Of Working with Children!

This week, I finally finished the project my mentor had me working on. I extracted all 636 diagnosis from 636 case files! I finished what was supposed to be a three week project in four days, much to my mentors surprise. That being said, I received another project to work on. Now that I know how to read an analyzes case studies, Dr. Miloh assigned me the task of filling out a 56-collum spreadsheet for a research project that he is working on. Fifty patients were selected to participate in a Text-Messaging study. In the study, patients half the patients were sent weekly texts to remind them to take their meds (which according to the case studies I have read, compliance is often poor even in life-threatening situations). The problem is that all of the data has not been properly recorded. Instead, I am to rely on the case studies of patients to see if there has been any effect. Here's what happens: every time a patient visits the hospital, the MD that sees him/her writes a two to three page report on what happened, why the patient came, the impression the MD had of the patient, a suggested course of actions, etc. Because this is written every time a patient steps into PCH, I can see the progression of each disease by reading every single report on the patient in all areas of the hospital (GI, neurology, genetics, dermal, Hem/Onc., etc.) In most cases there are well over forty documents per patient, and for each patient enrolled in the study, I have to read every word so I can properly record their progression. I am learning so much from reading these studies. By reading about each patient, I feel I really understand a lot of diseases and their treatments and causes. Working directly with cases has taught me probably as much as a whole textbook on the subject would. I also get to learn about how each patient reacts in each situation, and see exactly what doctors do to facilitate compliance. It is a very interesting look into the psychology of a patient. Additionally, I am learning as I am going, and the more patients I read up on, the greater my knowledge of GI diseases increases. Interning is really a very cool way to learn a new subject.

The good news is that I am now really good at reading case studies, and can easily understand them. Experience really is the best teacher.

On a side note, my mentor was in charge of coordinating a liver transplant at PCH the other day! I was SO impressed that (a) my mentor is such a boss and that (b) PCH offers transplant services! Apparently its a relatively new thing that they do, but its been working really well so far and lots of kids get the procedure done right in the hospital.

However, here is the best part of my internship: because I work hard and well, my mentor is pretty flexible on when I come in. Which means that I can get to the hospital as early as I want, work for a good seven hours on the research project, and then by 2pm get out of the office (which is exactly what I did on Friday). And do you know what I do after 2pm?  I get to volunteer with kids!!!!!!!! I am started on Friday!! I volunteer in the playroom with the kids from 2pm to 5pm every Friday from now on, and I absolutely love working with the kids. They are so adorable and you can tell they really appreciate having someone to play and talk with. Also, because I am 18, I can even go bedside with kids and play with them if they are unable to leave their rooms. It is really sad to see kids so sick, however at the same time it feels amazing to be able to put a smile on their faces. My first day working with them went really well, and I am definitely going to try to work more hours with the kids into my schedule.

I have an official purple volunteer apron, and I have the best Senior Project Ever! I am learning so much, my mentor is amazing, I get to work with kids in the one of the best facilities in the state, and I am able to make a positive difference in kids' lives. I could not have asked for a better internship :)

Hoping you all stay healthy and happy,
Lior

Of Medical Conferences

On Tuesday, I had the pleasure of attending a pediatric medical conference at the Ritz Carleton with my mentor. Sitting in a room full of physicians and MDs, it was a humbling experience being presented with the same information they were. The conference lasted about six hours, with each MD allotted forty minutes to present his or her research. In between presentations, various medical companies sold their latest products. There were many interesting products for doctors to invest in. One company presented a pen for diabetics that held nearly twice as much insulin as regular diabetic shot pens. Another showed a head lice shampoo that was gentle enough to be used on children as young as six months, and so effective that in clinical studies, after one use (without fine combing) children were found to have gotten rid of all of their lice, and even when they were put back into an environment in which lice was prevalent, they remained lice free for a minimum of two weeks. Another interesting product was a non-invasive blood-sugar level detector that could be attached to an iPhone. A free downloaded application would process the information and tell the user their levels immediately, and without injury to the user. There was also a company that sold syringes pre-loaded with vaccines, for use in emergency situations. Lastly, and most impressively, a neurological company developed a program that, using MRIs, could re-create an entire skull of any patient out of a metal net. The net could then be cut to fit whatever part the of the bone skull needed to be removed. Because of the mesh-like design, bone cells would start growing on the net, until the patients skull would be made completely out of bone, with metal underneath.

Following are the presentations that each MD gave and a quick summary.

Tamir Milo and Don McClellan-- Pediatric Obesity: Sweet Kids/ Fat Livers. This presentation focused on the differences between Non-Alcoholic Fatty Liver Disease (NAFLD), and Non-Alcoholic Steatohepatitis (NASH). NAFLD and NASH are both caused by obesity. What happens is that children accumulate adipose tissue in their bodies. Over time, their livers accumulate adipose tissue as well, and they become unable to process wastes properly. Then, the cells of the liver begin to die. If the patient does not lose weight or get a transplant, NAFLD may turn into a liver carcinoma as liver cells begin to die at a rapid and uncontrollable rate. NASH is also caused by obesity, but often occurs as a product of heredity. NASH, as the name implies, is much more severe than NAFLD because it most closely resembles Hepatitis, a quick paced disease that terminates liver functioning. Both diseases may be treated with diet and exercise. Dr. Miloh also touched on Type 2 Diabetes and how to recognize early warning signs. He also stressed the importance of setting realistic goals for patients. To get rid of the liver threatening symptoms of NAFLD, patients only actually need to lose 5 to 10% of their weight. Also, he pointed out that fructose is one of the leading causes of NAFLD and NASH in both adults and children, as it is incorporated in nearly every processed food and is a much more chemically based and fattening alternative to plain sugar.

William Raszka-- Flim, Flam, and Phlegm: Diagnosis and Treatment of Community Acquired Pneumonia (CAP) in Healthy Children. This presentation focused mainly on how to identify and treat CAP and Complicated Pneumonias. The MD stressed that the diagnosis of CAP is currently absurdly general, making it difficult for doctors to correctly diagnose the disease. The reason for this is that there is virtually no research on the viral or bacterial CAP (there are two kinds). Thus, it MDs have to use their intuition to diagnosis a CAP, rather than a set test. Complicated Pneumonias (that cause life-threatening symptoms, and CAPs that arise from a non-bacterial infection) are also difficult to treat. The end result is that MDs treat the symptoms of pneumonia, and sometimes not the disease itself. It is also interesting to note that viral types of pneumonia and also Bronchitis are not treated with antibiotics, as antibiotics are only used to treat bacterial infections. In these cases, the disease is not treated and MDs strictly treat the symptoms until the patient gets better

Hilary McClafferty-- Pediatric Integrative Medicine: Looking Forward. This MD works in educating doctors about Integrative Medicine. Integrative Medicine aims to integrate "alternative medicine," such as physical therapy, herbal and vitamin supplements, and acupuncture, with "hard medicine," which deals more with treatments such as antibiotics, surgery, and vaccines. Her point was that doctors should always consider alternative treatments, especially physical therapy, in conjunction with traditional medicine when diagnosing and creating a plan for patients. She argued that by considering integrative medicine, doctors had a chance of greatly reducing hospitalization time for patients and sometimes even reducing the need for surgery or harsh chemical treatments. She stated that she created this initiative through her alma mater, UNC Chapel Hill, and now teaches it at a specified branch of the U of A med program.

Scott Schraff-- Pediatric Head and Neck Masses: When to Worry About Lumps. This MD was a surgeon who dealt directly with masses protruding from children's head and necks. He explained that the masses, or "bumps," that were visible from the outside were really only the tip of the iceberg-- the masses often extend deep into children's head and necks, causing problems by physically pushing structures together. The masses arise in many ways, but a common course is that children are born with empty 'sacks' in their heads. After getting a mild infection (it could even be a cold), the sacks become inflamed and fill with fluid, extremely quickly. In some cases, these lumps appear in under a week. The problem is that  the lumps will push on the appendages in the head. For example, a mass occurring under the jaw could push the tongue up and restrict breathing. The traditional way of treating these masses was to operate on them and remove them. The surgery, however, is risky and goes horribly awry at times (the MD cited cases in which the frontal esophagus was cut out instead of the mass) because it becomes very difficult to tell where everything is during surgery, as it is all pushed together. Thus, the MD has started using steroids to reduce and drain the inflammation from the masses, which works very effectively. He also pointed out that at times the bumps arise from inflamed lymph nodes, and require multiple surgeries and medications to treat. Most interestingly, he showed photos of an MRI of a pregnant woman, who's fetus had a clear mass coming out of its mouth inside the womb. To save the child, Dr. Schraff opened the woman's stomach, removed the head and shoulders of the baby from the womb, put in a breathing tube and cut out the mass, and put the baby back into the womb to finish growing. Apparently, fetuses are born with masses quite frequently, and they can get very bad very quickly. He showed a photo of a newborn with a mass extending from its face all the way down to its feet. The mass was half as thick and as long as the baby itself, but by careful surgery it was successfully removed. This was presentation was easily one of the most interesting of the conference, and I learned a lot about a field I did not even know existed.

Jeffery Weiss-- Talking to Families about Preventing Injuries. This presentation was not very fact-filled. In summary, the MD said that teach a child under four years to swim is fine, which is a change in the official statement from a few years ago that recommended children do no not learn to swim before age four. Also, taking swim lessons and knowing how to swim does not prevent drowning. Additionally, the MD presented that Drivers Ed classes should not be taught in schools, as they give more 16 year olds incentive to drive, and 16 year olds are easily the worst divers. Ever. For all you parents out there, there are video cameras you can install in your child's car so you can see what goes on in the car when they are driving.

I enjoyed the conference very much. As a side note, I had a chance to hike Squaw Peak afterwards, which I highly recommend! It is an intense hike that leads straight to a summit (the second highest in Arizona), and the view is spectacular. It took about one hour up and one and a half down, but I can definitely see it taking up to two or three hours one way with a slow pace and frequent breaks. If you want to work hard an realize the rewards, and realize the true meaning behind "nothing worth having ever came easily," this hike is for you!

Warm Wishes,
Lior

Of Hospitals that Seem Otherwise

On Tuesday, February 26th, I will be going into work late because I will be listening in on a formal presentation that my mentor is giving at the Biltmore in Phoenix. The presentation is a lecture-type format, and will be discussing obesity, the causes of it, and the best way to deal with it.

Today, during lunch, I discussed the hospital with my mentor. If you have not visited the Phoenix Children's Hospital, I highly recommended you find some time to volunteer in it. The hospital is unlike any other hospital I have ever seen. To begin with, it is very easy to forget that you are in a hospital at all. This is partially due to the architecture, and partially due to the atmosphere the staff helps create.

Phoenix Children's is extremely well built. Everything is colorful, and serious efforts have been made to ensure that kids are not scared of it. Every wall is painted in a different color. The tiles are rainbow, and walking through the hospital to the emergency section, the tiles are colorful circles. There are giant windows everywhere which showcase a garden, and even a massive "laser wall" that consists of warped stained glass and moving projections of flowers and hearts that could easily belong in the Children's Museum of Phoenix. Each patient at Phoenix Children's has their own room. Some cases are extremely severe at the hospital, and there are notifications placed on the doors of each room which basically correspond to hazmat regulations (wear full body protections, refrain from contact, air controlled, etc.). However, the signs that indicate to doctors what to precautions to take consist of colorful laminated squares with pictures of smiling turtles, grinning rabbits, and cartoon figurines. Additionally, there are teddy bears that doctors put tiny IVs on to show kids exactly what will be done to them. There is even a tiny MRI machine that doctors but Barbie through to show kids how it works. Most impressively, all the medical equipment has been made to look, if not nice, then certainly less intimidating. sheets and pills are hid behind in-wall closets, and nurses wear bright scrubs often adorned with cartoon characters. The whole set-up of the place is really very impressive.

Additionally, the people that Phoenix Children's hires are just nice. Everyone smiles and is keen to have a quick conversation on how your day has been. Going up the elevators, a doctor on his way to do surgery was telling me about good hikes in the area. I have visited other hospitals to do volunteer work and sit in on surgeries before, and while the caliber of care and professionalism was of equal or greater caliber as Phoenix Children's, the general atmosphere of the Children's Hospital is much less stressful than at other places. It is not that there aren’t things to be stressed about--there certainly are-- it is that major precautions have been taken to make a family's stay as least awful as it can be.

 Hoping you all stay safe, healthy, and colorful,
Best,
Lior

Of Overcoming Ignorance

Today, day three at the hospital, I feel I am finally getting the hang of Hepatology!

Dr. Miloh sat down with me and had me sign off the skills I acquired on a, shocker, Skills Acquired worksheet that the hospital keeps for their records, and I was proud to be able to sign off on 'basic knowledge of Hepatology and Gastroenterology.'

Today, I was able to fly through three hundred more names, putting me at 500 out of 636. I also had time to get back to Scottsdale in time to hike Sunrise Peak before dark, which was absolutly gorgeous in the sunset.

With every case study I read, I become more used to the formatting the doctors use. I know exactly which ones use the dreaded One Paragraph Method, and which ones kindly break up the document into skimmable sections. The best MD though, is the Hepatologist. He writes all his diagnoses at the end of the page, so that it is extremely easy to find the right one once one gets accustomed to the usual diseases.

I can now discern most of the recurring Hepatological diagnoses, and can usually tell when a diagnosis does not pertain to a liver disease. I can now also quickly scan an entire study to find the diagnosis. I feel like a voyager slowly walking out of Plato's Cave. Ah, the feeling of ignorance being conquered is nice.

Here are some of the most common diseases I deal with:

NAFLD (Non-Alcoholic Fatty Liver Disease). This diagnosis is reserved for patients whose problems stem from obesity or extreme overweightedness. Often, their cases are sent in conjunction to the Psychology Department, where a licensed psychologist works with the patients to get them to change their habits, and explains to them the severity of their situation. These cases have similar "plans of attack" that seek first to help the patient loose weight through a strict diet and exercise plan. When asking Dr. Miloh if many patients loose enough weight to become healthy again through the hospital, he stated that though some seem insistent on staying the way they are, a much more significant amount lose enough weight to avoid surgery, and many acquire a healthy weight in the end.

Chron's Disease. This diagnosis often comes from the general Gastro department, and not the Hepatology department. The disease affects the intestines and the inner tube of the body that leads from the mouth to the rectum. It is basically an inflammatory disease that leads to liver complications, and treatment of Chrons will often remove any underlying liver problems.

Hepatitis, Hepatitis B (HBV) , Hepatitis C (HCV), and Autoimmune Hepatitis (AIH). Hepatis is the swelling and inflammation of the liver, and caused by a viral infection. Each type of Hepatitis comes in many flavors. The one I have dealt with have been Genotype 1, Genotype 1a and 1b, Genotype 2, Genotype 2a, and Genotype 2b. Hepatitis (in all its many flavors) is one of the main causes of lliver cancer, and consequentially many patients suffering from the disease get liver transplants. Some, however, especially those with "acute" and not "chronic" hepatitis, do get better without transplants. Additionally, I found one case study with states that there is a 50% spontaneous recovery rate amongst adolescents, which is quite impressive. While HBV and AIH originated mostly in the body, HCV often is transmitted via unclean needles, drug abuse, and through sexual transmission. This seems to be the most problematic flavor of this disease. However, HCV can also be simply a mutation in the body like HBV and AIH. There is no cure for Hepatistis currently. Looking at the case results, it seems most HBV patients get better or learn to live with their disease, while most HCV patients need a liver transplant, and it is heavily stressed that they discontinue any use of needles and make sure to cover all wounds in the skin, no matter how small.

Bilary Artesia. Most patients with this come to Phoenix Children's as a result of a liver transplant. From what I have encountered, Biliary Artesia seems to be one of the forefront reasons for patients to get a liver transplant. In this disease, the ducts that cary bile from the liver to the gallbladder become blacked. It is most often characterized my Jaundice (yellowing of the skin). In many cases, especially if the patients are diagnosed as infants, a Kasai procedure will be done to avoid a liver transplant. The Kasai procedure connects the liver to the small intestine, so to bypass the gallbladder completely.

Wilson's Disease. This is a very interesting and very rare disease, but it seems that pretty frequently patients visiting the GI will have (it was also featured on an episode of House if you are interested in some Med Drama). In Wilson's, copper builds up in the liver, as well as the brain, eyes, and other organs. It is a genetic disease, caused by a mutation in the ATP7B gene. The reason the copper (which in large amounts is poisonous) build up is because the liver becomes ineffective in removing it.

There are many more diagnosis’s I work with, but the above are the most common.

Hoping you are all keeping your livers in check! Best,

Lior

Of Sysophis and What Became of Him

Today, after reading and typing for nearly eight hours, I finished 284 names out of 636.

The reason this task is taking so long is because the case studies are written in a letter format. Each doctor has their own style of writing, and some are easier to understand than others. Additionally, there does not seem to be any standard for writing the case studies, except for a loose structure. One doctor may put the patients' diagnoses in the very last sentence of the letter; another may include it in a massive paragraph at the beginning; and yet still some will never explicitly state the diagnosis, but rather allude to it throughout the document. Additionally, some doctors clearly label the sections of the information (Assessment, Lab Work, etc.), some doctors do not label the sections, but only space them out into paragraphs, and still, most annoyingly, some doctors include the entirety of the information in one giant page-long paragraph.

The result is that skimming the studies for a diagnosis is not possible, because it is hard to know where it is located. Additionally, because a case study is written each time a patient meets with an MD, not all of the case studies contain explicit diagnoses or plans of attack. Some are follow ups, and some are referrals to other departments in the hospital if the MD feels the case no longer pertains to their speciality. This means that I often have to read multiple, if not all, case studies to discern the diagnosis.

Now, to the doctors' credit, the letter system is extremely efficient inside the hospital. The studies are easy to understand for the most part, and it is easy to see what the patient came in for from each one. It is also obvious that anyone with a degree in medicine would be able to understand the case studies. I think the hospital uses the letter system because it fits their patients best. It would be impossible and very inefficient to have the doctors fill out a set spreadsheet with all the patients information, because some patients simply do not fit into any mold. A lot of them suffer from problems that are interrelated amongst departments, and a "plug and chug" system would simply not be able to capture it.

So, the system works great, if your a doctor, and, well, educated. The biggest hurdle I am having to overcome is my ignorance. To begin with, I found out today that I would have to do some major personal research if I want to be able to stop googling every diagnosis I read to find out if it is a liver disease.

If this experience teaches me only one thing, it is that education is GOOD, and lack of it is utterly horrible. I want to be the person that can say, "Chron's Disease affects the intestines, and X% of the population has it," without having to look it up. Additionally, it is clear that even with an introductory level gastro course, I would be able to fly through these documents. The documents are not hard to understand, I simply lack the knowledge to process the most important part of the information.

Oh, the woes of a high school degree.

Finally!

I have finally gotten my official volunteer card! It is beautiful, and red, and oh so official. Today, after taking my very last physical exam, I started my first day!

Here is a background on what I will be doing:

Dr. Miloh is the only Pediatric Hepatologist in the state. He works in one of the biggest GI (gastrointerology) departments in Arizona. Additionally, Phoenix Children's Hospital is one of the only hospitals in the state to offer full GI/gastro/hepatology care for adolescents. Needless to say, this is an amazing opportunity.

As an intern, the more I do, the more I can do. Dr. Miloh wants me to start out small (ish) and then proceed from there. Today, I was surprised to find that when a patient visits the hospital, the doctor assigned to their case types up a Case Report at the end of each visit. Every time the patient walks into a hospital to get tested or to consult with a MD, it is recorded in a case study-like letter. The letters contain information on the patients. This information includes Reason for Visit, Physical Report (weight, height, etc.), Lab Work (if they have it done. This includes blood tests and cultures.), and, finally, the Assessment or Impression, which is the final diagnosis a doctor will give the patient and includes a Plan of Action for the patient to get better.

Each patient will often receive multiple diagnosis, especially in the Gastro department. The diagnosis actually reflects all the people the patient has seen. For example, if a patient admitted to Phoenix Children's saw a geneticist, a neurologist, and a general gastrologist, the doctor writing the report will write something along the lines of, "Today I had the pleasure of seeing XXXX, a fourteen year old girl who has Trisomy 21, numbness in her fingers, and abdominal pain." Please note that the above was a fictional example and does not reflect any real patient at the hospital.

At the hospital, the only way to get the diagnosis of a patient is to read through their case file. The files are on the computer, but they are scanned PDF documents, which means that it is impossible to search for one diagnosis without reading the entire case history of each patient. This, obviously, is  a problem. Dr. Miloh cannot do a research project on types of diseases because the information is not easily accessible.

My job is to read the case study, extract only the diagnosis that pertains to liver diseases (AKA Hepatology), and put the diagnosis on an Excell spreadsheet that contains only the Medical Record Number and the first and last name of each patient. When I am done, the entire Hepatology department will be able to conduct research, look up diagnoses for patients quickly, and compare treatment plans from one patient to another suffering from the same disease.

Phoenix Children's is a very efficient hospital, They are able to process hundreds of patients every day. The Gastro department has 636 patients. Therefore, I will be reading 636 case studies.

This task may seem Sisyphean in scope, but I have confidence I can do it in a timely manner!

Wishing you all the very best,
Lior

Of the Largest of Them All

Let us begin our discussion today on Mississippi, the only word in the English language that can be spelled with three sets of double letters.

Mississippi is also the only state in the United States to boast a 31% child obesity rate, the highest rate in the United States.According the the Mississippi Department of Health, 80% of children who are obese will suffer from obesity as adults.

And these adults are costing the state. Mississippi spends 757 million dollars on health care for adult obesity. It is estimated that Medicaid costs would be 11% lower in the absence of adult and child obesity, and Medicare costs would be 8% lower.

However, Mississippi has not stood idly by as its population expands. in 2004, the state implemented the Child Nutrition and WIC Reauthorization Act, forcing every public school to establish a Local School Wellness Policy, which included provisions to restrict vending machines, provide healthy options in school cafes, and other similar measures. Then in 2007, the state passed another major piece of legislation called the Mississippi Healthy Students Act. The law stipulated minimum requirements for physical education in public schools, required an official Physical Activity Coordinator in schools, required mandatory "health councils," required the State Board of Education to adopt measures to promote healthy food and beverage decisions, and, lastly, required every school to create a personalized Wellness Policy.

If it seems as though the state has passed extensive legislation to deal with the issue, it has. In fact, Mississippi passed so much legislation to deal with child obesity that in 2009 the Center for Disease Control and Prevention named Mississippi as one of the top states regarding school policy implementation.

Additionally, according to the MSDH, there are literally hundreds of grants to promote healthy living amongst school children-- everything from the Bower Foundation, which provides millions of dollars to make healthy options more attractive to students, to the Committed to Move grant, which provides over $ 9,000 to fund physical education teachers and top-of-the-line physical fitness equipment, has been showcased.

And yet,  Mississippi still has the highest child obesity rate, beating out second place by over 9%, though clearly not for lack of effort or funds. I believe that the problem lies in how the state is managing the millions of dollars it pours into the school systems. Perhaps, the solution to child obesity is not far-away government laws, no matter how well intentioned. Through my research, I have come to believe that the most effective solution lays in working directly with families, instead of forcing schools to change their ways. Perhaps with greater focused family attention, more productive change would come.

I have spent the bulk of this week researching Mississippi, and the more I read, the more I find out how much I do not know. However, I am fascinated by the states legal records, and the disparity between funding and results. Working with Mississippi first has proved invaluable, as I now feel I have a strong basis for understanding other states' policies.

I will post more research as I encounter it.

Thanks for reading! Please post any questions or comments you have! :)