#022 - Dr. Minesh Khashu - NEC research, Fathers in the NICU and the future of neonatology

Pr Minesh Khashu is a clinical leader reimagining healthcare with a focus on systemic wide transformation, continuous quality improvement and family centered care. Prof Khashu has held multiple hospital, regional and national leadership roles in neonatal and perinatal care. Professor Minesh Khashu is a neonatologist at University Hospitals Dorset. He is the founder of the special interest group NEC (SIGNEC; signec.org). He also works actively on advocating for fathers' involvement in the NICU, and to that end, collaborated on the development of the neonatal DadPad app.

https://signec.org
https://thedadpad.co.uk/neonatal/

Check out his NEC paper on the use of bowel US: https://pubmed.ncbi.nlm.nih.gov/32398270/

You can get in touch with Dr. Khashu via:
Twitter - @mkrettiwt
Email - mineshkhashu@gmail.com


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As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

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Transcript

Ben: 0:43

Hello, everybody, welcome back to the podcast Daphna. How's it going?

Daphna: 0:47

I'm doing well. No major changes here. What about you?

Ben: 0:52

Oh, things are good. I'm actually recording this from the hospital today. This is I feel like Indiana Jones you know, it's a big adventure. Today, today we have the pleasure of having with us Professor Minesh. Cashew, who is a professor of parasitology and the neonatologist, based out of the United Kingdom. Minesh is doing the pleasure of being on with us. He has a special interest in NEC for which he founded a special interest group and for NEC SIG neck, and for which there's actually a conference every year hosted in London. He'll tell us more about that. He also is he's a very interesting, very interesting physician. He works actively on advocating and facilitating the fact that father's involvement in the NICU will talk to him about that as well. And he was involved in the creation of an app and a lot of other cool stuff. So Manish, thank you. Thank you so much for being on with us today.

Minesh Khashu: 1:49

Thanks, Ben. Thanks, Daphna. It's a pleasure to talk to you guys. And I would like to start off by congratulating you for starting this initiative. I think it's important that the neonatal community comes together, and we learn to collaborate and share cool stuff as you're doing. So thank you once again.

Ben: 2:07

Yeah. Thank you. Thank you so much for that feedback. Yeah. I guess for the people who are getting to know you Manish the you're, you have a very extensive CV, but let's start. Let's start at the origins. I mean, you completed your medical education in India, then you move to the UK and then you you followed a path that led you to Canada and Vancouver specifically, where you did your fellowship in neonatology. Can you share with us? What ended up leading you into the field of neonatology?

Unknown: 2:39

Yeah, I think that's that's an interesting question. And I think sometimes in life, things happen for the right reasons, but you're not necessarily in the driving seat, so to say, whereas you might think you're in the driving seat. So I, as you said, started my MBBS medical graduation in India, then I did my masters in pediatrics, and actually I work in New Delhi, the capital of India, in what was at that time, the largest hospital in Asia, I worked in that hospital for a few years doing actually PICU. So I was doing PICU for quite a few years. And then I moved to the UK and unfortunately in Wales happens for a lot of graduates who move between countries, it's not always easy going. So I had to retrain, I had to retrain partly in the UK and then completed my training. What used to happen those days in the UK was there wasn't a separate specialist training for neonatology, you you became a pediatrician and then if you did a lot of years of neonatology, you became a new neonatologist, if you did, a lot of cardiology became a cardiologist and so on and so forth. So at that time, one of my mentors actually mentioned Vancouver to me as I was finishing my training. And I initially came to Vancouver for a one year fellowship, but then loved it so much, that I ended up staying over three years, and did a lot of a lot of, obviously, neonatal care did quite a bit of research as well. In fact, I was chief fellow there for a few years and a lot of air miles as well. So lots of getting sick, sick babies from all over by helicopter and fixed wing through the British, sort of beautiful, sort of complex Colombian countryside. So Vancouver was a great experience and in some ways, that was a turning point for me to really get stuck into neonatology as a speciality and locked you in almost it did I think that there was there was no no moving back and Vancouver was a lovely unit, and quite a big unit as well. So one of the things to understand is because of the size of the unit, you would see in one year what you would normally take three to four years to see in some of the other units or most of the average units. So that way, and it was it had a really nice culture as well. So that was beautiful. Unfortunately, at that time, they didn't have a vacancy for me. And if I had to go somewhere else in Canada, I would have had to train again and do three or four more exams. I think by that time that I was, I was fed up I had already. So I think I think that's why I ended up ended up coming back to the UK. But interestingly, interestingly, I came to the middle part of UK, then I was, in some ways, asked to come to where I am now. And this was the south coast of the UK. And I think, in some ways, it was the closest to Vancouver I could get in terms of landscape. And, and that's where I ended up landed. And sort of I guess, I set my roots up here. So this is a lovely place called door set here in the UK.

Ben: 6:01

And so what you just do to finish up on that, on that topic, you said that you were initially working in the pediatric ICU, I'm always interested in people who are sort of changing lanes, especially between the NICU and the pick you as to whether that you got fed up with the PICU? Or did you just fall in love with the NICU? Which one was it?

Unknown: 6:19

No, I think it was largely the latter. I think that the experience in Vancouver really, really crystallized sort of my my sort of long term career really, so to say, I see,

Daphna: 6:32

that's a good reminder for our PICU faculty that the residents who are really interested in Nikki, there's value to having residents interested in the NICU. I always try to convince me otherwise. So I'm always so intrigued by people who, you know, have to go to multiple facilities, multiple hospital systems, I think you've learned so much, but you've really worked in a variety of different healthcare systems, just the way that healthcare works in so many different countries. I wonder how that changes kind of your practice in your approach to medicine,

Unknown: 7:11

I think I would say that if not hugely, because you learn to see that different things can be done sort of in the same way or the same thing can be done very differently in different parts of the world. And it also gives you a broader prospect perspective, because it is it is not necessarily that the priorities within neonatology will be the same everywhere. Teams function differently. And I think you you you learn, I think you could have become a have a have a more open mind, you're more open, actually, I feel people who work in more multiple places are more open to improvement, they're more open to testing new things. So I feel I actually, I would always advise people during their training, they should try to see multiple multiple healthcare system, they should try to not work only at one place, because you don't know what you don't know. So I think it's useful. And also if you do it in your forming years, I think it it makes you a better clinician. Because because you get a lot of diversity in terms of your attitude to medicine in terms of your thought processes. So I would always always say to people, I mentor, say to people whom I supervise, try, try try different places out, even if you go somewhere for six months or three months, it's better than not going.

Ben: 8:46

Yeah, that's okay. So let's let's get into some of the of the stuff that you've done yourself in your career that is quite fascinating. I want to start off with Signac which is the special interest group for necrotizing enterocolitis. So this is a a collaborative that you you've built and you created in 2012. And I guess my question to you is what exactly happens to you in 2012 with NEC that you say, You know what, I need to I need to make this happen. I need to engage everybody on the subject of NEC on a global level. What drives the motive? What is the motivation to actually get this done?

Unknown: 9:25

Ya know that I think that's that's that's a very sort of pertinent question. So it wasn't necessarily something specific for me but I think at around that time we had some of my colleagues had a couple of cases of within what we would perhaps label as transfusion associated neck so relatively well babies almost ready to go home who collapse in a heap following a transfusion and, and I was sitting actually on the Dorset Coast thinking stuff through and then suddenly I guess I started thing Thinking is not just in terms of NEC as being an important cause of mortality and morbidity, newborns but more importantly, understanding that nothing had changed in the NEC domain in 2012 for the last 3040 years, so the treatment hadn't changed, the management hadn't changed. And in some ways neck was an interesting condition in neonatology where we hadn't moved ahead almost in 3040 years significantly, a lot of research happening a lot of insights, but not really moved ahead in terms of ATO pathogenesis, we hadn't moved ahead in terms of in terms of management. And it's also an interesting condition that is one of the few conditions within neonatal care that has actually quite different multidisciplinary input. So in in those in those terms, I felt this was something useful. I have always always had a huge interest in collaborative work and in improvements. So if you ask me, What is your overarching passion for work in medicine, I would say Qi quality improvement is my area of interest and expertise that said, that sort of embraces all that I do. So I started seeking NEC, not necessarily as as an research interests, but more as an improvement in press. And that's how it started. That's how it started. Sorry. Go ahead, Ben. No, it

Ben: 11:27

was gonna send so so far in the past, almost now 10 years, nine years, specifically, but almost 10 years, what is the biggest change that you've noticed or that you've able to implement? Thanks to thanks to Cigna, UK, and then partnering with people from across the world

Unknown: 11:42

should this do, I would say, there's quite a few things we've achieved. But there's still a lot to do. So to give you an example, we have done stuff in our own unit for in terms of a package of care where we hardly have any neck in our unit. So we've had a couple of cases, which were babies which came to us from elsewhere. Otherwise, in the last eight, nine years, we haven't had an economic unit, there's this

Ben: 12:07

audience wants to hear more, you have to tell us a secret.

Unknown: 12:11

I don't think there's necessarily a secret. Having said that, having said that, a few years back, because of centralization of care. Some of the younger, smaller babies now don't stay with us, they moved to one of our surgical units. But even if you looked at say babies 26, two weeks and abou and compare our rates with most units in the world, we would be we would be definite outliers at the bottom. And but anyway, we'll we'll come back to that later. But in terms of Signet, a couple of things that we did, which were different, and which actually changed the paradigm, I would say is, we were one of the first scientific meetings, which invited parents and families to sit down with clinicians with researchers at the same table for two days, discussing problems, I don't think in 2012, that was the trend. And after that a lot more conferences and a lot more associations and groups started inviting parents, but we were perhaps the first international conference that did that from the very word go. And that that was great. And obviously after Signet developed, then we had over time the neck society developed in the in the US with whom I work closely. And then we had a Brazilian society. Again, I invited them to signal conferences so so a lot more national groups have been set up. But I think Signac was the first forum internationally that bought all people together who had an interest in NEC at on the same platform. And I've had big stalwarts within the NEC domain like David haccombe. And others say that this is the highlight of their yearly calendar largely because this is the only place where people only talk about NEC they don't talk about anything else. This is such a focus meeting. And it they felt it's good for them to bounce ideas off other NEC researchers and stuff so I think that is that is one big achievement, that Cigna in some ways set the ball rolling with and then and the next society in the US has done great work, in fact, much more work than we have done. But I think in some ways, we set the ball rolling and set the paradigm there. The second important bit, as I said, was getting the parents to the same table equal members of an improvement and research paradigm. And the third thing I would say is we then initiated yuan for Goosen was, was the one of the sort of initial parent reps on stage next year unfortunately lost one of her twin sons to neck so she was with me from the almost the very go on sick neck. And we then delineated may 17. As a global neck Awareness Day, and then we collaborated with the neck society and the Brazilian charity. So that world over now 17th of May, is is designated as a global neck Awareness Day. So that would be something, again, for your listeners to utilize to improve awareness about neck to improve support for parents are using may 17, as a day for campaigns in relation to this.

Daphna: 15:32

I love that you, you know are including parents, I think that's so, so important. I think it brings a lot of value. Certainly, parent groups have pushed the boundaries, you know, on quality and research of numerous pathologies that we see what made you like you said it still wasn't pretty, it's still not mainstream to include parents in, you know, scientific communities. So what why did you feel so strongly about including parents?

Unknown: 16:04

I think, a couple of reasons. One is, my thought process is very focused on who the customer is. So if we're doing improvement, or if we're doing research, who is the customer, the customer is the patient, which is the baby and its family. And I think it's quite important when we're doing improvement or research. Our priorities are the real priorities. The priority should not be Minish who has an interest in molecule D, and he spends his whole life researching molecule D and publishing 1500 papers and molecule Do you I don't think we have a limitation of monies, we have a limitation of research time. So research and improvement should happen on priorities that are important to the people that matter. And who are the people that matter? Really, the people that matter are the baby and its family. So I think having parents at the table focuses people's priorities on what are the real problems. To give you an example of neck, there is no national or global data set that looks at long term outcomes of neck. Why isn't there it's there? Because we haven't heard what what is important to people. A lot of the neck difficulties related difficulties happen to parents when they leave the neonatal unit, isn't it? Why isn't any work done on that? Or very little work done? Because we don't use parents voice and ask them what is important to you. So I think any improvement any research should be done based on prioritization not just by healthcare workers, but by the parents and family as equal partners, then and then only we'll be focusing on the real important stuff.

Daphna: 17:52

Yeah, certainly our goal would be to get rid of neck altogether. But but the truth is, it still exists, right, like you said, and their babies recovering from it their babies who are not recovering from it. And and that's an interesting point, we should be just like everything else, we should be studying the long term outcomes, certainly. And the long term, you know, morbidities associated with it. You know, we have a lot of listeners who are pediatricians or pediatric intensivists. You know, people who are therapists, people who are seeing our babies long term long after they leave us. And so how do we, how do we guide them? I think that's so valuable. What do you think the biggest contribution that your parent members have provided so far?

Unknown: 18:45

I think one of the interesting things I found from especially basic science researchers who attended Signet conferences was they said they almost were rejuvenated by attending the conferences, because it added to their passion when they heard the parents speak when they heard the stories about the babies, because they don't normally, for you and me, we come into contact with parents and families on a daily basis because of clinical work. But for some of the basic science researchers who largely work in the lab, they don't they don't get that interaction. So I think they found that hugely valuable, they felt it's almost like a recharge for us for next year. Because because it adds passion to our work, we get an meaning why we're doing what we're doing. So I think that that is one is quite important. And the second bit as I said, it really focuses the clinicians mind on what is important, what is what is what needs to be prioritized. And also, I think one of the other things I wanted to highlight as part of this podcast is the problem in neonatology in say neck for example might be we don't understand The disease will and it's very difficult to treat a disease Well, if you don't understand the disease or its causes well. But there are a lot of things in neonatology where we have the answers, and we still don't implement it. Yeah, so we have a problem, not just in in the science, we have a problem and implementation as well. And by having sorry, by having parents at the table, it pushes clinicians towards better practice. And that's quite critical. We seem to have too long a gap between having the evidence and between changing practice and that needs to get narrower and narrower. Sorry, go ahead. Ben, you had something to say?

Ben: 20:41

No, I was gonna say I have I have the perfect follow up, then because I think the work that you've done that I've enjoyed reading about is the one on our neck, obviously, but also the use of bow ultrasound, I think you have a few papers that have been published. And that look at could we use abdominal ultrasound as a as a tool to diagnose NEC. For anybody that is interested in the topic, I think you recently, were the senior author on an article called implementation of bowel ultrasound practice for the diagnosis and management of necrotizing enterocolitis. It was published in 2019. It was an archives of disease in childhood, we'll put the link to the article in the show notes. But in the air, you have a very detailed, almost a protocol as to how to use abdominal ultrasound. And for what you were describing, if we could reduce the exposure to radiation of babies in the unit by using something that is less invasive, that is less exposure to radiation. It feels a lot like exactly what you were just describing, we have a way to make things better. And it's not something that I've seen in any of the units I've worked at, actually, I've gotten pushed back from radiologist when I wanted to do an abdominal ultrasound for NEC because I was telling I was being told how technically difficult it was. I'm just wondering, can you tell us a little bit more about what your experience has been without ultrasound? And where do you see the future of it? Most specifically, do you think that this is something that we're going to need to push for towards the radiologist? Or do you think that this is something that will come down the pipe for neonatologist interested in point of care ultrasound? So I'm just curious to see what what your thoughts are on on this at this point and what the future of it looks like for about ultrasound and NAC and attends

Unknown: 22:22

when and very pertinent question. I don't claim to be an expert in bowel ultrasound, so I'm far far, far away from there. So it's largely radiologists. But I do I do. A lot of the work I do, as I said is about improvement. And it's about leadership. It's about getting the right people together and moving things forward. So So in terms of bowel ultrasound, I think there are definite advantages over X rays, which is the traditional modality we use, and apart from obviously decreasing exposure to radiation, the critical main advantage is earlier, earlier diagnosis and and trying to rule out the diagnosis in doubtful cases where you're not sure based on the clinical picture or the radiographs. And there's there's reasonable evidence to suggest that an earlier diagnosis of neck will improve outcomes by either getting by either getting the child earlier treatment or transferring the child earlier to another center if need be, or whatever. So I think the critical advantage of bowel ultrasound perhaps is an earlier diagnosis and hence, most likely better outcomes. The article that you mentioned is largely we wanted to present it almost like a framework. So if you as a unit wanted to do it, it was just a template to get started. I feel its implementation will vary country to country. There will be countries like the UK where I feel or parts of Europe where I feel the neonatologist will do it as point of care ultrasound over time. Now my experience from North American perspective is is perhaps something that you need to push your radiologists to get started and have a protocol have some governance around it. And people will get to learn ultrasound overall will change neonatal practice or practice largely in most clinical medicine in the next 10 years in terms of its ease and in terms of the range of conditions and situations we use it in so I think it will come I feel perhaps in North America the best option is to find within an inverted comma friendly and interested radiologist and and find set up a group within or you own your own unit and start start doing it. I think it's definitely an improvement sort of pathway and it will It will help in earlier diagnosis. And also it sometimes helps you rule out. When it is not neck, which is, again, clinically, equally useful. I'm more than happy to get you in touch with some of the radiologists who have done extensive work in this domain so that they can they can mentor, say your particular units to get started. provide advice. So I think that that all is possible, because that's largely the idea is can we can we help disseminating this good practice? Can we help the implementation? And I

Ben: 25:35

think I think that sounds that sounds terrific. And I think for anybody who's interested, I really recommend you checking out that paper, there's there's actually an above average number of pictures in there. So that like you said, it will provide a nice framework and nice reference points for yourself or any or radiologist working with you to implement this modality as a potential tool for the diagnosis of NEC. So yeah, thank you for doing that.

Daphna: 25:57

Well, and and like you said, part of the problem is, you know, we still don't totally understand it. And we there are so many cases where we're saying is this NEC is this not NEC, and especially given the amount of antibiotic usage, you know, that we do for neck or neck rule outs? I mean, obviously, anything that will better define the pathology and the disease process, I think will benefit so many babies. I wonder how how you think that you know, ultrasound? Will, you know, will it be part of our diagnostic criteria you think in the future?

Unknown: 26:40

I think it will, but the most important thing I feel in terms of ultrasound overall as well as, as a point of care ultrasound, I think it will change a lot of neonatal unit practices. So 10 years down the line, we may not be doing X rays for ET tube placement, we may not be doing X rays for line placement. And so I think that there is a huge there is a huge potential in using it at point of care. So I think I think definitely, definitely an area to delve into deeper. Yeah, I want to

Daphna: 27:19

know, I was gonna say I'm, I was fortunate that I'm where I trained at the University of Florida, we were really moving forward with point of care ultrasound, and we had some wonderful radiologists who were just as excited about neonatologist using point of care ultrasound as we were and so I think it's so like you said we have to cross over our lanes and disrupt our silos and talk to people and in the other disciplines to really make progress. And so I really commend you for the work that you've done. I'm so grateful for the radiologists in my life that have you know, accepted us and trained us a little bit and you know, I think it's really exciting and like you said, the end goal is is helping babies and so you know, we've got to do everything we can to come together and do that what what was the hardest part about kind of designing your or introducing ultrasound into your unit? I think a lot of people are interested but there are certainly some some barriers to that what what were kind of the the hardest things that you guys faced,

Unknown: 28:36

as I mentioned to you, we don't really see NEC on my unit so we haven't we haven't I wouldn't I wouldn't we haven't utilized Ebola ultrasound within our unit but some of my other team members on on that project who were sort of authors on the publication they have been using it extensively and as I said, we don't see Nick on my unit so there's there's no patients to scan Braille there's no patients to scan that problem. So but but there are a few units there are a few units in the UK so and some some surgical sort of trainees and and Surgical Consultants who use it but the I know quite a few of my colleagues through the Signet world who utilize it in North America as well so I think anybody wanting to get started wanting some initial help or wanting some mentorship for their for their ultrasound program for NEC please get in touch with me and I'll set you up with the right people so that you have some support on the on the initial sort of

Ben: 29:54

Edward and we will leave your your Twitter handle on the show notes because I think you're very active on Twitter as well. I want to ask you one more question about NEC and then we can move on to another topic but anybody interested in in participating collaborating with you Signet can be found on the on the Web www dot Signac that org It's spelled si G nec.org And the question that I had this May 17 as NEC Awareness Day was there a reason why it may 17

Unknown: 30:25

We had a few alternatives and then we had to take into account the world prematurity day which was I guess a different end of the year so there was there was some reasons for May 17 But I think it was more out of excluding some other potential dates that we we we ended up we ended up with may 7 There are

Daphna: 30:53

only so many days in a year and

Ben: 30:56

yeah, it's it's a crowded calendar. I feel like every time you walk into the hospital and some but somebody's day or somebody's weekend there's there was initially Doctors and Nurses Week then there was therapist week, clerks weekend so there's it's so crowded, the calendar is very crowded. I wanted to talk to you about the dead pad neonatal. I mean, you worked with the team at Inspire Cornwall in 2012, to launch what's now called the DAP pad. And for the listeners who are not familiar with it with it, can you can you tell us a little bit? What are the what is the mission and the goals of that pad neonatal.

Unknown: 31:27

Thank you for that. So that pad. So the company that you mentioned, had already produced a dad pad, which was a resource for fathers in relation to having a baby. And I had always felt on the neonatal and maternity sort of pathway that fathers to some extent, don't get the same attention as mothers. And in some ways that is appropriate, because mother is the is the primary patient on the maternity pathway. But that's had a lot of unmet needs. And we've done some research to show that that's one met needs. They also, as a generalization react to stress differently, they communicate somewhat differently. They will also most of the time be going back to work earlier, so they're not on the unit all the time. So I will always felt that dads perhaps did not get the same quality and quantity of information and communication that mothers did. And they unfortunately did not get the same degree of support, but because they were not around. So we did some work on that. And again, that that Pat neonatal came about as as a quality improvement project really for me, so there is a lot of unmet need for fathers, how do we meet that need? And one of the main ways of meeting those unmet needs was through that pad. So that pad neonatal is is basically a physical resource that basically welcomes the father to the neonatal unit. It talks about who the people on the neonatal unit are, it talks about why your babies on the neonatal unit? What are the common conditions? What is the common equipment? What is expected to happen in the first 1224 hours? What is expected to happen after that? Who are the different people working? What work do they do? How do you interact with them, it also has space where the dad can write about his emotions, it encourage the father to ask questions if there is a place there for the father to put in pictures of his baby. And the reason we kept it as a physical copy was we wanted it almost like a momento as a keepsake of the neonatal journey for that, so that this was something particular for that. And that's how it developed we are in the process of making into an app as well. But we will still please keep the physical copy because the physical copy is like a moment to for Dad, it's about him and his journey with his with his just sort of infant. And so the way it happens is a lot of the times if mums are unwell or they have has a had a section they may not be able to come to the unit so dad is the first person visiting. So when dad visits the unit for the first time, we will give him the DAT pad neonatal we will signpost him to things but then we also utilize the deadpan neonatal as a conversation tool. So it's not just I give you a book go and read it and then tell me if you have any questions. So it's not like that. We tell them sort of some of the key areas and then we go back to the we go back to the resource and ask them and utilize that as As a way to generate conversation and engagement with fathers. But the dad part neonatal is is one of the things I think what we're interested in more is a paradigm shift within neonatal and maternity services where we focus on the co parenting paradigm, which means that mum is not the only carer mum and dad are both carer they all love they have need sometimes the same needs, sometimes different needs. So if we are serving them as they being our customers, we need to serve both of them. And so they are different needs. So that's largely how it is. It's it's done quite well, we got very good feedback. And actually, it's gone international hours. Well, we have, we have currently deliberations going on with with the large batch going to New Zealand. I also want to highlight the Ben and Daphna is, I've done this as a quality improvement work, I have no financial stake in the product. And I have said I'm not involved with the company financially. For me, this is just a QI project. And generating.

Ben: 36:08

That's good. Yeah, that's good of you to pointing that out as well. I mean, then for people who are interested, I think the we can find out more at the debt pad.co.uk/neonatal. And there's a ton of info there and the prototypes of the apps are there. And it looks pretty, pretty nifty. And I'm sure Daphna has tons of

Daphna: 36:28

this is certainly an area of interest for me. And then you know, for our listeners, we can we'll put the link in the in the show notes. But that they can actually download a like a 10 page kind of primer for the dad pads so they can see what it's all about. And I found that very useful. I think what I loved about it is that it is so simple, actually. Because it gives the the dad just some basic information, but it's really about empowering, and his participation in the unit. And we know that dads plays such a role, especially, you know, in our changing society that we you know, it's not fair that we don't bring them in from the very first day. So I think that is just phenomenal. I think the graphics are nice, I think they certainly are targeted to dads potentially. But knowing that we have all kinds of dads, we have all kinds of families in the unit. What maybe you can tell us about a you know, success story using the dad pad or you know, some of your, your favorite dad adventures?

Unknown: 37:46

No, I think I think it has weathered, excellent feedback from from from all quarters. And interestingly, actually mother's love it as well. So mother's find a lot of information in it as well, a couple of points I wanted to highlight for the audience. One is, if people want to have a preliminary chat, just to understand whether it's something that might be useful for them, feel free to contact me. So I think that's fine. What we have also done, I already told you that we're in the process of making into an app, we'll still keep the physical version. But we have also the capacity to make bespoke versions for you. Because a lot of the stuff is general neonatology stuff in the DAT part, but some of the stuff is specific, say to UK in terms of the types of units. So for example, if somebody in North America wanted a dad part version, we spoke version for that region can be made, languages can be changed without much difficulty. And also, we are aware in today's days and age about diversity and inclusion. So we are also open to make different versions for SES like same sex couples and stuff like that. So I think those are all possibilities. This was in a way, the first step in this direction to generate some improvement. But even though we call it the dad pad, it's largely about empowering parents. And we can easily make bespoke versions for different regions of the world we can make bespoke Korea, even for a particular unit, where you could have all your particular links to, to your phone numbers to your contact details. So you can you can make something similar, something similar and sort of make it make it particular for you for your needs. So there is there's ample opportunity to make bespoke versions.

Ben: 39:41

I think I think this is you're touching on a point that is going to it's it's so dense. I think we have a hard time understanding the perception of the neonatal ICU from the dads perspective, because there's a multitude of different types of fathers. There's the reserves, parent fathers, there's the more vocal one But when you're talking about some of to be more inclusive and includes are of same sex parents and stuff like that, I think we're only touching the surface as to the relationship between within these couples and their relationship to the neonatal ICU in the context of having a baby in the NICU. So I think maybe the deadpan and the app is going to help us understand I think, in this new generation, all these different couples that we're now including, and being much more sort of aware, aware of and trying to cater to in the NICU. So I think I think there's tremendous potential there.

Daphna: 40:36

And that's what struck me when I, when I opened it, as I said, everybody needs this, right? You know, all the caregivers and, you know, at least you know, right now, so many caregivers that are part of the family unit even even extended right, grandparents, aunts, uncles, siblings, you know, we're very much restricted on that because of the pandemic. But you know, it affects the entire families, and it affects entire communities and NICU admission of one very, very sick baby. And so I love that you guys are, you know, trying to do something different? I think certainly having the app, you'll be able to even reach more people. So I'm excited to see that come out.

Ben: 41:21

Thank you. I have one question about the death pad. And it's not really about the death, but it's mostly about supporting fathers in the NICU. But when you are creating and you're you're consulting on creating these pamphlets and these tools for fathers, is there a way? Or is there something specific about fathers that drives how information is presented or delivered? Because I'm sure that for example, if you go through some of the of the information on the DAT pan, there's a lot of topics that apply to obviously, both mother and father like breastfeeding and putting the baby to sleep. But is there a specific way that that needs to be taken when you're approaching information sharing and delivery to fathers specifically that you've noticed?

Unknown: 42:03

There definitely is, again, these are generalizations. So everywhere every person is individual. So when we talk about personalized care, you have to understand who's in front of you, and personalized care based on them. But as a generalization, dads will manage stress differently, their communication needs are different, the communication preferences are different. And so so we had a we had a focus group of dads about eight, nine dads with whom we worked in terms of the in terms of the dad band. And I think it is important, whenever we're doing this type of work, that again, the customer focus, who is the customer? Where is it gonna go to, I think that that is that is quite important. And I do feel that Fathers will, will engage differently. So if you look at, if you look at traditionally what neonatal units do to bring back, say, mothers get some peer support is they will create, like a coffee morning and the moms come in and they chat and they discuss true stuff. Most of the time, fathers don't engage in it. So you will even get them into the room, but they don't talk they don't open up. So you have to find you have to find different ways and means and avenues of engaging with fathers with sometimes a better than one to one or all you have to change, you have to change the context in which you are meeting. So I think it's quite important to understand, understand that and then tailor the product, as I said to the needs of the customer. Yeah, it's

Daphna: 43:41

a good reminder that it's not our information or dissemination of information is not you know, one size fits all right. It's not the same for everybody. That's such a valuable point.

Ben: 43:55

We're coming close to the end of the early interview. But I guess, for me one of I guess my last question would be, you are very involved in technology and quality improvement and innovation. And you do see the field of neonatology almost like a startup, right? I mean, you're thinking of it as the customer experience, what are the customer outcomes? And I know the word customer has a lot of stigma around it, but it's true. I mean, we do have to do we have to provide our patients and their families with the absolute best care and results possible. And when you put it in the in that in that frame, it makes more sense. Now, what do you think, in your opinion, is the next 10 years going to look like when we incorporate technology and especially new technologies AI innovation into neonatology what what do you think? What do you think? What do you think things are going?

Unknown: 44:47

Okay, so to me, the most important no intervention in neonatology actually in whole of health care in the next decade is not going to be a device it's not going To be a drug. So the most important intervention in healthcare in the next decade is going to be data. How we collect data, how we use data to generate insights, so data AI machine learning, to me, that is the biggest intervention, that should happen in the next decade to improve outcomes. Because there's huge potential there. And the reason I'm saying that is you will not generate an antibiotic or a pill, or a device that can match the amount of improvement that your data can do. So every day, every baby in every neonatal unit is generating data. What are we doing to that data, that data is going into a black hole somewhere that nobody knows about? Yeah, we're generating data on a on a daily basis, every baby's telling us stuff. So I think it is the amount of data

Daphna: 45:57

you're making speaking Ben's language right. Now I know that this excites him.

Unknown: 46:03

So we need to find we need to find a way of collating this data, getting insights from this data, it will also change our research paradigm. I think our current paradigm of research where we think that the RCT is the only thing that's good or useful, is, again, I don't have anything against RCTs. And there will be questions that our CTL will help us answer. But there are other ways of research faster ways of research, quicker turnaround times more cost effective using data using big data. So we have to, I think, to me, that is going to be the biggest and most important change needed in the next decade. In terms of devices, I think, what will also come about is the way we monitor so one would be remote monitoring, and the other would be monitoring without wires. So if you currently see a baby on a neonatal unit is like a foreign exchange of the old years, isn't it, there's 10s of lines going into the baby, those lines will go, those lines will go in five to 10 years, you will have ways where nothing is coming out of the baby or getting into the baby, you will be able to monitor a lot of the stuff. Obviously, we'll still need long lines and things like that. But in terms of the heart monitoring, in terms of other stuff, I think it will it will be almost wireless monitoring. So I think that will be that will be the big, big thing. And finally, what I'm hoping what I'm hoping is that the variation in outcomes in neonatal care, between countries, and between different regions of the same country, those variations are expected unwanted variations need to narrow down. So whether a baby's born in Colombia, or India, or Pakistan, or Poland, or Vancouver, every baby deserves to have the same good outcome. And that's a big challenge for the neonatal community to find ways where we bridge this big gap, not just between countries. So if you look at, say, outcomes in Africa or Southeast Asia compared to say, the West, even within us or even within the UK or Europe, there are areas which have worse outcomes. So I think this unwanted variation, these poor outcomes, which are largely related to perhaps bigger determinants of health within those populations, I think we need to find ways we need to find ways to improve those outcomes.

Daphna: 48:51

Well, I just love how, you know, it seems you obviously have a passion just for bringing people together. And I think that's one of the ways that your work is different than what other people are doing because it's hard, right? It's hard to talk to people who don't speak our language, either actually our language or you know, just what our interests are. But you seem to have a knack knack for doing that. So what do you recommend for for other people who are trying to kind of disrupt the typical ways that we do research?

Unknown: 49:29

When we talk about innovation, one of the quotations I use and I've been using for the last 810 years is that collaboration is the most critical innovation for healthcare. So the innovation we need isn't a magical device or a magical pill or anything it is people getting together all the right stakeholders getting together in in a room and source saying, yeah, yeah, yeah. So I think I think that that is the critical bit. You don't necessarily need the whole world, I think you need a small group of passionate people, and then you build the network accordingly. I think most people generally want to do good work, most people get up in the morning, and want to have a good day. So I think it is about it is about basically utilizing that passion that people inherently have and supporting them. Network, we win, again, is a sign so I can talk to you about that maybe some other time. But we've just finished a nine month program through one of the important health tanks here in the UK called called Health Foundation, where we focused on what is the what is the role of networks in improvement? And how what is the science of networking, what is the art of networking. But I think it is about taking no pun intended baby steps. And getting started. I think the most difficult bit is the first step. So if you take the right step, people will join you. So I think, I think I think that that's that's quite important. And there's a lot of good happening. So I'm not I'm not trying to paint a picture. Otherwise, but at the same time, there's a lot more that we could be doing.

Ben: 51:31

There's this famous author called Steven Pressfield, that has a book called The War of Art. And he says that the biggest hurdle to getting anything done with any creative endeavor is the is resistance. He says there's everybody is facing resistance. And that's really the impediment to getting anything done. It's exactly what you're describing. We just need to get started. And and then build on that. So that's that's a great message. Definitely anything else before we close?

Daphna: 51:54

I really enjoyed speaking with you today. I encourage everybody to check out the dad pad, get to the Signac website, it's very easy to use all of the information there is easy to find. And we're looking forward to seeing what else you come up with.

Ben: 52:13

Yeah, I really liked the Signet website, and you have a blog on there that were really like leaders in the field of NEC have written articles on different topics. These are amazing. I really enjoyed them. So I recommend people check it out. So yeah, I echo Daphna sentiment and thank you Manish for being on with us today.

Unknown: 52:28

It's been a pleasure talking to you. And as I said, keep up the good work. I want to leave you guys with two things. One is everybody is very busy. But these type of projects, I call them passion projects, these type of passion projects are important. Because even though they might mean extra time, they actually give you a lot of resilience and satisfaction. They make the other hard work better because they almost recharge you so so see these passion projects as a way to recharge yourself for much harder and more sort of drudgery of the normal day's work. So that's one and and the second bit I want to leave you with is that excellence is a habit. So true.

Daphna: 53:15

Yeah, that's so true. I don't have anything else to say. I think we're certainly learning that we're spending every free moment we have on on the podcast, but we're enjoying it for sure and getting to meet people like you.

Unknown: 53:30

Good luck and thanks once again. Bye Bye

Ben: 1:04:37

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikki spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you