Trauma Care 2050 Part II: New paradigms in surgery and ICU

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Compared to trauma surgeons of today, the trauma surgeon of 2050 will probably know a great deal more about their patient and what’s going on inside them as they paint their torso with betadine. Injury mechanism and the specific location of bleeding vessels or damaged tissues may be more clearly defined, consigning the ‘exploratory’ element of the laparotomy to the history books. The risk of coagulopathy and multi-organ dysfunction will be known allowing for expedited or prolonged surgical procedures as deemed appropriate. The printing of organs known to be damaged beyond salvage may already be in progress in the lab adjacent the OR. The surgeon may have even been able to use augmented reality to rehearse their approach on that exact patient with their reconstructed images having been fed directly from scanner to surgical VR headset. Senior or specialist advice could be remotely sought from elsewhere with the images being securely transferred to an attending or consultant surgeon outside of trauma centre also utilising VR hardware.

Even today, after a decade of advances in damage-control resuscitation we’ve seen the implications of patients who previously would have died at the roadside surviving to get to the OR and succumbing to multi-organ failure on the ICU in the days that follow. By that same reasoning, further advances in prehospital and ED resuscitation may enable even more patients with significant injury burdens to find their way alive (just about) onto the operating table. This calls for advanced surgical techniques that avoid adding to the physiological stress of the initial injury. Nanotechnology will most likely play a significant role in achieving haemostasis. The use of nanobots as an imaging adjunct in locating bleeding cerebral aneurysms, delivering targeted thrombolysis in atherosclerotic disease and delivering targeted chemotherapy has garnered much interest in recent years. Even at the turn of the 21st century in-depth discussions were taking place about the potential for artificial mechanical platelets (clottocytes) inundated with haemostasis promoting proteins to control haemorrhage. Circulating ‘respirocytes’ may be able to maximise oxygen tissue delivery even in low-flow states. With regard to nerve injuries, advancements in technology have led to the development of devices on the nanoscale which allow manipulation of individual axons.

The greater use of nanotechnology to target hard-to-reach bleeding could facilitate a minimally invasive approach to trauma surgery. Furthermore, the knowledge that these nanobots could be left to quietly go about their business inside the patient could mean shorter times on the operating table, minimising the additional physiological insult of prolonged large-incision surgery. Patients could go to ICU with surgery ongoing inside them. The patient’s ICU journey could become more predictable and manageable with greater knowledge of the expected inflammation response owing to genomic analysis and artificial intelligence.

Patients will have greater control of their long-term rehabilitation with individually customised recovery plans and specialist support, building on existing services such as MyRecovery.AI and AfterTrauma

There is no doubt that the surgeon of the future will need to be ‘multilingual’ in a number of biomedical and allied disciplines, be it genetics, bioengineering, computing or data science. They will need to employ quick thinking and common sense to piece all the various bits of information together. Greater flexibility and multi-disciplinary collaboration throughout medical training will be crucial to this. Technology, however, can never replace the ‘human touch’, especially in a specialty where both patients and relatives will potentially be having the worst day of their entire lives. An in-depth technical and scientific must be coupled the timeless qualities of empathy and compassion.

Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

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Trauma Care 2050 Part I: From roadside to ED

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Allow me to paint you a putative vision of trauma care in the year 2050 (assuming civilisation hasn’t been eradicated by climate change by then).

The predicted widespread use of driverless cars may  significantly reduce the trauma burden from road traffic incidents (see June’s article below).  But with the pressures of growing populations, stretched public services and rising social deprivation we can expect interpersonal violence to continue to provide a steady if not increasing flow of trauma cases.

 In the immediate aftermath of a violent or traumatic incident EMS dispatch is automatically triggered by distress signals from the victim’s smart watch-like device. This intelligent wearable tech will detect changes in stress hormones, nociception, significant force vectors and vital signs and relay these along with precise geographical data  to the EMS dispatch HQ.  Existing smart devices such as the Apple Watch Series 4 are already incorporating elements of this with their fall detection technology. First responders will receive all the relevant baseline vital signs and medical history such as anticoagulation status and allergies whilst en-route. Corroborating information garnered from bystander 911 calls will also add to the picture. Upon arrival at the patient’s side the EMS teams will already have an in-depth knowledge of patient physiology, injury pattern and mechanism, thus facilitating rapid triage to an appropriate level of trauma centre.

 Point-of-care genomic testing could feed into predictive models of coagulopathy, transfusion requirement  and subsequent multi-organ dysfunction, further informing the triage decision. Professor Tim Billiar’s group from Pittsburgh are one of several groups looking into the multitude of inflammatory mediators  and their underlying gene expressions that predispose different patients to develop multi-organ dysfunction following trauma. Real-time and predicted physiological data could be fed back to the receiving emergency department allowing them to fine-tune the make-up of the trauma team, prepare blood products and begin the process of creating bed capacity and readying the operating room. On-scene audio-visual feeds from EMS bodycams or overhead drone footage could provide vital information not easily communicated in a standard verbal handover. Police forces around the UK and elsewhere have been using real-time drone footage for a number of years to assist in searches and crowd management operations and we further highlighted the current and future capabilities of medical drones in the March edition of this blog.  Larger drones may even be used to expedite patient transport, especially from remote areas or when road transport would lead to delays.

 With significant life-threatening injuries identified prior to arrival, a targeted primary survey will facilitate rapid transfer of the patient to the imaging suite where static anatomical displays will be augmented with dynamic organ functional imaging to provide unprecedented cellular-level detail of organ dysfunction and hone in on specific bleeding points and the best surgical targets for haemostasis. Ultra-high-resolution 3D images of the scan will quickly be distributed amongst the surgical team to start planning their approach as well as providing a basic blueprint for the dimensions of any replacement organs that may need to be bioprinted at a later date. Recent breakthroughs in bioengineering allowing the printing of intricate vascular tissue beds herald the way for the  rapid mass production of organs on-demand and without the often-tricky issue of having to approach recently bereaved relatives to seek permission to harvest the organs of their loved one.

 In the next article we look at the crossover of advanced imaging into the operating room of 2050 where nanotechnology complements surgical hands and the continuum of care through ICU to rehabilitation is tailored to specific patient needs.

 Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

@drnnajiuba

Driverless cars and the journey to unintended consequences

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Tomorrow’s World is very much the here and now. As the technologies of childhood dreams continue to develop at a rate of knots, careful consideration must be given to the potential implications of exciting new innovations. This is especially true for the world of automated, driverless or self-driving vehicles. Not only are millions of taxi and delivery drivers about to be made redundant but we should expect to see both positive and negative implications for the healthcare sector.

The first thing worth noting is that there are different levels of automation ranging from your standard driver assistance aids such as forward collision warning and emergency braking (Level 0), adaptive cruise control and lane assist (Level 2) up to near full automation (Level 4). Lower level automation is widely incorporated into most modern cars and has significantly reduced the rate of rear-end frontal impacts

The benefits of removing humans from the driving equation altogether are obvious. Human error is a factor in 90% of vehicle collisions with a significant chunk of that down to people driving while under the influence of alcohol or drugs. Driverless cars allow the users all the benefits of owning a vehicle, with the addition of not having to worry about parking, or watching how much you drink on a night out and also allows for greater productivity during the 200 hours per year the average person spends commuting. Replacing millions of private gas-guzzling vehicles with a smaller pool of shared cleaner or electric vehicles also has positive environmental implications. The state of Arizona is one of several locations throughout the US and Canada that have been used as a testing hub for companies like Waymo, Tesla and Uber. Waymo (the offspring of Google’s automated vehicle program) hit the 10 million mile mark in October 2018, however despite this the long-term data required to make sensible safety comparisons between conventional and automated vehicles is lacking. Cars driven under traditional human control are currently involved in approximately 1.18 fatalities for every 100 million miles. It’s worth noting that there are still over 37000 road traffic deaths on US roads  each year, including around 6000 pedestrians. To date there have been 5 recorded self-driving car fatalities. Four of those killed were Tesla test drivers in the US and China and perhaps most tragically one involved a pedestrian struck by an Uber vehicle (with a human backup driver on board) in March 2018. It was later found that the car’s sensors had detected the victim but the emergency braking had been disabled owing to previous passenger complaints about the jerkiness of the ride. Until driverless cars clock up hundreds of millions of miles however, it’s difficult to draw any solid conclusions from a handful of tragic cases.

 It is projected that a 10% penetration of the vehicle market by driverless cars would result in a 4% reduction in the annual vehicle collision burden and that a 90% market share would result in almost 80% of vehicle collisions being avoided each year. Globally, 10 million lives per decade could be saved thanks to driverless cars. That’s awesome. But will such a reduction in work load make some trauma centers and their staff equally as redundant as the truck drivers? Will it provide governments with an excuse to cut back on health spending? Will we see a sharp downfall in the supply of organs for donation? Around 20% of organ transplants come from road fatalities. Or will a new source of death and disability arise, that, much like the impact of ride-hailing apps, we cannot even conceptualize at this point?

 We’ve yet to see how these vehicles function outside of their carefully selected test locations. Adverse weather conditions, roadworks and the subtle non-verbal social interactions that are integral to communicating your intentions (and frustrations) to other road users may prove tricky nuts to crack and it may be some time before fully automated cars are let loose on the streets of the world. However, the healthcare sector may find itself having to quickly adapt to the unforeseen second-order effects of this new technology.

Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone

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Don't Hire A Dud!

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There are 4 red flags you need to be on the lookout for

Recruiting the right acute care surgeon for your trauma center is a difficult challenge. The key is to find a candidate with the right mix of clinical abilities and interpersonal skills. And while certain characteristics are desirable in a trauma surgeon, other traits are indicators to proceed with caution.

 Following are four red flags to watch for when assessing physician candidates for your trauma medical staff:

 1. Not board certified within five years. Failure to pass board exams within a few years of graduation could indicate fundamental problems in clinical skill, cause major problems with medical staff credentialing, and actually lead to increased malpractice premiums. Focus on finding a board-certified  general surgeon with trauma experience and, ideally, added qualifications in surgical critical care. An acceptable alternative is a new physician who is making strong progress toward board certification.

 2. Multiple residency programs. Working in three different residency programs to finish a five-year training course may indicate issues. The physician may lack focus, or they may have trouble getting along with colleagues. Look for candidates who are able to “bloom where they are planted.” One positive sign: The candidate was chosen to do a fellowship at the same program where they did their general surgery.

 3. Multiple divergent fellowships. Training in several unrelated specialties could indicate that the physician has had trouble securing a job. The candidate may have jumped from a transplant fellowship to a surgical endoscopy fellowship before entering training for acute care surgery. However, there are several fellowship which are complementary, such as critical care and burns, or trauma and critical care.

 4. Vague evaluations. Strong evaluations include examples of a candidate's outcomes, practice style and interactions with others. Vague evaluations with few details and just a few adjectives may indicate that evaluators are reluctant to talk substance. Even less talented surgeons should be able to find three evaluators who have something good to say, so vague comments could indicate real problems with the candidate.

 Would you like to learn more strategies for identifying the strongest physician candidates for your trauma program? Just contact us!

Massive transfusion confusion: Changing practices causing new problems requiring simple solutions

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The recorded history of trauma resuscitation probably begins in 18th century London, where in 1774 a 3-year-old girl by the name of Catherine Sophie Greenhill was witnessed to have fallen from an upper storey window onto the cobbled streets below. A volunteer from the newly formed Humane Society arrived and applied an electrical current to her chest from a portable electrostatic generator, reviving the clinically dead child. Fast forward to the battlefields of France during the First World War and French physicians note that treatment administered within the first hour of injury resulted in improved mortality . The data would later inform R Adams Cowley’s Golden Hour concept. Dr Cannon observed during the same conflict evidence of poor outcomes in shock following intravenous fluid resuscitation in the absence of surgical haemorrhage control, however the benefits of permissive hypotension would be largely forgotten for the next three quarters of a century. The British (in their infinite British wisdom) started resuscitating with whole blood during World War 2, whilst their slightly slower American counterparts began by using plasma only, before noticing the inferior survival outcomes on the battlefields of North Africa and changing their protocols to include blood transfusion. Liberal approaches to blood transfusion in the civilian setting continued in the post-war years until the discovery of blood-borne viruses and the increased costs associated with screening prompted more conservative transfusion policies.

In modern day trauma resuscitation, major haemorrhage protocols are ubiquitous and we know that compliance improves outcomes.  The debate in recent years has been more of a philosophical and tinkering nature. What constitutes a massive transfusion? Is it 4 units of blood and/or FFP within 2 hours? 10 units in 24 hours? Does it really matter? Should we be giving extra cryoprecipitate earlier on? Should it be guided by viscoelastometry TEG or ROTEM depending on which side of the Atlantic you’re on) and should it be 1:1:1 or 1:1:2? We’ve also seen the inevitable encroachment of machine-learning algorithms and Bayesian prediction tools. 

Leaving all that aside, for the busy ED nurse or physician in the organised chaos of the civilian or battlefield trauma bay, the only thing that really matters is effectively keeping track of what products went in to the patient and when. The trauma team is often compared to a Formula 1 pit stop team. Everyone playing their minor role and doing it well in order to contribute to the overall slickness of the operation. Inevitably in the heat of battle some elements get overlooked. In my experience this normally becomes apparent during the clean-up and documentation when the question of “how much blood did we give?” gets asked. The number of empty bags on the floor almost never corresponds with the amount that was prescribed.

What is needed is a stand-alone system which incorporates the speed and simplicity of pen and paper, that provides real-time relevant information to all relevant parties and that does not require any significant IT infrastructural overhaul or change to institutional clinical processes to implement. A simple scorekeeper that performs a simple task well and can seamlessly fit in to any major haemorrhage scenario be it in the trauma bay, on the labour ward or even in the elective operating theatre. As we continue to develop ever more intelligent and complex approaches to trauma resuscitation the logistics of implementing effective strategies remains a challenge.  We leave room for mistakes to happen and mistakes in medicine cost lives and money. Perhaps it’s time to apply a simple solution.

Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

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How Can You Weed Out Surgeons That Will Cause Your Program Trouble in The Long Run? (It's easier than you think)

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When considering a trauma physician candidate, you need to understand how he or she will function on the job. The gold standard is personal experience—hiring one of your program's residents or a physician you have worked with in the past. But absent firsthand experience, the next best way to assess a candidate is to conduct an oral examination based on trauma team scenarios:

Clinical scenarios. Ask the candidate to tell you what they do when they suspect a hemothorax that may require operative exploration. What factors do they consider? What is their philosophy for resuscitative thoracotomy? How do they decide when to leave a colostomy versus primary anastomosis? Ask about the grey, or controversial, areas in clinical management. Even if you do not agree with the candidate’s perspective, you will very quickly see whether they are dogmatic about their views and how they respond to disagreement.

Non-clinical scenarios. It is also important to understand how a candidate deals with the many management headaches and organizational challenges that surround trauma care. How would the candidate handle a disagreement with the ICU charge nurse over clinical management? What would they do if they felt that referrals were not being distributed fairly? How would they react if the ER was consistently “dumping” intoxicated patients on their service?

 

What's The Most Important Factor That No One Thinks About When Trying To Recruit A Trauma Surgeon?

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If you said money, you would be close, but not right. After a certain amount of salary, it is the little things that make a difference.

What you need to do is limit additional duties

Make your opportunity more attractive is to set clear limits on physician duties. For example:

Non-call clinical care. You can limit non-call duties by hiring physician assistants and/or nurse practitioners to see patients in clinic for follow-up appointments. Mid-level providers can also be assigned to take care of patients post-op.

Paperwork. No trauma physician wants to sit up at night doing paperwork. That is why 24/7 support from either a physician assistant or resident is a very attractive recruiting incentive. The PA or resident handles the paperwork so the physician can focus on caring for patients.

Semi-elective surgery. Develop a rational policy for determining when trauma surgeons will and will not be called in for semi-elective procedures. Let physician candidates know that they will not be handed a gallbladder surgery just because they happen to be on call.

Performance improvement responsibilities. Create guidelines that spell out the expected physician contribution to PI activities. Let candidates know they will not be required to review two dozen charts for every PI meeting.

What good is a strong salary, if you are too stressed out to enjoy it?

For more tips, please download our free e-book by clicking here.

This Is The Most Overlooked Change In The Business of Trauma Surgery Staffing; So Why Don't More People Know

 
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*With the development of the Acute Care Surgery model, the door opened wide for surgeons to no longer live where they practice.*

So why wouldn’t someone want to live where they practice?

If the conditions were right, I am sure most providers would prefer to practice in the community where they provide clinical services. When the question is posed to surgeons that work essentially as hospitalists and do not go “home” for at least a week a month, a few themes began to appear.

  • Most training programs are in the urban environment. Therefore providers and their families begin putting roots down. Factors such as school continuity for their children and social support for spouses are important.

The market is saturated in areas such as New York City, driving compensation down.

  • Practicing in a rural or suburban environment allows a wider breadth of cases, and to be more “hands on” when not in teaching facilities.

So, how can a facility that is having trouble recruiting Trauma Surgeons use this information to get a good candidate?

Accept that this is the reality, and that you are competing with centers that have accepted this reality.

Accommodate physicians who are reluctant to relocate.

  • Make room for commuters. Trauma physicians do not have to live full-time in your community. Facilitate commuting by grouping a physician’s call days together in a block. For example, a trauma surgeon could be on call every other day for two weeks and then have the next two weeks off. He or she can staff your program for half the month, and then spend the other half at home.

  • Enable remote PI participation. Another strong incentive is to allow physicians to participate remotely in monthly M&M conferences and PI activities via HIPAA-compliant videoconferencing. Remote participation further supports commuter surgeons. It is also a benefit to everyone on your medical staff because it lets physicians participate in PI from home, while traveling for conferences, on vacation, etc.

Pre-hospital Heart Surgery: Will it be coming to the US anytime soon?

The MD-902 Explorer aircraft is popular with many UK air ambulance services. Being compact and lacking a tail rotor they’re perfectly suited to landing in tight urban spots.

The MD-902 Explorer aircraft is popular with many UK air ambulance services. Being compact and lacking a tail rotor they’re perfectly suited to landing in tight urban spots.

In many aspects of trauma care, the UK follows where the US has historically led, most notably in the establishment of organised inclusive systems of trauma care. However, one area where the UK leads is in the willingness and ability to put trauma physicians out in the field thus taking the trauma bay to the patient and driving forward innovation in prehospital resuscitation.

Helicopter Emergency Medical Services (HEMS) exist all over the UK. Each is its own charity staffed by NHS-employed doctors and paramedics, but essentially relying on public donations to maintain operational capability. London HEMS (also commonly known as London’s Air Ambulance) is unique in that it is only dispatched to time-critical major trauma incidents unlike other services which also respond to medical emergencies. Dispatch criteria include road traffic collisions with confirmed fatalities, person(s) hit by a train (common enough on the London subway network) or any other cause of traumatic cardiac arrest. The team consists of a specially-trained advanced paramedic and a senior trauma physician (typically an ED doctor, anaesthesiologist or surgeon coming towards the end of residency). Able to reach any location in London within 10 minutes of dispatch, the team is capable of delivering a variety of on-scene interventions including rapid sequence induction for endotracheal intubation, thoracotomy, blood transfusions, administering tranexamic acid and in recent years prehospital REBOA. London HEMS performed their first successful prehospital thoracotomy outside an Indian restaurant on Christmas Eve 1993. Since then a 15-year study of over 70 cases has shown an 18% survival rate for patients who were effectively dead on scene (with 85% of survivors reporting a good neurological outcome). The British philosophy is firmly that damage control trauma care starts in the field.

 Yet stateside of the Atlantic the pendulum still remains tilted towards ‘scoop and run’ rather than ‘stay and play’ and the idea of doctors performing heart surgery or REBOA guided by flashlights and beneath a subway train somehow doesn’t seem as appealing. This despite the fact that the world’s first successful prehospital thoracotomy was actually performed in Houston in 1988. Helicopters in the US still typically serve a predominately medivac/retrieval role rather than one of actually delivering hospital-standard trauma care to the patient. But what are the reasons for this? Is it due to the increased threat of litigation and associated indemnity issues? Is it that residency program directors or hospital bosses are reluctant to allow clinicians to take time off from their day jobs to fly around in orange jumpsuits? Or is it just a different medical culture- believe it or not US doctors typically enjoy a more pampered and revered life than their European counterparts, so perhaps it’s just not the done thing to be throwing them out into the cold and rain.

 The National Association of EMS Physicians (NAEMSP) website currently lists a number of ACGME-accredited EMS fellowships across 29 states which offer hands-on prehospital experience to Emergency Medicine residency graduates. These year-long programs are typically designed to provide EM physicians with a shop-floor understanding of the EM services they hope to one day lead as medical directors. They are not, however, tailor-made to ensure applicants receive an intense 6 to 12 months of helicopter-based advanced trauma care experience.

 London continues to lead the field of prehospital trauma research and innovation, from performing the world’s first successful prehospital REBOA in 2014, to the recent introduction of red blood cell/plasma composites and previous trials of devices such as the Infrascanner for detecting intracranial haemorrhage. Future trials of new devices and pharmacological adjuncts are to be expected including prehospital ECMO (although our Parisian cousins seem to be leading the field in that respect).

 Modern communications and social media have broken down logistical barriers and dramatically reduced the time it takes for new knowledge and ideas to disseminate and sink in. Opinions are shaped via visual abstracts posted on Twitter just as much as they are at major international conferences. It used to be normal to fill every bleeding patient with 2 litres of crystalloid (in some places it still is), but medical cultures change and adapt with the times and perhaps as growing European evidence continues to emerge of the merits of delivering high level trauma care to the patient at scene, we may see a culture shift in how prehospital trauma care is viewed in the US. Who knows, maybe someday we’ll see a survival rate of 18% for penetrating cardiac injuries in the US instead of the dismal 3% to 5%  we currently see.  

Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
@drnnajiuba