A day in the life of a pediatric hospitalist

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.

Female Physicians, Hospital Leaders Observe International Women’s Day

As the world celebrates International Women’s Day, we are highlighting a few of our female physician and hospital leaders. They offer insight and words of encouragement to women seeking to pursue careers in medicine.

international women's day

Kerri Schiller, senior vice president and chief financial officer

Don’t ever be afraid to take a leap – work hard and do your best.  You can be and have whatever it is you strive for – you just have to be willing to work for it.

Find yourself a mentor – someone who you trust and admire.  Keep in touch and reach out when you need advice or just to say hello.

Striking a balance between career and family can be very difficult. Healthcare, in particular, is a profession where the dedication to the well-being of others is of great importance. Having good friends and/or a partner who accepts your role and who shares and supports responsibilities  allows for greater satisfaction both at home and at the job. And, of course, working with people you enjoy and like is critical to your ability to perform your job and love what you do.

Accept the fact that some days will be hard.  I keep a small folder of mementos, including expressions of thanks or acknowledgement I have received from others through the years.  Going through that folder reminds me of times of accomplishments and success, as well as recognition.  There are going to be days when you feel like there’s no one in your court; that’s the day to pull out your file and give yourself a boost.

international women's day

Dr. Maria Minon, vice president of medical affairs and chief medical officer

It is my hope that women professionals in healthcare and other career fields will use Women’s Day as a reminder to exceed expectations and aspire to excellence as the Professionals they are – measuring themselves against all their peers – not just a select group.

A favorite quote of mine is from Eleanor Roosevelt, “One’s philosophy is not best expressed in words; it is expressed in the choices one makes… and the choices we make are ultimately our responsibility.”

I encourage women to take responsibility for themselves and their choices and to rise above to become the great individuals they desire to be.

international women's day

Dr. Mary Zupanc, chair of neurology and director of the pediatric comprehensive epilepsy program

Reach for the stars!  Go for it!  Whatever you want to do, follow your passion and your heart.  Don’t settle for less.  Money should not be the significant driver.  Money does not buy happiness or satisfaction.  In medicine and other careers, it is about making a difference, making the world a better place.

international women's day

Dr. Georgie Pechulis, hospitalist

Follow your instincts. Block out anyone trying to convince you otherwise. At times, you may feel like you have to prove yourself as a woman. Persistence, focus, and determination will allow you to reach your goal, no matter how unattainable it seems.  Failure and picking yourself up to overcome is part of the process. Be patient and respectful, but also respect yourself. Always make time to do something good for yourself. Surround yourself with other strong women to reach out to.

international women's day

Dr. Christine Bixby, neonatologist and medical director of lactation services

My advice for women pursuing a career in medicine is that practicing medicine is a great joy and privilege. The hard work is well worth it. Having a medical career and family can be challenging but finding the right balance can be done with good planning and a great partner.

Go for it! Find what is your passion. Put your head down, do the work and you will definitely succeed.

When I began my career, I wish I would have known that I would find a group of wonderful, smart and supportive women who are always there (even at 2 a.m.) to pick you up and raise you up on the tough days.

Learn more about exploring a career at CHOC Children’s.

Explore career opportunities at CHOC.

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A Pediatrician Explains AAP’s New Safe Sleep for Babies Practices

By Dr. Georgie Pechulis, pediatric hospitalist at CHOC

The American Academy of Pediatrics (AAP) recently released updated recommendations on safe sleep practices for infants under one year of age, which are outlined below. Safe sleep is a top priority for all parents to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related deaths that claim as many as 3,500 infant lives in the U.S. every year SIDS is the unexplained death of an infant, even after thorough investigation, autopsy, and review of medical history.

safe sleep for babies
Dr. Georgie Pechulis, a pediatric hospitalist at CHOC

What can be done to prevent SIDS and other sleep-related deaths?

We know there are a number of practices proven to lower an infant’s risk of SIDS and sleep-related deaths. Taking these actions can help to create a safer sleep environment for your baby. Here are a few of the key points from the AAP’s updated recommendations.

Back to sleep for every sleep

Research shows that putting your baby to sleep completely on their backs for the first year greatly reduces the risk of SIDS.

Once an infant can roll on their own, they can be allowed to remain in the sleep position that he or she assumes.

To help prevent flat head syndrome or positional plagiocephaly, supervised and awake tummy time is recommended.

Close but Not Too Close

It is recommended that infants sleep in the parents’ room, close to the parent’s bed, but on a separate surface designed for infants. This is recommended ideally for the first year of life, but at least for the first six months.

Evidence shows that sleeping in the parents’ room but on separate surfaces decreases the risk of SIDS by as much as 50 percent.

Separate designated sleeping arrangements can prevent entrapment, suffocation and strangulation that can occur when infants sleep in an adult bed.

Keep it Simple

Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment and strangulation

Although they are widely available on the market, crib bumpers and pads, stuffed animals and toys, pillows, and blankets are not recommended in the crib as they can easily block your baby’s breathing. The crib should only contain your baby, the mattress, and a fitted crib sheet.

If appropriate for the climate, infant sleep clothing, such as a wearable sleep sack or blanket is preferable.

Consider offering a pacifier at nap time and bedtime

A pacifier has been shown to have a protective effect, even if it falls out of the infant’s mouth. It doesn’t need to be reinserted if the baby falls asleep. It is not recommended to use any attachments to the pacifiers. Ensure breastfeeding is well established prior to any use of pacifiers in breastfeeding babies.

Avoid overheating and head covering in infants

Avoid the use of commercial devices that are inconsistent with safe sleep recommendations

Ensure that products conform to safety standards of the Consumer Product Safety Commission

Car seats, strollers, swings and infant carriers are not recommended for routine sleep, per the AAP’s recommendations. If an infant falls asleep in any of the above devices, they should be moved to a safe sleep surface as soon as is safe and practical.

What else is new in the recommendations?

Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.

The AAP’s SIDS Task Force also addressed infant feeding and comforting in bed. As always, it is recommended to have your infant sleep separately in a designated surface apart from the parent sleep area. However, the AAP does recognize that parents frequently fall asleep while feeding their infant and evidence suggests that is it less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair. No pillows, blankets, sheets, or any other objects should be in the bed. Many infants who die from SIDS and sleep-related deaths are found with their head covered in bedding.

Infants who are brought into bed for feeding or comforting should be returned to their own crib or bassinet when the parents are ready to return to sleep. If a parent does fall asleep, the infant should be returned to their separate sleep surface as soon as the parent awakens.

Among the above recommendations, parents should avoid smoke exposure, alcohol and illicit drug use during pregnancy and after birth, as these can also increase risk of SIDS.  Regular prenatal care and immunizations per the Centers for Disease Control and AAP guidelines are also encouraged. And as always, breastfeeding is recommended and is known to provide a protective effect. Any degree of breastfeeding has been shown to be protective, increasing with exclusivity.

The Dangers of Secondary Drowning

By Dr. Georgie Pechulis, pediatric hospitalist at CHOC

Dr. Georgie Pechulis

With Memorial Day weekend right around the corner, it generally signals the beginning of summer and the opening of the much-anticipated pool season. Our kids will undoubtedly be awaiting their water time with endless excitement, and we as parents will do our best to keep them safe. Amidst our best efforts to educate ourselves and our children on water safety, drowning still tends to peak in these summer months. Secondary drowning is another danger, albeit rare, that parents should be aware of.

What is secondary drowning?

We as pediatricians actually don’t like this term, since it creates a lot of confusion.

Drowning is defined by the International Liaison Committee on Resuscitation as, “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” So what does that mean? Any event from being in water that causes problems breathing, whether it is primary, secondary, wet or dry, or any other forms of drowning.

Secondary or delayed drowning refers to the phenomenon of water inhalation, followed by presumed recovery, and respiratory problems that appear afterwards. Often the story involves being underwater or inhaling water with immediate symptoms that appear to go away.  However, vague symptoms persist and cause breathing problems long after the event, to the surprise of parents. It is a subset of drowning and thankfully, is relatively rare.

Here are a few of the most common questions I receive from parents about secondary drowning:

My child coughed after accidentally swallowing some water- should I bring him to the ER?

Fortunately, most simple aspiration events are not serious. Parents will need to look for the persistence of symptoms. In other words, you’ll notice your child hasn’t returned to his or her normal breathing or behavior after the incident.

  • Breathing: Your child is working hard to breathe by using his belly muscles or if you notice her nostrils flaring or head bobbing. Also, look out for persistent coughing even long after the event, and darkness or blue coloring of the lips.
  • Behavior: You notice your child is not acting right. He or she is lethargic, irritable, or not their usual self. This will be different from what you’re normally used to. Use your parental instinct.

My child seemed fine. What happened?

If water irritates the lungs, it can cause inflammation, fluid buildup, and difficulty for the body to receive the oxygen that you breathe. Sometimes these effects happen long after the event has occurred. We expect these symptoms to show within 24 hours after aspiration of water.

 If you have any of these concerns, please seek medical attention with your pediatrician or even the Emergency Department if your child appears in distress.

How can I keep my child safe?

As always, the best way to keep your child safe is to monitor them at all times in the water and to ensure they do not have any access to potential water hazards.  This includes not only pools, but filled bathtubs, hot tubs, lakes, koi ponds, and fountains.

  • Never leave them unsupervised. For toddlers or any children who are not able to swim, an adult should be within arm’s reach at all times. Never leave the child unattended, even if it is to quickly run in the house and grab something. Commonly, drowning occurs when caregivers briefly leave the child unattended to grab cameras, phones, food or drink, etc. Appoint dedicated and qualified adult supervisors to substitute watch if you need to leave.
  • Supervise without distraction. Your job as the supervisor is to do so without distraction. No cell phones, no reading materials, and no distracting conversations. Those brief lapses of attention are when incidents can occur. It’s an important job to supervise your kids in the pool and really key to ensuring your child’s safety.
  •  Drowning is usually silent. The typical drowning scenario in a movie usually depicts arm flailing, screaming, and water splashing in all directions. The truth is that most drowning occurs without noise. Often the child struggles quietly and slips under the water without a sound. Always be alert and on the watch, for it may not be obvious.
  • Be aware of your environment. If you are visiting a family or friend’s home, be aware of any potential water dangers nearby. Homes that do not usually have children often have open access to pools, spas, and natural bodies of water such as ponds and lakes. Children are curious and will want to explore new environments. Be alert.

As a hospital pediatrician and as a mother, often I hear the stories of caregivers shifting their attention to engage in conversation, running in the house to grab something, or other forms of quick distractions that lead to these accidents. If I could ask anything, it’s that we just take time to really focus on protecting our kids by being their undistracted monitor.  We want them to enjoy many endless summers of water time to come.

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