Day 13: The End

Today I spent most of the day with Dr. Mills, but after lunch, I spent the afternoon with one of the pediatric nurses so that I could get the nurses’ perspective of pediatrics. 

During the first part of the day, I got to see and learn several different things. The first patient had cerebral palsy, a condition that involves impaired muscle coordination because of some sort of disconnect between the brain and muscles. This same patient was born with a twisted bowel and had to have two surgeries to untwist it. I asked if there was any correlation between the cerebral palsy and twisted bowel, and apparently there is some debate about the answer. Some doctors think the surgeries to correct the bowel cause a shock to the system, which then caused the cerebral palsy, but other doctors say that it is a complete coincidence. Most cases of cerebral palsy are idiopathic, meaning there is no identifiable cause.

There was a teething baby who came in today, and the mom expressed some concern that she thought one of the protruding teeth was blue. Dr. Mills checked his mouth then showed me that there was a little blue bubble surrounding the tooth, but the tooth itself was not blue. It is called an eruption cyst, which is when the blood vessels get irritated and look blue where the tooth is coming in. 

I learned something today that I am extremely surprised I haven’t learned before. Dr. Mills was examining a month-old baby who kept reaching for a black cord, which was directly contrasting in color with the white walls. Dr. Mills watched him alertly interacting and playing with the cord and said that he was drawn to the black and white contrast because babies don’t develop color vision until they are about four months old. Until then, their vision is only able to pick up black and white. I can’t believe that was new information to me! 

After lunch, Dr. Mills asked me if I would like to see the job of a pediatric nurse, so I spent the rest of my time with nurse Toya. She was extremely good at explaining the normal routine of her job. I was surprised at how fast-paced it was. A lot of the time she was calling patients back and asking them all of the preliminary questions, but when she wasn’t doing that, she was preparing her rooms for the next families, charting information for patients, doing labs, or drawing up and administering vaccines. She was very good at showing me the whole system on the computer and how she knew what her next task was. While I liked spending the afternoon with her, I am definitely more drawn to NICU nursing rather than pediatric nursing. Like I’ve said many times before, I think it’s hard to beat how hands-on a NICU nurse’s job is, and that is what I really liked about it. 

As of today, my intensive experience is over, and tomorrow will be a long day trying to put together as much of the presentation as possible. I definitely feel as though I accomplished everything I wanted to during these three weeks, including all four of my goals. As a reminder, these are the goals I had for this intensive: 

-To determine if I would like to pursue a career as a neonatal intensive care unit nurse

-To determine if I would like to pursue a career as a pediatrician

-To explore the differences in practice between pediatric (neonatal) nurses and

  physicians

-To learn and be able to identify the equipment used in the NICU

I got a really good picture of the life of a NICU nurse by spending so much time in the NICU for the first two weeks, and I found myself really liking the job. It fits a lot of the criteria I am looking for in a future career: a hands-on job in the medical field working with newborn infants. While it is no doubt emotionally taxing at times, I could definitely see myself in that role a few years down the road. I really liked the pace throughout the day; most of the time it was very unhurried yet still busy. One of the things I liked the most is that there are no appointments, which I think often tend to create a rushed schedule, which was absent in the NICU. 

Regarding my second and third goals, I don’t think I want to be a pediatrician. While I love kids, I don’t think medical school and becoming a doctor is for me just because I am looking for a job where I am the primary care for the patient, whereas pediatricians like Dr. Mills only spend a fraction of an hour with each patient, and then they’re on to the next. I have reflected a lot throughout my blogs lately on the differences that I observed between nurses and physicians, the biggest difference being that the nurses tend to do most of the hands-on work, whereas doctors (both neonatologists and pediatricians) are there to oversee everything and order everything from drugs and labs to X-rays. 

I most definitely feel like I accomplished my fourth goal. Throughout my two weeks, I learned in an incredible amount about so many of the machines and equipment the nurses use in the NICU, as I have shown throughout all of the blog posts I did. I saw so much more in the NICU than I was expecting. I saw and felt what it was like to lose a baby. I saw babies everywhere from less than a pound to over 15 pounds. I saw very healthy babies and extremely sick, critical babies. And I even got to see a C-section! It really was an amazing experience that I’m sure very few high schoolers get to have. 

Day 11 and 12: Dr. Mills–The "Bigwig" in Town

The nurses met me on my first day at the office, and the first thing they said is, "You got your walking shoes on, right? Dr. Mills is a fast one!" While I was waiting for Dr. Mills to arrive, I actually ran into Sam Sperlik, my classmate, who has been shadowing a different pediatrician for the past two weeks! I knew she had been with a pediatrician, but I didn't realize we would be at the same place.

Yesterday was a short day because we were supposed to do rounds at the hospital in the morning, but all of Dr. Mills' patients went home. He didn't have anybody he needed to go check on, so I didn't have to come in until 1:30 when his appointments started. Even in that short amount of time at the office, I learned a lot!

The first patient I saw had a strawberry hemangioma, which is a benign tumor formed by excess blood vessels, and it actually looked exactly like a strawberry on her arm. Dr. Mills told me that it doesn't hurt anything and is really just a birthmark that will eventually turn blue then back to normal within a few years.

Another patient I saw yesterday was having trouble with bronchitis and wheezing when she breathed. Dr. Mills let me listen to her breaths through the stethoscope, and I could clearly hear her wheeziness when she breathed out. He explained to me that sometimes the tubules in your lungs constrict, which causes the wheezing, much like a car window. When the window is slightly cracked open, the noise of the air blowing in is much louder than when the window is open wider. The nurse gave the girl a breathing treatment to open up the breathing tubules, then I listened to her breathing again after the treatment, and it sounded much better. Albuterol, the drug, is meant to relax the muscles around the tubules so that they can open more and lessen the wheezing, just like the car window.

An older patient came in who had a concussion a couple days previously and was still having headaches. Dr. Mills let me look in his ears, and in one ear I was actually able to see a blue ear tube, which is a tiny cylinder placed through the ear drum to allow air into the middle ear. The ear tube should have been in his inner ear but instead was in his outer ear because of the trauma of the concussion. Even in just two days, I have gotten to look into a lot of ears, and this morning I saw an example of an ear infection "as bad as it gets," as Dr. Mills said. First, I looked into her healthy ear, and it looked white, clean, and pearly, but then I looked into the other ear, and it was bright red and filled with pus. At least it was a good comparison for me to see!

Channel 11 actually came this morning, and they wanted to interview Dr. Mills for a story on the most common current illnesses, so he took a quick break in between appointments and was recorded on camera. Apparently, starting at five tomorrow morning, every half an hour they will choose a short clip of the interview to share on the news. Everyone was joking with him for being such a "bigwig" in town.

In the afternoon, I met a baby who has had a lot of complications, including a tracheostomy and a recent heart surgery. Dr. Mills had me listen to her heart, which instead of sounding like a normal, even beat, sounded like a gallop or series of three beats at a time. (Between the pediatric office and the NICU, I have gotten to listen to several different kinds of heart beats, including several heart murmurs in the NICU.) The baby had a big scar from the heart surgery, plus a bunch of little scars around it from several different chest tubes that were put in. Attached to her trach was an "artificial nose," which I learned moisturizes the air she breathes in like our nose does for us. If she didn't have that, she would just breathe in dry air, like if we breathed through our mouths all day long.

One of the last patients I saw, another baby, had a very yellow appearance, which is exactly the same as the jaundice I saw in the NICU. The whites of this baby's eyes were even yellow, which showed that the jaundice was fairly severe. Because a lot of the patients I have seen are babies, I have been able to connect quite of a bit of information I learned in the NICU to pediatrics. In fact, I wasn't expecting to see as many babies as I have in the past two days. At least half of the appointments I have been to were babies under the age of sixth months.

One big thing that I have noticed between the pediatric office and the NICU is that the NICU is much more hands-on because it is constant care, whereas the environment is much different when there are appointments all day. In the NICU, the nurses spend over 12 hours a day with the same patient, whereas pediatricians spend about ten minutes with each patient, and most of that time is spent diagnosing and prescribing drugs. One of the parents even said jokingly today, "So have you seen Dr. Mills give any vaccines yet?" It was a good point: in general doctors don't do as much of the hands-on jobs as the nurses. While I don't dislike pediatrics, I really like the constant hands-on work of the nurses (with the newborn babies!) in the NICU.

Day 10: My Time in the NICU Comes to an End

Today was my first and last day with Christina who had two babies, one critical baby and one healthy baby. The doctors tried to extubate the critical baby yesterday and use a different, less invasive form of ventilation, but he didn't last long, and they had to re-intubate him. They've tried to extubate him several times, but he always has to get intubated again. The neonatologists are debating about a tracheostomy, which would really be sad because of how involved it is. This baby has already had several surgeries, including getting his large epiglottis shaved, which is the structure that covers the trachea to prevent food from entering. They hoped that this would help solve his respiratory issues, but they saw no difference after the surgery.

Throughout my time in the NICU, I always saw new little faces when I came in every morning, but somehow I never saw the process of admitting a new patient until today. I watched the process of everything the nurses to do admit a patient, including drawing blood, putting patches on, and putting in an IV, breathing tube, and feeding tube. I noticed that everyone around the baby's bedside were nurses; they did all of the hands-on work to save the baby, and the doctor just came at the end to examine everything the nurses had already done. Again, this is another example of the independence and decision-making ability NICU nurses have, and I would definitely rather be in the hands-on position of a nurse than the overseeing eyes of a doctor.

Like I said before, I tried not to get attached to any babies, but sometimes that just isn't possible, which the nurses have also told me. Today, I fed and snuggled the most adorable baby ever. Even though he is only five days old, he was so much more alert and interactive than any of the other babies. He latched on to my finger and necklace with his hand and rested his head on my chest. Though I know this baby is in a rough situation because of choices his family made, all I and the nurses can do is give him the care and support he deserves. I think that is the most rewarding part of this job.

Next week I start with Dr. Mills, the pediatrician, but the last two weeks have definitely been a good experience. I strongly feel like I accomplished everything I wanted to in the NICU, including my goals. I think I might just have to go back as a cuddler once I turn 18.

Day 9: Finding "Friends"

Today was a somewhat regular day in the NICU. I was with Deb again, who had the 27-weekers (the very first babies I had on day one) with the addition of a third baby who was admitted at 1:30 a.m. last night for drug withdrawal. When I came in, three different people were trying to find his "friends" as they called them, but no one was able to feel them. They said either they are sucked up too far or he doesn't have any at all, and he will get an ultrasound done to find out. As soon as they were finished, I fed and cuddled him for over an hour.

Before today, I handn't done very much with my hands inside an isolette, but today Deb let me change their diapers, switch their oximeters on their feet, take their temperatures, and listen to their hearts. One of the babies still had a really distinct heart murmur, which I was able to easily hear. When I listened to the other baby's heart, the beat sounded crisp and clear, but I knew that he previously had a heart murmur, which confused me a little bit. I told Deb that I didn't hear a murmur, and she said that was because his medications worked, and he doesn't have one anymore! I was pretty proud of myself for being able to distinguish the difference.

Deb walked me through some of the important things she looks for in an assessment from top to bottom. First, she said she looks for ear tags, which apparently indicate that the baby has kidney problems or abnormalities! I would have never guessed that. Second, she said she makes sure they have a palate because sometimes babies can have cleft palate without a cleft also in their lip, so she opens their mouth to make sure they have a normal palate. Third, she makes sure they have an anus, because some babies can be born without one, which obviously is not good at all! In that case, they have to go to surgery to surgically create an anus.

Today I got to see one of the babies get suited up to be flown to another hospital. The baby was actually doing well, but the parents don't live anywhere near St. V's, so they flew the baby out to a hospital closer to the parents. Two of the nurses put on full-bodied navy blue suits that said "Neonate Team" on the back, and they were responsible for going with the EMTs and safely getting the baby to another NICU in a transport isolette.

St. V's has a cuddler program where occasionally people come in to hold and cuddle the babies, and today a cuddler came in, and it turns out she was Katie Holmes' mom! I talked to her for awhile and heard about what it is like to be the mom of a celebrity. Again...never did I expect that to happen during this intensive!

Some nurses that I have been with teach me a lot but don't let me do very much, whereas others are the opposite and let me do as much as I can. I've learned that both nurses complement each other and help me achieve different goals. For example, Kelli taught me so much about many drugs, syndromes and various medical conditions, as well as a lot of the different equipment and machines. She was really good at explaining somewhat complicated things in a very understandable way. On the other hand, Deb didn't teach in great detail but let me do a lot more than Kelli did, which really helped show me what it would really feel like to be in this role.

Baby selfie #3 

Day 8: "Do you faint?"

The nurse practitioner Steve hastily walks up and says, "Grace, are you allowed in the OR?" I reply, "It depends on your rules and if you allow me to be in the OR." He motions me to go with him and says, "C'mon we're going to see a C-section!" I jump out of my chair and half run beside him.

As we walked down the halls and rode in the elevator he prepared me for what I was about to see. His first questions were, "Have you ever seen a surgery? Are you ok with blood? And have you eaten today?" He explained that if I felt nauseous at all, I could step out right away because if I fainted, I would have to go to the ER and it would be a big ordeal. He told me that it happens quite often and not to be embarassed if I feel like I can't watch. He explained that once we got to the seventh floor, I would need to put on hair and shoe covers, a face mask, and a jacket to cover down to my wrists. He also warned me that sometimes the smell can be overwhelming and hard to get used to.

He opened the OR door, and we walked into the bright white room with a bed that was completely surrounded with people wearing blue scrubs. They were already pulling the baby's head out! Steve got me to a place where I could see them get the rest of the baby out of the incision. It was very bloody, but it didn't make me nauseous, and I thought it was amazing to see the process of cutting into a belly and pulling out a little baby! Once the baby was out, I followed Steve into a small room where I watched him evaluate the baby and take Apgar scores. Everything happened so fast because we got there right in the nick of time. Eventually I think it would be amazing to see everything from the time the doctors make the first cut into the belly.

Less than an hour later, Steve walked up to me again and said, "Follow me if you want to come see a vaginal delivery!" Of course I jumped up and followed him again. The NICU doesn't get called to every delivery, especially if it is expected to go smoothly, but in this case, the baby was in danger of Meconium Aspiration Syndrome (MAS). Again, as we made our way to the seventh floor, Steve talked to me the whole way, explaining exactly what was going on with this delivery. He explained that MAS occurs when the baby stools in the amniotic fluid, which isn't supposed to happen and can be an indicator that the baby is in distress and something isn't right. This meconium can get into the lungs with the amniotic fluid, which can then block the alveoli. He used a balloon analogy and explained that air can still get into the alveoli and lungs, but with the blockage, that air wouldn't be able to exit back out. In other words, the meconium can cause serious respiratory issues.

We got to the seventh floor and opened the room, but the baby had already been delivered a couple minutes before we got there, which was a bummer, but I got to watch Steve evaluate the baby. He told me that they can get a good idea of how long the baby has been sitting in the meconium by looking at how green the umbilical cord, fingernails, and vernix covering the baby are. He asked me if I had ever seen a normal umbilical cord, which I had, and the one on this baby was spotted with dark green, which meant that the baby had been floating in the meconium for awhile. Her fingernails were also tinted green, as was the vernix on her body, but she was crying and kicking and otherwise looked great, which is a good sign that she likely doesn't have MAS.

Like I said in my first blog, I didn't know exactly what this intensive would bring, and I definitely did not expect to see a C-section! I can't really make that a goal now that it's already over, but it's something that I can add to the list of many things I have been able to see and do throughout this independent study!

Day 6 and 7: Here One Day, Gone the Next

Yesterday the person at the front opened the door for me, and I asked, "Which babies does Christina have today?" She looked at her chart and said, "Well actually, Christina has mandatory time off today." It was supposed to be my first day with Christina, but I ended up spending the day with another nurse, Lynn, who had two babies I had never had before.

As I walked down the hall to the very back of the NICU, I noticed that three cribs that were still there on Friday disappeared. Sometimes I find myself just assuming that the same babies will be there forever and nothing will ever change, and then I get surprised when a quarter of the babies are replaced with new faces in just a single weekend. I'm glad that I'm here long enough to see the beginning and end of some babies' stays in the NICU because it gives me a bigger picture of what it is actually like to have to let go of the babies after a short time.

One of the babies Lynn had was new to the NICU and was having seizures from bad drug withdrawal. Her head was all wrapped up in gauze, and tons of tiny little colorful wires came out of the gauze, which connected to a screen showing all of her brain wavelengths and activity. The doctors eventually read the patterns to try and determine the cause of the seizures. The baby was on about four different medications to try and reduce or eliminate the seizures. She was on a B-6 vitamin because a B-6 deficiency can cause seizures, but after examining the patterns in her brain, the doctors were able to determine that it was not the cause of the seizures, so they took her off the B-6 supplement.

The other baby Lynn had was born with his insides on his outside. They call them "gut babies" in the NICU. He already had surgery to fix it, so now he is just in the healing process. He tends to be very fussy and want to scream at the top of his lungs when he is in his crib, so Lynn asked me if I wanted to cuddle him. His screaming stopped the second I started to rock him, and pretty soon he was fast asleep. I rocked him for over an hour until it was almost time for me to leave.

Today the person at the front opened the door for me, and I asked, "Which babies does Kelli have today?" She looked at her chart and said, "Well actually, Kelli has mandatory time off today." Does this story sound familiar at all? I ended up with Angie, who I met at the beginning of last week. I walked down the hall and the nurses said, "Speaking of the devil! We thought you'd have school off today!"

Angie had the same two babies as yesterday. Soon after I arrived, I saw one of the babies seizing badly, which I never saw yesterday. It looked like her whole body was twitching and flailing. One of the nurses pressed a red button on the monitor, which marks that they witnessed a seizure so that the doctors can pay special attention to that area of the monitor. Angie showed me that the way to distinguish a true seizure as opposed to tremors is by firmly placing your hand on the seizing area, and if the flailing continues, it's a true seizure, which is what happened. Her seizing lasted for 40 minutes while the nurses dosed her with more medications.

The other baby was screaming all day again, so I cuddled him for most of the day, which really calms him down. One of the nurses came up and commented, "He's really going to get used to you."

Day 5: Homeward Bound

Today was a bittersweet day in the NICU. One of the kids who has been there for over four months was finally discharged! While I'm sure his parents were thrilled, they kept repeatedly saying, "We will really miss seeing you guys every day." I can only imagine the bonds parents build with the nurses, doctors, and staff, especially when seeing them every day for 120-some days straight. Deb was in charge of this boy, so I got to see the complicated process of discharging a patient who still needs lots of medication, oxygen, and 24-hour assistance at home.

Deb had two of the same babies today, and because they are big and almost ready to go home, I was able to do a lot of their care. I changed quite a few diapers, took several temperatures, changed a couple oxygenation cuffs on their feet, and of course fed and snuggled them even more. That's the best part!

Because St. V's is located in down town Toledo, quite a few of the babies who are admitted to the NICU are going through drug withdrawl. I have helped care for several of these babies. The nurses use a system called Neonatal Abstinence Syndrome (NAS) scoring to determine the severity of drug withdrawl and how bad the baby's symptoms are. Deb gave me the sheet that they use to score babies, which assigns a certain number of points to each symptom the baby exhibits. Any score above an eight is considered too severe for the baby to be discharged, and ideally the scores should consistently be zero to three. There are a lot of symptoms of drug withdrawl, but a few are high-pitched crying, tremors, muscle tightness, poor feeding, and watery stools. I have seen all of these symptoms among several of the drug withdrawl babies in the NICU.

The NAS scoring chart