E06 Andy Kirkpatrick on Telementoring, Trauma Research, and the Trip to Mars

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Chad Ball 00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy.

Ameer Farooq 00:41

In this episode, we had the opportunity to interview Dr. Andy Kirkpatrick. Dr. Patrick is a trauma surgeon at the University of Calgary. And in this episode, we discuss a variety of things ranging from telementored ultrasound to space medicine, to tips for research productivity.

Chad Ball 01:08

Today, we’re lucky enough to have Dr. Kirkpatrick with us. Andy, firstly, we know how busy you are, you’ve really been a mainstay of academic surgery in Canada for a long time now. So, we really appreciate your time. Over the years, you’ve coauthored a number of really interesting Canadian journal surgery publications, certainly spanned a wide variety of topics, a wide range of topics, but they really clustered around two clear passions, but it seems like you have one being ultrasonographer and the other being space medicine. So, we were curious, how did you fall into each of those things? And kind of who influenced you? And what was that bridge like and who was involved with it in the early days?

Andy Kirkpatrick 01:53

You know, well, first of all, thank you to both of you for the invitation and again for your leadership. And it is an absolute pleasure to be here, and I’ll try to do justice to those questions. I’ll separate them out into ultrasounds. And the, to me, it just it’s always seemed natural that you would not go near a sick patient without an ultrasound. And that was kind of not only taught to me with demonstrated to me by Bernie Bélanger, Fred Brenneman and Barry Mclellan at Sunnybrook, and even when I was resident, I may not have realized at the time what national leaders, they were. I do recognize in retrospect, but they just, that was their message, like you use an ultrasound to see a sick patient. And I was lucky enough to be mentored by them. And I think a message that’ll come through this whole talk just how important mentorship is, and how, hopefully, we can try and get back. And I’m very proud of some of the people I’ve mentored, and I will humbly include you in that list. But Bernie and Fred and Barry just brought ultrasound in, and we did research with it, I kind of left from my fellowship, expecting that every surgeon everywhere was using ultrasound. And I very quickly learned that wasn’t, it’s, how it was working. And when I took that with me to Vancouver, and I will, wound up in my first year in front of the diagnostic accreditation committee of the College of British Columbia. And I sort of just explained what we were doing with ultrasound, why we were doing it. And I think I was one of the first people in or non-radiologists in British Columbia that had permission to use ultrasound. And I think one of my passions has been trying to expand the use of ultrasound in point of care resuscitation beyond the FAST. I think the FAST is an incredibly powerful tool that has been borne out using ultrasound for innumerable indications has just become accepted. And I think one of the things I lament maybe is that I think, based on the early work of Bélanger and Brennaman, surgery had a had a chance to lead the adoption and the rolling out a point of care ultrasound for sick people across Canada. And I think that was an opportunity that was partially squandered. And I thought, I talked about that in some of my presidential addresses to the Trump Association of Canada. But to be honest, I think ultrasound is still underutilized. They still have 1000s of things to learn about how to use it. And then I’m excited by the next generation that has embraced this. I think the other question was space medicine. I have always been interested in flying. I’m a private pilot. I was a flight surgeon in the military. And I think it was that military exposure that opened my eyes to space medicine was a natural progression of challenges. And I think that comes back to wanting to do a better job with saving lives and with the real opportunity to save lives in trauma care is pre hospital or even before the patient arrives in hospital and whether you call it space medicine or austere medicine or expedition medicine, or far forward medicine is really this the challenges of trying to resuscitate catastrophic injuries in a setting without all the resources that you have in the hospital with often without all the personnel you have in the hospital. That some of the leaders, I would have to think Mark Campbell, who’s probably the surgeon in the world who has done the most [inaudible] in weightlessness and parabolic flight and Doug Hamilton, one of our colleagues here in Calgary, who were very influential in exposing me to space medicine and helping me very early on in my career. And this may be even out of place, but I’m trying to think of where to fit it in. Maybe it could be cut and pasted somewhere, but I really, I was thankful enough to say it to his face. But I really would make Dr. Bryce Taylor, who is the program director when I was a resident, and there’s three things he did that are totally out of the box. And he allowed me to go to D-Day Plus 50 as a regimental medical officer of the Queensland Rifles, and I was able to be on the beach with veterans, when they were still healthy enough to tell stories that you couldn’t imagine. We were told that they’d never had chance to tell their families. And he also let me do the first year of my IC fellowship as a fourth-year surgical resident, which, which was incredibly efficient and saving years of my life. But the other thing that Dr. Taylor, let me do was actually a month-long elective, where I did the flight surgeons course, as a reserve officer in the Canadian military, but also surgical residents. So those are out of the box things that had an incredible influence in my life. So, I do have to thank Bryce Taylor for those decisions he made many years ago.

Ameer Farooq 08:16

One thing that stands out for me as being your trainee is, you know, when you look at someone’s research profile, you kind of look and think, oh, you know, where do my future interest lie? Can I make my practice like theirs, my career, like theirs and you look at your academic career, and you think, whoa, that those are very unusual, different, unique, kind of academic interests. What’s that been like for you, in terms of your profile? Has that been lonely? Or has that just kept you alive and, and passionate?

Andy Kirkpatrick 08:55

I would say absolutely not. That this research and this challenge, and these adventures and learning have brought me a network of 1000s of friends and colleagues worldwide, that are just as passionate and when you interact with colleagues around the world who are facing the same challenges, what you know, if it’s somebody else’s challenges or in a different language and from a different structure of their oversight committees or their legalities, or even the country’s health system, but they’re all the same challenges of trying to, to make things better and, and so it hasn’t been anything but, but lonely.

Chad Ball 09:46

If we switch gears a little bit, and I would ask you a bit of an esoteric but fun question. When do you think we’re going to be on Mars and more than that, how do you, how would you see ideally, space medicine on a trip like that, that’s extended duration?

Andy Kirkpatrick 10:11

When I was an ICU fellow, I spent a month down in Houston at [inaudible] Life Sciences. I actually, because I was Canadian, I could never get on to Johnson Space Center. So, I was able to sit in the corporate library, at [inaudible] Life Sciences, and I had access to all kinds of unpublished data. And I basically wrote up a review of surgery and space and trauma and space from A to Z. And that was one of my first huge breaks that I got, because it opened all kinds of doors for me. Then there’s the time when, when, what I went down here for was to work on trauma pod. And trauma pod was built, and I came from DARPA, the Defense Advanced Research Projects Group [Agency], and was also one of the, so it was part of the US military for battlefield robotic surgery and completely autonomous salvaging of far forward casualties. And, and it was also, there was going to be a complete surgical capability on space station Freedom. And space station Freedom was going to have a level two trauma capability. And it was, it was incredible, and planning was very advanced for it. But albeit, Trauma Pod, there was a working mockup a few years ago, that, you know, certainly was not ready to be in a mobile armoured platform. And space station Freedom eventually became a reality with the International Space Station, but many, many degrees reduced. There have been countless plans put forward. And at the time I was down in Houston, to design reference mission was a series of advanced drawings and concepts about when humans were going to go to Mars. And when I was down there, it was just accepted, hoping we’d already be on Mars in about 2009. So that has come and gone. So many other proposals. And I, to my understanding, I haven’t followed as closely as I used to, we, NASA is still hoping to be on Mars in the mid-2030s, to some degree, but nobody exactly knows how that is going to happen. But I think no matter no matter what, whether we go or not, I think having a mission brings out the best in the human race, that, you know, and a positive mission. You know, when we people work together for a challenge they overcome, they learn, it stimulates kids to do want to do sciences. So, I think trying to go to Mars may even be more important than actually going to Mars. That’s kind of my personal thoughts on that. And how space medicine will be involved in in going to Mars, again, that’s many people are trying to figure that out right now. And I think space medicine on a mission to Mars is going to be different, has to be different from space medicine on the on the International Space Station right now in low Earth orbit, and the just the difference is going to have to be that space medicine the way to Mars will have to be autonomous. And so, the interim space medicine that supports the space station is an example of how space medicine can give back to the planet. And I was very lucky to be involved with Scott Dulchavsky, Doug Hamilton and Ashot Sargsyan who really, were the innovators of remote telementored ultrasound. Because on a on an International Space Station, there’s a state-of-the-art ultrasound machine, but there’s nobody that can actually use that ultrasound or sorry, that was trained to use an ultrasound. But they have shown that if you take an intelligent person who is willing to listen. They can be mentored by a remote expert to get incredibly accurate results, if you work out the communications, and just the human factors involved in that. And so, one of our other projects for a long time has been how to spin back off remote telementored ultrasound back here on earth. And I don’t think we have, you know, there’s much more to do. But I think that remote telementored ultrasound has led into recognizing that just making a diagnosis doesn’t save lives, is remotely entering interventions. And our work in the last few years have been very much in trying to learn how to best mentor, a point of care provider who’s having to perform hugely out of scope, to save a life, somewhere far forward, austeer, remote, or operational, whatever you want to call it. And we have been awed, or just so impressed by what people can do, if they are mentored properly. But that whole science of how to mentor, what to mentor when the mentor is, is largely untouched body of knowledge and I think needs to be studied, defined and documented that is almost as a standalone, medical specialty. I would predict, again, learning those technologies and techniques, and especially human factors, will again, have way more benefit back on Earth than it will for actual manned mission or the people mission to Mars.

Chad Ball 16:45

This is a bit of a meandering sort of leveraged question on that, Andy. But, you know, in knowing you and being around you for what’s pretty close to 20 years now, or coming up on 20 years, and my experience at the Johnson Space Center, as well as you and giving talks around the world, looking in places, for example, like Australia, where when there’s a trauma resuscitation up in Darwin, that is real time fed into Brisbane, where the trauma surgeon sits in a in a closed quiet room and helps them facilitate and care for that patient real time. Whether it’s ultrasound, or just the resuscitation, non-ultrasound sort of work. There are some really amazing things going on. And, and when I’ve always listened to you talk about this element of telementoring and simulcast and, and all that terminology. In the space medicine world, it does make me feel somewhat guilty that we haven’t, at least from my point of view, we haven’t leveraged it properly in this, in Canada, in this country that very much, you know, huge, huge portions, you know, are outside of an hour’s care, as we know from [inaudible] study, we just don’t seem to have either that infrastructure or that will to try and deliver that care to remote Canadians. What do you think about that as a concept and as an issue, whether I’ve imagined it or not?

Andy Kirkpatrick 18:10

No, I feel your guilt, just, if not more intensely. Because I had a couple more years to think why haven’t we done more? Why haven’t I done more? And I and sometimes I feel like, the more we work with this, the less we’re ready for primetime. And I think we haven’t necessarily proven that it makes a difference. And I think that’s a part that seems that would make a difference in wanting to do good research versus just publishing papers. But again, I’ll thank Doug Hamilton. After it became, after NASA adopted remote telementored ultrasound, as one of the basic platforms for all medical care on the space station, looking at an incredible wide, wide array of out of the box uses, Doug came back and said, you know, we’ve got satellites in Canada up north with unused bandwidth. They were they wanting to give the bandwidth away almost we need to make this happen. We started off with kind of a bite and hold type strategy. And we I believe, had the world’s first-time acute care, live patient teleultrasound link between the Banff Mineral Springs Hospital and Foothills in the trauma room. And we, I believe made the first remotely mentored diagnosis of pneumothorax. We identified major hemoperitoneum that facilitated a direct to the operating resuscitation bypassing emerg. It worked amazing for the first couple of months. But the Achilles heel was the human factors. And I think that has been learned time and time again, around the world, that it wasn’t sustainable, without a huge amount of goodwill, and patience. And I think that goodwill is always there. But patience is not something that fits into acute trauma care, because we had to respond physically to a telemedicine console that was in the emergency room of Foothills, and even a few minutes is just something you don’t have for acute trauma care. And so that that that was kind of the Achilles heel where it’s like, no, people are not going to wait for me to drive in and show up on the ultrasound console, they want decisions now. And that led us to the whole pathway of mentoring on handheld devices, wanting to be completely mobile, so that now that the fact that we can connect. You know anybody can, you know, with the computing power that you’re probably holding, we’re all talking on our phones, I think that computing power, there’s just so much more than a room size computer 20 years ago. We can connect and communicate with anybody. So, then I thought, okay, this is the answer now. But then scratching a little deeper, we realize that we don’t really know how to mentor, and what to mentor because, you might agree with me, some of the greatest tactical surgeons in the world are some of the worst mentors, you know, they don’t have those abilities to speak the language of a non-surgical first responder or ski patroller or military medic. So, all in all, this whole area, we need to figure out what we want to do, not just the fact that we have the technology to do it, but what we want to do how we have to do it. And then I think realistically, to get it funded, we need to prove it makes a difference. So, we do need well-structured clinical trials, including randomized trials, involving simulation where you can actually have pathology or no pathology, and hopefully that those are the next steps towards making a difference. And that may be working, I kind of, you know, hoping really bottom-up, an alternative would be to have a government or a health minister or somebody mandate from top down, which would be nice. But I suspect the mandate from top down, they’re going to want some evidence. And I think that’s a responsibility for us to produce the evidence to allow somebody to say, we’re all doing it, end of story.

Chad Ball 23:13

Andy, do you have any advice or take-home tricks or even framework for achieving satisfaction in terms of research and research productivity for surgical trainees or junior staff surgeons or people who aren’t as, as all in and experienced as, as you? What would you say to those folks to try and ignite that passion or maintain that passion?

Andy Kirkpatrick 23:38

Do something that excites you. That if you have a project, and it’s your project and your question, and you’re just, you’re interested in the results, you will do the work. If somebody, if you said, okay, I want to project and somebody gives you an idea that’s theirs, and you’re not behind it, nothing’s ever going to happen. So, when people come to me, looking for ideas, I try to get them to reflect a little bit and like what, what interests them what will make them passionate, and, you know, passion will drive you a long way. But the lack of it is a huge barrier.

Ameer Farooq 24:24

Is there anything you wish someone had told you? Let’s say, if you were sitting in my shoes sort of just about to start their career? Is there anything you wish someone had told you? At that time?

Andy Kirkpatrick 24:44

I think I always knew it. Or it was integral to me, but I wish somebody had maybe told me it was okay. Don’t be embarrassed about being an opportunist. And I am and I think I mean that in a positive way, as opposed to the negative spin on it, but when there’s an opportunity to learn, grab it, when there’s an opportunity for research, grab it, even if it doesn’t fit. But if it’s, you know, that’s your, you can work on a passionate project now when it doesn’t really fit into your life versus wait until you three months from the block, then you’ve lost that opportunity. Be an opportunist in killing three birds with one stone that combining your passions and working. And I think, working with people who you click with that click with you, that empower you, even if they’re in another continent, you know, may, is in this day and age where we really, we text the people in the office next to us anyways, that don’t let geography hold you back. You know, to kind of build those networks of collaborators as early as you can because they’ll empower you for your entire life.

Ameer Farooq 26:25

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback.  So, feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.