Day shift at the neonatal intensive care unit (NICU) begins at 7:00 am. The night shift neonatologist is finishing her notes in the physician lounge before the 7:30 am handoff. I asked why she isn’t using the hospital’s Epic system. She explains, “We are part of Pediatrix, a MEDNAX subsidiary. Forty percent of neonatologists are part of this group.” (When she’s finished with her note it will be exported to Epic as a picture, thus resulting in a hard-to-use chart for the patient. The Pediatrix system is problem-oriented and, though less flashy than the Epic screens, is superior in terms of information presentation and productivity.)
My attending, a 50-year-old who speaks softly in a thick Indian accent, arrives at 7:15 am, and opens a discussion regarding the consolidation of physicians (Pediatrix employs more than 1,750 doctors). The night neonatologist: “We have no one to blame but ourselves. Physicians want to only focus on patients and do not want to deal with billing so we just handed it to administrators who took over. We don’t get paid if we don’t bill.” He responds: “It just seems that the administrators took the power and have made it so complicated it is impossible for any physician to understand it. Every year they change the reporting requirements, change the codes. They purposefully make it such that you need an army of administrators behind the scenes.”
“The administrators think we are naive to their little ploys,” she added. “They make a big deal that they sent us a link to a live feed of the 9:00 am annual shareholder meeting. Are you freaking kidding!?! We have babies to take care of in the morning. They have no idea what we do. They are just profiteers. Our company will never raise our salaries. New hires get paid more than we do. Instead of raises they’ll give us bonuses from the profit, but of course they take the first 50 percent.”
After the night neonatologist left, my attending summarized: “People remember the $500,000 per year salary from the good old days, but they forget that they had to work every single day, no weekends off, to earn that.”
We proceed to the actual NICU, double-washing our hands and sterilizing our phones and badges with UV light. We then take turns listening to the neonates from the individual child stethoscope hung on each pod (to avoid cross-contamination). I am assigned two babies. I try to conduct a full physical exam on them but the nurses shoo me away because it is outside of scheduled “Care Time”. Neonates are given four hours of undisturbed nap time in between medical interventions.
The attending heads off to the physician lounge to write notes while I set up in the respiratory supply closet, which doubles as a respiratory therapist (RT) station with three computers. I finish my note and then study UpToDate on various neonatology topics, e.g., respiratory interventions and feeding regimens.
Around 12:00 pm, a nurse pops her head in and asks if I want to “join for stairs.” I agree, despite not knowing what is involved. The 30-year-old nurse, my attending, a 60-year-old RT and I walk up and down the hospital stairs (13 floors) three times before we head to a meeting on provider well-being. The RT keeps going. We all get pretty sweaty and the nurse says, “We better not show up at the same time to the meeting. Could be questions.” Despite carrying 20 extra pounds, the attending is able to smile: “Yes, yes, I’ll show an hour later.”
[Editor: How long would a male nurse last after making a sex-related joke?]
The meeting regards the emotional fallout from caring for a particular baby, in his seventh week in the NICU, with skeletal dysplasia, a fatal disease with numerous bony deformities and cardiac anomalies. One nurse confides: “It’s just hard to go to work seeing this baby in pain day after day.” The child has a gastrostomy tube that has had two episodes of cellulitis. The infection is cured, but there continues to be wound breakdown. “No matter what position he is placed in he squirms.” Two nurses have refused to care for the child. The nurses have to suction out the tracheostomy tube to prevent the child from desaturating due to mucous plugs. The nurses thanked both physicians for their clarity to the family. “I think the family had different impressions from the beginning compared to what you two have conveyed.” The attending said that the family is slowly coming around to the idea of letting nature take its course.
We slip out of the meeting for a Caesarian section. A neonatologist is present at every vaginal delivery of a pre-37-week infant and at every Caesarian section regardless of gestational age. I get permission to watch from behind the surgical tech’s Mayo Stand (stainless steel table near the surgical field, holding commonly required instruments) the Ob/Gyn team performs a laparotomy (opening of the abdominal cavity). After they reach the anterior abdominal fascial sheath, the resident makes a small incision with her dissecting scissors. They widen the hole until the attending and resident can each fit one of their hands into the peritoneal cavity. “Lots of pressure,” announces the attending as she pulls laterally to tear open the fascial sheath. They’re casually chatting about a recently retired physician during this 8-minute procedure.
Once they’re inside the peritoneal cavity, I can’t see anything more so I head back to the baby response team (nurse plus neonatologist). The surgical team announces uterine incision time, then membrane rupture time. The baby response team doesn’t even look at the mother or surgical site until the surgical team announces membranes are ruptured. The nurse hangs a large blanket on my shoulder and demonstrates how to carry the baby. After a 15-second struggle, the resident pulls the baby out of the uterus, cuts the cord, and passes the baby to me. I wrap the baby in the blanket, take two awkward steps, and place the baby down on the warming bed for the neonatologist to evaluate.
The baby has a low blood oxygen saturation so we begin BIPAP (bilevel positive airway pressure). The neonatologist grabs an oxygen mask from the nurse and places it on the newborn. There is a small hole in the mask out of which the 44-percent oxygen mixture escapes until the attending places his index finger on the hole, at which point positive pressure is applied to the lungs. The neonatologist demonstrates how to deliver the pressure by toggling the pressure every two seconds. I take over and watch the oxygen saturation go from 80 percent to 86 percent.
The neonatologist whispers, “Does this look like a funny baby?” I look for classic syndrome characteristics: he has a smooth philtrum (groove between mouth and noise; bad), macrosomia (bad), low set ears (bad). I open his hands: two palmar creases (good). My attending points out sandal gap toes (wide-space between big toe and the 2nd toe). The neonatologist admits the baby for respiratory distress and further evaluation of syndromic characteristics.
The nurses 10 feet away: “How does she think she’ll get to keep this baby?” The other nurse: “She doesn’t think we know about her other kids. She keeps having more kids thinking CPS won’t be notified and she’ll get to keep this one. Maybe stop doing drugs and be a mother.”
The nurses see me listening in and comment, “Welcome to the NICU. Not your Cinderella stories.” The notion that NICU care would be heroic work saving premature babies, a completely clean slate, from certain death to bring them to adulthood and productivity is typically wrong. Similar to my trauma experience, these patients are “high risk”. Unfortunately, a majority of the babies are in the NICU because of terrible mothers. And business is booming. They just doubled the NICU beds in a large renovation.
I dig through the mother’s chart. She’s a 38-year-old Hispanic and this is her ninth child. She does not have custody of any of the previous eight, three of whom have Down Syndrome. (She likely has a Robertsonian translocation, which means each child has a 50 percent chance of Down Syndrome.) She admitted throughout this pregnancy to using crack and other narcotics, but did stop using meth at 14 weeks into the pregnancy. The neonatologist and I interview the mother. It is taboo to ask about who the father might be so the discussion centers on CPS and the likelihood of them taking over custody of this child.
We get called down for a 34-week vaginal delivery. Fetal ultrasound at 20 weeks showed excess amniotic fluid, but no renal abnormalities or tracheoesophageal atresia. The patient is only 7 cm dilated. We ask the Ob/Gyn resident if she needs our help. “No, I think it’ll be awhile.” Why did she page us? My attending: “OBs have no sense of time. Do they think we just sit up there twiddling our thumbs waiting for them to call? We have an entire NICU to run upstairs.” The baby is born two hours later, and nephrology is consulted for a rare inherited kidney disorder from a genetic defect in a kidney channel furosemide or hydrochlorothiazide use leading excess diuresis. (There are only an estimated 8,000 people in the world with this disorder. Prognosis: there is relatively good prognosis for the child if treated consistently with nonsteroidal antiinflammatory drugs and electroylte monitoring)
While finishing the day’s notes my attending says, “Look at this. A 34-weeker was given a portable warmer. This costs $600. A 34-weeker does not need this warmer. Under 28 okay, but 34-weeker. I don’t even know why I try to save money. It’s all Medicaid money. No one cares.”
Friday afternoon is our clerkship director leads a lecture from 1 to 6, ostensibly on the topic of Failure to Thrive. Looking at the weight charts, however, spawns a tangent on the subject of obesity. “Weight percentiles on growth charts are calculated off of the 1960s and 1970s NHANES [National Health and Nutrition Examination Survey] data. Over half the country are above the 75th percentile.” Pinterest Penelope asked when we would update them to reflect our actual population. “I don’t think we want to lower our standards.” Our clerkship director shared her personal secret for motivating children to lose weight: “You have to frame it as a personal problem. I tell the mom: ‘You unfortunately are an easy weight gainer, and you will have to work extra hard to get it off.’ The parents and child all have to lose weight together.”
She covered familiar ground about kids playing indoors with electronics rather than outdoors with neighborhood friends: “I flip out when I see a one-year-old swipe at a Fisher-Price iPad App before he can run. It’s scary, right? I can’t even do that.”
She concluded this topic: “Positive thoughts lead to positive feelings that lead to positive actions and positive results! Repeat after me.” We all repeat in unison.
[Editor: From Life of Brian… “You’re all individuals”; (in unison) Yes! We’re all individuals! “You’re all different!”; (in unison) “Yes, we are all different!”]
She talks about acetaminophen overdoses. Two classmates report seeing two acetaminophen overdoses each during their inpatient pediatrics rotations. She explains: “The parents a lot of time don’t think it is serious. They want to take their daughter home, but it hits them when we put one-one suicide precautions: minder in the room at all times, take their phone, place them in paper gowns. Parents think it is situational. Their teenage daughter is temporarily depressed after a break-up, so there is no need for treatment. Do the parents think there won’t be another boyfriend and another breakup? I had to get a restraining order to prevent a mother from taking her daughter home.”
She attributes the bulk of the problem to glorification of suicide in our culture. Pinterest Penelope responds by mentioning Amy Winehouse and the Netflix show 13 Reasons Why. “I hate that show. It’s just terrible, we need more advocacy and awareness for this.” Did she still have a Netflix subscription? “Well yeah.”
Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: trip to the county fair with Engineer Edward.
The rest of the book: http://fifthchance.com/MedicalSchool2020