My last day of shadowing a neonatologist was a little sad! I had become a little attached to our patients; some of them had been discharged during the short time I had been there and new patients had arrived. I think many people who have a passion for medicine can agree that often unfortunately the most fascinating cases are those that afflict the poor patient with the most severe conditions. You are constantly in this tug-of-war of emotions; the curious cases suck you into this obsessive flurry of academic journal reading and create a titillation, but at the same time the dark cloud of potential fatality reigns you in, reminding you of reality. This cold, dark reality feels even more somber for these sweet neonates who have not had the chance to experience many of the joys of life because of their condition. What struck me the most as I stood in the patients’ rooms was that all of their belongings looked mostly unused. The wheels on the strollers are free of wear and tear and the bouncers lacked stains, even if the patient had spent weeks in the hospital.
Today I was going to do my presentation on retinopathy of prematurity which is a fairly easy subject if you are well versed in the physiology of the eye as well as all the neonatal lingo…but researching this topic took me a while. First of all, Current Medical Diagnoses & Treatment only covers retinopathy of diabetes and absolutely no topics on the neonatal population. I had to root around the internet for unbiased academic sources and fortunately found that the Journal of Perinatology has an excellent slew of free articles regarding topics such as retinopathy of prematurity. Unfortunately, the most informative article I found was somewhat poorly written and while reading it at 2 am I was understanding even less than I would have otherwise. I did half of a presentation in the wee hours of the night after our guests went to sleep, woke up late, and slapped the rest of it together in the morning. I was feeling very uneasy about the presentation because it wasn’t perfect.
Over the course of this week I had learned a lot about medicine in general and a little about neonatology. Shadowing in a level 1 NICU is an amazing experience because of the wide variety of emergent cases and transfers that come to the hospital. For example, there are only two places in all of the state of Virginia that have ECMO (extra-corporeal membrane oxygenation) one of which is VCU. This is basically a system that oxygenates the body by by-passing the heart and lungs; this is needed in cases when the heart-lungs are not working properly. Example of situations when this might be required includes: meconium aspiration syndrome (MAS), persistent pulmonary hypertension, congenital diaphragmatic hernia (CDH), sepsis/pneumonia, respiratory distress syndrome (RDS), air leak syndrome, and other cardiac problems. You should read this excellently comprehensive paper on ECMO; I especially recommend this if you are going to shadow in the NICU! When a neonate is put on ECMO, the surgery team arrives to the NICU and the surgery takes place in a room that is about twice the size of the other NICU patient rooms, but is equipped for surgery and has an area to scrub in. During my time in the NICU, I was not able to be in the room to watch the surgery, but neither were the medical students due to the lack of space. Watching neonatal surgery is not very interesting from afar because the patient is so small you can’t see more than the surgeon’s hands and a nest of surgical towels. When you are outside of the room you see even less because there are usually people standing around blocking the windows. Instead of craning my neck to see basically nothing, I decided to spend some time sprucing up my presentation using Lange’s Neonatal Medicine manual as well as some hurried Google searches to define terms I came across. Every day this week rounds had ended at noon, but today because of the surgery as well as events in labor & delivery, rounds were interrupted so many times (a condition our attending jokingly referred to as roundus interruptus) that my last day extended well beyond noon. I was happy, however, because I had the chance to mingle and learn more!
Throughout the shadowing experience, our attending taught clinical pearls. These were mainly directed at the intern, who was only into his first month as a doctor. There were two things that stuck out to me in particular; the first is to systematically review every organ system rather than skip over it because everything looks “normal.” This is a very painful practice, especially when the TPN or Chem-14 is reviewed. The second, I had already learned as a medical scribe, but was a nice reminder: always have a definitive assessment so you can rule out the diagnosis. When writing SOAP notes (which I hate doing because I much prefer writing notes in a slightly different style but with the same information), being specific in your assessment is a challenge. I can probably explain this best with an example I came across in emergency medicine. Saying “this is a 40-year old male with chest pain will order chest x-ray and EKG” rather than saying “this is a 40-year old male with chest pain; will order chest x-ray and EKG to rule out pneumonia.” In some cases you can be even more specific with your assessment. The importance of this is two things: looking back you and your peers can easily identify your thought process, and communication with your patient is more clear “well I think you likely have pneumonia since the EKG en route was normal and you are having xyz, etc. symptoms, but I am going to go ahead and order ABC to rule this out.” A definitive assessment allows you to think “well I wanted to find that out, but this test shows that’s not what is going on here, what is my next consideration?” Definitely a great way to organize your clinical decision making.
Working in the NICU, I have observed, is a great privilege. Although heartbreaking at times, working to save the lives of neonates can
be very rewarding. Many of the treatments needed to sustain life can, however, depreciate the quality of life for the patient, but many advances in medicine have allowed babies that would not have graduated to become pediatric patients to do so. Once, our attending told us, he baptized a child at the edge of death at the parent’s request. He has no religion, but states that he was proud to do so and felt that if doing so could help, then why not? Neonatologists also perform circumcision. Whenever you are working with the very ill, religion and moral beliefs are bound to surface and you have to be prepared to respect the beliefs of the patient and their family, no matter your own thoughts.
Overall, being in the NICU was a very rewarding experience. Screwing up undergrad made me feel inadequate many times, and my worry about eventually being accepted to medical school is ever oscillating. Sometimes I feel that I am not prepared for the rigors of the graduate-level science courses of my postbac, and looking at the looming student loans made me question the value of pursuing this in relation to my likelihood of becoming a physician. But seeing a parent all smiles because their baby’s condition was stabilized and they are still fighting for life is a wonderful reminder of the joys of practicing medicine. There were many times while shadowing when the discussions went over my head. Medical school often feels so far away and unfathomable. I have always known how little I know, but upon hearing the knowledge gap between a medical student and me, a third year student and a fourth year student, an occupational speech therapist and the attending…I felt a pressure to succeed. By building the foundation for efficient studying while doing this postbac will be an excellent starting point for my medical education. As much as I have not enjoyed reading Costanzo’s Physiology book, I am newly motivated to do so.
Because of the chaos of the day, I did not have time to present. The attending said I could go back the week of September 23rd and shadow again! I’m excited about that but a little unsure how I will have time since I have 8 am classes that continue through rounds. Hopefully I can find some way to work this out.
Shadowing a neonatologist in the NICU is a great opportunity that I recommend for any premed!
You can read about my other 3 days in the NICU here: