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A day in the life of a pediatric hospitalist

By Dr. Georgie Joven-Pechulis, pediatric hospitalist at CHOC Children’s

What is a pediatric hospitalist? We are your general pediatricians when your child is admitted to the hospital. I like to think of hospitalists as air traffic control in the busy whirlwind of a child’s hospitalization. There are many clinicians on your child’s care team, but we help direct the flow of traffic and unite everyone in communication and management. CHOC Children’s Hospital and CHOC Children’s at Mission Hospital provides 24-hour hospitalist coverage to provide the best care for our patients.

5:30 a.m.― Alarm goes off. I may or may not be already awake depending on how my three kids ages 5 and under slept that night. So, my alarm is either my cellphone’s gentle tune or a screaming toddler. Dress, feed, and tend to all kids as we all fluster to get ready for the morning. In between walking our family’s dog and making school lunches, I brew my coffee and pack my “to go” breakfast. On my drive to CHOC, I listen to a pediatric podcast to get into the work mindset. 

7:30 -8:00 a.m.― I arrive at CHOC. My team covers CHOC Children’s Hospital in Orange and CHOC at Mission, but today I’m rounding in Orange. When I arrive, I obtain my list of patients from my night-shift colleagues and learn about the patients ’conditions and overnight events.  We usually talk over tough cases and run things by each other for discussion. One patient had increased seizures and required emergent anti-epileptic medications. One patient developed increased respiratory distress and needed to be switched to high-flow oxygen. Another patient was vomiting and unable to tolerate his diet, so IV fluid hydration needed to be established. I look over my patient list and make a plan for what order to visit patients that morning. I also review lab results for my patients and any imaging they’ve recently had done.

8:00 a.m.  – 12:00 p.m. ― Every morning, our team does bedside rounds to learn about our patients’ overnight and current events. The care team is made up of doctors, bedside nurses, social work, nutrition, and case management. With bedside rounds, we visit every patient’s room (and sometimes have to search for them in playrooms), examine them and establish our plan for today and for discharge. Parents are encouraged to participate in family-centered rounds. They ask great questions, and some need emotional support. Some of the children we see during rounds are not feeling well, and others require playful interactions to break the ice. I make silly faces, tell horribly bad jokes, and discuss Elsa’s upcoming Frozen 2 movie to gain trust from the little patients to perform a physical exam. Usually I can reach some sort of common ground and I work hard to get there. Diagnoses of the patients we see can range from pneumonia, bronchiolitis, gastroenteritis, and seizures to even more complex cases with elaborate medical histories. Our patient lists can run from a handful of patients to over twenty during the busy winter season.

12:00 p.m. – 1:00 p.m. ― Time for lunch, and a chance to go over the day’s events with my fellow hospitalists.  We talk, and I listen to everyone’s expertise. We manage to also chit-chat about life and hopefully share a laugh or two to lighten the mood. A few times a year, I also teach noon conference or morning report to our pediatrics residents. We are a training hospital, so we help teach the next generation of pediatricians through case report presentations and specific pediatric lectures.

1:00 p.m. – 3:00 p.m. ― This afternoon I spend a couple hours in meetings, including multidisciplinary care rounds (similar to this morning’s rounds but with a variety of specialists), meetings with patients’ parents, and medical staff committees. I help run the Morbidity and Mortality cases every month, where we discuss ways to improve patient care. I make a few calls to pediatricians in the community whose patients I am caring for while they’re hospitalized and update them on their status and plan of care. I also spend some time circling back to rooms and families from the morning. A baby in my care develops a fever and requires a lumbar puncture, also called a spinal tap, to rule out meningitis. This is a procedure we routinely do where we draw fluid from the spine in the lower back. Another patient is developing a worsening rash, so we reevaluate their antibiotic regimen to make sure it is adequate. Lastly, an emotional teenager having a tough time needs some one-on-one sit-down advice. I pause, take a breath, and tackle each task one by one. Statuses of patients can change so quickly while they are admitted, and it keeps me on my toes.

3:00 p.m.- 5:00 p.m. ― I spend time updating patients’ charts and reviewing their plans of care. Part of this includes collaborating with other specialists and discussing certain cases. During this time, we also receive a few new patients from the emergency department. Some have obvious diagnoses and others were admitted to determine the root cause of their illness. Sometimes patients are admitted from our hospital’s emergency departments or transferred from others via ambulance or helicopter. Often times the work of a hospitalist feels like the TV show “House” because we are solving medical puzzles. Medicine is fascinating and thought-provoking, and part of the reason I love what I do so much.

5:00 p.m. – 8:00 p.m. ― Just like the morning frenzy, my evenings are a rush to pick up my kids, cook and eat dinner, pick up around the house, and walk the dog. These precious hours, although very busy, are a chance for me to spend some quality time with my family and learn about how their days went. We end our nightly family time with bedtime stories and lullabies. 

8:00 p.m-10:00 p.m. ― By this time, my house is finally quiet. This is my chance to get out my yoga mat and do some flow yoga. My husband and I watch our favorite binge show of the season. After he goes to bed, I stay up a little later to check in on what’s going on with my patients and read to keep up to date with current articles in medical review journals.

I go to bed feeling thankful and to be able to do this every day as “work.” Often people tell me, “I can’t imagine doing your line of work,” but I can’t imagine doing anything else. I love who I work with and am grateful to be part of such an amazing place as CHOC Children’s.

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Bringing awareness to a rare kidney disorder: Alyssa’s story

When nine-year-old Alyssa was four, a doctor discovered she
had high cholesterol. 200 would be high for an adult, and her levels were at
600, her mom Madelynn says.

“We were just at her normal 4-year-old checkup, and her
pediatrician and I were stumped to see those numbers,” Madelynn recalls. “No
under age 50 in our family has ever had a cholesterol problem before.”

Alyssa’s pediatrician recommended diet changes and fish oil.
But during a check-up a few months later, her numbers hadn’t improved, so her
pediatrician referred her to a cardiologist. That cardiologist confirmed
Alyssa’s heart was healthy but couldn’t explain why her cholesterol levels were
so high.

Back at their pediatrician’s office, a urine sample showed
high levels of protein. They were referred to a CHOC Children’s nephrologist, who
was finally able to diagnose Alyssa with nephrotic syndrome caused by focal
segmental glomerulosclerosis (FSGS), a rare kidney disorder.  FSGS is a disease where scar tissue develops
on the part of the kidney that filters waste from the blood. Symptoms can include
swelling, weight gain and high cholesterol. FSGS can lead to kidney failure.  Alyssa’s FSGS is caused by a genetic
mutation.

Alyssa and her family hope to raise awareness of her rare kidney disorder. She is living with nephrotic syndrome caused by focal segmental glomerulosclerosis, also known as FSGS.

FSGS is a rare condition. Currently, there is no cure for
FSGS, although various research studies are in progress. To date, Alyssa has
tried ten different medications and treatments—each of which are originally
designed for other diseases, but she has not responded to those treatments.

“If my own mother were not a registered nurse, I think I
would’ve been overwhelmed with the medical world we were thrust into upon
diagnosis,” Madelynn says. “I’ve had to educate myself about a lot of these
medicines, so I knew what I was putting into my daughter.”

Because Alyssa is immune-comprised, she gets sick more
easily than others. She’s been admitted to CHOC several times during flu season
when she just can’t fight off certain bugs.

Besides those unplanned admissions, Alyssa comes to CHOC
every four to six weeks to see her nephrology team, including: Dr. Dorit
Ben-Ezer
, Dr.
Patricia Veiga
, Dr. Shoba
Narayan
, Dr. John
Nguyen
, and nurse Mary Stangeland. Alyssa’s care
team monitors the progression of her FSGS with lab work.

Alyssa, diagnosed with FSGS, comes to CHOC every four to six weeks to see her nephrology team.

“Her doctors are just as frustrated as we are that she
hasn’t responded to all the treatments we’ve tried,” Madelynn says. “FSGS is
rare, and her team wants to find new medications that will help her.”

Madelynn hopes to offer sympathy and comfort to other
parents whose children are living with rare diseases.

“Parenting a child with a rare disease is worrisome and frustrating,” she says. “It’s important that we try to educate people about the need for further research.”

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What to do if my child is suicidal: 8 tips for parents

A serious public health problem, suicide is one of the
leading causes of death in children and adolescents.

And while suicide and depression are interwoven, other triggers of suicidal thoughts and actions can include a romantic relationship breakup, failing in school, being bullied, or experiencing abuse, loss or other trauma.

Here’s what parents need to know about suicide prevention:

1. Know the warning signs

  • Pay attention to children talking about wanting
    to die or kill themselves, feeling hopeless, having no reason to live, or being
    a being a burden to others.

  • Suicide notes are a very real sign of danger and
    should always be taken seriously. These notes may be in the form of letters,
    emails, social media posts or text messages.

  • If someone has attempted suicide in the past,
    they are more likely to try again.

  • Watch for children making final arrangements like
    saying goodbye to friends; giving away prized possessions; or deleting social
    media profiles, pictures or posts.

  • Making sudden dramatic changes can be a sign
    too. Watch out for teens withdrawing from friends and family; skipping school
    or classes; becoming less involved in activities that were once important;
    avoiding others; having trouble sleeping or sleeping all the time; suddenly
    losing or gaining weight; or showing a disinterest in appearance or hygiene.

  • A suicidal child or adolescent may show an
    increased interest in guns and other weapons, may seem to have increased access
    to guns or pills, or may talk about or hint at a suicide plan.

  • Sudden risky behaviors can indicate suicidal thoughts. Watch for increased use of alcohol or drugs, showing rage or talking about seeking revenge. Self-injury is also a warning sign for young children and teenagers.

2. If you have any suspicion, ask your child if they are thinking about killing themselves. This will not put the idea into their head or make them more likely to attempt suicide.

3. Listen to your child without judgement and let them know you care.

4. Help your child stay engaged in their usual coping activities life family activities and sports.

5. If your child is in danger, stay with them or ensure they are in a private, secure place with another caring person until you can get further help.

6. Remove any objects that could be used in a suicide attempt like medications, guns, sharp knives, ropes or cords, or cleaning products.

7. If danger of self-harm or suicide is mounting, call 911.

8. Know your resources.

  • Find a therapist by calling CalOptima Behavioral Health at 855-877-3885 or checking with your insurance provider on its website or phone number printed on the back of your card.

  • Here are other ways to get help for a child having suicidal thoughts: Call the MHSA Suicide Prevention Line at 877-727-4747 or the National Suicide Prevention Lifeline at 800-273-8255. Text CONNECT to 741741. Call 911 or go to the nearest emergency department.

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Living with polymicrogyria: Angelina’s story

Johanna and her husband Graham were expecting a healthy baby.  Already parents to one little girl, they were looking forward to expanding their family.

At Johanna’s 33-week anatomy scan, she and Graham were thrilled to learn they were expecting a girl, but shocked to learn she might have club foot, a birth defect where the foot is twisted out of shape or position. They learned there was a chance it could be due to a neurological defect since everything else was showing up as normal.

“We started mentally preparing ourselves for our baby to have a club foot,” Johanna said. “We had another anatomy scan, but they couldn’t say for certain what was going on.”

On January 26, 2018 Johanna delivered a baby girl named Angelina via c-section. A neonatologist was in the delivery room in case Angelina needed immediate medical attention after birth. She was having trouble swallowing and was monitored in that hospital’s neonatal intensive care unit (NICU).

Three days later, a CHOC neonatologist rounding at the delivery hospital recognized that Angelina needed a higher level of care and a bigger team of specialists. He suggested that she might need an MRI to give doctors a better look at her brain, and determine if her condition was neurological.

“Even though I’d never been to there, I knew that when it was an option to go to CHOC, you go to CHOC,” Johanna said.

Their older daughter Genevieve had been born at St. Joseph Hospital in Orange, next door to CHOC Children’s Hospital.

“I was so freaked out before I had my first child, because of all the things that can go wrong during childbirth. I delivered Genevieve at St. Joseph because I liked knowing that CHOC as right next door if we needed them” Johanna said. “When they gave us the option to send Angelina to CHOC, there was no question—we just immediately went.”

angelina-baby-choc-childrens-nicu
Angelina during her stay in CHOC Children’s NICU.

Angelina was admitted to CHOC’s NICU and evaluated by neonatologist Dr. John Tran, of CHOC’s neurocritical NICU. Special rooms of CHOC’s NICU are designated for the neurocritical NICU, where neonatologists and neurologists have the expertise and equipment to carefully treat babies with neurological issues.

An MRI showed that Angelina had polymicrogyria, a condition characterized by abnormal brain development. Johanna and Graham had never heard of this condition and had a hard time processing the diagnosis. Then they met with Dr. Donald Phillips, a pediatric neurologist at CHOC.

He explained to the family that typically, the surface of the brain has many ridges and folds, called gyri. In babies born with polymicrogyria, their brain surface has too many folds that are too small to process information received, which leads to problems with body functioning, similar to the effect a stroke can have on the brain.

Dr. Tran explained the spectrum of care for polymicrogyria. Some patients are nonverbal, some go to school, and some even live with this condition and never know. It was too soon to tell where on that spectrum Angelina would fall.

“Caring for babies with neurological conditions can be difficult. Not only are you medically treating a newborn baby, but you are also counseling a family and giving them an uncertain prognosis,” says Dr. Tran. “In the neurocritical NICU, our first goal it to treat the baby’s underlying condition. The second goal is to educate the most important members of our care team― the parents. We know that the NICU is not a part of the birth plan, but our job is to help alleviate some of the anxiety that comes with uncertainty. We strive to optimize the potential of our patients, whatever it might be, as they go home.”

The diagnosis was a lot for her parents to take in.

“We knew we were getting the best care for our daughter, but it was such heavy news,” Johanna said. “Even with a typical kid, we don’t really know what their life will be like. Every life is a gift. Once I started going towards that mentality, I realized that nothing is certain, even with typical kids.”

At her delivery hospital, one of the red flags that Angelina needed a higher level of care was that she kept crashing when she was breastfeeding.

“It made me freaked out to feed my daughter,” Johanna said.

Soon after coming to CHOC, Angelina began swallowing therapy. When someone experiences swallowing difficulty, they are at risk for food or liquid entering their lungs, called aspiration, which may lead to pneumonia. Karin Mitchell, a speech and language pathologist who specializes in the NICU setting, worked with Angelina on swallowing safety. Karin guided baby Angelina through exercises for her mouth and tongue to learn how to properly swallow saliva. Then, they could work on breastfeeding support and syringe feeding.

Angelina couldn’t move her legs when she was born, and her parents weren’t sure if she ever would. Thanks to physical therapy, today she can bend her legs more than 90 degrees.

Throughout their stay in the NICU, Johanna and Graham were thankful to have the ability to sleep overnight in their daughter’s private room. Because Angelina was born during flu season, her 3-year-old sister couldn’t visit the NICU. Her parents would stay at CHOC all day, go home to do their older daughter’s bedtime routine, and then one parent return to CHOC to sleep alongside their new baby.

“We had the privacy we needed, and I felt comfortable doing kangaroo (skin to skin) care,” Johanna said. “I hadn’t planned on my baby staying in the hospital, and at least having our own room, and even something as small as being able to watch TV gave me a small sense of normalcy.”

Johanna and Graham also appreciated the sense of normalcy provided by a Super Bowl party thrown for parents on the unit. An infant CPR class offered on the unit helped them feel more prepared to eventually take their baby girl home.

For big sister Genevieve, CHOC offers an innovative webcam system so family members can be together and bond with their newborns when they can’t be at the bedside. The system allows families to see real-time, live video of their infant remotely, from anywhere they can securely log onto the internet.

“CHOC had a lot of things in place, like the secure camera in Angelina’s room, to make things easier on us as a family,” Johanna said.

A month after she was born, Angelina got to go home for the first time.

angelina-first-halloween
Angelina dressed as a pumpkin on her fist Halloween.

“We were so ready to take her home, and finally be together as a family,” Johanna said. “But it was still a little nerve-wracking. We bought four different types of baby monitors; we were used to seeing her surrounded by machines.”

A few weeks later, Angelina began swallowing therapy twice per week and physical therapy three times per week. Now 15 months old, the amount of progress she has made has made her parents proud.

She couldn’t move her legs at birth, but a year later she is rolling and reaching. Her parents credit her CHOC physical therapist Lauren Bojorquez.

“Lauren didn’t just think of what Angelina was doing now; she was always thinking ahead about what would benefit her in the future,” Johanna said.

For example, Lauren and Angelina worked on rolling because it would eventually help her learn to sit. When babies roll, it helps develops muscles that will later help them sit.

angelina-speech-therapy
Angelina with her speech and language pathologist Annie.

Meanwhile, Angelina was working with CHOC speech and language pathologist Annie Tsai to learn how to cough, swallow, and accept food by mouth. Swallowing therapy focused not on quantity of food consumed but on quality of how the child feeds or swallows safely. Angelina’s work with Annie focuses on movement, strength and coordination within the mouth to prepare for eventually swallowing food.

Angelina still receives most of her nourishment through a feeding tube, also called a g-tube. The tube can stay in a patient’s stomach for months or years and allows the child to receive fluids, medicines and nutrition when they can’t take in enough nutrition by mouth. Every few months, Angelina sees gastroenterologist Dr. Jeffrey Ho for follow-up appointments for nutrition, feedings and g-tube care. Dr. Ho remains in close contact with Annie, her speech and language pathologist.

“Being able to eat in a typical manner is always the goal,” says Dr. Ho. “Every baby and child are different. Right now, we are focusing on what we can do to better optimize her potential to orally feed.”

Now, Angelina can sit in a highchair, bring her hands to her mouth, accept small tastes by mouth and better clear her congestion especially when she’s sick.

“Something I hadn’t realized before Angelina was how big a part food plays in our culture. As people get older, going out to eat or meeting for coffee is a social activity. I was sad that she wouldn’t get to have those same experiences,” Johanna said. “When she started to accept tastes by mouth, it made me think of her in the future, and being able to go out with friends and at least taste something, and still participate socially.”

To further practice feeding therapy at home, Angelina has a mesh pacifier typically used to soothe teething babies. Her parents often put the same foods in her pacifier as the rest of the family is eating. So far, there hasn’t been a food she’s tried that she hasn’t liked.

Angelina’s paternal grandma was an adult speech and language pathologist by training. When Angelina started speech therapy, she updated her license and certification to help her granddaughter at home. She comes to some of her sessions at CHOC and learns from Angelina’s care team.

Also participating in therapy is big sister Genevieve, who helps hold the pacifier and can even spoon-feed her baby sister, with a little bit of help.

angelina-family-disneyland
Angelina with her family at Disneyland.

“I am super grateful for CHOC,” Johanna said. “That’s why our family started participating in CHOC Walk when Angelina was born.”

These days, Angelina likes playing with toys, playing with her big sister, and listening to all types of music.

“I had a lot of preconceptions about disabilities and special needs,” Johanna said. “Having a child with special needs is not what I thought it would be. It’s better than that.”

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What to do if you feel suicidal

Suicide is one of the leading causes of death in children
and adolescents – but it doesn’t have to be.

If you are considering suicide or self-harm, pausing to take these 5 steps can save your life:

1. Get help!

You need to seek help immediately if you can’t see any
solution to your bad feelings besides harming or killing yourself or others. If
talking to a stranger seems easier for you, call 1-800-273-TALK or text
“CONNECT” to 741741.

2. Know that there is always another solution – even if you can’t see it right now.

Remember that these emotions will pass, no matter how awful
you feel now. Many people who have attempted suicide and survived say that they
tried it because they felt there was no other solution or way to end their
pain.

3. Remember that having thoughts of hurting yourself or others does not make you a bad person.

Depression can make you think and feel things that do not
reflect your true character. These are reflections of how much you are hurting.

4. If your feelings are overwhelming, tell yourself to wait 24 hours before taking any action.

This can give you time to really think things through and
see if those strong feelings get a tiny bit easier to handle. During this
24-hour period, talk to anyone who isn’t also feeling suicidal or depressed. Call
a hotline or talk to a friend or trusted adult. Remember there are likely
several solutions to your problem.

5. If you’re afraid you can’t stop yourself, make sure you are never alone.

Even if you can’t talk about your feelings, stay in public
places, hang out with friends or family members, or go to a movie — anything to
keep from being by yourself and in danger.

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