Purple Pacifier Ire, Blue Babies and LTEs – NICU

If anyone had asked me on July 31st how I thought my NICU block would be, I’d have immediately responded with one word: awesome. Much of my desire to become a doctor in the first place was sparked by my fascination with neonatology; the epic stories my mom would tell about how I spent my first month of life in a NICU probably brainwashed me to the point where I felt like going to the NICU would be like a homecoming. The children’s hospital at which my residency is based has its own NICU where senior residents staff and take call but the interns are sent to the level III NICU of the local general hospital which is run by a team of attendings and neonatal nurse practitioners. It’s a state-of-the-art 60 bed facility where babies as young as 23 weeks are managed and ECMO can be performed if necessary. I remember how brightly I smiled on the first day, thinking of all the deliveries and resuscitations I’d be able to attend, all the tiny babies I’d be able to care for and all the things I’d be able to learn from the attendings. I’d even imagined myself well-prepared because I’d had a 4-week NICU elective in med school. Looking back, I realize how terribly naive I must have seemed. The shock of reality was like icy water in the ear.

There were certainly moments of awesomeness during the block – the adorable babies never failed the make me smile. The youngest one I’d managed was a 28-weeker born the first day of rotation. She was mine for the entire block and she did marvelously well. There was another baby who stole my heart, a 33-weeker who’d suffered some sort of cerebrovascular event in utero and had grade IV IVH. I’d read about the dreadfully poor prognosis and couldn’t reconcile it with the perfectly normal-seeming baby I’d examine each morning. There was the twin I’d carried who tried to die on me one morning while I was checking on him before rounds – all of a sudden, formula started pouring from his nose and mouth and he stopped breathing as I watched, stunned with terror. I fumbled to suction his airway but luckily the loud cacophony from his wailing alarms alerted some nurses who wisely grabbed the oxygen source and ventilated him (as PALS guidelines direct us to do in such a situation instead of panicking). There was the tiny 24-weeker whose stability was so precarious I got nervous every time I passed her room. She had the most optimistic parents in the world. Some of the parents of the NICU babies were great; appreciative of the efforts of the staff, supportive of their babies and just generally nice. Some were really quite odd, like the parents of my twin who’d apparently objected to their sons having purple pacifiers, unaware that the pacifiers are color-coded by size and that their tiny babies didn’t have mouths big enough for binkies in a more masculine color. And don’t get me started on some of the magnificently ridiculous names.*

Despite occasionally feeling overwhelmed, I’d thought things were going well in the NICU until one Saturday morning when I was the only intern on. A code pink** was called so I dashed to the OR – it was a 33-weeker being born precipitously to a mother with a recent history of drug use. The least-pleasant of the NNPs was also there ready for the delivery and soon after everything had been set up, out rushed the OB nurse with a limp, non-vigorous baby which was set before us on the warmer. It was the third week of the block so by that time I was comfortable being at the right side and so I proceeded to stimulate the baby and attempt to palpate a heart rate. It was there, but weak, and the baby was still looking rather cyanotic. The respiratory team started giving some oxygen which made the baby’s color improve but he still wasn’t taking adequate breaths and he didn’t seem to be as wriggly as a newborn should be. While the respiratory therapist started to talk to me about CPAP, the NNP started firing questions in my direction. “What tests would you order for this baby? What antibiotics would you give if the mom is GBS +? What are the doses? What fluids would you start?” I remember thinking, ‘Is this lady seriously pimping me? Now?’ as I tried to answer her questions, but in hindsight, I realize it was some sort of test, which I must have failed because later that day, one of the attendings pulled me aside and told me how concerned she was because it seemed like I didn’t know anything about anything. And that’s only a tiny exaggeration of the actual substance of the conversation. “It’s not like you’re going to fail the rotation or anything,” she said. “We just think you need some help.” I actually ended up crying in front of the attending, something I’d hoped I’d never do. It was the height of humiliation, and probably the lowest point of the block. The second-lowest point was on the following Monday when one of the nicer attendings, who I guess had heard about what had happened over the weekend, patted me on the back with such pity that it set off the waterworks again and I had to shut myself in the bathroom and pull myself together. The consequence of all this was that I was sent to the smaller NICU at our children’s hospital basically to remediate. I spent a couple of days under the tutelage of a chief resident practicing number-gathering, presenting and calculating TPN on a few babies. The experience was certainly humbling but ultimately, educational and I actually felt more comfortable in the NICU at the children’s hospital than I did at the general hospital. Whether it was because of the atmosphere or for other reasons, I’m not sure.

Towards the end of the block at the general hospital NICU, I did get some positive feedback. One of the attendings with whom I’d spent a lot of time said that she’d seen improvement in my presentation skills over the month and that my notes were always strong. Those few positive words went a long way toward making me feel like less of a failure and less like perhaps I just wasn’t suited to neonatology like I’d always thought I would be. Even though it was a rough month, the adversity hadn’t scared me away from the NICU. It just made me determined that the next time I found myself in one, I’d make sure that no one would be able to stump me with questions about stuff I knew or question my capability.

*Seriously, don’t get me started. It’s a HIPAA violation

** At this hospital, a code pink is called when there is a delivery that may require resuscitation

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