Stephanie F. Smith
Elective Report Dates: 14th June 2014 – 2nd August 2014 (7 weeks) Visiting centre: Boston Children’s Hospital, Massachusetts, USA Department: Paediatric Neurocritical Care Program, Division of Critical Care Medicine Supervisor: Professor Robert Tasker Elective summary: This 7 week Neurocritical Care elective placement at Boston Children’s Hospital provided practical experience of Paediatric Intensive Care as well as an insight into research and innovation within the specialty, in the context of a US centre of clinical excellence. Where did I go and why? I chose to apply for an elective placement in the USA as it is one of the leading nations in healthcare and medical research. I hoped the placement would help widen my global perspective of Medicine, and allow me to gain a better understanding of the American health system at a time where both British and American healthcare systems are undergoing significant changes. Boston Children’s Hospital has a 120-bed intensive care unit – a far higher capacity unit than paediatric ICUs I have encountered during my medical student training to date. I thought this would be beneficial from an educational viewpoint as there would be a large number and great variety of patient cases to follow-up, as well as an opportunity to learn more generally about managing larger-scale ICU centres. I was also interested to see whether there are differences between Paediatric ICU provided within a specialist hospital versus a general hospital (as I had seen so far in my training) and whether there are lessons to be learned from this different way of clinical practice. Being set within the context of a well-funded hospital with a superb reputation – Boston Children’s Hospital is ranked as the top children’s hospital in the USA – I felt it would pay dividends to learn by example from “the best”. Finally, Boston Children’s Hospital is a Harvard Medical School teaching hospital. Sharing high quality teaching sessions with the Harvard students and residents, having access to medical libraries and anatomical museums are some of the benefits that would be directly relevant as a visiting student; as well as all the attractions and amenities that living in the city would offer.
What did I plan to do and what did I actually do? I planned to divide my time between gaining clinical experience and participating in a research project. In reality, a typical daily schedule worked out as follows: 0730 - 0830: Attend daily morning teaching conferences for residents 0815 - 0830: Attend daily “cardflip” rounds (Handover meeting) 0830 - 1100: Attend daily medical rounds
Stephanie F. Smith 1100 – 1200: Project work / Supervisor Meetings 1200 - 1400: Attend conferences on morbidity and mortality, case discussion, lectures/didactic teaching, Neurocritical care conference, extracurricular conferences elsewhere in the institution. 1400 - End of day: Project work; following up on patients seen in the morning rounds, The timetable enabled a thorough insight into the specialty, facilitating completion of my learning objectives as well as an opportunity to network with clinicians within the field.
What experience did I gain from my elective? I gained a combination of clinical and research-based experience on the elective. From a clinical perspective, the first thing that was apparent on immersion was the differences in the American system to the workplace that I am accustomed to in the UK – such as the different staff hierarchy (interns, residents, fellows, attending), fast paced handovers and ward rounds, differences in clinical measurement units, a great affinity for using abbreviations/acronyms (e.g. “the patient’s having a pneumo-”, “I’s and O’s”) and predominance of drug brand names rather than the generic form. Given that Addenbrooke’s will soon be transitioning to an “eHospital”, I found it particularly enlightening to see how efficiently Boston Children’s Hospital ran using an “e-system” – rather than paper notes, a computer was wheeled over on the ward round, and patient checklists were performed using iPads. Blood tests and investigations were all centralised through the system, as well as paging could be performed via the computer system (enabling more efficient communication between staff members, with a text preview of the message appearing on the bleepers rather than the recipient having a mystery call to attend to!). A tannoy system in the ward alerted doctors and nurses when patients were arriving on the ward, or staff members were available (e.g. “if you require a phlebotomist, please see the front desk”). Teaching sessions for residents which I attended were helpful in building theoretical foundations for clinical topics that I encountered on the ward. Lectures included topics such as trauma, status epilepticus, airway, ECMO, shock, TBI, sedation. Using the online Open Pediatrics learning platform, I was able to learn in depth about these PICU topics. A particularly useful experience was attending practical sessions in the ward simulation suite (topics covered included central venous line placement, thoracic ultrasound, defibrillation, ventilation, airway) and on Friday mornings there was a “mock code” aiming to simulate a medical emergency to rehearse the management of a critically ill child or infant. World Shared Practice Forums, Morbidity and Mortality meetings, Case discussions, Grand Round topics at lunchtimes were valuable learning experiences (with the added bonus of free food!) There were three different teams working on the PICU and I was able to spend some time shadowing each; the medical resident-led team (MS1), the medical nurse-led team (MS2) and the surgical team (MS3). Through the ward rounds and following up on patients, it was possible to gain a broad overview of a number of conditions as well as topics such as ECMO and ventilation. On one occasion, I witnessed
Stephanie F. Smith a brain death examination of a young boy which, whilst perhaps being one of the most harrowing experiences I have had during my clinical training, was the first time I that I had seen certain clinical signs such as fixed and dilated pupils as well as learning the realities of paediatric end-of-life care. The first research project I undertook during the placement was a literature review of outcomes following paediatric severe traumatic brain injury. Traumatic brain injury (TBI) is a significant cause of morbidity and mortality within the United States. In 2010, there were 91.7 hospitalisations per 100,000 and 17.1 deaths per 100,000 US population. In addition to the immediate and long-term threat to life, TBI has significant socio-economic consequences. Children and adolescents are most likely to sustain a TBI. Whilst clinicians bear into account a wide number of physiological variables when assessing prognosis of childhood sTBI (for instance, hypotension and hypoxemia are associated with poor outcome), uncertainties in predicting patient outcome still exist. In the literature review, the quality of studies on outcome from childhood sTBI were assessed and the information from different centres was evaluated. Information on both short-term outcomes (mortality on discharge, PICU length of stay, etc.) and long-term outcomes (Glasgow Outcome Scale scoring) were evaluated and presented – making comparisons between different centres. A second project that is ongoing is a literature review looking at outcomes that can be used as reliable PICU performance measures. The single most memorable event of the elective was visiting Harvard Medical School and the associated anatomical museum with Phineas Gage’s skull on display. Did the elective meet my expectations? Overall the elective was a fantastic experience and it not only met my expectations, it exceeded them! I am immensely grateful to the Selwyn Medical Elective Fund for supporting my trip.