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Utilizing the Full Team in Pediatric Cardiology

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Interprofessional Collaboration

7.2 Use the knowledge of one’s own role and the roles of other health professionals to appropriately assess and address the healthcare needs of the patients and populations served

As a pharmacist who is now in medical school pursuing a career in medicine, I have long thought there is value in an interprofessional team to take care of patients, especially complicated ones with multiple comorbidities or rare diseases. I got to see the value of this type of team during my rotation in pediatric cardiology at Nationwide Hospital. During my time on this rotation I was exposed to some extremely rare cardiac abnormalities that I will likely never get the chance to see again unless I spend additional time there. I had no idea it was even possible to live with a single ventricle heart, let alone function reasonably well in the world. However, as you might expect, patients with these types of rare and extreme cardiac abnormalities require a high degree of very specialized care from many different practitioners.

I am reminded of one patient in particular that really illustrated this point. We had a patient with a single ventricle heart that had been in the ICU for almost 6 months that was transferred to our service because he had been doing well. I took this patient on as one of my patients, and I have never taken care of a more complex patient before. The needs of this patient were extensive as he had a GJ tube, a trachiostomy tube, and several other needs on top of his cardiac abnormality. On this service we had multidisciplinary rounds that included the physicians, pharmacist, nurse, dietician and social worker, and it was absolutely necessary. It was simply too much to ask for the physician team to manage each of these aspects of the patient’s care; having each individual team member be able to have their own domain to take care of with the physician directing general goals was the only way to really keep straight this patient’s complicated needs. I had to become good at adapting to making my plans not be extremely specific but instead just goals or ideas for the patient and deferring to the appropriate team member to get their opinion as to how best to achieve those goals. If I had to plan out each aspect of this patient’s care myself, it would have taken my entire day and I would not have been able to do as proficient a job as each team member did with their own domain. During this patient’s course, I utilized and communicated with the pharmacist, nurse, dietician, respiratory therapist, social worker, speech and language pathologist, and physical therapist and every single one of their interventions and knowledge was needed to help this infant achieve the best outcome. A goal of mine is to meet and develop a relationship with all of the other care team members such as social work and pharmacy that work in the clinics that I will be working at next year as an intern.

Above: An animation from Nationwide demonstrating the remarkable first stage of the cardiac surgery to fix hypoplastic left heart.

Learning to Plan Disposition for Patients in the ED

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Knowledge for Practice

2.3 Apply established and emerging principles of clinical sciences to diagnostic and therapeutic decision making, clinical problem-solving and other aspects of evidence-based health care

A skill that I have had to learn while rotating through the emergency department is the ability to decide what workup patients need and whether or not they need admission into the hospital. In essence, it is the core function of the emergency department doctor, but it is not something that I have had much experience with prior to this rotation. Generally, all of my previous rotations have been serving patients that are either being treated for chronic problems in outpatient clinics or are already admitted into the hospital with significant workup completed. It takes a different skill and mindset to be able to see a patient with no previous knowledge of them and discern what workup and disposition they need. I felt fairly comfortable with my ability to gather a good patient history and generate an adequate differential diagnosis, but going the next step and creating a plan for workup and most crucially, whether the patient should be admitted or discharged was more unfamiliar to me. Over the course of this rotation I got a lot of experience with this.

There are many particular cases that I could use to illustrate my growth in this area but one that comes to mind is a middle aged patient that came in to the emergency department with complaints of dysuria and fatigue. When I saw the patient, she appeared clinically well, only complaining of feeling somewhat tired and a painful burning sensation when she urinates. On first thought, I was inclined to simply treat her as an outpatient due to her looking subjectively quite well. However, I soon learned that it was somewhat more complex than that. Her vitals indicated that she was moderately tachycardic to around 115 and her CBC came back with an elevated white count of 18. Therefore, she met two SIRS criteria and although she was not objectively febrile, she did complain of occasional subjective chills. This made us concerned for possible sepsis despite her good subjective presentation, so we decided to admit to observation for IV antibiotics and fluids. This case really illustrated to me the importance of looking a bit deeper than just the patient’s general appearance to decide the level of care that a patient needs. It also helped me learn about different sepsis criteria such as SIRS and qSOFA that can really help take some of the subjectivity out of evaluating a patient for potential sepsis. In the future, my goal is to always use these criteria when evaluating a patient with potential infection and refer them appropriately based on their result.

Above: Sepsis definitions and criteria taken from the OSU Clinical Practice Guidelines for Sepsis/Septic Shock

Gaining New Respect for Professionalism and Compassion in Psychiatry

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Professionalism

5.1 Demonstrate compassion, integrity and respect for others

I always strive to be as compassionate and respectful with all patients as possible, and my psychiatry consult rotation at OSU East Hospital really showed the importance of that goal. In contrast to what I had seen on most of my other services, many of the patients that I saw on this service could be very challenging to deal with. They were often abrasive, combative, and actively ungrateful. It is very easy to be compassionate and respectful towards patients that are friendly and cooperative, but it is much more challenging to do so when a patient may actively be insulting you or raising their voice at you. Additionally, many of these patients have been in the hospital repeatedly as a result of their own behaviors, which can be frustrating for the medical team. Although we can remind ourselves that logically, these patients may have underlying psychiatric, personality, or addiction disorders that are contributing to or causing their behaviors, it is still exceptionally difficult to not be personally affronted when a patient is difficult. However, these patients are every bit as deserving of respect as any other patient.

One thing that really opened my eyes and helped illustrate that point is getting collateral from many of these patient’s families. Often their families were concerned for their family member’s health and mental well being and and very appreciative of whatever help we could provide. A mother of a patient that I spoke with talked to me at length about how her son had once been doing very well and she was so alarmed that he was now having so many issues. It really helped me to realize that even the most problematic patients may have someone who cares for them and is desperately hoping that they will get better. Trying to center myself on that makes it much easier to not get hung up about any negative encounters that I might have with patients. Over the course of the rotation I found that it became progressively easier to build rapport with these patients and stay empathetic despite any difficulties. This was reflected in my CPA comments and overall ring evaluation, and I actually attained a letter in psychiatry. It is definitely an experience that will continue to inform my interactions with patients in the future and helped provide me with context to assist with maintaining professionalism in the future. A goal I have is to continue to get collateral for patients when indicated and appropriate to not only inform what the patient’s baseline clinical state was like, but also to help maintain that empathy in the future.

Learning to Cope with the Stress of Losing a Patient

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Personal and Professional Development

8.2 Demonstrate healthy coping mechanisms to respond to stress

As a nontraditional student that has worked in a high stress full time job in the community; I have in general been able to manage the stress of medical school without too many issues. However, there are certain situations and stressors that are fairly unique to physicians and other healthcare personnel that work in higher acuity settings where patients can very quickly decompensate and encounter poor outcomes. On my emergency medicine rotation there was one patient who had come in for a fall on the ice and was found to have a broken femur but was otherwise stable. She was evaluated and found to be in no acute distress pending an admission so that orthopedics could take her for surgery the next day. She was asking for food and doing well when the attending last saw her, but approximately 20 minutes later the orthopedics resident came to consent the patient for surgery and she was found to be unresponsive. A code was called and I participated by assisting with compressions and pulse checks. She was found to be in PEA and unfortunately despite extensive efforts she expired. I had seen patients expire before as a medical student, but in general they were extremely sick patients where it was not completely unexpected that they eventually passed away despite our best efforts. This was different in that it was a patient whom we were talking to only shortly before with essentially no life threatening concerns from her history, exam or workup thus far. That fact made the situation much more affecting and stressful to me, and also to the rest of the ED team that had been working with her. All of us kept going through the scenario in our heads and wondering if there was something that we had missed or should have done differently.

The best thing that I found to deal with that stress was to talk through the situation with the rest of the team, and the attending did a great job facilitating a debriefing session to help all of us process what we were feeling and what questions we had. I think one common mistake we all make is to think that as physicians we should be able to deal with that kind of stress by just internalizing it and going on with our job because we are supposed to be the leaders of the team and infallible. However that attitude of ignoring our own needs can adversely affect not just our own health but the quality of care we give other patients. Simply talking through the thoughts and feelings we were all having as a team was immensely comforting by just showing that all of us, including the attending, were feeling the same things and that it was OK. I felt like seeing that attending’s leadership in facilitating that conversation really helped me grow and gave me a great framework for how to talk through these types of scenarios with any teams I lead in the future.

Another thing that helped was to use social media to read about other medical students, residents and even attendings experiences about losing patients and how to cope with that stress. I think essentially all of my classmates and really just about every medical student eventually takes care of a patient that ends up dying, and participating in some of those conversations on platforms like reddit really helped me realize there is a whole community of people out there that are processing the same feelings that are willing to help. One goal I have is that throughout my residency I intend to help any medical students I work with come to the same realization and help them with any stress they are dealing with; there are many great tools out there, I particularly like Dr. Abraham Verghese’s talks about physician burnout and self-compassion, which are all related.

Above: A talk with Dr. Verghese about empathy and physician self care, available at https://www.youtube.com/watch?v=ywRGNi82kfo&ab_channel=ZDoggMD

Gaining Proficiency with EKGs

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Practice Based Learning and Improvement

3.3 Identify and perform learning activities that address one’s gaps in knowledge, skills and/or attitudes

One area that I feel I have always struggled in is interpreting EKGs. I could see the very obvious abnormalities such as a patient in V. fib or torsades or ST elevations but really never got a good handle on how to see the more subtle findings that you can see on EKGs. Whenever I heard residents or attendings talk about J-point elevation versus ST segment elevation I wasn’t really sure how they were making that determination. As I started to get to rotations where we would see more EKGs regularly, especially my pediatric cardiology and emergency medicine rotations, I made a distinct effort to let the residents and attendings know that I wanted to see any EKGs that we received even if they were not for a patient that I was personally following. I wanted to try and read the EKGs on my own before the rest of the team and then go through them systematically with the resident or attending so that I could get used to seeing different findings and how to interpret them. One of the cardiology fellows was actually kind enough to give a presentation and go through a large number of EKGs with the entire team to show a lot of different findings. There are a couple of tips that I still immediately remember from her presentation; particularly the “thumb method” of quickly determining axis deviation by looking at the direction of the QRS complexes. I was also recommended to buy Dr. Dubin’s classic “Rapid Interpretation of EKG” book as it is a great quick reference that you can refer to very easily. I did buy that book and it has definitely helped me as a great refresher whenever I need it.

Later, on my emergency medicine rotation, there were obviously a multitude of EKGs to look at as essentially nearly every patient that comes into the ED gets an EKG. On this rotation I also made an effort to look at EKGs whenever they were available, but also wanted to go to the next step and decide whether they warranted any additional investigation or workup since these were undifferentiated patients, unlike my previous rotations. Although the majority of EKGs are quite unremarkable and do not require any additional follow up; I did get to analyze a few that were quite significant, such as a patient that came in with afib in RVR and required electrical cardioversion. By the end of these experiences I started to feel much more comfortable with my abilities to read and interpret EKGs for any clinically relevant findings. This ended up being reflected by a strong score on my AMHBC EKG assessment and I am now confident in my abilities. As a future primary care physician, interpreting EKGs will be an essential skill, so I intend to keep up my skills in reading and interpreting them. My goal is to systematically analyze each EKG that I order in the office for my patients, manually determining the rates, rhythms, intervals and axes of each regardless of findings. If needed, I will use my reference book to help.

 

Above: Proud of my score on our AMHBC EKG Assessment

Above: A great reference that I plan to take with me throughout my career!

Utilizing and Coordinating all Aspects of Care for a Complex Type 2 Diabetes Patient

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6.2 Coordinate patient care within the healthcare system relevant to one’s clinical specialty

During my time completing my longitudinal family medicine I encountered a number of complicated patients that required a high level of care from multiple different members of the health care team. There is one patient in particular that comes to mind that I had seen multiple times in clinic that had poorly controlled type 2 diabetes along with COPD, obesity, and hypertension. She had been struggling to control her diabetes since we had started seeing her about a year prior; her most recent A1c was roughly 11%. When I interviewed this patient, I found out that she had a lot of factors that were creating barriers to getting her diabetes under better control. As a medical student with less time constraints than my preceptor, I was able to take some additional time to really get to know this patient. I was able to find out that she really did not have a good understanding of what diabetes really meant and the potential complications from it. She was still under the impression that diabetes just meant you had too much sugar and couldn’t eat candy bars or sugary drinks. She also let me know that it was difficult for her to access good healthy food and fresh produce due to where she lived and transportation issues. Additionally, she showed some confusion about the different medications that she had been prescribed and when and how to take them. It became apparent through the interview that there really was not going to be much we could do from a medication standpoint to get her diabetes under control, as most of the issues that were causing her treatment failure were social and behavioral.

After this interview, my preceptor and I made an effort to get her referred to a number of different specialists and programs that could really help with her particular problems. First, we made sure to arrange an appointment with our pharmacist who is also a diabetes educator so that she could do some extended teaching about diabetes with this patient and really make sure that she understood the importance of getting her condition under control. We also were able to work with our social worker to get her into a program that allowed her to get fresh produce at no charge. The patient also indicated she would be interested in talking to a therapist as she was feeling very overwhelmed with her medical conditions, so we coordinated that as well. Although I would say that none of these actions are particularly uncommon in the family medicine clinic I was rotating at, it really helped to illustrate to me the need for primary care physicians to be the “quarterback” of the patient’s health care team to coordinate and direct multiple aspects of the patient’s care. Luckily, at Ohio State, that work is supported and there are lots of resources available to help coordinate that care, however not all practice sites are the same. It is encouraging to see more emphasis placed on the care coordination aspect of primary care, including from payors such as Ohio Medicaid. My goal as a future family medicine resident is to research and foster relationships with partners both in my clinic and in the community; this can be assisted by partnering with other physicians at the practice who may already have established some of these relationships.

Above: A model for Comprehensive Primary Care created by the Ohio Department of Medicaid

(https://medicaid.ohio.gov/static/Providers/PaymentInnovation/CPC/Enrollment-Webinar-2020+.pdf)

Learning How to Communicate Like an Intern

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Interprofessional and Communication Skills

4.2 Communicate effectively with colleagues within one’s profession or specialty, other health professionals and health-related agencies 

One of the best and most formative experiences I have had is working with the residents and attendings on the family medicine service at OSU East Hospital. It was the first time I really got to work with some autonomy as an equal member of the team rather than as a subordinate.  I was expected to be the primary point of contact for each of the patients that I was taking care of, so I had to communicate any issues with the rest of the family medicine team as well as the nurses and other practitioners in the hospital. It was a strange at first to have that level of responsibility but I quickly adapted to it and learned to communicate and act as a full member of the team. I also got much more proficient at presenting my plans and assessments to the rest of the team and our attending in a confident and concise manner. One particular thing that I got much better at was communicating only the most important information that could potentially change management for our patients. In the past I tended to report too much information, which while accurate may not have always been necessary for the situation at hand, making the information I reported less clear and take longer to report. There was actually one time on a previous rotation in third year that a resident consultant rather rudely cut me off as I was talking to him because he said “he didn’t need to know any of what I was telling him”. Although the point could have been delivered more gracefully, I knew this was something I wanted to improve so I made sure to take advantage of opportunities to communicate with consultants, attendings, nurses, etc. on behalf of the team during my time on my sub-I rotation.

By the end of the rotation there were many times that I would autonomously call or send a message to a nurse or consultant for one of our patients. Prior to this experience I would not have had the confidence to do those things without direct supervision and clear instructions. I owe a lot of thanks to the residents on the family medicine team for allowing me to have much more autonomy than I had been given in the past and for being very supportive whenever I needed any assistance. By the end of the rotation, the residents and attendings frequently gave me positive feedback that I was communicating at the level they would expect from a new first year intern, which was very encouraging to me. I will continue to work on my ability to be clear and concise when communicating with other health care team members throughout intern year by frequently soliciting feedback from each senior resident and attending that I work with at the end of my time working with them before they rotate off of our service.

 

Above: Myself and Dr. Fu (second from right), the attending from my first week on service, as well as Drs. Cheng and Anderson, the residents on service with me.

Making a Clinical Difference for a Patient

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Patient Care

1.5 Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence and clinical judgment.

On my Mini-I rotation with the family medicine service at OSU East I had the opportunity to see and evaluate a multitude of patients with many different presentations. One particular instance when I was working the overnight shift was very educational and stands out in my mind. On the overnight shift, it was only myself and the second year resident on service, so we were responsible for any admissions that came in through the evening and night. Together, we were in the process of admitting a patient who had been diagnosed with acute pancreatitis in the emergency department. I was familiar with the very basics of how to care for this condition such as giving IV fluids and making the patient NPO, but I had never actually cared for a patient with this condition so I was unfamiliar with the specifics of exactly what to order for them. I knew that I needed some more information to take care of this patient. The resident was more familiar with the diagnosis and what exactly to do but also wanted to review to make sure we were not missing anything. When we returned to the work room after taking the patient’s history and performing an exam, I decided to look to see if there was a clinical practice guideline for acute pancreatitis. I found that OSU did have a great and concise guideline that outlined what steps to take in the process of caring for a patient with acute pancreatitis.

While the resident was working on some documentation and returning calls, I reviewed this guideline and put in orders for the items that we did not think to order yet, such as a RUQ ultrasound, triglycerides, CRP, and calcium. I also changed the patient’s fluids from LR to normal saline since we did not have a calcium for her yet. Unexpectedly, the RUQ ultrasound that I ordered because of this clinical practice guideline actually revealed an unknown hepatic abscess. Although it is questionable whether this was directly related to the patient’s pancreatitis, it was absolutely something that needed to be treated and the patient ended up getting the abscess drained by the IR team. The team was very impressed that I had been the catalyst for this workup and this was an occasion where I truly knew I had made a massive difference in the care of a patient. Because of this patient, I will definitely always remember what tests and procedures to run when I encounter a patient with acute pancreatitis, and I will always look to see if there’s an OSU clinical practice guideline for the diagnoses that I am involved in treating.

 

Goal:

I will review an OSU clinical practice guideline at least once per month to familiarize myself with common presenting conditions that I have encountered in my rotations. This will be tracked via a google doc and calendar that I use to organize my schedule and activities.