Transcription:
APP Approach to Pediatric Headaches

Trisha Williams (Host):  Hi guys. Welcome to the Advanced Practice Perspectives. I’m Trish Williams.

Tobie O’Brien (Host):  And I’m Tobie O’Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. We will be highlighting our amazing APPs here at Children’s Mercy and do some education along the way.

Trisha:  We are so glad that you’re joining us today. So, sit back, tune in and let’s get started.

Tobie:  Today, I’m so excited to introduce to you all Lara Koral. She is a Nurse Practitioner at Children’s Mercy in Neurology specifically the Headache Clinic. Thank you for joining us today Lara.

Lara Koral, MSN, FNP-BC (Guest):  Thanks guys for having me.

Tobie:  Yeah, so Lara and I met during the Academy for Professional Development which you guys have all heard us talk a lot about. And I just found Lara, her story of how she decided to become a Nurse Practitioner super interesting and so I’m hoping that today she will share with you guys a little bit about her background and how she landed here at Children’s Mercy as a Nurse Practitioner. So, Lara tell us about you.

Lara:  It’s always hard when people say so tell me your background because it’s always like I can go so deep into the story and we could be here for hours. So, I’m always like how do I make my story a nutshell. But I think in terms of trying to figure out my path to the Headache Clinic, if you want me to expand in any area, let me know. But I think it’s always important to know that – so I am part Japanese. I grew up in Japan. I went to an International School. Everyone is always like why do you speak English? So, that’s usually why I have to explain that part. And then I always thought actually I was going to go to law school and so I was kind of in the prelaw track, I don’t know Tobie if I ever mentioned that. But that’s why I was a – I actually had an undergrad major in political science and Russian. So, there’s the tangent White Russian. So, since I speak Japanese, the languages I was interested in were actually Chinese and Russian because I had gone to Russia at one point and I couldn’t communicate. Whereas being Japanese and American, I could always speak one or the other languages wherever I was and communicate.

And I didn’t like that I couldn’t communicate when I was in Russia. So, I was like well you know, I better learn Russian next time I have a chance. So either way.

Trisha:  Which I heard is not an easy language to learn by any means.

Lara:  It was. I know but I was really interested in international relations, you know growing up in Japan then being at two different country citizens and whatnot, but I really liked political science so I kind of figured you know, okay that’s kind of the route I was going to take. I went to Duke University and majored in political science and Russian. But when I graduated, I went to DC, kind of a good place to be to do international work but I noticed that without some type of a skill, you did a lot more paperwork and a lot of grants and just, I really hands on work and working with people. And by chance, I worked at a nonprofit that was partnering doctors between America, so the United States physicians and nurses and former Soviet Union countries and to help develop their programs to improve quality of life and healthcare in these countries.

So, I got to work as the administrative person in this nonprofit working between these partnerships and that was kind of my first take on seeing nurses or physicians in action internationally. And that kind of really peaked my interest. So, of course, at this point, I’ve had an undergrad degree and I’m like well what do I do from here. And of course, there was the great nursing shortage, and I was like oh, you know, I worked with a lot of great RNs, I’m going to go and get my nursing degree. And it may not sound great but then I got my mom saying so you have all these loans from your undergrad, and you’re going to go and do a nursing degree? So, I was like ah is there any kind of program that would fit the scenario and then I found the Yale University program for people actually that did study something completely different. It’s called the GEPN, Graduate Entry Prespecialty Nursing Program at Yale. And they actually want you to have been working somewhere else, have no nursing background. That’s kind of who they want to them help you educate and learn to be a nurse practitioner.

Loved the program. It was awesome. I feel like I’m going on and on but, do you want me to keep going?

Tobie:  No, I think it’s super fascinating which is what peaked my interest in you.

Trisha:  I am fascinated.

Lara:  So, I love taking care of people and of course I wanted to save the world. Who doesn’t. So, I wanted to be a Family Nurse Practitioner. So, I wanted to be able to take care of everybody. So, I went through the FNP track and as you learn and not being an RN first, that first year honestly was the hardest year, right learning all the RN clinicals and things like that. And then you have two years of masters to be the NP. I ended up becoming a National Health Service Corps Scholar and this is kind of the also tangent story that Tobie probably remembers. So, I couldn’t drive. I’m from Japan. You have trains and buses. You don’t drive. So, at this point, I’m in grad school and I can’t drive. That was the other thing. Going into a nursing program, I need to go like a city, right. So, being a scholar, you have to either serve in intercity or rural America upon your graduation.

So, they said if you’re used to intercity which that’s where Yale is is intercity, you need to go rural. And I’m like but I can’t drive, not to come back to that part. So, they were like so – how do you not drive in a rural area right. So, they placed me in an Alaskan Island, if anyone has every heard of Dutch Harbor, because of Deadliest Catch, that’s the one that I think people know of but those are the Aleutian Island chains off of mainland Alaska. They have a little island called Sandpoint there. So, driving around was not necessary. You could walk around the entire island. So, I ended up serving there to do my rural rotation.

Trisha:  How long were you there?

Lara:  That was my summer. It’s a summer I don’t know what they called it but you do it as a summer thing in between when you are still in school as a scholar.

Trisha:  So, it was like summer solstice or like where

Lara:  It was very beautiful.

Trisha:  Long periods of daylight.

Lara:  Exactly. Best time to be in Alaska. Yep.

Trisha:  Wow, your life is fascinating.

Lara:  So of course you learn the most when you are in the middle of nowhere. I always think it’s funny to say I’ve traveled a lot of different places, that’s been a blessing. Growing up in Japan, I tried to hit different countries in Asia and anyway, I’ve been a lot of places but the most rural and isolated place I’d ever been is what I would say is Sandpoint, Alaska. Just you are two and a half hours away by flight to Anchorage. So, the things you see in health and community and social and psych issues, I learned a lot there. So, that was really, really neat.

But I ended up also meeting my husband there. So, that’s also kind of –

Tobie:  Oh, I don’t think I knew that.

Lara:  Yes, he’s not from Alaska. He’s from Rochester, New York. But he happens to be a radio person, so he was out in Alaskan Islands, that’s actually a really important job because you’re kind of telling the fishermen about weather. It’s a news source for the entire islands. It’s kind of a different picture of what you would think of a radio here in the mainland. But anyway, we ended up meeting there and I won’t go into that tangent but essentially, we’re married and so. I don’t even know.

Trisha:  Living a life of why does my –

Lara:  I know right, like how do I explain all this and so, after my – we ended up serving in Yoke so from we’re in Alaska, I can’t even picture this on a map. Where am I going to serve my rural scholarship but Sedalia Missouri. There goes Missouri comes into this picture. How does that happen. Honestly, I thought we were going to go back to Alaska. That’s where I thought I was going to work upon graduation. But they took too long, and I needed to start having an income and Sedalia, Missouri was starting a community health center and the CEO there was awesome and the doc I was going to learn under there was awesome so. It’s always good to learn under the right people. So, we picked up and moved to Sedalia. And I spent a good five years there learning primary care and community health center and I just loved it. Honestly, I love primary care. I was big diabetes, hypertension, cholesterol overall wellness type typical primary care if you will, but I loved it.

And you’ll like this tangent. So, guess what came in handy in Sedalia, Missouri? From everything I just told you. You’ll never guess.

Trisha:  Ah, Russian.

Lara:  Oh, good job, good job. How does that happen.

Trisha:  Did it really?

Lara:  It was a Ukrainian population there who did not trust doctors or anybody really, I would say because that’s a close knit community and of course I can speak some conversational Russian, I wasn’t fluent compared to Japanese, by any means. But then we could develop a relationship and it was just really neat. Because it was always like oh, I want to go see my Lara, you know and who knew. But yeah, for five years I treated that community and that was really neat.

Trisha:  So how did you land in the Headache Clinic at Children’s Mercy Hospital from this vast experience that you have like, we are so fortunate to have everything that you have to offer and give it to our population of patients. But how did you make that transition?

Lara:  I’ll try and fast forward it fast. So, I went from the community health center to now my poor husband who is like going along with my whims, right? Oh we’re going here, we’re going there because of my career. It was kind of his turn. So, he was in radio like I told you, but his actual undergrad degree was public administration. So, he ended up – he started working for the City of Sedalia and ended up transitioning his career into city administration. So, he took a job becoming a city administrator, we moved to the outskirts of Memphis, Tennessee for his career. So, I just continued primary care but this time, out of community health center into the private sector because that’s when I was raising two little ones at that point. And so it was a good balance of continuing what I know but also letting him take off on his career and continue my, at that point now, it will be 12 years of primary care experience. And this is where your – Trisha, your answer comes in.

So, after that, I was starting to get burnt out, I guess. I know that’s kind of a common term these days for many reasons. But –

Trisha:  Well it’s a real term.

Lara:  I know. It’s just how many more patients can you squeeze in seeing like 11 in the morning, 11 in the afternoon and you’re not addressing one diagnoses but everything, right, plus the psych and everything else. So, I was getting tired, but I also was getting discouraged for my patients and myself because I didn’t want to just prescribe the fifth medication for diabetes. I really tried to work on the lifestyle and the eating and the physical activity. My favorite population at that point to work with was the metabolic syndrome group. Because I felt like there was a chance for me to help avoid the type 2 diabetes diagnosis and things like that.

So, I really worked on like eating healthy and Tobie will tell you that was kind of like my big areas like the how do we eat like food for medicine concept if you will and how do we just thrive not just treat disease if you will. So, by chance, my daughter, not a good thing, ended up in the Children’s Hospital at Memphis with osteomyelitis. It’s one of those things that just happens. And our weeklong stay there, I fell in love with that hospital. I thought they were amazing. They were doing really good work and I’m like I want to work here. I think this will be a good switch. But I didn’t know after so many years in primary care, what does that mean. And then, at that point, the neurology group at Le Bonheur was looking specifically for people or someone to help start the headache clinic at Le Bonheur, Memphis, Tennessee. And they really wanted someone to focus on the nutrition and wellness and education piece not just the medication side.

So, the nurse practitioner that was in that position hired me to help develop that program which was amazing and exciting along with a new headache specialist at that point. And him and I together, we were developing the program there from like scratch and so I got to be there for about two years, and we were running into a lot of obstacles. I don’t know how to kind of talk about that but for example, like the acupuncture program at the headache clinic here is absolutely amazing but I was even just trying to explain to them that acupuncture can help decrease pain and it’s a really good treatment for a lot of people with headaches.

So, I brought in a medical acupuncturist to come and talk to our neurology group and I started doing things like that, but it was still in the infant stage as Dr. Bickel would say and when my husband and that was the reason we moved out from Memphis, again, he got another city administration job out here in Riverside, Missouri and when we did that, I was like well I really love working in the headache clinic. I really like the specialty. I did do general neuro actually; it wasn’t just headache clinic when I was there just because we needed more people to do general as well. So, I did get to do both, but I leaned on the headache very heavily.

So, and then by chance and this is what Tobie likes that part of the story is he got accepted his job, I looked at it online and I just like I don’t even know if it was indie, but it was just the generic something and it said Headache Clinic Children’s Mercy Kansas. I said are you kidding me. So, I’ll kind of stop there. I feel like I’ve been going a mile a minute. So I don’t know of any of that speaks to you all.

Trisha:  No that is, yeah, I think that it’s perfect. I love it.

Tobie:  Such a cool background and then how you landed here kind of seems like a perfect fit for you. So, yeah so tell us about – what your role is like here?

Lara:  Well

Tobie:  And kind of like that was just the perfect meaning for Dr. Bickel was looking for someone and you happened to be just like that perfect person.

Lara:  Well and it’s funny because when I started trying to develop the headache clinic out in Memphis, and I did my research and this is something now being on this side, I want to work on is I couldn’t find the Children’s Mercy Kansas Headache Clinic. Like it didn’t pop up at the time. Because gosh if I had seen that I would have totally contacted one of my current colleagues and be like heh, tell me what works, what doesn’t. And at the time, whenever however many years ago that was, it didn’t come up in my searches as much as like kind of the big name hospitals at the time. So, it was really neat though that once I found it and I dug into it I couldn’t believe the program Dr. Bickel had made and she always was like it’s because it’s ten years from what you were trying to do. I’m like oh, okay. That makes me feel a little better because I’m like trying so hard to go over here and we were stuck over here.

Tobie:  Sure, yeah, she’s worked – it’s been so much a part of what she’s created here, right? I don’t even know how long it was – how long ago was the headache clinic developed at Children’s Mercy? Do you guys know how old it is?

Lara:  I am not sure because she and one of my NP colleagues saw headache on their own without that title for a while and then I know she – last I heard, I heard her saying something about 12 years.

Tobie:  Okay, that sounds right.

Lara:  I think the unique –

Trisha:  I know that it’s been in fruition longer than six years because my daughter visited the headache clinic with one of your colleagues about six years ago. So, I know that it’s been longer than that.

Lara:  Yeah, I think it’s at least ten but what’s cool about this headache clinic is the layers. I think headache management is one of those things that’s so complicated but can have so many ways to treat, not just a medication and that’s what I love about this diagnosis. I always tell kiddos you know yes you have headaches and we’re going to work on it but let’s look at the whole picture and then we start going into yes, how much are you eating, what are you eating, how much do you drink, what stresses you out. Let’s talk about sleep. Let’s talk about the quality of sleep. I mean it’s just such an overview of everything. It’s like perfect. And then at the same time, it’s still primary care for me because so many times we will get different scenarios like I think one time I had a type 2 diabetic that had just become type 2 and she was getting a lot of hypoglycemia but just because the way it fell, she hadn’t seen a follow up person so she ended up being in the headache clinic for and it turned out it was her sugar. So, you have to still kind of keep in mind it could be something else, right? So I like that I can make sure to not assume it’s something else all the time.

Trisha:  Yeah, we see some headache kiddos in the ENT department and we kind of share those patients because they present with vertigo or tinnitus and then we have to rule out the inner ear abnormalities first and then try to do just to let you know, we do the baseline education like are you getting enough water, do you drink a lot of caffeine. What kind of foods are you eating? What kind of foods to avoid kind of thing. And then we send them to you guys to help with all of that ongoing management. So, it’s interesting how we share these patients because of potential – the differential diagnosis of what a headache is and how it presents is so vast. So, it’s interesting.

Tobie:  So, tell us a little bit about how the headache clinic works, kind of and about maybe even general. So neurology is a pretty big section, right because there’s not just the headache clinic, there’s other stuff kind of like ENT, we’re a pretty big section. So, are there many of you that do the headache clinic?

Lara:  Yes. There’s a good team of us NPs that are kind of the first line headache provider. We’re also very open access. That was part of Jen Bickel’s vision is like we don’t want to create barriers. So you want to have access. So, we will get self-referral headachers and those are the ones especially that I get nervous about because usually it is a lot of times something primary care could have dealt with. But sometimes they are appropriate, and we can get them treated correctly as well. So, but we are the ones that they will see first when it’s a headache and only headache. If there’s a secondary neuro concern, sometimes it will go to our general neurologists, but we do also get general neurologists within our department once they establish that it’s only headache, will send to the headache clinic for management as well. So, it helps the neurologists be able to see the other specialists you need if you will. Yes and then –

Tobie:  Okay that makes sense.

Lara:  If we can’t after our many levels and treatment options, if the headache is progressing and not doing well and it’s causing a lot of dysfunction like missed school; we refer internally to our comprehensive headache clinic. Which involves that multidisciplinary having the pain psychologists, social work, and a neurologist all looking at this case to try to see what we can do to improve function.

Tobie:  Oh nice. Okay and so what about the acupuncture. I mean tell us a little bit about like besides what all is available within the headache clinic for you guys to yeah to offer families.

Lara:  Do you know much about the acupuncture program at Children’s Mercy in general?

Tobie:  No. Do you Trisha?

Trisha:  No, I do not, and I would love to hear about it as well and probably our listeners as well.

Lara:  It’s so awesome. So, Dr. Jen Bickel, Dr. Jen Dilts and Dr. Anna Esparham are three physicians that are trained in medical acupuncture which is an advanced acupuncture program offered to physicians and takes like a year to complete. Anyway, they can actually do a big scope of acupuncture. I wanted to mention that because that’s just neat that we have that within our headache department and there is appointments available again, through us to refer to them for that. But the other cool factor that Dr. Dilts and Esparham and Bickel have created is the RED physicians have a basic acupuncture curriculum they can do to try to decrease pain medication at ER visits and they can actually do – there’s two versions of basic acupuncture. One is called the Battlefield and the other is called Four Gates but essentially one is an ear acupuncture and then the other one is inserting needles one in each hand and one in each foot. And that’s the Four Gates. The idea is to open up the Chi if you will and letting the energy flow and thereby decreasing pain. Both of those basic acupuncture techniques are open for our ED physicians to learn and actually they use it in our ER right now. So, it’s really neat.

Trisha:  Now are there any advanced practice providers that are credentialed to do acupuncture at Children’s Mercy?

Lara:  So, one of our pain rehab NPs, she developed the privilege program at Children’s Mercy and it just went – it just happened in this past year pre-COVID, if you will. And she is trained. She’s actually a medical acupuncturist as well but because of Missouri’s law on NPs, and collaborations, it gets very complicated because you have to have a physician that’s also trained in that and as you can see, that’s a pretty hard thing. So, to answer your question, we have one NP that has that in pain, but I believe she’s waiting for her physician in pain to finish so that she can practice with him. So, my collaborating is Dr. Anna Esparham who is one of the medical acupuncturists, so I’ve been trying to also get that privilege right now and I’m really excited. I think I’m almost there. But yeah, I can do the basic though. She did train me to do the basic because I work at the headache treatment center which I think we hadn’t talk about but that’s the other wing of this whole headache clinic that’s really neat that we do. That’s the Urgent Care Headache Treatment Center. Do you guys need me to talk about that a little bit?

Tobie:  Yeah, tell us a bit about that.

Lara:  I would love to. Now we talked about kind of the first line headache provider and then we talked about the comprehensive for improving function. So we also have the – we’ve used all our medications and we still have this really long headache, and we don’t want to go to the ER group of folks. So, really cool nationally amazing. We can – because they’re – this doesn’t exist as far as I know nationally. But so you can call the nurse line and we can schedule you at same day or next day headache treatment option and we are at the moment on College Boulevard location. We used to be in Overland Park, Kansas but for space, we went to College Boulevard. And we do IVs, injections, and acupuncture along with other treatments like neuromodulation at this headache treatment center to try to break a headache that you can’t break at home and that you don’t want to go to the Urgent Care or ER, or you’ve already been there. This happens a lot. We’ve already been there. And then they go to go to HDC for further management for acute treatment.

Tobie:  Wow, that is so great for these families, for these poor kids. Man, how nice to have that.

Lara:  Yeah, a scheduled appointment and also, it’s cool that you’re working with headache practitioners that can look at it a little differently because we can sometimes, honestly, I’d say for me when I work there, more than half the time, I’m not using IVs. We’re using other ways to decrease the headache and that’s kind of neat too.

Trisha:  That sounds. I’m in awe of you right now. I can definitely tell that you are extremely passionate about this specialized area that you have found your niche, I call them little God winks. Tell us what is your – if you could pick one thing that is your favorite about working with the headache clinic or this particular population of patients, what would it be?

Lara:  Oh that’s hard. It’s so rewarding because you know people come to you in that pain state or usually a lot of times it’s been a year of headaches because they have just been throwing Tylenol, ibuprofen at it. But when we address it with the parent if you will, and realize it isn’t something we just have to throw medicines on, and it might be a simple fix like low iron or all you needed was maybe a vitamin supplement. It’s so that release or that – from the parent you know as a parent myself, seeing that like oh thank goodness. Like that’s really rewarding. And then on the flip side, for the child, who has just been kind of living with this and you can see it that they don’t want to be a bother maybe to the parent or they’re kind of getting tired going to the nurse but then it’s so much more you can do and I’m always like oh I wish you had come to see me sooner. Like we have so many ways to make this better guys. And it just – they leave happy.

Tobie:  Oh absolutely. It’s so nice to be able to have such hope for them, right? They may not even know that this is an option that they think gosh, I did not even know that Children’s Mercy would be able to do all of this for my headache. I’m sure that it’s really nice to see families or to see the child actually having relief and knowing that it wasn’t all these medications. I mean perhaps sometimes it has to be but that there are other options.

Lara:  Yes, yes.

Tobie:  Well gosh, we so appreciate you and you sharing all of your expertise. I mean really, this is your expertise area. Yeah so, we are so, so happy to highlight you and your background. I mean really. Who goes to Duke and knows Russian and then lives in Alaska. And anyway.

Lara:  It’s hard to explain see.

Tobie:  Yes, exactly.

Lara:  Yeah but Children’s Mercy is great right and you all are great. I mean the NP group here is so awesome. I think you’ve mentioned it’s just so energizing to be a part of that.

Tobie:  Yeah, we – and we’re lucky in ENT to just like as you had mentioned all of the docs that you work with, we have I mean awesome surgeons in ENT, that’s how we get to do what we get to do. Because they really have been so supportive and helpful and stuff. So, it’s nice to have a good group in general that we work with at Children’s.  

Trisha:  Definitely.

Tobie:  Well we love to end each episode; I mean we could talk forever but I think we probably. We’ll wrap it up. So, we would love to know some fun or outrageous way you have taken on the challenges of life in 2020.

Lara:  So, it doesn’t sound maybe that crazy because everyone seems to have a dog. But we ended up getting a dog during COVID. As soon as we knew we were going to be home for three months, and we had to cancel spring break, the kids have wanted a puppy, but I never thought we’d have time to train it. So, I’m like well here we are, three months at home so, if we’re going to do it, we better do it. And we have a Siberian Husky puppy and he’s loving this snow today.

Tobie:  Nice.

Trisha:  Oh, those are beautiful dogs.

Lara:  It forces us to be active. I mean it really has. It’s easy to hunker down, go on your screens and we have no choice with this husky. We are out and about every day.

Tobie:  Yeah, for sure.

Trisha:  I love it. Plus having a pet decreases depression I heard. So, everybody needs a good pet for life.

Lara:  And they are very soft to pet.

Trisha:  Yes, I love it. Well Lara, thanks again so much for sharing your expertise and spending your afternoon with us. But listeners, thanks for tuning in today. Our next episode will feature Ann Mattison. Come listen as we talk with her about her role in the PCC clinic and her thoughts on COVID versus flu. We will also be talking about the flu vaccination and how to debunk the myths around it.

Tobie:  If you have a topic you would like to hear about or you’re interested in being a guest on this podcast, just please reach out to us. Email us a tdobrien@cmh.edu or you can email Trisha at twilliams@cmh.edu. And once again guys, thank so much for listening to the Advanced Practice Perspectives Podcast.