By Harumi Hope, emergency department pharmacy technician at CHOC
A pharmacy technician works under the direct supervision of a licensed pharmacist and perform many pharmacy-related functions.
At CHOC Hospital, pharmacy technicians prepare, dispense and deliver medications and make sure required administrative work is kept up to date. They take on these responsibilities so the pharmacists can focus on assisting patients and healthcare providers to ensure patient safety and satisfaction.
In addition to CHOC’s inpatient and outpatient pharmacies there are three satellite pharmacies—the operating room pharmacy, the emergency department (ED) pharmacy, and the intensive care unit pharmacy.
This is a typical day in my life as an ED pharmacy technician
6:45 a.m. — My alarm goes off. I make breakfast, get my kids ready and choose colors for my scrubs (my favorite is maroon!), and drop kids off before work.
8:25 a.m. — Arriving at work a little bit early, I stop for a cold brew to jump start my day. My shift as an ED pharmacy technician starts at 8:45 a.m. Before heading to the ED pharmacy, I spend a few minutes catching up with my colleagues in the main pharmacy. Getting handoff from the morning crew helps me plan and prioritize my work.
8:45 a.m. — As soon as my shift starts, my first priority is to determine if there are any urgent medications to dispense. Keeping a watchful eye over the programs we use to manage these is essential to preventing delays in drug delivery. My first order to fill today is an IV antibiotic that is commonly used to treat infections.
As soon as the pharmacist verifies the order, I start preparing the medication in our sterile hood. Mixing ingredients together to prepare a medication is known as compounding. It is a specialized skill that requires clean technique, strong math skills and attention to detail. This is a very important task that can help to save the lives of sick or injured patients. I find this part of my job as a pharmacy technician especially rewarding and satisfying. After compounding this medication, I deliver it to the nurse who is taking care of the patient.
9:15 a.m. — I go to the MRI suite to replenish emergency medication trays and replenish them. Ensuring that emergency medications are available is an important function of my job.
10 a.m. — An emergency code is called, and I grab our emergency medication cart quickly and go to the patient room along with the ED pharmacist. A patient is seizing and needs a rescue medication immediately. After the pharmacist receives an order from the doctor, I draw up the dose have the pharmacist double-check prior to handing the medication to a nurse. Thankfully, the patient responds to the medication quickly. Once the patient is stable, we return to the ED pharmacy.
11 a.m. — Throughout the day, I check inventory and replenish medications stored in the two medication rooms and medical supply carts to ensure the medical team has the supplies they need to take care of patients.
12:15 p.m. — A patient in the ED who takes multiple medications at home is going to be admitted to the hospital, so I stop by her room for medication reconciliation. This is where we take a thorough medication history in order to make sure the appropriate medications and doses are continued while the patient is in the hospital. . .
1 p.m. — I try to eat healthy, so I pack salad with homemade dressing, spaghetti and fruits. When there is not a lot of time for cooking, pasta is always the answer.
1:30 p.m. — When I return to the ED pharmacy, I continue with drug preparation, inventory replenishment and medication reconciliation.
4 p.m. — While my priority is ED patients, I try to help the main pharmacy whenever I can. This time is usually the busiest time in there as they have the biggest medication batch for the entire hospital.
5 p.m. — The ED pharmacy receives a page of an incoming trauma patient. The pharmacist and I go to the assigned room with our emergency medication cart and wait for the patient to arrive.
When the transport team arrives with the patient, a paramedic explains what happened, and I try to catch all the important information in case medications are needed. Although the patient has some wounds on his forehead, fortunately, he is stable and doesn’t seem to need any medications at the time.
6:30 p.m. — After several orders and a medication reconciliation, I start cleaning my work station, IV hood, and other areas in ED pharmacy.
7 p.m. — The night shift ED pharmacy technician comes in, and I update him on the day. After making sure everything is clean and stocked up, I head home.
7:50 p.m. — My kids have already eaten dinner, so I quickly eat when I get home. Before tucking the kids to bed, we spend some precious time reading together. They both like to read a lot, and I am very proud of them especially because I never liked to read as a kid. Although there isn’t much time with them around this schedule, I do my best to support them in different ways, and I really appreciate my family for understanding my work.
8:30 p.m. — After preparing lunch for tomorrow and giving the kids a shower, there is finally some time to myself. I enjoy unwinding with music. It is my favorite time of day.
In bed, I think about what I can improve the next day for a better patient care. Sometimes, I dream about making medications.
Although the days can be hectic, I enjoy being a mom and working as a pharmacy technician. There is so much to learn every day and so many opportunities for growth in the pharmacy. It can be stressful, but I work with a passionate group of people who like what they do for our patients, and I am proud to be part of the team.
By Dr. Georgie Joven-Pechulis, pediatric hospitalist at CHOC
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 Hospital in Orange and CHOC 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 Hospital in Orange and CHOC at Mission Hospital, 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, pharmacists, 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.
The CHOC Mental Health Inpatient Center is an inpatient psychiatric center exclusively dedicated to the treatment of children ages 3-17 with mental illness who are in immediate risk of hurting themselves or others. It is the only inpatient facility in Orange County that can treat patients younger than 12. Our doctors and care team are all specially trained to treat children and provide the very best patient- and family-centered care 24 hours a day, seven days a week.
During a child’s stay, he or she engages in daily multidisciplinary therapeutic groups and receives individual therapy, family therapy, brief psychological testing and psychiatric care.
In observance of Mental Health Month, follow along for a day in the life of Madeline, a clinical nurse in CHOC’s Mental Health Inpatient Center.
5:15 a.m. – After fighting my snooze button, I wake up, shower, and drink some much-needed coffee.
6:30 a.m. – My cat yells his goodbyes to me as I give him a treat and leave for work. On the way, I vibe out to music to get pumped up for the day. I’ve worked at CHOC for over a year now. Last year, I was accepted into CHOC’s Registered Nurse Residency program. As a new nurse, I felt called to work in a mental health setting. I am beyond proud to stand alongside the brilliant CHOC team on the frontlines of mental healthcare.
7:00 a.m. – I join my team in our conference room for a daily briefing report. Together, we review any newly admitted patients, our current population of patients, and any safety concerns. One of the ways we keep kids safe is through trauma-informed care. Upon admission, we work with patients and their families to determine any triggering situations or actions the patients may have, and then learn how strong emotions may manifest outwardly; such as pacing, shaking, or becoming very quiet. This information helps us to rapidly identify when patients are struggling and may need extra support or encouragement to utilize their coping skills. One of my favorite environmental adaptations we can provide for patients is our sensory room. It helps stimulate a few of our five senses to help kids cope and be more present in the moment. Sometimes, just hearing the rhythmic movements of the bubbles can be soothing and have a great calming effect.
7:30 a.m. – Once I have an understanding of our environment, I walk the unit to check on the patients. Most are still asleep, so I then look up my patient’s medications, while verifying medication consents. All pediatric psychiatric medications need parental consent obtained by the patient’s psychiatrist.
8:15 a.m. — Our medication room has a barn door, so I can efficiently and safely administer patients’ morning medications, preform a quick mental status check-in, and obtain vitals.
9:30 a.m. — One of my patients is currently taking a new medication. In order to better understand her body’s acceptance and tolerance of the drug, we need to run labs. Before drawing her blood, I numb a small area of her skin using a J-Tip®. During the blood draw, a child life specialist and I help the patient cope by offering her modeling clay and a hide-and-seek activity book.
10:00 a.m. — Throughout the day, our patients are divided into groups based on age to attend group sessions. This creates a structured environment that promotes the development of coping and social skills they can utilize when they go home. The sessions focus on our various themes of the day that can range from problem solving or emotional regulation to nutrition and wellness. These sessions are led by our team of nurses, social workers, child life specialists, plus and art and music therapists. This morning’s group session is focused on gross motor skills. Our group leaders soak up some sunshine in our beautiful outdoor area while supervising patients socializing and joining in on a game of handball.
11:00 a.m. — I sit down with one of my patients to discuss their day so far and check in on any thoughts of self-harm that we can work through together. Afterwards, as part of the patient care team, I meet with that patient’s psychiatrist Dr. Lavanya Wusirika, and social worker Gaby, to discuss the patient’s care plan.
12:30 p.m. – It’s time for the patients to have lunch. Our patients eat together, so I assist with passing out lunch trays and pouring drinks. One of our licensed vocational nurses, Brenda, has become our unofficial DJ, and she plays music during lunch to help create a fun, therapeutic environment.
1:00 p.m. – I receive a call from a patient’s parent. After addressing their questions, I update them on their child’s plan of care, medications and current temperament.
2:00 p.m. – I use my own lunch break to catch up with my coworkers. We spend a lot of time together, and I’m lucky to have such an amazing work family.
3:00 p.m. – It’s time for one of our patients to head home. Upon admission to the unit, our team begins organizing outside resources and planning ways to increase safety and support at home. This information is built upon throughout their stay and is incorporated into an individualized safety and coping plan. After our social workers discuss the plan for home with the patient and their parent, I review current medication information and additional discharge instructions. Staff members and fellow patients send off their peer with warm wishes and words of encouragement.
4:30 p.m. –As a nurse, it’s my turn to lead one of our nursing groups. After the patients participate in a discussion about favorite coping skills and we do a check-in of their current emotions, we follow a painting tutorial to practice our theme of the day, mindfulness.
6:00 p.m. – I spend time updating my patients’ charts, including their mental status assessments and treatment plans. This way our whole team can see the patient’s progress and any concerns.
6:45 p.m. – During daily community meetings, all of our patients join together, and our staff leads a check-in to summarize what has been learned from our theme of the day. Patients take turns sharing their high and low of the day and how we can build on these experiences for tomorrow.
7:00 p.m. – As our night shift nurses arrive, we take turns giving a report of their patient’s day and mental status. We share new triggers that we have learned from the patients as well as new coping skills that were helpful. Knowing how we can best care for patients before, during and after a crisis or stressful situation is fundamental for trauma-informed care. By caring for every patient as a whole, not as a diagnosis or as someone defined by their trauma or maladaptive behaviors, we are able to better understand and care for them.
8:00 p.m. ― Get home and share a delicious meal with my husband. A long hug and many kisses are bestowed unto my cat Boots. The three of us will cuddle up and watch a show before we head to sleep and start again.
Stay Informed about Mental Health
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The Cherese Mari Laulhere Child Life Department at CHOC strives to normalize the hospital environment for patients and families. “Normalizing” the hospital experience means making things like medical equipment and procedures feel less strange or foreign. By doing this, patients and families can feel more at ease while at the hospital and will be able to focus on what is most important: feeling better.
But just because we’re a children’s hospital, doesn’t mean we only treat little kids. CHOC child life specialists work with teen and young adult patients, too. Follow along for a day in the life of Karlie, an oncology child life specialist.
6:00 a.m. – My alarm goes off and I quickly push snooze. I lay in bed for a bit longer as I am still trying to master the art of getting out of bed as soon as the alarm tells me to. After a few more moments of relaxing I get up, ready to take on the day. I get ready, make some breakfast, pack my lunch and my workout clothes, and head out the door by 7 a.m. to get to work on time.
8:00 a.m. – After making it through infamous Southern California traffic, I arrive at work. During my drive, I usually listen to some sort of motivational worship talk or devotional and once I park, I say a quick prayer to help me be ready for the day. I walk into my office and greet my fellow child life specialists. The office is full of smiling faces, and despite the early hour, it’s already bustling with colleagues talking about various patients and their needs. I work on the hematology/oncology unit, but we have child life specialists embedded in practically every unit and area of the hospital. Our team is filled with energetic, gracious and positive people trying to provide the best support possible to the patients and families that we serve. I feel so grateful and able to take on the day with them by my side.
8:15 a.m. – To start the day, I get a copy of the patient census—an overview of the current patients admitted to the hem/onc unit. I also check the surgery schedule to know what surgeries or procedures my patients have that day.
8:30 a.m. – I head to a meeting with the oncology multidisciplinary team which consists of the medical and psychosocial team. We discuss various patients and their plans of care. We also discuss what psychosocial needs have already been met and what support they still need. We make sure to communicate with each other so that as a team we can ensure we’re meeting our patient’s physical, emotional, spiritual and mental health needs.
10:00 am – I head up to the hem/onc unit and check in with the bedside nurses, so I know what the plan for the day is for each of the patients that are on the unit. We discuss how we can work together to best help each patient. I talk to one nurse about a 17-year-old patient that was just admitted last night with a new diagnosis of leukemia. She tells me that he is feeling nervous about a procedure he’s scheduled for later that day. We go over my plan to support him and I tell her I will keep checking in and keep her updated with how the patient is feeling. I then go into his room and introduce myself and tell his family more about what child life has to offer in terms of “normalizing” the hospital environment. We also talk about what he likes to do, his favorite sports teams and who makes up his family. After we have built some rapport and trust, we talk about his upcoming procedure and I explain it in a way he’ll understand, and it helps ease his anxieties. We talk about why the doctors want him to get some tests done and what these tests will tell the doctors. We talk about the roles of each staff member he will meet, and how they will help him. We set up a hospital tour for later that day. In the meantime, I call my volunteers to drop off a soccer Xbox video game for him to play in his room while he waits.
10:30 a.m. – I get a call to come and help one of my long-time patients with her port access. A port is a medical device surgically placed under the skin in the chest that can be accessed with a needle for infusions and lab draws. When she was first admitted, we worked on coping techniques including medical play, and now she doesn’t get as anxious for procedures. She’s been in treatment for six months, but she still prefers me to be there, and I enjoy seeing her and being there for her. We play her favorite iPad game together while the nurse does the procedure. During the procedure I remind her of each step of the process as it comes, to help her feel empowered and ready. During the needle poke, we do deep breathing exercises together to breathe away any pain or discomfort, and she squeezes my hand. As soon as the poke is done we go back to playing on the iPad and laughing at inside jokes we’ve developed over the last few months. I applaud her for how well she has been doing with her port needle accesses and tell her how proud I am of her.
11:00 a.m. – I take the time to check in on some more patients that I know, and make sure they have everything they need for the day, including some fun activities to look forward to. A few of my longtime patients are in the middle of long hospital stays, so I come up with a plan for something fun and different for them to do that day to help make the most of every day they are there.
11:30 a.m. – I check in on my new 17-year-old patient and find that he is ready for his tour. We start by walking around the hem/onc unit and I show him the gym and the teen room. He loves air hockey, so I show him the air hockey table in the playroom as well. On our tour, we cross paths with a pet therapy dog, so we stop to spend some time with him, and we all laugh as the dog does one of his famous tricks that he has practiced for a doggy treat. We then head down to the second-floor lobby to check out the amenities it has to offer. We check out Seacrest Studios (our in-house radio station), the movie theater, another teen room, Turtle Talk, and two outdoor patios. Child life organizes a lot of special events for patients, and today we are hosting several baseball players from the Angels. We stop by that event while we’re on the second floor and check out the games going on, crafts, giveaways and my patient snags a few photos with his favorite players before I escort him and his family back up to their room.
12:00 p.m. – I take time for a quick lunch break with my fellow child life specialists. I work with some of the kindest, strongest, most giving and selfless people that I know. We enjoy some great conversation about work and about our lives outside of work. My coworkers are my greatest support on the job and I feel grateful to be able to work alongside them and the other wonderful staff at CHOC. I am thankful every day for the wonderful coworkers I have that are also some of my closest friends!
1:00 p.m. – I head back up to the 5th floor to take part in one of the best parts of my job. Today we’re celebrating the final chemotherapy treatment of a 22-year-old patient. I have a trophy and a sign that reads “Happy Last Chemo!” I gather the nurses, clinical assistants, nurse practitioners, and any other available staff to join in. We parade into the patient’s room cheering, and sing the “Happy Last Chemo” song to the tune of “Happy Birthday.” As I look around the room, I see that the patient, her family, and all the staff have tears of joy in their eyes. We are so happy for this patient reaching the end of her treatment. This is definitely something worth celebrating.
2:00 p.m. – I get a call from the front desk that some special visitors are waiting for me. I know it is the surprise we have in place for another patient. This patient, a 13-year-old girl, has been in the hospital for a while and I know she could definitely use an emotional boost. Today is her golden birthday, which is the perfect time for a big surprise. I reached out to a local jewelry store and asked for their help. They agreed to bring some cute gold jewelry items for this patient to help celebrate her golden birthday. I feel so grateful for our community partners that are so generous and willing to help our patients. Seeing my patient’s face light up warms my heart. She knows that she was thought of individually and that people wanted to make her day brighter. I am so grateful to be able to help provide these special and meaningful experiences to a patient like her that is so kind, strong, and such an example of perseverance.
2:30 p.m. – I return to the room of my 17-year-old patient and take him down to the pre-operative unit for his scheduled procedure. We talk about new questions and concerns that he has thought of since this morning, but we also talk about the things in his life that are important to him; his friends, family, sports, school, and fast food. When it’s go-time, I stay with him as his parents go wait in the lobby. Before he receives anesthesia, I stay with him as we listen to his favorite artist and talk about what songs he likes. I’m a terrible singer, but we sing together to take his mind off the procedure. We continue doing this while the wonderful team of nurses, technicians, physicians and anesthesiologists get everything ready. The patient and I continue to talk, and I interject every once in a while, to let him know what the procedure staff is doing as we go along. It is time for him to receive his anesthesia and I talk with him until he falls asleep. Afterwards I thank the procedure room staff and doctors for all that they do and I exit the room for the procedure to begin.
3:00 p.m. – Afterwards I head back up to the hem/onc unit for a planning meeting for our biggest event of the year. Each year, the CHOC Oncology Ball presented by The J. Willard and Alice S. Marriott Foundation is a chance for oncology patients and their friends to celebrate their life and all they’ve been through. This event is part of the Adolescent and Young Adult (AYA) treatment program. Our team spends months planning this event so that every patient, no matter their age, can feel like Prom King or Queen for the day.
4:00 p.m. – After that brainstorm meeting, I check in on the family of a newly diagnosed 2-year-old boy. As I enter the room I see that the patient is napping but that his big sisters have come to visit. I talk with the siblings and educate them about what they see in the room and help them understand their younger brother’s diagnosis through a medical play activity. I help them understanding what the nurses and doctors are doing to help him get better. We talk about how they are feeling and concerns and fears that they have. One sister thinks this diagnosis happened because she once got really mad at her brother for taking her toy. I assure her that her brother’s cancer is nobody’s fault, and that there is nothing anyone did wrong that made this happen. We talk about how they can help their brother while he is in the hospital. They can play with him, draw him pictures, give him hugs, wash their hands so he doesn’t get germs, and help mom and dad around the house. I want them to know that as siblings they are important too, and I am here to provide support to them as well. I remind them that every fun thing in the hospital is for them too! With their parents’ permission, I take them down to Seacrest Studios to hang out with the staff there. Seacrest Studios music and programming is broadcast to every patient’s room, and the girls get to help host the daily game of Bingo. To see them feel special and get the attention they need warms my heart. Illness really does affect the whole family and taking the time to acknowledge and be there for each family member is so important.
5:00 p.m. – After leaving the siblings in the excellent care of the staff in the Seacrest Studios I head back to my office to gather my things and head home for the day. On my drive, I call my mom who lives in Utah. I talk to my mom about my day as much as I can without breaking patient confidentiality. I enjoy talking to my parents and know they will always give me sound advice. My mom hands the phone over to my youngest brother, who is a senior in high school and we catch up on his day. I love hearing about my siblings’ lives. I am one of ten children!
5:30 p.m. – I arrive at the gym for my workout. Exercise is a great time to decompress from the day and relieve any stress I may be feeling from whatever sad or difficult situation that may have happened that day. I absolutely love my job, but it can be hard to watch these patients and families go through such difficult things― patients feeling sick, losing their hair, hearing that their cancer came back, having to get a poke for blood, and the reality of sometimes losing a patient to cancer, all takes a big toll on our staff. In addition to support from my colleagues, I also try to find things outside of work that help me cope, and working out is one of those things. Today was not one of those really difficult days, but running on the treadmill and doing some weight training definitely helps me decompress and transition out of work.
6:30 p.m. – I head home and make dinner while I talk to my roommates. We talk about our days and then we have friends come over for a fun game night. It is a great night spent relaxing and connecting with friends.
10:00 p.m. – Time for bed so I can give tomorrow all the energy it needs! I count my blessings, especially being able to spend every workday with the most amazing kids, teens and young adults who are fighting their illnesses with grace, positivity, joy, strength, wisdom and the desire to make the most of every day. I look forward to tomorrow, and the opportunity to offer each patient and family member I come across my best care and support to make their day even a little bit brighter.
5:00 a.m.: Alarm rings. I hit snooze once, for an additional 9 minutes of peace. Then it is time to get up and at ’em. In the dark, I attempt to avoid injuring myself on the various toys that are strewn about the house–one of the hazards that comes with raising young children. I start the coffee maker, brush my teeth, shave, get dressed and kiss my slumbering family good-bye. Then it is off to swim practice.
7 a.m.: Swim practice is over. Fatigued but happy, I shower and joke with the teammates on my masters swim team. I am grateful for my health and momentarily enjoy the small personal accomplishment of having completed my workout for the day.
7:30 a.m.: After navigating moderate traffic and enjoying NPR, I arrive at CHOC. I meet with the very kind family of my first patient, a 5-year-old boy who is having inguinal hernia/hydrocele surgery today. In children, an inguinal hernia is a small, congenital opening in the groin that allows communication between the abdomen and the scrotum in boys and the labia in girls. Thus, things like fluid, fat, omentum or intestines can pass through this opening, creating a bulge and sometimes causing pain. A hydrocele is related to an inguinal hernia and is due to fluid that has passed from the abdomen, through the opening, and into the scrotum. Inguinal hernias occur in about 1-5 percent of all children. Hernia and hydrocele surgery are routine operations for all pediatric general and thoracic surgeons and, as expected, the operation goes smoothly.
9:00 a.m.: For my second operation of the day, Dr. Mustafa Kabeer, a fellow pediatric general and thoracic surgeon, and I perform a minimally invasive Nuss procedure on a teen athlete. This patient, who hopes to earn a college scholarship, has pectus excavatum or sunken chest, the most common congenital chest wall abnormality in children. For many, this is far more than a cosmetic problem. Using small incisions that will ultimately be well-hidden in this patient’s armpits, we are able to insert a metal bar between his heart and his chest wall that helps to pop the sternum out into normal position. This bar will stay in place for three years, before it is removed in an outpatient procedure. Our operation today took only 2 small incisions and 45 minutes of operating time. We prefer the minimally invasive Nuss procedure to the older, more invasive Ravitch procedure since it achieves a wonderful outcome with less pain, minimal blood loss and only tiny, hidden scars.
10:00 a.m.: As the anesthesiologist and the operating room staff prepare for my final case of the day, I walk over to the surgical neonatal intensive care unit and medical/surgical unit to make rounds and touch base with my team of excellent, experienced surgical nurse practitioners (NPs). Not a day goes by that I am not thankful for their contributions to the outstanding care of our surgical patients at CHOC. Currently, on the surgical floor, I have patients who have recently had appendectomies, a cholecystectomy (removal of the gallbladder), lysis of adhesions (cutting of intra-abdominal scar tissue) to treat a small bowel obstruction, port placement for chemotherapy, and a Nissen fundoplication for gastroesophageal reflux disease. In the NICU I have one baby with congenital diaphragmatic hernia whom I recently placed on ECMO (extracorporeal membrane oxygenation), state-of-the-art technology that supports the heart and lungs by taking over the heart’s pumping function and the lung’s oxygen exchange. A second patient of mine in the NICU is a baby who recently had esophageal atresia/tracheoesophageal fistula surgery to repair a congenital defect where the trachea, or windpipe, abnormally communicates with the esophagus, or food tube. Fortunately, all patients are doing well, I am able to address the questions of each of my patients and their parents, and the NPs and I come to a consensus on the plan of care for the day for each one.
10:30 a.m.: Once rounds are done, I head back to the operating room for my final case of the day, a thoracoscopic lung lobectomy. This is one of my most favorite operations and is my area of expertise. This 3-month-old patient was diagnosed prenatally when an ultrasound showed a congenital lung lesion, also known as a CPAM (congenital pulmonary airway malformation, formerly known as CCAM). This diagnosis is becoming more and more prevalent, occurring in about 1 in every 5,000 babies. Fortunately, more than 90 percent will be symptom-free during pregnancy and after birth, allowing pediatric general and thoracic surgeon such as myself to hold off on surgery until the infant is a few months old and better able to tolerate the stress of an operation. Even though infants with CPAMs may be asymptomatic, it is still recommended that these lesions be removed because they can often become infected and, in rare instances, may become a cancer later in life. The benefit of operating sometime during the first several months of life is that the CPAM has yet to become infected, making surgery easier and allowing for a minimally invasive removal. Thanks to the patient’s young age, the remaining portion of her healthy lung will grow in size and compensate for the removed lobe.
Thoracoscopic lung lobectomy is extremely technically challenging because the surgeon navigates major blood vessels such as the pulmonary artery and pulmonary vein, and operating time can vary from two to six hours depending on a patient’s particular anatomy. Fortunately, this little baby’s anatomy is favorable and I am able to complete the minimally invasive operation in about 2 hours with minimal blood loss and an excellent outcome. After surgery, I have the privilege of giving her parents good news, which is always the best part of my work day. I anticipate that she will have a two-day hospital stay with minimal pain and no complications, and her tiny scars will ultimately be unnoticeable by others (except for mom! Pediatric surgeons know that moms see everything).
1:00 p.m.: I have a quick lunch with my NPs and Dr. David Gibbs, another pediatric general and thoracic surgeon at CHOC who is also the medical director of trauma. He has established the excellent trauma program we have here, the only trauma center in Orange County that is exclusively dedicated to children. We take a moment to enjoy each other’s company, get trusted input on current clinical situations, and catch our breaths from this very typical, fast-paced workday.
2:00 p.m.: I participate in a fetal counseling session. Given my special training in fetal surgery, I work closely with community perinatologists (also known as high-risk obstetricians or MFMs–maternal fetal medicine physicians) to counsel expectant mothers and fathers on what to expect when their baby has been diagnosed in utero with a condition that will require surgery.
Today, I meet with parents whose daughter has been prenatally diagnosed with congenital diaphragmatic hernia, or CDH. Simply put, CDH is a hole in the diaphragm, which is the muscle that divides the abdomen from the chest. The diaphragm helps us breathe, and a hole here allows things that are normally in the abdomen, such as the liver or intestines, to pass into the chest. Besides potentially compromising the intestine itself, this can also lead to small lungs (pulmonary hypoplasia) which may not be able to adequately oxygenate the body. Another severe consequence of CDH is pulmonary hypertension, which is abnormally high pressure in the blood vessels of the lungs. This is a problem because a newborn’s heart must work extra hard to pump blood into this abnormal high-pressure system, which can lead to heart failure and death if not appropriately treated.
I go over the diagnosis with mom and dad, and explain to them that, after birth, their baby will require a breathing tube and ventilator to support her small lungs. Special inhaled and intravenous medications will be used to decrease the high blood pressure in the blood vessels in the lungs and to help support her beating heart. If these measures are not enough, we will need to use ECMO. If ECMO is needed, I will perform a surgery to make an incision on her neck to access her carotid artery and jugular vein so that ECMO catheters can be placed.
Ultimately, once their daughter’s heart and lung condition has stabilized—which may take days to weeks after birth—I will repair the congenital diaphragmatic hernia. To do this, I will make an incision on the abdomen, move the intestines and liver from the chest back into the abdomen, and stitch the hole closed.
I am careful to be upfront and honest about the situation: CDH is a serious and frequently life-threatening condition and the national average for survival is approximately 65 percent. Their daughter will likely require a two to three month stay in our NICU and may need to go home with supplemental oxygen and special medications for a period of time. However, I’m able to reassure them as well. Nearly 90 percent of newborns that have this surgery at CHOC survive. At CHOC, we are fully equipped and have the expertise to handle any possible outcome, thanks in part to our surgical NICU, the only one of its kind of the west coast.
Mom and dad are tearful at the gravity of their daughter’s situation but they also express how grateful they are for the opportunity to learn more about CDH, have their questions answered, and leave feeling better prepared for the next steps. They know they can contact us at any time, day or night, and we will be there to address any problem and provide support. They also feel relieved that they will be surrounded by familiar, trusted faces when their daughter is born.
3:00 p.m.: I head back to my office with some precious time to complete some homework—yes, I said homework—and work on research projects. Believe it or not, I have gone back to school to get my Master of Public Health degree from Johns Hopkins University. This is feasible because I am able to complete the majority of my coursework online. I wanted to get this additional degree to gain knowledge and experience in outcomes research, a relatively new branch of public health research that seeks to understand the end results of particular health care practices and interventions. While pursuing this degree, I am simultaneously working on outcomes research projects with my research partner, Dr. Yigit Guner, another pediatric general and thoracic surgeon at CHOC. Together we are utilizing large national databases to create risk calculators that can help better predict CDH outcomes, as well as predictoutcomes in other neonatal diseases such as VACTERL (vertebral defects, anal atresia, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb abnormalities).
6:00 p.m.: I head home for the day. En route, I call my mother who lives out-of-state to check in. My father recently passed away after a long struggle with illness and I just want to make sure she’s doing alright. She assures me that she is, and stubbornly resists my suggestions to have her move to Orange County. She is happy and comfortable in her home, which makes me happy as well, but I am concerned that I will be unable to adequately help her in the years to come should her health someday fail.
6:30 p.m.: I’m happy to be home with my family. It’s dinner time and I’m famished. I relish the chance to catch up on the day’s events with my wife and kids. I play with the kids for a bit and then it is time to help my oldest with homework. After that, my wife and I get all the kids ready for bed and tuck them in.
9:00 p.m.: My wife and I finally have a precious moment to ourselves. We watch a favorite TV show together and I barely make it to the end before falling asleep. It feels so good to lie in bed, with the cool night breeze filtering in through my bedroom window. I dream of my family, work and old friends. Tomorrow, I have clinic and then I will spend the remainder of the day and night in the hospital, as I am on call for any pediatric general, thoracic and trauma emergencies that come to CHOC. I feel so blessed to have the family that I have, and to be able to do the meaningful work that I do.