed the training, which is an online training option. And then the second person who has to give an okay, that could be a nurse or a social worker or speech pathologist, is that correct? Max?

 

Dr Max Ryder  10:39

No, in fact, it's two medical clinicians that do need to sign off on this, the role of the nurse is delineated similarly, so they do differentiate between registered nurse and nurse practitioner. And the role of a registered nurse is that they can act as the administrating practitioner should the patient choose to have the intravenous formulation, they are able to discuss conversations about voluntary assisted dying, but not to initiate and nurse practitioners the main differentiation there is that they can initiate conversations about voluntary assisted dying whilst being able to administer as well. And they must meet the same requirements of online training and also have a level of seniority as well.

 

Dr Elissa Hatherly  11:28

Okay, so we've got two medical practitioners who are signing off both of whom who have conducted the appropriate training and then the administering person could be a nurse or a nurse practitioner who has also undergone the appropriate training.

 

Dr Max Ryder  11:43

Correct.

 

Dr Elissa Hatherly  11:44

When we look at the history of voluntary assisted dying in both Victoria and Western Australia that you mentioned, I imagine there are a lot of really great learnings that the Queensland team will be able to take from those groups. I understand that in Queensland, being able to fulfill the requirements for voluntary assisted dying, if you are expected to pass away within about 12 months is a little bit more generous than in Victoria. Can you talk us through that timeline?

 

Dr Max Ryder  12:16

Yeah, so there's there's two things there. There's one about the the eligibility criteria, which you refer to as ours is 12 months, there's is a lot shorter. And also in Victoria, they actually need to get involvement from their direct specialty, depending on their illness. So if it's a cancer, an oncologist, and a neurological condition a neurologist, which can be a bit of a burden for people in a geographically spread out area. And so that's why we've gone from a very general level of training, but made sure that there have been a level of experience. The second thing that differs from the states is the actual route of administration. So both states have the option for intravenous and oral. However, Victoria does state that they would like people to have the oral version unless there is a medical reason that they can, they cannot and that might be swallowing related absorption related concerns. So when when we're coming to our model, we work similar to the WA model where people get the option to choose between either or and that's a personal preference rather than a requirement. And what we're expecting is that when people do get the option, it seems that intravenous has been a more favored option from patients based on the WA data. And so I guess that's something that's worth noting, because it requires there for a nurse or a doctor to be involved in the administration as opposed to that patient taking home the medication and having someone observe them at home, who may be a family member or a friend to observe the process. So it will require substantial health care manpower to make sure we have enough people who are comfortable, administrating, administering the medications, which we know is going to be more potentially more confrontational for people to be involved in when you compare it to checking against the eligibility criteria and filling out the necessary paperwork.

 

Dr Elissa Hatherly  14:17

Sure. Okay. So in Victoria, I'm not sure about in Western Australia, but I know in Victoria, there have been quite a lot of people from regional and rural communities who have taken up the voluntary assisted dying option. The ability to have practitioners with more general registration involved in signing off those patients in the first place will make an enormous difference in our community, as you say, being so dispersed across our enormous state. Has the experience been similar in Western Australia? Do you know or have the patience being mainly those In the centres?

 

Dr Max Ryder  15:02

Well, I'm not too sure about the exact geography of WA, I know you are right in Victoria. General practitioners were responsible for a large percentage of almost all the percentage of regional and rural, voluntary assisted dying patients. I expect that that would be not dissimilar to our our snapshot as well. But it will be interesting to see the distribution. Obviously, large density populations will have inevitably more voluntary assisted dying episodes. However, as telehealth and especially the services are able to be given in regional rural areas, we find that there are lots of patients that remain in their rural and regional areas to receive their health care. And inevitably, that leads them to, to want to pass away at home through this process.

 

Dr Elissa Hatherly  15:52

So Max, how are we going to proceed from here? What happens next with voluntary assisted dying in Queensland?

 

Dr Max Ryder  16:00

Well, we're we're working on it at the moment, at our local level, we've developed a working group in this region, and that includes people from the hospital and also the community sectors, medical nursing, pharmacy, social work, indigenous liaisons, and we're working on our terms of reference to make sure that we're set up to help facilitate this rollout from the health care, HHS level trainings going to start coming online towards the back half of the year. And we'll start enlisting people to undertake the training and be prepared for the beginning of next year, January 1. And were working on building up our workforce to ensure that we have appropriate levels and staffing to support this rollout. So we're in the process of making budget requests to get access to medical nursing, and, and other allied health input to make sure we have appropriate staffing, because we are going to be predominantly holding on to this through the health service network. But also having a heavy involvement with the community as well as they step into our network to gain access to provide service, begin access to get training, and also to get involved with getting access to the drugs as well that are required.

 

Dr Elissa Hatherly  17:16

Right. So there's a lot of work to do, I imagine too Max, practitioners are probably looking at the skill set they already have around delivering quality palliative care to their patients in the community and in the HHS, what are some of the trainings that you undertook? Where have your supports been? How can people, medical practitioners in our region upskill so that they are more well prepared for patients at end of life?

 

Dr Max Ryder  17:45

Yeah, it's a great question. I mean, I guess we all we all do it innately. In any case, we deal with people who have these terminal conditions, you know, from the beginning of our careers and early in our training. And I think that this is a conversation that had been brushed aside when when people inevitably bring it up, asking for that relief that, could you help me end my life earlier. And now I think it's time that we, we relaxed our conversation, we explore by asking patients what what they mean by that and unpacking what their concerns and queries are. I think that we have the skills I don't think it takes a specialist of any particular kind to have these discussions about what end of life looks like for people if they were to have their, their their say in the matter. And I think that, yes, good palliative care is essential for these people because they have less than 12 months prognosis inevitably, will have symptoms that need managing. And yes, that does require more focused training. And I think in our health service, we rely heavily on telehealth services through Sparta and through one through PallConsult, and, and they're referral, they're referral networks that inevitably allow people to engage with palliative specialists and and learn from their experiences and learn from the way that they treat their patients. And so I think that it just takes a curious mind to ask more questions and, and make those referrals earlier. So that way people can learn, learn alongside their patients to see what what good palliative care can look like, in order to support people to make sure that this is the right decision for them. And that they have reached a place where their symptoms are well controlled or, or they feel that they've explored all the options to get to the point of having well controlled symptoms to satisfy a curious mind I think.

 

Dr Elissa Hatherly  19:36

Yeah, and for those of us in general practice, just talking to our colleagues can be incredibly beneficial too can't it. When I first started in Mackay, palliative care was delivered by senior experienced GPs and some of those GPs are still working in our practices, who have the experience in palliative care and are happy to take us on the journey with them.

 

Dr Max Ryder  19:57

That's right, and that goes to my point we've been doing it for a long time, we've been caring for people in their last 12 months and then their last moments of life, no matter if you're a GP or a medical oncologist for that matter. So I think this is just going to give us more more flexibility to have deeper conversations with our patients and really make sure we're meeting their needs. And you know, this isn't, this isn't something that everyone particularly signs up for and gets excited about. I think this is part of our job that isn't the most obviously pleasant thing. But you have to appreciate that, that we're here to serve our patients and our patients have been asking for this. And obviously the government has listened and that's why this is happening. It's something that is in demand from our communit and we should respect that and make sure we we do the right thing to support them.

 

Dr Elissa Hatherly  20:45

Thank you so much, Dr. Max. So we'll have training coming in an online capacity towards the end of the year, ready to roll out voluntary assisted dying for the patients who need it from the first of January next year. What are the other take home messages for today?

 

Dr Max Ryder  21:02

I think it's good to start talking to your patients and exploring the the idea about for these people who are in the last 12 months of their life. We're not waiting for January 1 for this to happen. We we want to start the conversations early so people open up and feel free to talk about their wishes and make sure that if there's something that's underlined, that needs to be addressed, it gets addressed to make sure that people are getting the best in their terminal illness and making sure they do achieve quality of life which is ultimately everyone's goal.

 

Dr Elissa Hatherly  21:37

Dr. Max Ryder, thank you so much for joining us today. We appreciate your time and your insights.

 

Dr Max Ryder  21:42

No worries. Thanks for having me.

 

Dr Elissa Hatherly  21:46

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 7: Sleep Solutions 

Sleep plays an important role in our overall health and well-being. For a variety of reasons, getting a good night's sleep can be difficult, and that's where more targeted treatment may come in.

Join your host, Dr Elissa Hatherly, as she talks to local pharmacist Karalyn Huxhagan about commonly used medications to treat insomnia, and pharmacist Glen Clark who provides insight into melatonin metabolism and its effects on sleep.

Transcript

Dr Elissa Hatherly  00:02

Welcome to the Round Up, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, we wanted to explore how we might manage patients experiencing insomnia using the wide variety of medications available today. Our first presenter is Karalyn Huxhagan, one of our local pharmacists who works particularly in rural communities. Hi, Karalyn.

 

Karalyn Huxhagan  01:01

Hi, how are you going today, Elissa?

 

Dr Elissa Hatherly  01:03

I'm very well. Thank you so much for joining us today to talk a little bit about the medications that we use in insomnia. I wonder if you could just start with talking about the different classes and when they might be useful.

 

Karalyn Huxhagan  01:16

Okay, so there are several classes. So benzodiazepines, which have been around for a long time, and the one that's most often used for sleep is Temazepam so it has a action of about six hours. So it increases your total sleep time. It has less sedation the next day, as long as the patient takes it at a reasonable time. And so I always say to my patients, you should take this after tea, normal bedtime, you can't take it at midnight or two o'clock in the morning, expect to get up and be good for the next day. The next class is what we call the Z drugs. So the Z drugs work definitely in the GABA area of the brain, they potentiate GABA, they're very good for people who are like, reps or traveling and that to improve sleep when in a short for a short period of time. But they do have a lot of issues and they shouldn't be used definitely with alcohol. That's that's a definite no. Their use is very much for a short term use to improve sleep.

 

Karalyn Huxhagan  02:34

Okay, so we can't use the Z drugs with alcohol, that would be because of that GABA activity. The same with the Benzodiazepines. Is that right?

 

Karalyn Huxhagan  02:44

Yeah, but the Benzodiazepines the effect is more the sedation and the increased effect on on the sedating effect with alcohol. But with the Z drugs, they have a particular way that they, the alcohol then causes them to go into that real GABA area and you get the hallucinations, you get the the really poor side effects. So patients have been found to go out of their house and get in the car or on a motorcycle and go for a drive with no awareness that they're doing it. I've had patients who get up in the middle of the night and do things like, you know, heap of baking, or they'll clean the house furiously. The the interesting area of when they discovered this was a problem was actually identified in England. In the first part where security personnel in hotels were finding that certain patients, certain guests were getting up in the middle of the night and going off and doing things and they had no clothes on. So they'd left their bedrooms, and we're wandering around the hotel with nothing on and doing weird things. And it got linked back to the use of the Z drugs and, and having alcohol with their meal or you know, a couple of beers after dinner or whatever. And it's, it's a very significant issue. So anybody that's using any of the Z drugs so Zolpidem or Zopiclone definitely should have no alcohol within their system within 12 hours. And this is a problem and it's well documented now with some very good research by people like Dr. Geraldine Moses, from Mater in Brisbane about the effects of, of what that Z drugs plus alcohol can do. It's a it's far more of a It's not truly hallucinogenic, but it's a total lack of awareness. And you know, it's been quite severe because people do some really bizarre things when they combine the two.

 

Dr Elissa Hatherly  04:49

Yeah, although I think cleaning the house without any awareness, I wouldn't mind I must admit. So then melatonin probably wouldn't have that same interaction with alcohol, is that right?

 

Karalyn Huxhagan  05:03

Correct. So, the melatonin is very much there to improve the circadian rhythm. So to get you back into a good sleep cycle, it doesn't have any potential to interact with alcohol. In Australia, the dose of melatonin is normally two milligram. Overseas countries do use higher doses. But Australia, it's registered at two milligrams. And it's registered for a use of up to 13 weeks to reset the circadian rhythm. It does have its place, it's certainly well tolerated. It doesn't make the person sedated and groggy the next day, it's been used in aged care a little bit because it doesn't have the same risk of falling as some of the hypnotics. So the benzos can increase the risk of falls so melatonin certainly being used, the downside of melatonin is its price not covered on the Pharmaceutical Benefits Scheme. So the affordability is one area for that drug, particularly in aged care.

 

Dr Elissa Hatherly  06:15

Right. So then the benzos, the Z drugs and the melatonin, they're a more short term use medication, it sounds like. Then looking at the orexin receptor antagonists, that's for people with longer term concerns, isn't it?

 

Karalyn Huxhagan  06:34

It is. And it's very much for a very small subset of patients who you really have to make sure you've done your homework in looking at all the other medications they're on and everything else that they do. It has a it's a got a tiny area of practice. But it's definitely for only for chronic insomnia. And it's a drug that when you start it, you must monitor that patient. I've had some severe adverse reactions with Suvorexant, but not in all patients. So it's just one that does have some other potential side effects. So you do have to monitor them, and they really, truly have to have chronic insomnia that the diagnosis is important for the use of that drug.

 

Dr Elissa Hatherly  07:24

Okay, so can you just remind me, Karalyn orexin is the protein, orexin protein B, the neuro peptides that help promote wakefulness? Is that right?

 

Karalyn Huxhagan  07:37

Yes. That's how it works. Yeah, it has the blocking in that pathway. Yeah, it's, it's a tricky pathway. So you do need to, to watch it, but that's how it works. It does blocking that neuropeptide pathway to B.

 

Dr Elissa Hatherly  07:58

Okay. So what about more old school medications like those more sedating antihistamines? I think, certainly, they were very popular when I started in general practice 20 years ago, is there still a place for those do you think?

 

Karalyn Huxhagan  08:13

There is, but doxylamine is the one that's used the most, and there's probably at least 20 brands of doxylamine. You know, sleep assist, restavit, you know, they've all got sleep or rest or tiredness or something in their brand naming. It's it's short term, the ones the patient that we see that uses them probably the most are your shift worker type patient. So the miner, the nurse, those who, when they flip over from daytime work to night time work and are trying hard to get their sleep cycle back. The ones that we see use it. The problem with using the sedating h2 receptor antagonists is that if you use them every day, for a long period of time, the sedation effect disappears. These are an anticholinergic medication, but, and then, because of their structure, they do cause sedation. But with time that sedation effect will wear away

 

Dr Elissa Hatherly  09:20

with the anticholinergic effects, which aren't so pleasant,

 

Karalyn Huxhagan  09:23

that's right. So you've got to be careful with them. And because they can buy them over the counter, it's, you know, one of the hardest tasks is to explain to them you, you really should only use this two to three times a week on your swing week, when you're a shift worker to get your back into cycle. It's not something you should use all the time. And you've got to watch out for the anti cholinergic effect because you don't want to be using it, you don't want them using a lot of that if they've got other things happening like you know, prostate issues, urinary retention, or dry eye glaucoma and things like that, that you do don't want to add an anti cholinergic into as well. That's a hard drug to persuade people that it's not the easy sleep tablet that they will think it is. But yeah, which brings you back to, if they've been taking it forever, and they still find it, it makes them sleep, how much placebo effect they're getting from the medication is probably another discussion to have.

 

Dr Elissa Hatherly  10:23

We love a placebo effect. Okay, so when we're looking at those hypnotics, and we talked about the benzodiazepines, the Z drugs, and you mentioned temazepan is the best one because it's short acting, and it's quick onset too I think, isn't it?

 

Karalyn Huxhagan  10:40

Yeah about 20 minutes.

 

Dr Elissa Hatherly  10:43

Right. Okay. So,of course, with the sedating drugs, there's a concern with impaired performance and coordination, cognitive function, and there's also a concern about maybe less good quality sleep, is that right?

 

Karalyn Huxhagan  11:03

Yes. So if they're trying to achieve to get into the deep sleep for when memories lay down and audit the, the function, re coordination happens in the brain, you you've got to, if they don't get into that, the right layer of sleep for all of the that healing and all of the function late work to happen, then they're just lying in that very light sleep area. That's not, in the long term that's not good, because that's why then you end up with this cognitive function issues. So with sleep, it's important that there's enough time down into the proper, deepest sleep phases. If you've got a patient that's just tripping up and down very quickly, they're not getting the restorative sleep that they need.

 

Dr Elissa Hatherly  12:01

Right. So then if patients are using have been using those for quite a long time, I imagine we need to wean them off that quite slowly too. Would that be correct?

 

Karalyn Huxhagan  12:11

Yeah, it's it's not as hard to wean them off Temazepam, as it was back in the days, or Nitrazepam, or Mogadon which was much longer acting. But if you can start to wean them back to, you know, three times a week then twice a week, and then you know, when needed, it certainly is, you shouldn't just take them away, you know, stop and that's it all over rover.

 

Dr Elissa Hatherly  12:41

Cold turkey would be unkind it sounds like.

 

Karalyn Huxhagan  12:44

Yeah, that would be not good for them. Because they'll get a whole rebound activity happening. But you just taper down and do it slowly. So you know, as I say, three days a week, we always suggest and then we say you pick your pick your two days and then bring them back to when needed. But the flip side of it is to really delve into what's causing that patient not to sleep, and my primary area of work is in aged care. So yeah, I'm forever saying well, do they truly need to temazepam? Is it the noise of the facility? Are they in pain? what else? What else is happening? Are they fearful? Do they have anxiety? I think when we say we're going to taper off, we have to offer another a flip to it. Or let's explore why you don't sleep. What wakes you up,are you going to the toilet four times a night? you know, are you fearful in your environment? It does need to be a deep and considered conversation which may then bring in you know, the use of someone more like a counselor or a psychologist. You know, as a practitioner, you can't just take away one thing without offering a better solution.

 

Dr Elissa Hatherly  14:06

Yeah, you're so right there. So talking about mood then Karalyn, in the past we might have used tricyclic antidepressants to help with sleep too, because sometimes they'll have that sedating effect. And with any luck, the patients will sleep through any anticholinergic concern with their dry mouth or dry eyes. Do you think there's still a place for the tricyclic antidepressants?

 

Karalyn Huxhagan  14:31

There is, the patient who struggles to sleep due to their pain and discomfort. If we look at some of the tricyclics' like Amitriptyline and Nortriptyline, you can use low doses of that type of medication for both the sleep part of their ability and their pain relieving ability. So those patients who say they can't sleep because they need that, you know, by three hours that they're very in a lot of pain and, and you know, they have to get up and walk around and that. They definitely can benefit from using something like a tricyclic. Those patients who have terribly irritable bladders that, you know, just no matter what won't stabilize and won't hold, it's worth a try of something like Nortriptyline to see if just using the actual anticholinergic side effect helps to stabilize the bladder longer for them to get maybe two, three hours before they have to get up to go to the toilet. They do have a role, you know, some adverse reactions are a side effect to one patient and a benefit to another. So you do need to consider that with the drug.

 

Dr Elissa Hatherly  15:54

Okay, so looking for those beneficial side effects then and making it quite case specific.

 

Karalyn Huxhagan  16:00

Yes

 

Dr Elissa Hatherly  16:00

So we've talked about the benzos, we've talked about the Z drugs, we've mentioned melatonin and Suvorexant, the tri cyclic antidepressants, and then we also have Quetiapine that we use a little bit these days to help with that severe anxiety in a proportion of our patients. It can be really helpful for initiating sleep in those patients, is there any thing we need to be on the lookout for when using Quetiapine?

 

Karalyn Huxhagan  16:31

Yeah, Quetiapine certainly, if the patient has an anxiety or that kind of classification, Quetiapine is certainly used. And in aged care, there was a lot of work done saying Quetiapine was good to settle patients to sleep, who did have you know, fear of, of the dark, fear of their new environment and things like that, and doses of 50 to 100 milligrams were like the recommendation. You've got to be careful, it's different to in aged care to a patient in the community because now with the aged care guidelines from the Senate, and the Royal Commission, the use of things like Quetiapine, for sleep is considered a chemical restraint. So you, you can't use it in that kind of patient without putting yourself into a whole area of regulation. So, but out in the community, for patients who are fearful of whatever, you know, there certainly is a role for Quetiapine. It doesn't have to be high doses, but I sadly see some shockingly high doses of Quetiapine for sleep. To reduce the anxiety for sleep, it should be more into that 50 to 100 milligram area of practice. But Quetiapine is a drug that has a an ability to become addictive's probably not the correct word. But it does have a certain type of patient will become very use, you know, like the feeling that the Quetiapine gives them and then tend to want to grow the dose and go on from there. So Quetiapine is a drug to be used in caution, bit like the benzos in the valium days. So you do need to watch your patient. The other medication that you would see most prescribers use before Quetiapine would probably, in the anxiety patient, would be Mirtazapine.

 

Dr Elissa Hatherly  18:44

Yeah, let's talk about Mirtazapine a little because it's a class all on its own, essentially, isn't it?

 

Karalyn Huxhagan  18:51

Yeah, it's a very individual little drug all by himself. So Mirtazapine is a wonderful little drug in its right place. But it has different dosing schedules for whatever you're using it for. So if you're using it for sleep, to reduce anxiety for sleep, 7.5 to 15 milligrams is is usually adequate. You certainly don't need the 45 milligrams that we see people getting placed on though but you do also need to be careful about his weight adding ability. So at the low doses, it's used for sleep, but it does have we use it very much in our anorexia patients to try to reduce their anxiety and to improve their appetite. So you know, just be careful a very obese patient may not like you putting them on Quetiapine and then they're going to eat a bit. So yeah, but it's a good drug. And I find it good in practice, using it low dose, getting them back into a sleep cycle, getting the anxiety under control by also using a psychologist or a counselor to sort out the cause of the anxiety, getting that sleep pattern happening so that then they cope and they more restorative in looking at the bigger picture of what's causing the anxiety by onboard counseling. And then you can usually take it away to a PRN stage. And they just use it for those bad days, you know, the cat got run over or whatever. It's a drug that can be used PRN. And but it's, you know, it should be used in a multidisciplinary team format, you know, what's causing the anxiety and use the drug plus the counselor.

 

Dr Elissa Hatherly  20:55

Right. So that's probably our take home message today, isn't it, Karalyn, that sleep will often have other associated issues that need to be addressed, like mood or sleep apnea or any other medical condition and make sure we're tailoring the medication for that person so that we're using something that's an appropriate medication for the duration that the patient needs it for and an appropriate dose.

 

Karalyn Huxhagan  21:24

It's absolutely correct. I think we should approach sleep like we do with opioids. You set up a plan with the patient to get them back on track. And then the plan says then you evaluate the long term parts of the plan to reduce the drug away once they're coping and have got their sleep patterns back on track.

 

Dr Elissa Hatherly  21:49

Or Excellent. Thank you so much, Karalyn Huxhagan. I really appreciate you going through sleep medication with me today. Thanks again.

 

Karalyn Huxhagan  21:56

Thank you. Bye.

 

Dr Elissa Hatherly  21:59

Our second presentation is by Glen Clark, another local community pharmacist who has a particular interest in melatonin metabolism. Welcome Glen.

 

Glen Clark  22:09

Hi, how's it going today?

 

Dr Elissa Hatherly  22:11

Thanks so much for joining us. Sleep is such a difficult thing to manage with some of our patients. Could you help us understand a little bit more about melatonin metabolism, please?

 

Glen Clark  22:23

Yeah, sure. So melatonin is a derivative from serotonin. It's through the pathway chain that we also need serotonin to make melatonin and it's a it's kind of a negative feedback with that, that serotonin factor. So throughout the day, when you're having your cortisol levels dip, to the end of the day, our melatonin is actually rising. And that's why when we go into bed, we have that increase in melatonin and get us that nice sleep throughout the night.

 

Dr Elissa Hatherly  22:52

Okay, so that might help to explain why I have difficulty with sleep with some of my patients, when I use an SSRI. I do have one patient, I think you might have seen her. She's about 16. She started on venlafaxine, which she's taking in the morning. But then since commencing that medication, she's waking at about two o'clock every morning. Can you help explain what's going on there, please.

 

Glen Clark  23:21

So like I mentioned with the negative feedback side, so with with the SSRIs, what they're trying to do is obviously allow that more serotonin to hit that interstitial space acting on those 5HT 1, 5HT 2 and 5HT 3 receptors. As we all know, insomnia is a common side effect of that because of its action on 5HT 1. But with melatonin, what we're trying to do is obviously we can supplement that into the patient and give them a little bit of assistance again, the sleep. The problem is, is if we give them too much, we actually cause the melatonin to negatively feedback into serotonin so remake itself into serotonin. And that's why they wake up about four to five hours after the fact that they've taken the medication.

 

Dr Elissa Hatherly  24:08

Right? Yes, of course. I often use the melatonin the two milligram extended release formulation in those super anxious girls. So I've probably created that insomnia, haven't I?

 

Glen Clark  24:18

It could be a number of factors, but it is always best even trial, just drop it drop the dose don't actually increase the dose because sometimes more doesn't always mean a better outcome for the patient and actually if you drop the dose, we might find that that will actually give the patient a full night's sleep.

 

Dr Elissa Hatherly  24:35

Okay, so maybe instead of a two milligram extended release formulation, get a compounding pharmacist to make me up a one milligram tablet and have that just an hour or so before bedtime would that be the best way to manage that?

 

Glen Clark  24:47

We always when we were when compounding is available. It's actually quite a good start to trial the patient's on liquid formation. The reason why that is is that we can adjust the dose to work out how they operate really well, so that that liquid formation can be in, you know, one milligram changes, or even half a milligram changes. The advantage with compounding is that once we have that strength and we know what works best for the patient, we can actually formulate that into a capsule formulation, which can be any, any value what we want it. So even if it's 2.56 milligrams, they can make it that way. So it makes it easier.

 

Dr Elissa Hatherly  25:25

Yeah, I suppose that capsule formulations then a bit more stable, it doesn't need to be refrigerated. So it's convenient with traveling and things like that, isn't it?

 

Glen Clark  25:33

And obviously, capsules are a little bit more easy than tablets for patients.

 

Dr Elissa Hatherly  25:37

Yeah, for sure. Okay, so the other thing I suppose to do would be to reduce the dose of the venlafaxine in this particular patient, isn't it? What else could we try?

 

Glen Clark  25:48

We could look at actual less than pharmacological factors if there is other factors that are causing so non pharmacological factors would come into play. So simple things of working out how they are getting to sleep, whether, you know what, what are they doing before they go to sleep, whether they are using their phone or their iPad, right before they go to bed, because we know that that blue light can really affect that retinol pattern on the back there, and making them stay awake. Even simple things, looking at their medication, what else they're taking might also influence them. So what vitamins and minerals they're taking even magnesium is really helpful for their sleep.

 

Dr Elissa Hatherly  26:29

Okay, all right. Any other tips and tricks for using melatonin in our patients, Glen?

 

Glen Clark  26:36

one of the best things is to try and assist the patient with the melatonin side. In terms of giving us the best kind of reaction to them is to record what you're doing every night and seeing how each night they go with it. It will take about two weeks for you to get a full valuation of what's going on. But even if you can just write down the diary, how well your sleep was and how well they go the next day after, whether they're sleepy or if they you know, having too much coffee throughout the day. That's really helpful for, I'm assuming for the GP side, but also from the pharmacological side of how we can help them treat their medication.

 

Dr Elissa Hatherly  27:18

Fantastic. Okay, so Glen, thanks so much for your time, we need to think about keeping a diary in terms of sleep symptoms with our patients, be mindful of sleep hygiene, and all of those tips and tricks that we know to be so important. And then think about the serotonin surge that our patients might be experiencing in the early hours of the morning and adding back a little bit of melatonin. Look Glen thank you so much for your time and your expertise. We really appreciate it.

 

Glen Clark  27:47

Thank you very much Elissa.

 Dr Elissa Hatherly  27:51

For more information about the Round Up to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 8: MTOP Matters 

Managing the Medical Termination of Pregnancy (MTOP) is not as difficult as we might imagine, but the care we provide must focus on what’s important to our patients.

Join your host Dr Elissa Hatherly and learn how Mackay GP, Dr Jasmine Davis, navigates providing this service from her regional general practice. Dr Davis also works in Mackay's Sexual Health Clinic and is an advocate for access to Women's Health services across Northern Queensland.

Resources

Transcript

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, I'm joined by Dr. Jasmine Davis, a GP in Mackay, who also works in the sexual health clinic here in Mackay. Jasmine is particularly interested in improving access to women in regional and remote areas for womens' health concerns, particularly for medical termination of pregnancy or MTOP. Welcome, Jasmine.

 

Dr Jasmine Davis  01:06

Thanks Elissa, thanks for having me.

 

Dr Elissa Hatherly  01:08

What is it that we as clinicians in the community really need to know about unplanned pregnancy options to best help our patients when they come and see us?

 

Dr Jasmine Davis  01:18

Yeah, I think you're right, I think we need to focus on what's important for the patient. So when someone presents with an unplanned pregnancy, we need to have the skills and knowledge to be able to counsel the patient as to what their options are, and then to be able to refer and guide them to the most appropriate option for them. You know, sometimes people find that it's quite a difficult situation to be in, quite an emotional decision to be making. So I think we need to do our best to support our patients, and help them through the process.

 

Dr Elissa Hatherly  01:52

I think that's great advice. And I would know, from my experience, it's not unusual for a woman or a couple to come in with an unplanned pregnancy, who has until that moment had really fixed ideas about how to manage an unplanned pregnancy. But once they've experienced their own unplanned pregnancy, those previous beliefs or particular persuasions kind of go out the window, people start to look at other options as may be the right option for them.

 

Dr Jasmine Davis  02:20

Yeah, absolutely. And I think until you're in the reality of a situation where there could be a new baby in your life, bringing a child into the world is a pretty big decision. And you know, when it's a hypothetical situation, it's easy to say, I would never do this, or I would always do that. But when the reality comes in, then I think people often need to think a bit harder about what their decision is, whether that be continuing with the pregnancy, or going ahead with a termination.

 

Dr Elissa Hatherly  02:53

Okay, so medical termination of pregnancy. We haven't been doing it in Australia all that long. But it's a really important option for women, particularly in rural, regional and remote Australia, isn't it?

 

Dr Jasmine Davis  03:05

Yeah, absolutely. Well, I think particularly for the women in our area in Mackay, it's quite difficult to access a surgical termination of pregnancy, unless someone's got private health cover, and a bit of money to pay excess in gap fees, or to pay for flights down to Brisbane since the closure of the regional surgical termination clinics. So in understanding that, then we've got to know you know, there are people that can't travel or don't want to travel away from their home to access surgical termination. So then we've got the option of doing a medical termination where they can undertake that in their own home. And, you know, they're probably out of action for about a day, but then can continue to work and provide care for other children if that's what they need to do.

 

Dr Elissa Hatherly  04:04

So, in terms of medical termination of pregnancy, how do we walk our patients through those options?

 

Dr Jasmine Davis  04:12

Yeah, so, I think um, the first thing to figure out is the gestation of the pregnancy, because depending on gestation under the PBS, we can only prescribe the medical, the medical termination up till nine weeks and zero days, whereas the surgical termination can be done for any reason, up till 22 weeks. Obviously, as the gestation increases, the costs increase and also does the medical risks to the patient. So, you know, if they can get it done within that first trimester, that's ideal, but sometimes, we've got patients that are finding out or have a change of circumstances at a later date. When I'm helping someone to make that decision first I'm looking at what's their past medical history? And do they have any contraindications to a medical termination of pregnancy, like a bleeding disorder or being on anticoagulants, any chronic adrenal failure or dependence on oral corticosteroids for another problem, because that would immediately make me lean towards the surgical option. Other times, we've got to have caution with a medical termination, if any conditions where excessive bleeding would be a problem for the person so a cardiac condition anyone with anemia or a severe kidney or liver disease. Other than that, it would be mostly talking to the person about, you know, what are their preferences? Would they prefer to go to the clinic, have an anaesthetic and wake up and have it all be finished? Or would they prefer to be able to be in the comfort of their own home and go through that cramping and bleeding process, you know, with their support people nearby, rather than having to travel, you know, get on a plane, take time off work, potentially be away from their other kids. And then of course, the cost. So the cost of a surgical termination, that do outweigh the medical termination.

 

Dr Elissa Hatherly  06:17

Right. So what would be the expected process then for our patients when they're coming to see you to commence a medical termination of pregnancy?

 

Dr Jasmine Davis  06:26

Yeah, so it really depends on whether or not they've seen their regular doctor and had some initial investigations done. You know, ideally, someone could see their usual doctor, have an ultrasound to confirm the pregnancy is intrauterine and to get the dating of that pregnancy. And ideally, I'd want to see a blood test haemoglobin and beta hCG for a baseline reading for them, and sexually transmitted infection testing if they need that. At that stage, then people will send a referral to one of the private providers. In Mackay, you know, we've got quite a few GPs who are now providing medical termination of pregnancy. And then for our financially or socially disadvantaged people, there is a service at the sexual health clinic. When they come to that appointment, we would check through their investigations and their past history and make sure it is appropriate to proceed with the medical termination. Of course, we'd be checking that they do have the capacity to consent, and that they're making the decision of their own free will with no coercion from maybe a partner or anyone else. And then going through with the patient what to expect and what can go wrong and go through the consent process, just like any other medical procedure,

 

Dr Elissa Hatherly  07:50

Really all patients need to know is that they need that quantitative beta hCG and a haemoglobin and that ultrasound to confirm that the pregnancies intrauterine when they come for that initial consultation.

 

Dr Jasmine Davis  08:04

Absolutely. We also need to start that conversation about future contraception, just so that the person has the opportunity to have a think around what they want to do after the termination. particularly encouraging the long acting reversible contraceptives, but give them their personal options, so that they can think about it and we can get that happening straight after the termination.

 

Dr Elissa Hatherly  08:31

Great. Okay, so for women who are pregnant, often we'll do a blood group and antibodies screen. We're not really doing that for the women who were looking for a medical termination these days are we?

 

Dr Jasmine Davis  08:44

So certainly knowing if a patient is rhesus negative is really important if they are going to have a surgical termination. So if they were undecided. I would order that but if we knew that we're going ahead with a medical termination of pregnancy, if it is within that time, we can prescribe up till nine weeks, there's no requirements now for the anti-D injection.

 

Dr Elissa Hatherly  09:07

Okay, so it's pretty straightforward then for women who do find themselves needing a medical termination of pregnancy. You have mentioned some of the risks around severe kidney and liver disease and adrenal insufficiency. What are some of the other things that we need to be mindful of with our patients?

 

Dr Jasmine Davis  09:25

Oh, look, I usually like to make sure that someone lives within an hour or so of a hospital where they can provide emergency support, just in the case of excessive bleeding. I like someone to have a support person available. So that if things do go wrong, that they have transport to get to a hospital. You know, in terms of the major risks, the risks are that we could have excessive heavy bleeding. Now that is uncommon, but that does happen. So I ask the woman to monitor her bleeding, monitor her blood loss. And if she does find it excessive, so soaking, saturating through more than two pads in an hour, then she should be monitoring that closely. And if she's experiencing dizziness, lightheadedness, or fainting, then seeking out emergency medical attention. In terms of other complications, you know, we do have the odd occasion where it's not, it doesn't work. So a continued pregnancy. And in that situation, we certainly would recommend that they continue the process, either through a repeat of the medical termination or by going through a surgical procedure, mainly because the Misoprostol is teratogenic. So, you know, it's not ideal for someone to change their mind and continue the pregnancy. And if they were to do that, then they would need to have some tertiary scans, some monitoring of the baby.

 

Dr Elissa Hatherly  10:53

Right, so, sorry, you mentioned the Misoprostol. Can you just talk us through the medication that we give to the patients and the timing of that?

 

Dr Jasmine Davis  11:04

Yeah, absolutely. So the medication that we use is called MS-2 step and it's a packet including Mifepristone, which is 200 milligrammes and Misoprostol, which is 800 micrograms. So, how I usually work it is I ask the woman what day it would be to be most convenient for them to have that bleeding day when they're probably going to be stuck at home with a support person with a hot water bottle and pad. So you know, if that if that falls, they would prefer that to fall on the weekend, then we can work backwards to figure out what day to take the Mifepristone, the Mifepristone has to be dosed 36 to 48 hours before the Misoprostol. So I work that out for the patient and give some written information as to how to take the medication. Mifepristone is taken orally, and the Misoprostol is taken in the cheek where it absorbs so that if they do have any nausea or anything following that medication is already absorbed into their system. It's really important that we make sure that the person has adequate pain relief, and antiemetics available again so that they can manage their own symptoms at home and avoid ending up in the hospital and this is absolutely necessary.

 

Dr Elissa Hatherly  12:32

Okay, so the complications of the procedure then you've talked about the excessive bleeding and the nausea and the heat pack with them before the significant pelvic cramping. What are some of the other complications we might expect? And how are we best managing those?

 

Dr Jasmine Davis  12:50

Yeah, so probably the most common complication would be retained products, similar to after a miscarriage. There can be some membranes or products left behind and when a person experiences prolonged ongoing bleeding, I would usually expect the bleeding to last about two weeks but if it was lasting longer, say three, four weeks, or got suddenly heavier after it was getting lighter, then I'd be wanting to investigate, usually with an ultrasound and involving our gynaecology colleagues at that point for management of ongoing retained products. I suppose from a medical perspective, managing retained products after termination is very similar to after a miscarriage. So I would expect that, you know, the majority of GPs' would be well within their comfort zone of being able to manage complications like that. The complication again similar to after miscarriage is that they can get an infection, so endometritis. So we ask them not to use anything inside the vagina, so no sex or tampons, those menstrual cups until we're happy that the product has passed. And if their discharge becomes smelly or malodorous, or they do get the temperature, then we need to treat with antibiotics. Again, that's that complications, quite uncommon. But it does happen. And in that case, we need to ensure the patients have access to prompt medical care so that we can manage those complications.

 

Dr Elissa Hatherly  14:32

Right. So we've given the MS-2 step medication having counselled the patients about their options, what to expect with the process and obtained written consent. The patients have had the progesterone blocker 36 to 48 hours before having the prostaglandin and then we'll start to pass the products of conception, hopefully and there'll be getting some bleeding. We've talked about the risks and the complications, how do we then follow up those patients after they've had their medical termination?

 

Dr Jasmine Davis  15:10

That's really important that we follow them up to make sure we find out nice and early, whether there's been a complication. So my personal practice is to give people a phone call a few days after that bleeding day, just to make sure that they did bleed, that they did pass products, and that everything went according to plan. You know, with telehealth over COVID, it has made things a lot more convenient for the patients that they don't have to keep coming in for these appointments. So people find that pretty convenient. The other thing that we need to do is do a follow up  beta hCG, usually about seven days after the Misoprostol. That's when I arrange it, and making sure that the beta hCG has dropped by 80%, at least, if there's an ongoing increase in beta hCG, or if it hasn't dropped significantly,that makes me think that, you know, things haven't really gone according to plan. And that we need to investigate further to determine, you know, is there an ongoing pregnancy? Or is there significant retained products that that could keep that beta hCG up high?

 

Dr Elissa Hatherly  16:24

Right, so I imagine that history then from those patients about whether or not they've had significant bleeding in the first instance is super important too. Now I understand there's a 1300 number that we can register our patients to provided by the Marie Stopes organisation to help provide that after hours care for our patients after they've commenced, their MS-2 step. Can you talk us through that, please?

 

Dr Jasmine Davis  16:51

Yeah, so the manufacturer of the medication provides a 24/7 support line. And that's staffed by a nurse. So it's really helpful for the patient to be able to make a phone call and get some immediate advice by someone who's got that expertise in the area, particularly when our clinics may not be open. I think that would probably save a few people a trip up to the emergency department for sure because they get that immediate feedback as to whether the bleeding they're experiencing is okay, or is it too much, or what to do next. So that we can put a link to that phone number, I don't know it off the top of my head, to be honest. But you know, often providing that in the written information for the patient so they've got something to refer to.

 

Dr Elissa Hatherly  17:44

Yeah, having that reassurance is incredibly important when you're embarking on this kind of medication for sure. Now, you mentioned contraception earlier, Jasmine, you mentioned larcs, in particular, those long acting reversible contraceptives, and starting that conversation about contraception early in the process for these women. What do you talk about with your patients in terms of contraception?

 

Dr Jasmine Davis  18:11

Well, look, I find that most people are quite receptive to contraception in these consults, because they've seen, you know, the immediate consequences of either their contraception not working, or that they haven't been on anything. So, you know, I'd like to encourage them to use something that's reliable. So you know, if they had been taking the contraceptive pill, and they've been missing a few doses, and that's why they've had a failure of the contraception, well, then, you know we need to find something that works a bit better for them and doesn't rely on them, you know, being able to take it every day. So, you know, something like the hormonal implant, the implanon or the IUD the Mirena or the Kyleena, are all really appropriate choices. It does have to be a bit of a delay in inserting the IUD after having the medical termination just to make sure that all the products have passed and the uterus is empty. So there is that little window there where the person could get pregnant in that time. So I do always offer that we could bridge that gap with the Depo Provera which can be given on the day of the termination. The implanon can also be inserted on the day of the termination and the combined contraceptive pill can be started on the day after the Misoprostol.

 

Dr Elissa Hatherly  19:37

So, Jasmine, yeah, once the products of conception have passed, it'll only be about eight days before fertility returns for that woman. So starting that contraception early and that bridging contraception as you mentioned before they continue with a long acting reversible contraceptive of their choice would be ideal.

 

Dr Jasmine Davis  19:58

Absolutely. And look, I mean, at the end of the day, we have to remember that it's people's choice, whether they want to be on contraception or not. So it's all about facilitating them, providing them with the facts and encouraging them to make a choice that that works well. But, you know, all of our contraceptives do come with the risk of side effects. So I can appreciate that some people want to avoid the hormonal option. In that case, the copper IUD is certainly a good choice and is highly effective. Or if they if they are choosing to use barrier contraception, like condoms, then, you know, they just need to remember that condoms only work when. So if they break or if they forget, you know, then they just need to think about emergency contraception like the morning after pill.

 

Dr Elissa Hatherly  20:53

Okay, so you've given us a lot to think about Jasmine, I understand MS-2 step prescribing, you need a particular qualification for. Can you talk us through how we might become a prescriber?

 

Dr Jasmine Davis  21:08

Yeah, absolutely. So it's quite straightforward to become a prescriber, but you do have to do initial additional training. And you can access that via the MS-2 step website, the trainings all online. And once you receive your certificate, then you can start the process of of becoming a prescriber. I also found that there was a really useful module via the RACGP, which talked through non directive pregnancy counselling. And if you go through that planning process, then you do have access to the additional item number for that non directive pregnancy counselling. And another excellent resource is the therapeutic guidelines they've got really comprehensive advice on there now. So that's a great place to go if you do become a prescriber and need to troubleshoot any complications.

 

Dr Elissa Hatherly  22:05

That's fantastic information. And of course, for those clinicians who are not keen on becoming a prescriber themselves, or might even be conscientious objectors, of course, that's their choice. But it's important that they don't create barriers for women's access to those services with another clinician in their practice or at a neighbouring practice. How do we go about managing that difficulty with some of our peers?

 

Dr Jasmine Davis  22:30

Yeah, so I mean, look, the the law recognises that a doctor can have personal values or beliefs that mean they can't provide care for someone for termination of pregnancy. So in that case, they can invoke conscientious objection. But there is that legal obligation that they do need to advise the patient and refer to someone that can provide that care in a timely fashion. And, you know, we've talked about time being of the essence with, with the gestation, being able to provide the medical termination up to nine weeks, any delay in referral would be very inappropriate. You know, from an ethical point of view, the AMA Code of Conduct really outlines that doctors should continue to treat their patients with dignity and respect, and really refrain from expressing their own beliefs in a way that causes a patient any distress. So I think, you know, we've all got to be really aware of our own personal values and judgments. And sometimes it's a matter of keeping them to ourselves, and providing the care that the patient needs.

 

Dr Elissa Hatherly  23:34

Oh look Dr Jasmine Davis, thank you so much for your time today. This has been a really important conversation to have around medical termination of pregnancy. You've given us all a lot to think about. And we look forward to talking to you another time about another hot topic. Thanks so much.

 

Dr Jasmine Davis  23:52

Thanks goodbye Elissa. Talk to you next time.

 

Dr Elissa Hatherly  23:54

For more information about the Roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health Council Health services, Aboriginal Community Controlled Health Organizations and general practice clinics.

For more information about The Roundup, or to share your feedback and ideas for future episodes, contact us at nqrth.mackay@jcu.edu.au 

We want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. 

Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline (IRTP) and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council (QAIHC), health services, Aboriginal Community Controlled Health Organisations (ACCHOs) and GP clinics. 

NQRTH is an initiative of the Australian Government's Integrated Rural Training Pipeline (IRTP) and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council (QAIHC), health services, Aboriginal Community Controlled Health Organisations (ACCHOs) and GP clinics.

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