I chose to work with children because . . .
My decision to dedicate my life to providing care for children occurred during medical school. I saw that pediatricians play with their patients on rounds, while physicians who take care of adults rarely seemed to be having fun with their patients.
The other thing that I liked about taking care of children is the fact that children don’t usually hurt themselves intentionally. They are not admitted to the hospital because of a lifetime of poor choices that have resulted in their needing medical care. Children usually need our help when something has gone terribly wrong over which they and their families had little or no control.
I decided to work in critical care medicine because...
I had the wonderful opportunity to rotate through the intensive care unit at Children's Hospital of Philadelphia during my medical school experience. This was an uncommon rotation for a medical student and I found it to be a very rewarding experience.
I had great role models, including one of the founders of pediatric critical care, very early on who helped me see how exciting and challenging pediatric critical care could be; nothing has dissuaded me from that vision that I had years ago.
I joined Children's Hospital Los Angeles because...
I was practicing pediatric anesthesia and critical care medicine at Saint Louis Children’s Hospital for many years and was very satisfied with what I was doing. However, Dr. Wetzel, who is the Department Head for Anesthesiology and Critical Care Medicine here had been after me for years to come to work for him here at Children's Hospital Los Angeles; I relented to the pressure and am very glad I did.
I agreed to come out here to take on this leadership position – not just a title – but to really learn true leadership skills in an innovative department and hospital, and have really enjoyed my time here so far.
What I love about my field is...
Providing critical care for children is, for me, the most exciting and challenging part of pediatrics. As a physician, you have the potential to do the most good in a very quick period of time. You can, literally, watch children get better right in front of your eyes.
Having my position means that I provide...
My role is to manage a division of 16 attending physicians who:
- Provide direct care for patients in the Pediatric Intensive Care Unit and the Cardiothoracic Intensive Care Unit
- Provide training for fellows and residents
- Conduct clinical research to improve the delivery of care
My job is to ensure that these three objectives are achieved at all times. Keeping all of the balls in the air to make these objectives happen has been a challenge that has been very rewarding for me so far.
A typical day for me is like...
When I’m on service in the Intensive Care Unit, we make rounds in the morning. I work with staff to make sure that we have enough beds for patients who need them and help prepare orders for patients to be discharged when they are ready to leave.
I meet with the families of patients so that they remain involved as part of the caregiving team. I speak with referring doctors for patients who are coming to our unit or have newly arrived. I also meet with other specialists when consultations are needed to manage patients in our unit.
In my estimation, my role is 80% diplomacy and 20% medical care. Very few of the patients that are sent to us are truly “our patients.” Typically they are sent to us from surgeons, other subspecialists in our hospital, or from private pediatricians. We are the stewards of each patient’s care while they are here and we want to orchestrate the care so that it is optimal for each child.
Each day I interface with...
We use a team approach for care, so that means that, every day, I am interfacing with our patients, their parents, the physicians, nurses, respiratory therapists, dietitians, pharmacists, social workers, chaplains, and others.
One member of the team cannot function without the others. The care of these kids is simply too complicated for any one person to handle by themselves and it would be completely inappropriate to do so.
Clearly, the majority of the care is provided by the nurses and they are our closest allies in assessing the patients minute to minute and providing the care. When the nurses tell us something is wrong, 99% of the time, they are correct.
My favorite part of my job is...
The thing I love about my job is the challenge of finding ways to improve care for children in an environment where the care that is being provided is already of the highest quality. No matter how good we are, we can always get better. For me, finding ways to fine-tune all of the pieces of the orchestra within our division and the intensive care unit has been very rewarding.
I believe my greatest contribution is...
My hope is that through some of my initiatives, I have opened the minds of my fellow healthcare providers to the idea that being able to identify the diagnosis of a child, or the deteriorating condition of a child, at the earliest possible moment, is important because it can result in better care outcomes for that child.
Developing a Rapid Response Team...
Standard medical practice for providing critical care for children relies upon the child’s health deteriorating to a situation where “critical care” is needed. One of the efforts I have been involved at Childrens Hospital Los Angeles has been to prevent a child’s health from deteriorating by implementing early critical care consultation.
In coordination with the hospital, we developed a Rapid Response Team (RRT) with representatives from our Division. The team members of the RRT include a critical care fellow, a critical care nurse, the nursing supervisor for the hospital, and a respiratory therapist. The duty of this team is to be at the bedside of the child within a few minutes of being called to assess and intervene as needed.
The intention of developing this Rapid Response Team is to develop a way of recognizing early signs of deterioration and early application of life-saving therapy before a significant event occurs. Dispatching the RRT to the bedside of a child means that members of the critical care team are being consulted well before a child deteriorates to a condition where they may be subject to a cardiac arrest, a stroke, or some other event that could have negative health consequences.
Ensuring that our critical care team sees this child as soon as possible, rather than waiting for the child to become obviously critically ill, can make a big difference in the health outcomes for the child. We began piloting the RRT program on two of the hospital floors in October 2007. In March of 2008, it was implemented across all of the inpatient units. We are seeing improvements in health outcome measurements for our patients already, which is very gratifying.
Improving collaborative practice in the ICU...
The traditional way of handling rounds is for a child’s physician to present the health to fellow physicians to determine the plan of care for the child during the day. In this method of rounding, it was not considered critical for the patient’s nurse to be present when the patient was discussed.
One of the things that we have implemented in the Pediatric Intensive Care Unit is the use of nurse presentations during rounds. This means that, when the physicians make rounds in the morning, each patient’s nurse reports on what has happened overnight, the patient’s vital signs, any changes in medications, etc. The nurse is on hand to answer any additional questions, and is also present to hear the plan of care instructions when they are agreed upon by the group. This model was already being used in our Cardiothoracic ICU, and it made perfect sense to adopt it to the Pediatric ICU.
Implementing this change in communication ensures that all of the relevant people are at the bedside when a child’s plan of care is determined for the day. And using nurse presentations during rounding provides an extra insurance policy against a major source of medical error.
Implementation of physician diagnostic support program...
Our hospital cares for children who have the most complex, serious, and rare conditions in our region and beyond. As a result, we see kids who are the toughest to diagnose and the most difficult to treat. Clearly, in order to provide treatment, we first need to provide a child with an accurate diagnosis. The quicker that happens for a child, the more effective the delivery of care can be.
Traditional methods of diagnosis research require a physician to somehow recognize that certain symptoms go with certain diagnoses. However, when a physician is faced with a set of symptoms with which they have not dealt before, putting together the right diagnosis can seem like searching for the proverbial needle in the haystack.
One of the things that I have been involved with in the past year has been to encourage the implementation of a diagnostic decision support program, referred to as Isabel. Isabel resolves many of the traditional diagnostic problems for physicians. Doctors are able to input a list of symptoms into Isabel and receive a list of possible diagnoses that includes:
- related diagnoses
- side-effects that could be caused by drugs
- effects caused by bio-terrorism agents
Isabel pulls its information from the gold standards already used by physicians such as: textbooks, journal abstracts, the Centers for Disease Control, and web resources like PubMed, OvidSP, and MDConsult, to name a few. Isabel has already won awards for its ability to assist with physician decision-making. Our hope is that, by making this service available to our physicians, we will improve our physicians' ability to make a diagnosis quickly so treatment can be provided more quickly, and more accurately, with all of the right information provided at the right time to the physician.