Many months ago I had applied to shadow a neonatologist in the NICU at VCU and finally got to shadow today. They offer two tracks for shadowing:
1) one day of shadowing
2) four days of shadowing rounds in the NICU followed by a 10-15 min presentation
I opted for the second track, of course, because I wanted more time in the NICU. My only other experience with inpatient medicine was a few days of heme/onc rounds while I was doing a summer internship; this took place over 5 years ago and the research left a larger imprint on my memory than rounds. My most recent clinical experience was in the Emergency Department where I worked as a medical scribe and although I knew the NICU different, I had few expectations.
Walking in the NICU was eerily quiet, in the ER this is usually the “calm before the storm” when no one wants to say the q-word. When I worked shifts that started at 6 am in the ER this was often the pace…for 15-20 minutes. I was led back to the residents’ lounge which was brightly lit, had a somewhat cute view of the residential areas outside of downtown, and scattered with papers. I settled in awkwardly and waited for rounds to start; soon enough we were alerted to come out into the hall and I trailed behind the medical students and out the door.
Rounds take place from 9 am to approximately noon but can last until 3 pm. Before rounding, NICU safety is reviewed; any patient incidents are discussed and the number of days since MRSA infection, etc. is noted. Then, the patients are discussed. First, the patient’s nurse presents the most recent changes in the patient. This was the easiest part for me to understand because the nurses usually just said how many stools the patient had, how much they ate, and what the most plan of action enacted by a previous physician. Then, the resident or the nurse practitioner would take the reigns. Unlike the ER where the focus of the patient encounter is the chief complaint, in the NICU all organ systems are discussed: cardio/respiratory, GI, renal, and CNS.
I had thought that NICU rounds would be like the heme/onc rounds I went on at NIH where we would go into the patient’s room, say hello, check out their portacath (or I guess in the NICU trach tubes), and then discuss the latest as a group (well excluding me I would just listen.) However, during NICU rounds we didn’t see any patients at all. The medical students on the service this week would peer in through the blinds to get a glimpse at the sleeping babies, but besides that there was not patient interaction. Later, when I read the NICU guide book I noticed that VCU guidelines ask that patients are seen before rounds. Perhaps this is to save time; there can be up to 40 patients in the NICU at any time! We had almost that many today; I didn’t keep count of how many patients we discussed though. I started losing count because I was making a mental note of unfamiliar terms that I wanted to read about.
Fortunately because I had worked in the ER as a medical scribe I was required to know some medical terminology in order to make my doctors’ notes look professional. Words like emesis (vomiting) and lab results like AST/ALT (indicating liver function) were familiar. However, I am not familiar with neonatal medication dosages and the range of normal lab results for neonates. Most of the talk in rounds revolved around the patients’ most recent lab results, their urine output, and their TPN (total parenteral nutrition). Figuring out what TPN meant took me a while; in the ER the only nutrition our patients get is usually in the form of “sandwich” or “saltines” and all I could think of was TPA and brain bleeds…but eventually after probably our 15th patient, it clicked.
If you are going to shadow in the NICU, review these terms before you go so that you don’t die of boredom during rounds:
|NPO||Nil per os (nothing by mouth)||By default almost every neonate in the NICU is NPO on arrival|
|TPN||Total parenteral nutrition||The nutritious concoction given to the patient because they are NPO. This is a balance of protein (usually in powder form), carbs, fats (such as vegetable or soy oil), and electrolytes. The TPN for the patient is adjusted based on their lab results and of course underlying clinical condition.|
|Picc Line||peripherally inserted central catheter||How TPN is given to the infant|
|EBM||Expressed breast milk|
|CVVH||continuous veno-venous hemofiltration||Basically dialysis for short-term renal failure|
|IVH||Intraventricular hemorrhage||interestingly the plasticity of the neonate brain makes determining the extent of damage difficult–unlike in adults|
|BPD||Bronchopulmonary dysplasia||Premature infants can develop BPD secondary to being on mechanical ventilators too long or from infections such as pneumonia because their lungs cannot handle the changes|
|EMCO||Extracorporeal membrane oxygenation||Basically a heart-lung bypass machine that oxygenates the blood for the infant; needed because of meconium aspiration syndrome, pulmonary hypertension, and respiratory distress syndrome|
|MAPs||Mean arterial pressures||Average blood pressure; controversial whether systolic >100 is enough concern to warrant severe therapeutic management in neonates|
|PDA||Patent ductus arteriosis||Neonate’s ductus arteriosis (blood vessel which keeps blood from going to the non-functioning lungs) does not close after birth|
|ABDs||Apnea/Bradycardia/Desaturation||The big three concerns indicating stability: apnea (stop breathing), bradycardia (slow heart rate), desaturation (low oxygen levels); basically all connected physiologically|
|ABG||Arterial blood gases||Indicates levels of oxygen/carbonI dioxide in blood thereby indicating acidosis or alkalosis; an assessment of respiratory and renal function|
|AGT||Coombs test||Tests for hemolytic/autoimmune diseases|
|Polycythemia||More red blood cells in blood volume than normal|
Looking back, rounds would have been way more interesting if I had an iPad so that I could google everything everyone was discussing. Over time I figured out a few things on my own (like what ABDs means). However, I don’t have an iPad and I don’t want to sit on my phone during rounds…it would look bad if I was using an iPad or a phone.
From this first day I did learn a little about the career of a neonatologist.
To become a neonatologist:
1) graduate from medical school
2) do a residency in Peds (or also seemingly popular IM/peds aka med/peds)
3) do a neonatology fellowship
The neonatology fellowship is structured such that for the first 6 months of the first year, 4 months of the second year, and 2 months of the third year the fellow are on service (meaning working in the NICU.) The rest of the time is dedicated to research. As well, there are on-call days scattered throughout the months to help cover service. The fellow told me that sometimes they work up to 6 days in a row and occasionally their shifts can last up to 30 hours.
In non-academic centers, some neonatologists have an amazing schedule where they work from 8-5, 5 day a week, only 11 days out of the month! Obviously though, someone has to work night shifts.
Overall the job of a neonatologist is very different than what I have seen before. The patient population is very unique. The attending loves being a neonatologist because he gets to treat all of the “organ systems;” basically he gets to be a specialist in everything…if he wants. But he prefers to do minimal consults; you can be a neonatologist and call most problems out to consult if you want. Our attending also explained that neonatology and pediatrics is different than working with adults because of the vast physiologic changes that will take place during your care of the patient. The difference between an adults physiologic condition from one month to the next does not hardly vary, but a neonate changes very quickly!
Another difference between neonatology and emergency medicine (beyond the actual clinical aspects) is the role of the family in patient care. The family’s competence is of great importance when planning discharge. If the family seems to not agree with the nutrition plan or understand how to feed their baby through the NG tubes, for example, the physician may decide that staying longer in the NICU until the infant can tolerate PO (per os…by mouth) is in their best interest. Additionally, caretakers with substance abuse problems or psychiatric disorders may need counselling from a social worker before the child can be discharged with the parent. Since the neonates stay in the NICU for an extended period of time, some families take great pride in decorating their child’s room. The windows of some of the patient rooms were covered in posters that proudly proclaimed milestones (weight gain and birthdays) or drawings and love notes from their siblings and parents. During rounds, the family member is allowed to listen in; some parents are old hat at the NICU and just sit back and relax while the nurses and doctors discuss. New admits are easy to spot; their parents stand in the doorway looking lost and scared. The healthcare team uses the acronyms I defined above the entire time…I imagine for a first-timer it must be very overwhelming. I spent much of rounds confused and I cannot eve begin to imagine the stress and confusion one of our patient’s parents must have felt in that moment!
The fellow told me that I may have the opportunity to watch an emergency resuscitation while I am shadowing. This is when the neonatologist gets paged to labor & delivery to resuscitate a newborn. I hope I have this opportunity just because I’ve never seen something like that before. If by chance we do get paged while I am shadowing, I will be able to don what my neonatologist calls a “bunny suit” and watch the resuscitation from a corner. I am also very anxious to see more of the procedural work that neonatologists do because the three hours of rounds that I saw was not very stimulating although it was very educational. Tomorrow I will probably ask if I can stick around longer so that I can see some action!
Here is a video of a neonate in what looks to my untrained eye like respiratory distress and some serious retractions. I have yet to see anything this sad while shadowing.