stewart, penny — life and death in the red center
TRANSCRIPT
The Intensive Care Unit I Alice Springs Hospital
Life and Death in the Red Centre
Penny Stewart
Alice Springs Hospital Intensive Care Unit
March 2014
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
Different Creatures
The Intensive Care Unit I Alice Springs Hospital
Australia’s Biodiversity – 1 of only 2 developed
countries in the 17 mega diversity countries of the world
Species Australian Species Desert Species
Vertebrates
Frogs 210 42
Reptiles 800 210
Birds 760 230
Mammals 360 95
Invertebrates
Cicadas 202 32
Butterflies 397 92
The Intensive Care Unit I Alice Springs Hospital
A Backpackers Dance with
Death
The Intensive Care Unit I Alice Springs Hospital
Case 1
From Uluru
To Alice
To ECMO
The Intensive Care Unit I Alice Springs Hospital
Case 2
ALICE
And
The
Spider
The Intensive Care Unit I Alice Springs Hospital
Case 3
Another Tourist
Bitten by the Alice BUG
The Intensive Care Unit I Alice Springs Hospital
What is Going On?• potential immuno-modulation by envenomation• apparent late effect• is this primary?• is this synergistic with antibiotics?• is this a new species (all un-identified)?• is this a known species with a novel venom?• how do we progress this?• Is this another creature related mystery from the red
centre?
the moral at the moment…
The Intensive Care Unit I Alice Springs Hospital
“Trust no Spider…”
The Intensive Care Unit I Alice Springs Hospital
Differences in Population
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
Drug reactions
• Severe drug-induced hypersensitivity syndrome with a
shared HLA-B allele causing DRESS in phenytoin
• HLA typing all HLA-B*56:02 as a common allele
>10% of the desert MOB.
The Intensive Care Unit I Alice Springs Hospital
Alcohol
The Intensive Care Unit I Alice Springs Hospital
Statistics
• Age adjusted rates Aboriginal vs. non
Aboriginal:
– Death rate 3.5x higher
– Hospitalization rate 6.5x higher
• Alcohol responsible for:
– 48% of fatal road trauma
– 56% of suicides
The Intensive Care Unit I Alice Springs Hospital
The Grog Story
Reducing the sale of high percentage alcohol, the opening times and the number of alcohol outlets does work.
The Intensive Care Unit I Alice Springs Hospital
Is it the drugs or the life style that makes the difference?
The Intensive Care Unit I Alice Springs Hospital
Population in Northern Territory
The Intensive Care Unit I Alice Springs Hospital
Statistics
• 70% of deaths among Indigenous Australians occur before the age of 65 years
compared with
• 21% of deaths among non- Indigenous Australians.
• Age specific:
– 25–34: 4x
– 35–44: 5x
– 45–54: 6x
The Intensive Care Unit I Alice Springs Hospital
Spending per-Capita vs. Life Expectancy
The Intensive Care Unit I Alice Springs Hospital
Spending per-Capita vs. Life Expectancy: Australia
Australia, non-indigenous
90
80
70
60
50
40
30
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
The Intensive Care Unit I Alice Springs Hospital
Australia, non-indigenous
90
80
70
60
50
40
30
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Australia, indigenous
Spending per-Capita vs. Life Expectancy: Australia
The Intensive Care Unit I Alice Springs Hospital
Exploring Disease- Diabetes
• prevalence:– 30% indigenous Australians vs. 6% general population
The Intensive Care Unit I Alice Springs Hospital
Exploring Disease- Diabetes
Now explore the age group 20-45 years old:– 18 x more likely to have diabetes– indigenous diabetics 19 x more likely to have end
organ damage – therefore, absolute risk of chronic organ
impairment is:
The Intensive Care Unit I Alice Springs Hospital
Exploring Disease: Diabetes
Now explore the age group 20-45 years old:– 18 x more likely to have diabetes– indigenous diabetics 19 x more likely to have end organ
damage – therefore, absolute risk of chronic organ impairment is:
380
The Intensive Care Unit I Alice Springs Hospital
Why so much diabetes?
• 50,000 years
Desert MOB- thrifty gene
Foetal life:– poor nutrition during pregnancy
– gestational diabetes
The Intensive Care Unit I Alice Springs Hospital
Why so much diabetes?
50,000 years 150 years
The Intensive Care Unit I Alice Springs Hospital
Why is diabetes different?
The Intensive Care Unit I Alice Springs Hospital
Why is End-Organ Damage
Accelerated?
• High HbA1C is bad
• 50% of ASH indigenous diabetics
HbA1C >10%
• ? accelerators to endothelial
disease such as recurrent sepsis
The Intensive Care Unit I Alice Springs Hospital
Accelerators of endothelial damage
Two nations: racial disparities in bloodstream infections recorded at Alice Springs Hospital, central Australia, 2001-2005. Lloyd J Einsiedel and Richard J Woodman
Med J Aust 2010; 192 (10): 567-571
The admission-based BSI rate for Indigenous patients was 2.65% compared to 0.52% for non-Indigenous patients per year.
The Intensive Care Unit I Alice Springs Hospital
Alice Springs Hospital Data• Catchment area- 45,000 people; 15,000 are
indigenous, 10,000 indigenous adults
• 70-80% of the patients are indigenous
• 180 beds; 110-120% full
• 43,000 presentations per year to the emergency department– 10,000 over10 years with little change to
population size
• 28% readmission rate within 28 days
• 15-20% take your own leave rate
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
ASH ICU Outcomes
ASH Data Pooled ANZICS
Age: 50.1yr 60.9 yr
% indigenous: 65% 5.9%
APACHE II 19.7 15.6
% Emergency 95% 68%
ICU Mortality 2.15% 6.19%
The Intensive Care Unit I Alice Springs Hospital
Acute Pancreatitis
July 2003 to June 2010
• 1000 episodes of acute pancreatitis
• Annual Incidence : 259/100,000
• 206 in that group CT scan grade severe
– 96 of that group with necrosis
– 1 person palliated: 84 years old with an
advanced directive
• 205 in ICU - 205 survived
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
Is there a survival advantage?
• Genetic- mortality from sepsis is genetically linked
• Pre conditioning:Remote Ischemic Preconditioning: No Loss in Clinical Translation Michael Rahbek Schmidt, Steen Buus Kristiansen, and Hans Erik BøtkerCirculation Research. 2013;113:1278-1280
The Intensive Care Unit I Alice Springs Hospital
The Intensive Care Unit I Alice Springs Hospital
Road Deaths per 100,000 people
NT- 21.3
Australia-6.1
The Intensive Care Unit I Alice Springs Hospital