My long winter break:
The South American and USA school calendars do not coincide. It is currently South American summer vacation which means I got an exceptionally long winter break this year!! 2 WHOLE MONTHS of freedom. I didn't think I would be able to chill on the couch for two whole months, so I set up a shadowing position at North Shore-LIJ hospital in NY.
I am very lucky to have a retired neurosurgeon for a grandfather who helped me make connections at his old hospital and along with my grandma welcomed me into their home. I had two goals going into this shadowing experience:
- Get a feel for the maternal and fetal healthcare system in America as a point of comparison for my research in Chile
- Broaden my knowledge of medical specialties and think about what kind of doctor I might one day want to be!
I began my experience in LIJ's Neonatal Intensive Care Unit, an incredible unit that held an average of 55 babies during my time there. My "work day" started at 7 am with a meeting held by the charge nurse to update everyone on staff about the sickest babies, babies with similar or repeated names (to avoid confusion), babies going in for surgery, and discharges. After the meeting the doctors who were on at night updated the day team and rounds began.
- Realization 1: Doctors do not speak english. I realized very early into rounds the first day that I was going to have to learn a whole lot of acronyms and jargon in order to gain a basic NICU understanding. An example:
- Doctor: "The baby is POing Q2"
- Me: *nods head yet has is utterly lost*
This simply means the baby is feeding by mouth every two hours. OHH well why didn't you just say that??!?
*See "Carrie's NICU Appendix" below for more words I didn't understand but now do.
Rounds in the NICU lasted many hours (one rounds I was on lasted 7 hours!) but were such an incredible source of information. I also learned about the inner workings of the hospital by paying attention to the communications between staff members.
- Realization 2: NICU care, and all hospital care for that matter, is interdisciplinary. The doctors, nurses, NP's, PA's, technicians, social workers, lactation counselors, palliative care counselors, and rehabilitation centers all work together with the common goal of providing the best possible care for the patient and family. I saw some doctors who collaborated perfectly and others who treated the hospital staff as inferior. This observation will hopefully stick in my mind for a long time and help me to treat others professionally no matter how stressful the situation.
- Realization 3: Due to advances in medical technology, hard ethical decisions are faced daily in the NICU. With countless types of ventilators, medicines, shunts, and imaging devices, many more lives are saved than ever before. However, there seem to be more babies in chronic care facilities with poor qualities of life as well. It is difficult because although predictions about a child's prognosis are helpful, kids are resilient and some babies do much better than anyone expected. In addition, NICU medicine in a new field and the first NICU babies have just reached adulthood. We are not entirely sure about all the difficulties or lack of difficulties they will face. I saw medical staff and families work tirelessly to make decisions that gave children the best life possible, yet the words of one doctor haunt me:
"The parents credit me with saving his life, but I am not sure if I really did him a favor"
My best experiences in the NICU
-I got to attend many c-sections with the NICU interns. I was able to help stimulate and clean the babies as soon as they came out, watched the APGAR scores get read at 1 and 5 minutes, the first physical examination, and the suctioning of the babies noses and mouths if necessary. I liked watching the entire procedure, from the PACU consent signing and pre-op discussions, OR set up, epidural administration by the anesthesiologist, to the pre-op "time-out", uterine incision, delivery, and eventually the closing stitches. By watching the whole procedure it becomes apparent how many people and pieces are in play and just how incredible hospitals are as institutions.
- Realization 4: The Pre-Operative "time out" is a brilliant and lifesaving procedure. According to the Joint Commission Guidelines, before any procedure or surgery a verification must be performed. The "time out" is standardized so that no part is ever forgotten. Everyone in the room states their name and position on the operating team, the patient and procedure is verified, the relevant documentation is verified, all images are reviewed to make sure they are properly labeled and displayed, the risk of the case is discussed, and all staff are asked if they have additional concerns for the patient that should be addressed.
-With the Labor & Delivery Team I got to observe the complete vaginal delivery process. I LOVED this for as my disgusted friends can attest to, I think birth is the most incredible miracle and was honored to be allowed in the delivery room. Seeing the joy on parent's faces as they saw their child for the first time makes me understand why someone would go into OB/GYM annnddd led me to realization #5.
- Realization 5: I will do everything in my power to never have a c-section unless it is absolutely necessary...vaginal deliveries seem to be much happier occasions for everyone involved (the mother might not agree in the moment...)
-I got to go on a NICU consultation for a Preeclamptic women who was about to deliver her baby very prematurely. I just did a semester-long research project on the Darwinian cause of Pre-eclampsia, so you can imagine how excited I was by this case. Ethical issues were discussed such as whether or not to resuscitate the fetus if necessary. I highly respected the doctor's ability to lay out the facts and prognosis of the fetus without letting her personal opinions on the case interfere. She was able to comfort the patient on a personal level yet never let her emotions cloud her judgement or professionalism.
-During a hospital-wide meeting I connected with a Well Baby Nursery (WBN) physician who allowed me to shadow her as well. I saw more doctor-parents interaction in the WBN, which I enjoyed. This doctor helped me see how one can shape her medical practice to her needs. This doctor spent half of her time in the nursery and half of her time in a general pediatrics clinic. This variety was very fulfilling for her. We had many interesting discussions about the challenges of being a woman in the medical field. I greatly admire this doctor and inspire to be the kind of doctor that she is: someone who takes the time to connect with every patient, someone who has a positive attitude from morning to evening, and someone who is always willing to share her knowledge with those who ask.
Neurosurgery
In addition to my shadowing in the NICU, I spent a week in Neurosurgery with some of my grandpa's old partners. I was quite surprised by the extent to which I enjoyed surgery!! I spent some 10 hr days with my eyes glued to the table, unable to get myself to leave the OR. As a really big people person, I also enjoyed the consultations that are part of a surgeons job. The surgeons thought this was weird since most surgeons dislike that part of the day. As one neurosurgeon so eloquently stated:
"I became an operator to operate...not to talk" hahaha :)
The most interesting surgery I got to see was a transsphenoidal pituitary tumor resection. The surgeons went in through the nose to access a HUGE tumor in the pituitary gland. This surgery is done with an operating microscope that projects onto a TV screen.
Realization 6: Neurosurgery, and surgery in general really interests me. I expected to like medicine much more than surgery, but I am no longer so sure about that. Although they call neurosurgery "the old boys club," it may be a club I one day want to join.
and in summation... Realization 7: Grandparents are the best. Like actually. There is no one better. I really believe there is no greater love than that which grandparents have for their grandkids. I was insanely spoiled for a month by 3 loving grandparents, and boy do I miss it. The constant opinions and worries about my safety did get on my nerves, but as my dad stated, "If I had had seen and experienced everything there is to see and experience in the world, I would have opinions about it as well"
ooff that was a long post! I hope it is interesting or informative to someone!
Today was my last day in Connecticut and I head off for Chile in the morning. Today Raffi and I went on a very snowy walk and I cooked that avocado egg thing that everyone on Pintrest is raving about. I coated the avocado with lime and sprinkled on some salt & pepper, tomatoes and cheese before cracking the eggs into it. The recipe called for lemon, but I used lime because I am a badass and also because I had no lemon.
Happy Sledding to you, New England!
Besos y Abrazos,
Carrie
Experience Tally
Number of c-sections seen: 8
Number of NSVDs seen: 4
Code 100’s: 1
Circumcisions: 1
PICC line insertions/modifications: 3
Intubations: 2
Lectures attended: M+M, Evaluation of Inpatient Education from Lindbergh to Sulley, High Risk Deliveries, Gemini, Hypoglycemia, Cyanosis, Intern Case Presentation, Benefits of Breast Feeding (Lactation consultant)
NICU Consultations attended: 1( 25 wk preeclampsia)
Physical Examinations seen in WBN: ~25
Brain Surgeries observed: 4
Brain/spine surgery consultations observed: 8
Pediatric Physicals attended: ~30
Carrie's NICU Appendix(some of it..I can't possibly write it all!)
Apgar: Taken at 1 and 5 minutes. Baby is given a 2,1, or 0. greater/equal to 7 is good
A:Appearance
P: Pulse
G: Grimace
A: Activity
R: Respirations
Bilateral Red Reflexes: Indicates an absence of cataracts or intraocular pathology
Bilirubin/Bilirubinemia: A yellow breakdown product of normal haeme catabolism. Haeme comes from haemoglobin, a principle component of RBC’s. Bili is excreted in bile and urine and can make the baby jaundice. Diagnosed through a blood test. Treated with phototherapy.
Duodenal obstruction: small bowel obstruction. Yellow/green emesis may lead to a diagnosis along with a funky x-ray.
Epstein pearls: retention cysts seen on hard palate or gums. Harmless and go away over time.
Fontanels: gaps between cranial bones in infant. A great variation in size exists at birth.
-anterior tends to enlarge in first few months
-an excessively large anterior fontanel is associated with a lot of problems
G-tube: used for stomach drainage
GDM: Gestational Diabetes Mellitus
Glycerin Suppository: Helps the baby pass stools/ alleviate constipation
Harlequin Color Change: Harmless division of body into red and pale halves.
Hypernatremia: electrolyte disturbance, higher sodium ion [ ] in plasma.
-sodium cant freely cross from interstitial space to cell
-often is due to dehydration
IVH: Intraventricular Hemorrhage: Bleeding in the brain, most common in premature babies. Bleeds are given a score of 1-4 (4 is the most severe). Jejunal atresia: malformation of jejunum. Type 3b looks like an apple peal. Surgery is required.
Leukocoria: white pupil reflex. may indicate cataracts, tumor, retinopathy of prematurity etc.
NEC: Necrotizing Enterocolitis: Infection and inflammation causing destruction of the bowel. May be caused by a reduced blood supply or reduced oxygenation of the bowel. A baby with NEC must be fed by IV until the bowel heals.
NPO: Not by mouth
NSVD:
Prader-Willi Syndrome: Prader Willi is a genetic disorder related to genes on chromosome 15
-decreased muscle tone
-short stature
-cognitive disabilities
-chronic feeling of hunger--> obesity
-imprinting is at play
Peripherally Inserted Central Catheter: PICC: different kind of IV line. It goes into the heart for kids who would have long term IV or are on TNP
Persistent pulmonary hypertension of the Newborn:
-may be from GBS (group B strep) and hypoxia
-may need ventilator
-nitric oxide: relax blood vessels--> improve blood flow in lungs
at birth: baby’s lungs don’t take over so blood does not flow to lungs as it should. so oxygen cant move to the rest of body
-ECMO is a machine that takes over job of lungs requires major surgery. Only use if child if child is
Pyloric stenosis: A narrowing of the pylorus, the lower part of the stomach. This condition affects the GI tract and causes the baby to forcefully vomits. Pyloric stenosis may lead to dehydration and a fluid/salt imbalance. This condition requires surgery.
-usually recognized in babies 1 month-> 6 weeks
-I also learned of aortic stenosis, duodenal stenosis, jejunal stenosis, ileal stenosis. Stenosis is a suffix.
RDS: Respiratory Distress Syndrome: Severe breathing problem. Often seen in babies delivered at/before 34 weeks of gestation. These babies lack surfactant. Treated with surfactant, C-PAP, and other ventilation devices.
Russell-Silver Syndrome: A growth disorder seen in the baby ante and post partum.
-Normal Head Growth (but may seem large compared with body)33
-May develop hypoglycemis
-Short stature for adults (4’8” for female, 4’11” for male)
-distinct facial features
SCID: Screening for severe combined immuno-def.
Sepsis: Infection of the bloodstream
-Babies whose mother had a fever or an infection are “presumed sepsis” and admitted to the NICU for monitoring and antibiotics.
SGA: Small for gestational age.
Spontaneous Triplets/multiples: without IVF
Synagis: An antibiotic used to treat babies who are at a risk for RSV or Respiratory syncytial virus.
TPN:Total Parenteral Nutrition: Used for patients who can not get nutrition through eating. It is a combination of nutrients. Sugars, carbohydrates, proteins, etc may be give. A child on TPN may have a little breast milk put into the corner of their mouth to improve their micro biome with maternal antibodies.
Umbilical Vessels: Babies should have 3, 2 arteries and 1 vein.This is examined at birth.In the NICU, UVCs and UACs are used regularly.
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