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Shadowing in the NICU: Day 2

August 14th, 2013  |  Published in Pre-Med Tips

baby in the NICU

Source: Flickr/Bill Keaggy

Today was an emotionally charged day in the NICU. Yesterday I briefly discussed how neonatal medicine (like pediatric medicine) is interesting because the physiology of the patients change rapidly. I did not touch on how quickly the stability of the patients can change as well. Today I wondered if the death of a patient in geriatric medicine is somehow less horrifying than the death of a neonate. I have yet to meet a physician who does not feel a sense of failure and loss after the death of a patient; I am sure that these feelings would arise after the death of an elderly patient as well because I have seen that happen. However, I feel that when the elderly die there is a general sentiment of “it was their time” or “their quality of life [after ICH, stroke, etc.] would have been horrible” in addition to the overwhelming feeling of loss. But in neonates, who are at the cusp of life, whose brain plasticity is such that they may or may not have severe neurological defects, and whose family is almost always cheering them on…the loss is more profound. Many times I have seen adults and elderly patients come to the ER alone with altered mental status and no family or friends to be seen. The NICU is a stark contrast to the ER in many ways. Family presence in the NICU is greater than in the ER, but I think that is natural in an inpatient setting.

I reflected today my grandmother’s experience losing her daughter; my aunt passed away in her 40s after complications from uncontrolled diabetes. I know not a day goes by when she doesn’t think of my aunt (who I never had the chance to meet, but have heard countless stories of a life well-lived!) I cannot imagine the strength my grandmother must have had to be able to pick up and move past my aunt’s death, but she had to continue living for her other children. The mothers I see in the NICU must be preparing themselves in case they ever have to do the same.

I am an avid blog reader and stumble upon a wide variety of blogs. One blog I have been following for a long time now recounts a mother’s experience caring for children with trisomy & monosomy. I remember feeling devastated reading about the death of her two daughters; at times their condition would improve and I would hope for her babies, hope that their healthcare team would find a way to prolong and better manage their sweet little lives. I read once, perhaps on that blog, perhaps on a blog similar to it, that one day the parents realized that they had to let their child go…that the days connected to a tracheostomy tube, feedings through an NG tube, the seizures, the recurrent infections that their child can no longer battle…are too much. Shadowing in the NICU, I can’t help but look at these mothers and wonder if they have ever felt they were going to need to make that decision…if they ever woke up in the morning and brought a cute balloon to the hospital, but by lunch time thought they were going to have to say it: that enough is enough. I read in a blog that one mother who knew that her baby had a genetic disorder waited for the birth of her child with unsettled apprehension, feeling that in the uterus the baby was safe and out in the world were the unknowns. This resonated even more strongly with me when I stood in the NICU feeling somewhat like I ate an entire turkey for breakfast because of the uncomfortable stretching in my gravid abdomen. There is a certain degree of safety in utero.

Because I got to witness a procedure today I was late to rounds, but of course no one minded because I don’t have any patients and I’m just the shadow. I don’t think they would even notice if I just ran off to IHOP in the middle of rounds! There are two med students on the rotation this week; one is an M4 who is doing a one month elective in the NICU and the others is an M3 who is just going to be in the NICU for one week. The M4 is assigned patients to round on because they are going to be in the NICU for an extended period of time. The M3 is learning and asking questions but as far as I have seen, is not being given patients. The M4 learns quickly and was able to use all the lingo (see this post for a list of common abbreviations used in the NICU), but the M4 is very interested in neonatal medicine…or so it seems! They had brought a neonatal med review book with them to the rotation. Rounds felt very short today, but I think that is because I was wearing tennis shoes (so I didn’t constantly feel like I was going to fall over in pain–unlike yesterday when my new cute shoes turned into torture devices) and I didn’t need to use the restroom (because I strategically went before rounds began: lesson learned!)

As to be expected, I learned more about neonatal medicine today. I found a book on a desk and read a little about the history of neonatal medicine. Here is it evolution in brief: in the 1950s and 1960s there was increased interest in decreasing infant morality and with much effort this was achieved. However, in the 1960s because of the growing popularity of contraceptives and change in family size, there was almost no chance in infant mortality rates. In the 1970s, the Robert J Wood Foundation invested over $20 million to improving maternal and neonatal care. As well, Title V expansion specifically set out to improve parameters in prenatal, perinatal, postnatal, and neonatal intensive care. From this, many advances in neonatal medicine were made.

Neonatal medicine differs from adult medicine in many ways. As our attending explained today, neonatal medicine is like veterinary medicine in that the patients cannot communicate with the physician. His statement reminded me of this quote:

“The best doctor in the world is a veterinarian. He can’t ask his patients what is the matter — he’s got to just know.”
—–Will Rogers
In this moment, I realized that I will probably never want to pursue neonatal medicine. Not because of the nature of intensive care, but because of the inability to communicate with patients. This is exactly why I do not want to be a veterinarian; although I love animals of all shapes and sizes, I decided long ago that the frustrations of not being able to communicate with a patient is overwhelming. I would have great difficulty euthanizing a sickly pet at the owner’s volition because I would wonder if the pet would consent to the procedure if they were able to speak. Although end-of-life care is not always an easy road, I hope that in my professional practice I would often have the opportunity to discuss with a patient their wishes before they decompensate. In neonatal medicine, the patient never has a voice; instead you have to rely on the parents.
NICU monitors

Source: Flickr/NomadicEntrepreneur

The neonate’s inability to communicate with the physician can make evaluating pain difficult. Evidence suggests that preterm babies experience greater pain that full term infants. Pain can be evaluated by physiological signs such as increased heart rate, but behavioral changes such as agitation and changing facial expressions must also be taken into account. (Source.)  This is one of many times when the NICU nurse can be the champion of patient care. The NICU nurses spend more time with the patient than the physician as they are the ones responsible for the feeds (unless an occupational therapist is called in), baths, diaper changes and other routine care. Because of their frequent contact the nurses often form a bond with these babies and can also interpret their behavior to reflect pain or comfort.

Having had a lengthy clinical experience in the ER, I was momentarily surprised to hear on rounds that these preemies are given narcotics, but this made sense a few seconds after my silly thought. These small patients experience a large number of painful procedures in addition to the pain of their condition. Reading this, you may be imagining that the NICU’s halls echo with the screams and cries of babies, but in reality the ward is very quiet. Occasionally, there is a small cry that sounds almost like a duck, but the nurses are very attentive. The physicians try to sedate the patient as much as possible before doing any painful procedures, but sometimes because of the neurologic depression associated with sedation or because of possibly negative interactions with medications the patient may be taking, sedation options may be limited. Most of the time though, pain is reduced to an absolute minimum.
In medicine, you never just treat the disease (unless you are particularly daft and live your life wearing blinders.) Neonatal medicine has many social concerns; I touched on these briefly on day 1. Discharging a patient from the NICU is probably the best part of the day. Knowing that a baby’s life has been improved for the better is wonderful, and the cheerful parents and nurses bring a smile to everyone’s face. However, there are times when discharging a patient would be appropriate, but because of the incompetence of the patient’s parent, this is an impossibility.

 

Every year, 400,000 babies are admitted to NICUs in the United States. (Source.) Many of these admits are premature, but others need to be resuscitated or have other medical problems that need to be addressed in the hospital. The babies who are born premature without additional medical complications, seem, in my opinion, to have shorter NICU stays than babies with multiple comorbidities. When a child is facing a lifetime on a ventilator, the child’s caretaker/parent must be properly counselled to the child’s care needs. Many times, the child may be eligible for at-home nursing care, but these nurses only come to the child’s home during the day; at night, the parent is left alone. Before discharge the stability of the parent’s home must be assessed. Furthermore, the parent’s general cognitive abilities must be assessed. Quite simply, some people are not smart enough to figure out how to care for their special-needs child. Not everyone who gives birth to a special-needs child is physically, emotionally, or financially equipped to care for them. Additionally, the extended family members may be pressuring the parent to take their child home. This can result in a flurry of desperate pleas for discharge and reluctance to consent to any further diagnostic procedures that have potential to increase the length of stay. In instances like these, intense counseling of the parent must take place and in some cases the influential family members should also be counselled. So far, I have yet to learn what happens when a parent refuses to care for a special-needs child, but I imagine they most likely become a ward of the state. I imagine that if a parent is willing to care for the child, but that their home-life situation is not a fit for the child’s care, the patient’s stay in the NICU is extended. In my opinion this is an unecessary inflation in healthcare costs, but at the same time the safety of the child is more valuable than money lost to a hospital bill. On the other end of the spectrum is the very doting parent that is concerned their child will be over-medicated and subject to too many procedures. In an effort to be as natural as possible, the parent will not want to give consent to necessary procedures because of a founded or arbitrary belief that their child will be harmed by the medication. In these times as well, the parent must be counselled.
NICU carseat trial

Source: Flickr/mulf

Determining if a neonate is ready for discharge hinges on adequate growth, ability to feed from mouth, and no sign of infection. Of course, there are instances when patients who will never be able to feed by mouth but are discharged home, so I imagine discharge is decided by the doctor on a case-by-case basis and does not strictly rely on these standards. Once the plan for discharge is made the neonate must undergo the car seat trial. In the NICU there is a large stand-alone passenger seat complete with seat belts. During a car seat trial, the baby is placed in their parent’s car seat and assessed for apnea on the pulse-ox. If they pass, they are ready to go home.

Overall, my impression of neonatal medicine is positive. The diversity of patients is very fascinating. I always enjoy seeing a variety of patients rather than complaints regarding the same organ system. The VCU NICU is family-centered which also makes the experience more rewarding. Parents are encouraged to bond with their children, allowed to bring pictures and decorations from home, etc. The downside of neonatal medicine is, like I said earlier, the inability to communicate with the patient. Well, you can speak to the patient, but they won’t say anything in return! Emergency medicine is rather procedure-heavy, and so far neonatal medicine has proved to be mostly management of drug therapies rather than hands-on procedures. When there are procedures these are almost always stressful life-or-death situations; in Emergency Medicine there is a balance of low acuity and high acuity procedures. I like seeing both pediatric and adult patients, so in this moment I cannot imagine only seeing neonatal patients during my career. I think I would miss the opportunity to interact with adults and have the ability to counsel someone who is cognitively aware of their own condition (most of the time.)

Tomorrow is a new day in the NICU! I have to make a presentation on day 4 and have yet to pick a topic. I am considering discussing apnea during feedings, but I am also debating if I should cover the diagnostic efficacy of barium swallows in neonates. I think the latter could be an interesting topic for premed journal club, too, but unfortunately I have not found a neonatologist who would have the time to be a guest for the premed journal club meeting. The only one I know on Twitter is Jen Arnold from TLCs “The Little Couple” and I seriously doubt she would have time to host a meeting. Especially since turnout has been relatively low in the past.

I’ll report back tomorrow about day 3!

 

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