An innovative internship approach during COVID-19

A year ago, Jenae Vancura joined an elite group of college and high school students for a unique and innovative summer internship program at CHOC Children’s. The interns shadowed physicians, joined doctors on their rounds and attended meetings with a wide range of professionals in the medical field.

The days were long. The work was challenging.

And Jenae, a 21-year-old biology major from UC Santa Barbara, is back again this year, now serving as a lead intern for the Sharon Disney Lund Medical Intelligence and Innovation Institute  (MI3) summer internship program. She now helps guide a new group of students through the rigorous program.

“But this year is a little different,” Jenae says.

Now in its eighth year, the internship has been effectively reimagined as a virtual program, a pivot quickly executed at the onset of the global coronavirus pandemic.

virtual MI3 internship meeting
Jenae participates in a virtual meeting as part of the MI3 internship.

The COVID-19 crisis emerged just as CHOC leaders and physicians were gearing up for this year’s internship program. That meant that the 63 participating students would not be able to work directly with hospital staff or go on rounds to interact with patients as in years past.

Cancelling not an option

While many internship programs have been halted worldwide due to COVID-19, canceling the MI3 internship was simply not an option, organizers say. The experience was much too valuable and too many young had worked too hard to get this far.

“Many of our interns look to our program to affirm and motivate their decision to apply to medical school,” says Debra Beauregard, director of MI3. “Nearly all of the interns aspire to become physicians.”

So, with just weeks to go, the decision was made to recalibrate the program and put the whole curriculum online.

“The easy thing would have been to postpone or cancel,” says Dr. Anthony Chang, CHOC’s chief intelligence and innovation officer who launched the program eight years ago. “We wanted to give the students the same level of opportunity. To their credit, the team stepped up and made the internship rotation on par with previous years.”

Dr. Chang started the internship because he wanted to give young people an in-depth experience of the medical field.

“I felt like no one was really doing something like this,” he says. “The students were staying with one mentor doing one assignment. That sounds like a research assignment, not an internship. I wanted to give them access to something that gave them access to a hundred mentors.”

A rigorous pace remains

Even though the pandemic has restricted access to the hospital, it hasn’t slowed the  interns’ pace. Their work schedule starts early and, with a few breaks between, doesn’t end until the evening.

“We set up a lot of Zoom meetings,” Debra says. “Our interns have a full schedule. They participated in rounds and shadowed our physicians virtually. They were even able to remotely view multiple surgeries. This was a challenge, but everyone pulled together to provide what turned out to be a great summer program.”

a virtual session as part of the MI3 internship program
MI3 interns participate in a Zoom meeting as part of their virtual internship.

Dr. Chang says that while the interns are receiving the same level of instruction, what’s missing are some of the personal interactions that come with face-to-face contact.

“Not having one-on-one time in person and not having more intimate moments in small groups is difficult for us,” he says. “For instance, in past years they’ve had one-day retreats where they come to my house for breakfast and lunch. I wasn’t able to do that this year.”

But that doesn’t mean there isn’t room for a little fun.

“Our directors and lead interns made sure that all interns felt connected,” Debra says. “We included team-building exercises, interactive small group sessions, and even a virtual graduation ceremony. The leads even organized a virtual talent show and Zoomie Awards, in addition to a competitive team competition. Our leads have gone above and beyond to ensure that our interns had a meaningful and memorable experience.“

Dr. Sharief Taraman, internship co-director and pediatric neurologist at CHOC, has been part of the program almost since it started. He’s confident that this year’s group is better off than students anywhere else.

“They’re way ahead of their peers in terms of experience and what they can get out of the summer,” he says. “We have a lot of moving parts, so we had to pivot very quickly.”

And to ensure the interns get all the experience they can, they are being invited back next year when they are hopefully able to receive hands-on work.

“We have offered guaranteed spots for our interns next year, so they can have an in-person experience,” Debra says. “We are confident that most will be coming back.”

Student gratitude abounds

The interns themselves are grateful for the chance to continue their internships during these difficult times.

“When I thought it wouldn’t happen, I got very upset,” says 20-year-old Julia Keating from the Massachusetts College of Pharmacy and Health Sciences University. “It’s such a competitive internship.”

For Jessica Octavio, a 20-year old San Diego State student majoring in microbiology, going online was positive experience.

‘’We’re lucky,” she says. “They’ve been more than flexible. The biggest thing was learning this online interface, but as far as programming goes, it’s almost advantageous for us.”

While working on site would have been ideal, Luke Arnold says he appreciates all the work the health system staff have put into making this year’s program a success.

“It’s not ideal and obviously we’d like to have this in person,” says the 21-year-old biology major from Chapman University. “But being in quarantine has given us opportunities to work in group settings. We’re all in this together.”

For intern Nicole Fraga, working from home has had some surprising benefits.

“It can be a very rigorous process,” says the 22-year-old recent graduate from Brown University. “But ironically, I think they’re getting closer to the interns online because we are meeting in small groups. We are able to communicate on Slack and share memes. We have a smaller community.”

Dr. Chang calls the internship a “circular experience.” The health system staff, he says, learn as much from the students as the students do from the physicians.

“We’re grateful that the interns are even more inspired to go into medicine despite the pandemic,” he says. “It’s very heartwarming to hear. The future of medicine is in good hands. I see the interns push back against the temptation to give up. They have the idealism and no fear of failure.”

Learn more about CHOC's MI3 internship

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How a car accident changed my life

By Jacob Werkmeister

My journey with CHOC started on Dec. 18, 2016, when my dad and I were hit by a car. The weeks following the accident were terrifying, and my 18-month rehabilitation process afterward was physically and mentally challenging. Now, I’m doing incredibly well and so is my dad.

My dad and I were in a movie theater parking lot in South Orange County. We’d just seen the latest Star Wars movie. We were standing next to our car when a driver careened off a nearby road at 100 miles per hour and hit us. I was immediately knocked unconscious and flew into a nearby body of water. I was completely submerged and almost drowned. I suffered a traumatic brain injury, broken shoulder and multiple facial fractures. My dad and I were not initially expected to survive. I was rushed to CHOC Children’s at Mission Hospital. I underwent multiple tests, scans and procedures, including one to drain leaking cerebral spinal fluid.

I don’t remember much of my time at CHOC Mission – I was comatose for most of my first week there. I finally woke up on Christmas Eve, and over the next 10 days I made significant progress – sitting up and even taking a few steps.

Jacob Werkmeister_after accident
Jacob after the car accident.

During this time, my dad was recovering at Mission Hospital. Thanks to the partnership between CHOC Mission and Mission Hospital, my mom was able to go back and forth between my room and my dad’s room without even having to leave the building.

CHOC doctors and nurses exemplify kindness and caring. One of the kindest things they did for us was allow my dad and I to see each other. Once we were both awake and extubated, they brought my dad up to my room. The simple act of allowing a father and son to see each other and hold each other’s hand was instrumental in our healing process.

Jeff and Jacob Werkmeister hold hands for first time since accident 12.21.16
Jacob and his dad hold hands for the first time after the accident.

Dr. Gary Goodman, medical director of the pediatric intensive care unit at CHOC Mission, was incredible. He kept my parents well-informed about my care and progress. Every single nurse who treated me went out of their way to also ensure that my mom felt cared for. She was included in every conversation about his care.

My mom has been a nurse for 25 years. She works with the American Hospital Association and helps hospitals implement strategies to improve outcomes for patients and make care as safe as possible. Because of her clinical eye, she noticed everything that happened with every shift. Even during the holidays or shift changes, she always said my care at CHOC Mission was impeccable. This shows the entire team’s commitment to excellence.

Despite being incredibly complicated trauma patients, with high-alert medications and surgeries, neither my dad nor I experienced any adverse events during our hospitalizations. We both received perfect care.

My dad and I went home after around two weeks. Next, I started 18 months of rehabilitation through CHOC. I worked with an occupational therapist and a physical therapist. I had to relearn how to walk, hold a pencil, do math, read and remember things.

I also worked with Dr. Sharief Taraman, medical director of neurology at CHOC, and Dr. Jonathan Romain, a CHOC neuropsychologist, as part of CHOC’s concussion program. Even though I wanted to speed up my recovery so I could try and get back to playing baseball, Dr. Taraman and Dr. Romain made sure I was safe.

Before the accident, I was a lifelong baseball player. After the accident, no one imagined I would play baseball again. Not only did I return to baseball a few months after the accident, but I recently signed a letter of intent to play baseball for Ohio Christian University.

Jacob Jacob Werkmeister_today
Jacob today, back to baseball.

This journey has taught me so much. I really shouldn’t be alive right now. Now, I don’t let the small things get to me. I know I can get through anything.

Our family could never repay our gratitude to CHOC. We are so thankful for everything CHOC has done for us.

Learn more about CHOC Children's at Mission Hospital

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6 do’s and don’ts of concussion

If your child experiences a concussion, it can be scary to think about the effects on their developing brain. The good news is, more than 85% of concussions heal well if managed properly early on.

“Early, appropriate treatment prevents kids from having to come see me as a neurologist,” says Dr. Sharief Taraman, pediatric neurologist and director of the CHOC Children’s Concussion Program. “It’s important to do as much as we can to prevent kids from getting a concussion, prevent reinjury, and treat them as aggressively and appropriately as possible in the early intervention stages.”

sharief-taraman-pediatric-neurologist-choc-childrens
Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s.

Follow these do’s and don’ts for proper prevention and treatment of concussion. If your child does sustain a concussion, be sure to see your pediatrician as soon as possible.

  1. Do protect a young brain

Athletes should be taught safe playing techniques, equipment maintenance and to follow the rules of the game. Always wear a helmet while playing contact sports like football, hockey and lacrosse, and during activities like horse riding, biking, skateboarding or snowboarding. Helmets should fit correctly and be in good condition.

  1. Don’t miss the signs

A concussion isn’t always obvious. Watch for these signs in your child or teen, especially while they are participating in sports. Symptoms may take up to a day to appear after an incident.

  • Headache
  • Nausea or vomiting
  • Balance problems
  • Dizziness
  • Visual problems
  • Fatigue or drowsiness
  • Sensitivity to light or noise
  • Numbness or tingling
  • Dazed or stunned
  • Irritability
  • Sadness
  • More emotional
  • Nervousness
  • Trouble falling asleep
  • Feeling mentally “foggy”
  • Feeling slowed down
  • Confused about recent events
  • Sleeping less or more than usual
  • Difficulty concentrating or remembering
  • Forgetful of recent information or conversations
  • Answers questions slowly or repeats questions

Seek emergency care immediately if your child or teen has experienced unconsciousness for any amount of time or has changes in alertness, convulsions or seizures, muscle weakness, persistent confusion, repeated vomiting, unequal pupils, unusual eye movements or walking problems.

  1. Do sit on the sidelines

The most important thing your child should do if they are injured during a sports activity is to immediately stop playing. It’s crucial that they avoid more hits, jolts, shakes or bumps to the head or spine. Getting back in the game is not worth the risk. Remember, the signs of concussion aren’t always clear, so when in doubt, sit it out.

Athletes may not want to tell their coach if they had a concussion. Encourage them to come forward if they have an injury, or if they notice a teammate is injured. Young athletes should never ignore a head injury or impact to the head.

  1. Don’t skip treatment

Even a mild concussion should be evaluated by a doctor. Get in to see your child’s pediatrician as soon as possible.

When a concussion is severe or symptoms won’t go away, talk to your doctor about a referral to the CHOC Children’s Concussion Program, which includes pediatric sports medicine specialists, neurologists, neurosurgeons, neuropsychologists and rehabilitation therapists who are all trained in concussion management.

  1. Don’t rush recovery

Rest is important immediately following a concussion. For 24-48 hours, your child should stay home from school and get plenty of quiet time and mental rest. This includes limiting activities like:

  • Television
  • Texting
  • Social media
  • Reading
  • Driving
  • Doing homework
  • Social interaction
  • Attending loud events

After the first 24-48 hours, light activities may help speed up recovery. Most children should be able to tolerate some school after a few days. If they need to miss more school than that, contact the school and your doctor to help intervene with short-term adjustments. Before returning to sports, be sure that symptoms have resolved and get medical clearance from your child’s doctor.

  1. Do prevent future injury

Parents, coaches and athletes should be extra cautious to prevent future concussions. One concussion is rough enough, but additional injury is even worse. Research has shown that repeated jars to the head can have long-lasting effects on the brain. And, if a child or teen suffers a second concussion before the first concussion heals, they are at risk for Second Impact Syndrome, a life-threatening condition.

“The CDC has called concussions an epidemic in the United States,” Dr. Taraman says. “Kids really do get into trouble if a concussion is not recognized, and if we don’t take the proper steps to get them better and avoid those second injuries, which can be catastrophic.”

Download 5 questions to ask an injured athlete

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Is Your Child’s Headache Cause for Concern?

When your child complains of a headache, it can be anything from a plea to stay home from school in hopes of avoiding a test, to a sign of something more serious. But how can you tell the difference? And when is it time to see the pediatrician? Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice on what parents can do to keep headaches at bay, the importance of identifying a pattern in your child’s headaches, options for treatment, and what types of headache warrant a trip to the emergency department.

sharief-taraman-choc-childrens-pediatric-neurologist-offers-advice-childs-headaches
Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice for parents concerned about their child’s headaches.

First, it’s important to be able to identify what type of headache your child may be suffering from.

What type of headache does my child have?

Migraine symptoms in kids

At least 5 attacks that meet the following criteria:

  • Headache lasting 1 – 72 hours
  • Headache has at least two of the following features:
    • Pain on both sides or only one side of the head
    • Pain is pulsating
    • Moderate to severe intensity
    • Aggravated by routine physical activities
  • At least one of the following:
    • Nausea and/or vomiting
    • Sensitivity to light or noise

If your child has more than 15 headache days per month over a three-month period, and at least half of those are migraines, they may be suffering from chronic migraines.

It’s a common misconception to assume that only adults suffer from migraines, which isn’t true, says Dr. Taraman. If your child has migraines, they are not alone. About 1 out of every 20 kids, or about 8 million children in the United States, gets migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.

Tension headache symptoms in kids

  • Headache lasting from 30 minutes to seven days
  • Headache has at least two of the following characteristics:
    • Pain in two locations
    • Pressing or tightening feeling (not a pulsing pain)
    • Mild to moderate intensity
    • Not aggravated by routine physical activity such as walking or climbing stairs
  • No nausea or vomiting – many children experience a loss of appetite
  • Either sensitivity to light or sensitivity to sound
  • Tension headaches occur most often in children ages 9-12

Cluster headache symptoms in kids

  • At least five headaches that meet the following criteria:
    • Severe pain in one location: within the eye, above the eyebrow, or on the forehead, that lasts from 15 minutes to three hours when left untreated
  • Headache is accompanied by at least one of the following symptoms on the same side of the body as their pain:
    • Conjunctival injection and/or lacrimation
    • Nasal congestion and/or excess mucus in the nose
    • Eyelid swelling
    • Forehead and facial swelling
    • Droopy eyelid and/or small pupil
    • A restlessness or agitation
  • Cluster headaches usually start in children at around 10 years old

Post traumatic headache symptoms in kids

  • Acute post traumatic headache: lasts less than three months and caused by a traumatic injury to the head
  • Persistent post traumatic headache: lasts more than three months and caused by a traumatic injury to the head
  • Both acute and persistent headaches develop within one week of: the injury to the head, regaining of consciousness following injury to the head, or discontinuing medicine that impairs the ability to sense a headache following a head injury
  • Extended recovery risk factors:
    • Prolonged loss of consciousness or amnesia
    • Females
    • Initial symptom severity
    • Premorbid history of ADHD, mood disorders, and migraines

Sleep apnea headache symptoms in kids

  • Typically occurs in the morning
  • Pain is present on both sides of the head
  • Lasts more than four hours
  • Not accompanied by nausea, nor sensitivity to light or sound

Medication overuse headache symptoms in kids

  • Headaches on 15 or more days per month
  • Takes over-the-counter medication for headaches more than three times per week over a three-month period
  • Headache has developed or gotten worse during medication overuse
  • Pattern of headaches resolves or improves within two months after discontinuing the overused medication

What to do when your child has a headache

A variety of non-medical interventions can be helpful for children who are suffering from headaches. These non-medical interventions for headaches include: ice packs; warm baths; taking a nap in a cool, dark room; neck and back massage; and taking a walk.

Parents shouldn’t be tempted to immediately turn to medication such as ibuprofen or naproxen, says Taraman.  Over-the-counter pain medications (such as Tylenol or Motrin) should be limited to no more than three days per week with no more than two doses per day, in order to avoid medication overuse headaches. Follow the dosing instructions on the label and ask your child’s pediatrician or pharmacist any questions before beginning a treatment regimen. Follow dosage instructions given by your physician or pharmacist, or download a guide to ibuprofen and naproxen.

dosing-instructions-ibuprofen-naproxen

How to avoid headaches

There are a number of things parents can do to prevent headaches, says Dr. Taraman. These include:

How to talk to your pediatrician about your child’s headaches:

Keep a journal of your child’s headaches so you can identify a pattern, and show your child’s primary care physician. If you don’t have a primary care provider, find one near you. In your headache journal, keep track of:

  • Headache start date and time
  • What happened just before the headache?
  • How much did your head hurt, on a 0-10 pain scale?
  • Where did your head hurt?
  • What did you feel just before and during the headache?
  • What did you do to make yourself feel better?
  • Did you feel better, on a 0-10 pain scale?
  • Headache end date and time

Your child’s pediatrician may adjust your child’s diet, headache hygiene routine, or their NSAID regime. In some cases, your primary care provider may refer you to a pediatric neurologist, who have specialized training in the nervous system (brain, spinal cord, muscles and nerves), who work in tandem with imaging and other specialists and pediatricians as necessary.

Patients should immediately be taken to the emergency department for some headaches including:

  • Thunderclap headache: severe, sudden onset of pain that occurs anywhere in the head, and grabs your attention like a clap of thunder. Pain usually peaks within 60 seconds to a few minutes.
  • Any headache that comes with weakness or numbness on one side of the body, or changes in consciousness or awareness.
  • Blurred, double or loss of vision that persists after the headache resolves.

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5-year-old Rayaan fights through battle with brain, spinal cord inflammation

By Hina, mother of CHOC Children’s patient Rayaan

When Rayaan was 16 months old, he caught a simple cold. He had a typical low-grade fever and slept more than normal. I figured he needed the rest and would feel better the next day. The next morning, he was having a difficult time waking up so I thought I should take him to his pediatrician. She recognized something was very wrong and described him as being “unresponsive.” He was immediately transported to CHOC Children’s via ambulance. CHOC’s emergency department team was waiting for our ambulance and ready to care for Rayaan as soon as we arrived. They quickly assessed him and then placed him on a ventilator as he was brought up to the pediatric intensive care unit (PICU).

His care team ordered an MRI of his brain and diagnosed him with Acute Disseminated Encephalomyelitis, also known as ADEM. This means there was widespread inflammation in his brain and spinal cord that damages the myelin, which is a protective covering for nerve fibers. ADEM had affected over two thirds of his brain. We didn’t know it yet, but we would be at CHOC for the long haul.

Over the course of the next six weeks, Rayaan received multiple types of treatment for ADEM. His care team was vast, and included many different specialties: Dr. Nguyen Pham, a pediatric otolaryngologist (ear, nose and throat specialist or ENT), Dr. Gregory Wong, a pediatric gastroenterologist, Dr. Sharief Taraman, a pediatric neurologist, in addition to infectious disease specialists, in-patient physical and occupational therapists, a respiratory therapist, and the feeding team. He was in a coma and on life support for three weeks. During this time, his doctors kept a very close eye not only on him, but also on our entire family. Dr. Nick Anas, CHOC’s physician-in-chief; Dr. Jason Knight, medical director of emergency transport services; Dr. Paul Lubinsky, associate PICU director; and critical care specialists Dr. Juliette Hunt, Dr. Anthony Cherin and all of our nurses became family to us. I remember when Dr. Anas came to check up on Rayaan and he asked me when was the last time I layed next to Rayaan, I replied it’s been a while, and he ordered the PICU staff to transfer Rayaan from a crib to a full-size bed immediately, so I could lay next to my son. Rayaan was connected to every machine and monitor you can imagine, but his doctor was keeping my feelings in mind.

During this extremely difficult time when we were waiting for him to wake up, we were fortunate to have a wonderful support system. The Ronald McDonald Family Room let us escape for a few minutes, occaisionaly breakfast and lunch was provided by generous donors, and my daughter who was only three years old at the time was taken care of by child life specialists, while a social worker and case manager were assigned to us to provide us with counseling. This period was the hardest thing we had ever dealt with in our lives.

After three weeks of being in a coma, Rayaan began showing signs of waking up. He began by slightly moving his hands and arms. A few days later, we noticed his eye partially open. It would take him almost two weeks to be fully awake.  Although he had woken up from his coma, his journey was just beginning. The inflammation in his brain caused severe brain trauma and he lost his speech, and his ability to walk, eat, swallow and drink. While he was still in the hospital, a feeding tube was placed, as his oral muscles were to weak to swallow and chew. After his discharge, the rehabilitation team came in to ensure he would relearn the basics. Nicole Well, a speech language pathologist at CHOC, taught my son how to talk again. A feeding therapist named Polly provided electrical stimulation feeding therapy to make his muscles strong enough again to be able to eat, drink and swallow on his own.

rayaan-emergency-transport-to-pediatric-intensive-care-unit
Four years after his health scare, Rayaan is in Transitional Kindergarten and still undergoes multiple therapies in the effort to make a full recovery from his illness.

Rayaan endured several surgeries and procedures during his hospitalization, and even more after his discharge and as well as multiple visits to the emergency department at CHOC. The CHOC specialists always worked so hard on Rayaan as if he were their own child. I am very grateful to CHOC for saving his life and I know that the comprehensive care we received at CHOC we wouldn’t have been able to get anywhere else.

Today, four years later, Rayaan is in Transitional Kindergarten and still undergoes multiple therapies in the effort to make a full recovery from his illness. He remains under the care of CHOC specialists. I am inspired every day by his strength and his courage to overcome so much at such a young age. Above all, our family is grateful for CHOC, who has provided him with the comprehensive medical care throughout his journey.

Learn more about the pediatric intensive care unit at CHOC

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