School Based Health. The good and sometimes difficult parts about running a school health center

Transcription

1 School Based Health The good and sometimes difficult parts about running a school health center

2 OVERVIEW Typical day Facilities Staffing Numbers Planning for a year Programming Fun Difficulties A couple cases

3 The Good! Campus housing View from front porch

4 Hi-Ho, Hi-Ho Commute Plenty of water

5 .Off to work I go!

6 Quick check on patients Inpatients outpatients

7 Connect with staff Nursing station Check waiting room

8 Try to do some work before.. My office View from the window

9 Heading to Chapel

10 chapel

11 Back to the health center View from chapel to the Med Line

12 Clark House Health Center Open 24/7 during the school year 1 MD ARNP 4 hours per week with occasional coverage 3.5 counselors a full staff of nurses Nutritionist 20 hours/ week Psychiatrist every other week LNA Administrative assistant I work very closely with Athletic Trainers

13 The Facility Medical Clinic Self check-in 3 exam rooms Procedure room A place to collect urine samples (drug testing) 14 beds 8 inpatient Illness Injuries Mental health Concussions: expand 6 outpatient Sleep deprivation Rest observation

14 The Facility Meditation room Full spectrum light room

15 Programming Programming LiNC : Living in Community Residential life curriculum Classrooms How to be a good member of our community 5th and 6 th Form Seminars Relationships Sexual Health Consent

16 Programming Wellness initiatives Flu shots -> 450 in one night Handwashing Helmets Bug spray Safety Yearly inspection through DHHS Fired codes Travel programs US and abroad ISOS Chaperone training Epi pens 1 st aid Emergencies

17 Programming Team work Dean s, Academics, Health Center, Chaplaincy Student Support Team Students of concern Community concerns Student Teacher Assistance Team (STAT meeting) Advisers and parents get involved Make a plan to support a struggling student Health Team Health Leaves When students needs are beyond what we can provide Sanctuaries Report suspected harmful behavior Self report or other community member Can be acute Intoxicated and passed out Someone in need of immediate help Can be chronic Response is non-disciplinary

18 Programming Committees Quality Assurance Crisis Management Team Pandemic Preparedness Planning Data Destruction and Protection Safety Committee Health and Wellness Joint Loss Management ADA Committee Site Review: 2016

19 The Students Adolescence Need I say more!!! Fun Student groups Smart They do their research!! challenging Communicative Cultural challenges Depression Shaming Developmental Age ranges Must meet them on their developmental plane Be compassionate Empathetic Engage BUT..be fair! I stopped asking, you did what?

20 COMMUNITY Living spaces Fitness Center Dining Hall Faculty Space for gardens, bees, chickens Extracurriculars Faculty band Hockey Basketball Stocked trout brook

21 SCHOOL PREPARATION April Start of school Parent portal directly into EMR Administrator inputs insurance Nurses input data Review immunizations Communicate with parents when information is delinquent or lacking I review all new students medical information Update changes of returning students August Crunch time Finalizing all medical and mental health information Contacting parents to meet Students on medication that need to be stored Mental health Complex medical issues

22 School Starts Opening Week 150 new patients every September Staggered start Check-in line to welcome all Local pharmacy Dean s office Clark House Business office Parent meetings New family meetings = Medication storage at Clark House Complex mental or physical health issues Medication compliance agreement Review with parents and student Signed by student AND parent

23 ...AND IT BEGINS Primary care office Urgent care center Emergency room Walk-ins welcome Scheduled appointments Referrals Terrific network of specialists Ortho clinic at COPA Open 24/7 After check-in students call safety office to transport call Teaching Dartmouth Medical students Residents occasionally 3 terms of 10 weeks Break after 10 weeks of fall term Holiday break Spring break

24 OTHER DUTIES Meet with headmaster weekly Cover football and hockey games with ATC s

25 STUDENT NUMBERS Total students =530 Total visits=25,000 Medical visits= Medication pickup= Counseling visits= counselors 9 years ago Now 3.5 counselors See 1/3 of student body ER visits= 3-6 per year Ortho visit= about 300 per year Top reasons to be seen Injury URI GI

26 THE BAD! Not really THAT bad! Some typical adolescent behavior and not so typical adult behavior

27 Teens take risks Swim in the winter No helmets on bikes Flip flops in the snow Injuries Lacerations Orthopedic Concussions ImPACT Return to learn Return to play I see some aspect of concussion daily

28 EXPERIMENTATION Drugs, alcohol and nicotine Busts = disciplinary Sanctuary = non-disciplinary Random drug testing Mostly beer, vodka and pot Students research undetectable substances Kratom DMT (N,N-Dimethyltryptamine) Synthetic cannabinoids mushrooms

29 PARENTS All types Very nice and collaborative Aloof The traveler The intellectual The financially successful The extremely poor and uneducated The agreeable The disagreeable The reactive and confrontational Mostly, they are very nice and respectful Though we do seem to remember the difficult ones!! Some disrespectful The best doctors are NOT in NH!! Scary sometimes what I find Student with delusions cured by the best neurosurgeon in the world by performing brain surgery!

30 PARENTS

31 PARENTS

32 PARENTS This is BOARDING SCHOOL Students from all over the world Function independently Live in community Be respectful Partake in all activities But some parents don t like to see their child make mistakes. They may blame you for their child s behavior you have to give them something, they have a test tomorrow! Full disclosure I was one of those parents you just need to work harder! Creates increased anxiety Children do better when they figure it out themselves Very hard for us adults to watch this happen to our kids Kids need to fail, but parents often cannot tolerate it

33 CHALLENGES AND LIMITATIONS We are the facility where students who don t feel well come We do not divert We do not send overflow to UC or ER We live in a petri dish Flu Parainfluenza, RSV Norovirus Pandemic planning

34 CHALLENGES AND LIMITATIONS Norovirus 7 confirmed on Wednesday 13 on Thursday 23 on Friday 42 on Saturday 14 bed facility We started IV s Staffing We don t charge for any care we provide Fixed budget We do have a pool of per diems, but it is hard to staff acutely if needed in situations of overflow Put cots in all our extra rooms Hired a couple temp nurses Faculty helped I cancelled all sports that day

35 MY CALL SCHEDULE

36 CALL I do have an ARNP that takes first call one weekend per month and one evening per week I do have nice breaks when there are no students on campus During breaks I still communicate with parents and sometimes specialists I still have to do administrative work during some breaks I cover summer school I communicate with my staff until about 11 PM every day (Mon-Sat) Sundays I call in when I get up and schedule if needed I have to go in after 11 about 1-2 times per month Coverage of sports games often until 7-9PM Cover fall and winter hockey tournaments

37 THE UGLY!!!

38 Read the News! Phillips Exeter still reeling from sexual abuse claims Ex-faculty member at Phillips Exeter Academy barred after admitting sexual misconduct with students St. Paul s Before and After the Owen Labrie Rape Trial. Vanity Fair NMH fires longtime religion teacher over sexual misconduct allegation

39 The Ugly Stress, anxiety and depression Self or Parent pressure? self destructive behavior Cutting trichotillomania Drugs and alcohol Busts Kids not at their best College admission Are there really only 7 colleges? What are good schools?? Disordered eating or full blown eating disorders By far one of the most difficult situations with which we deal Little down time for students Students are evaluated 24/7

40 A COUPLE OF CASES Case 1 15 yo girl new freshman Problems listed in health record Learning disability Anxiety Ear troubles s/p tubes UTI s Migraines Immunoglobulin deficiency Growth delay Hx of pneumonia Hx of sinusitis Hx of tonsillitis s/p T&A

41 Case 1 Problems at school Rhinitis GERD Migraines Developmental disability Insomnia Anxiety Adhd Acne Sleep deprivation URI headache Nausea and vomiting Jet lag Abrasions Abdominal pain multiple injuries Nose contusion Dizziness?PCOS?Hypothyroidism

42 Case 1 Medication Allegra Nexium Zomig Nordtropin (growth hormone) Melatonin Lexapro Vyvanse (Mega doses) Dextroamphetamine Minocycline Amoxicillin Medication (cont.) Omnaris Retin-a Benzaclin Synthroid started her late sophomore year Metformin later in her Junior year

43 List of Specialists Psychiatry Otolaryngology Pediatric Endocrinologist Dermatologist Other endocrinologists (yes a 2 nd and 3 rd one) Adolescent pediatrician Immunologist Neurologist Psychologist for a psychoeducational evaluation

44 Day 1 Meet with family and student Review school policy on meds Dad emphasizes importance of medication and comments on all her medical issues Negatively comments on student s weight and height She is 5 5 and about 115 lbs 1 st Month Only fair medication compliance Multiple phone calls with angry father blaming system for his daughter s poor compliance of stimulants and growth hormone 1 st Year Student did fine academically although parents were not pleased She gained a little weight Dad not pleased Commented that she is not as tall and as thin as her younger sister Dad continues to push for GH compliance Weaned off GH after 1 st year and reaching a height of Every time she went home she was seen by multiple specialists Medically stable while at school

45 My curiosity is piqued Chart review (request entire chart) 2 inches thick Poor evidence for immune deficiency, maybe slightly diminished IgA Reports by dad of severe sinus infection despite negative CT that he pushed to obtain No good evidence to suggest she needed GH except as demanded by dad Dad controls who she sees for specialists and what medications she takes He pathologizes everything I speak with her providers 2 nd year Much of the same Dad concerned about weight Dad blames all her poor grades on her medication She is tired frequently Stays up late doing homework Dad thinks she has a thyroid problem despite normal labs and negative thyroid biopsy We find a few of her stimulants in her room (against policy) I speak with her providers again Common theme of dad bullying to get seen Demanding medication or procedures to fix things Report made to DCYF

46 3 rd year I develop a Medication Compliance Agreement Stemmed from this family s ignorance of the school s medication policy. Parents and students review it with me and sign. She has lost lbs over the summer Was now taking Vyvanse 90 mg bid Hit in the nose with a squash ball Histrionic Normal exam Dad demanded x-rays which were negative Nose injury (cont.) During a long weekend after the injury, dad brings her home to see a plastic surgeon with whom I spoke Surgeon noted only a plastic surgeon would have noted this barely noticeable fracture His recommendation was to leave it Dad lobbied hard to fix it despite the student s desire to avoid another nose operation I made another call to DCYF

47 Munchausen s by Proxy Difficult and sad case Consulted with a forensic psychologist who confirmed diagnosis Ultimately the girl was found to have over 60 Vyvanse 70 mg in her room and over 100 dextroamphetamine She left school

48 Case 2 17 year old girl who comes back to school her junior year after taking a leave of absence her sophomore year because she is homesick During her freshman year her height was 5 3 and weight 107 lbs She is athletic and runs cross country Nothing medically notable during her freshman year She returns junior year and all health forms completed and submitted without anything particularly interesting except her weight of 94 lbs She is given all necessary sports clearance from her PCP She starts cross country training during the 1 st week back I am contacted by multiple faculty worried about her appearance She looks too thin

49 She is referred by her cross country coach to our nutritionist and a counselor She is vegetarian Admits to losing 14 lbs since her physical exam probably because she is exercising too much Now weighs 89 lbs (1 st percentile) 2 inches taller than freshman year (35 th percentile) when she was 107 lbs BMI = 16% (1 st percentile) Taking nutritional supplements We discover through her home nutritionist that she was hospitalized over the summer Parents are NOT forthcoming with any information Correspondence with parents: Regarding the weight, it is true that she gave up eating meat about a year and a half ago. She does eat fish. Her transition away from eating meat combined with her ongoing physical fitness has created a situation where she needs to eat more calories to match her output. As she told you, we have been working on this with a local dietician over the summer. This summer she trained and completed a 198 mile relay. In preparation for this we had her thoroughly evaluated with a pediatric cardiologist at [a prestigious teaching hospital]. He cleared and moreover encouraged her to continue her running. He also encouraged her to eat more calories (an engine needs fuel!). We appreciate St. Paul s willingness to partner with the nutritionist (and you are welcome to speak with her), however we wonder if it would be more beneficial for her to meet with a SPS nutritionist for some eating suggestions there.

50 Parents normalize her behavior because she is an elite athlete I get permission to speak with her cardiologist who tells me her heart is structurally fine He informs me she was seen by an adolescent specialist who reports that he admitted her due to a pulse in the 30 s I then spoke to the admitting physician who reported she was there for 24 hours, seen by psychiatry, cleared of anorexia and discharged When I speak to the parents again, I voice my concern as her pulse was in the 40 s at SPS. They fall back on, she was seen by [our prestigious teaching hospital] and cleared for all activities. I tell them I am nervous about her situation but will closely monitor unless a red flag necessitates action Weekly nutritional visits with weights and vitals

51 Parents NOT concerned A week later her pulse is in the 30 s and I admit her From ped s hospitalist, why don t you send her here so if her heart stops at least we have some medication to get it going again Pulse at night gets into 20 s I discuss situation with parents who come to school and think she will be discharged the following day Transferred a week later to Boston Children s adolescent / eating disorder floor She is started on nutritional supplements until her heart rate is sustained above 40. Sees psych: dx= Female Athlete Triad; no anorexia nervosa 3 weeks later she returns to school in improved and stable condition with weekly vitals and continued support No exercise Parents sign agreement that she will follow up with children s and follow their recommendations She continues to follow Children s and our guidelines for the remainder of the term

52 However.. She is seen by her PCP and again by the pediatric cardiologist over Christmas break who give her the green light to return to all activity without restrictions I have to remind parents that ultimately it is my call what she does at school and that she still needs to be cleared by the folks who have dealt the most with her issues, namely Children s Parents start threatening to take it to the next level and call the headmaster to complain Again I speak with her cardiologist at the prestigious teaching hospital and the folks at Boston Children s We agree that she can start exercise, but will be monitored closely despite her parents reluctance Her weight remains stable, pulse above 50

53 LIFE IS GOOD

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59 ..The End!!