The neonatologist, Dr. Schuller, said, “How do you think the baby feels?”
The collective group rolled their eyes behind Dr. Schuller's back since the less than two pound infant was buried in an octopus’s worth of monitors and lines for her ventilator and umbilical venous and arterial lines. Already struggling with the massive responsibility of reciting a plan for every single organ system, poor Kimberly stammered in an attempt an impossible answer. “Drier. Maybe.”
“In the isolate?” Schuller asked, a partial truth, as the clear plastic box was both heated and humidified to minimize energy loss from heat and skin integrity.
Kimberly was in panic for any type of guidance. Schuller was a part-time substituting neonatologist in her sixties who suffered from the dual problem of not being familiar with the current patients and asking inane questions that rarely enhanced patient treatment.
This was Kim’s first encounter with Schuller since they usually had a weekly, stable, rotating neonatologist who knew the patients well. The nighttime on-call neonatologist didn’t round and focused on putting out the endless number of fires that popped up via new deliveries or handling the myriad medical issues of the 120 beds in the NICU.
They were midway through her April NICU rotation, and Clarissa wanted to get out on time for her twenty-seventh birthday. Roan had promised her a birthday party post-call and then a naked session afterward. The sooner they finished rounds, the sooner she could hand off her pager for her escape to noon lecture and then home.
She nodded vigorously to answer the affirmative behind Schuller for Kim. If they didn’t move this along, they would end up in a physiological discussion of the ‘wetness’ of amniotic fluid versus humified air.
Kim finally got the idea and said, “Yes. Feels drier.”
The NICU pharmacist, Bisma, chimed in, “The isolette’s forty percent humidity is less than amniotic fluid, which is a hundred percent.”
“Where’s the mom?” Schuller asked.
“Still in L and D, recovering from her emergency C-section. The father of the baby has been by to visit and take pictures,” Clarissa answered, having been the one present at the bedside, and chose not to mention how he’d cried on the isolette.
The NICU social worker was checking her watch and progress of the other two teams through the glass windows of the pod. She had responsibilities to the fellow and the neonatal nurse practitioner teams, each in charge of another forty babies each. Those teams had their own neonatologist during the day and were moving along at an appropriate pace.
“I see. Where are we going next?” Schuller’s question was odd in the sense that the normal rounds went one ten-bed pod at a time and they were moving to the next bed space, cared for by the same nurse. The babies were generally grouped by acuity, starting at Level 3, critical; moving downward to Level 2, step down; and then Level 1, feeders and growers.
Of course, almost everyone outside of formal documents and presentations referred to them as The Factory of Sadness, Limbo, and the Good Place.
Right now, they were stuck in the Factory of Sadness, and it didn’t seem like they were leaving anytime soon.
“That’s me.” Fellow second-year Lilith Cadawan presented a 27-weeker named Sally Glankler. This baby had been born at 500 grams at 23-weeks and had not successfully transitioned from ventilator to CPAP yet. The baby did have a left arm PICC line for most of her IV nutrition and was starting on small feeds through a nasal-gastric tube.
As Lilith went through Sally’s long list of problems, it demonstrated the inherent challenges of the NICU. The first two weeks of a micro-preemie’s life were critical. They had to fight against premature lungs, non-existent immune systems, IV access, brain bleeds, and the ever present threat of infections, ranging from pneumonia to intestine-destroying necrotizing enterocolitis to sepsis to bladder infections.
Most NICU infants had an entire step by step decision-making logarithm for best practices—Roan would have loved it. Starting with the decision to resuscitate in L and D, it branched onward from there based on their birthweight and gestational age. Anytime Clarissa saw these micro-premies, she was reminded of the Veteran’s Day blizzard and the baby she’d let pass on at 20 weeks when the mom had bled out from placenta acreta.
Case in point, Sally was on the border of survivability based on gestational age and birth weight. She’d already struggled with two urinary tract infections, the first of which had almost killed her at one week of life. After the second UTI, they had opted to continue her on preventative antibiotics.
Lilith’s presentation was halting and stumbling. With thirty residents per class, Clarissa and she had never shared a rotation, and it was clear Lilith wasn’t neonatology material. Lilith hated the ICU, disliked call, and wanted nothing more than to embrace a future of outpatient general pediatrics.
Which made Clarissa the designated resident team group leader and the one to set the tone. She prodded the nutritionist with her foot to remind her to get a word in after the presentation ended since Sally needed her protein in her TPN adjusted.
Luckily, Lilith’s presentation was brief because they hadn’t made any major changes in the past week after she’d failed extubation.
“Excellent,” Schuller said, and the less luckily, “What do you think her favorite thing is to do?”
Lilith froze, glancing between the isolette and Dr. Schuller, unable to come up with anything.
Yep, Gallo would have certainly told Lilith she wasn’t Chief Resident material.
Clarissa sketched a picture of the face of a dog on the back of her notes and held it up.
“She likes looking at the stimulation pictures,” Lilith said, successfully recognizing the signal. Newborns could only see about a foot and generally in light versus dark, specifically for faces. Laminated black and white cartoon animal faces were taped on the ceiling of the isolettes to provide visual stim.
“We need to always consider the comfort of our new babies,” Schuller confirmed. Not wrong but also not moving along rounds.
The nutritionist spoke up to make a few minor TPN adjustments, which were immediately entered in the computer by Lilith.
Pharmacy must have elbowed their remaining intern Linga Phan to start ASAP at the next bed. This intern was the total opposite of Kimberly and Lilith. Phan wanted to be neo and deliberately selected one of the more interesting and complex patients... in a way.
