There are many ways that neonatologists organize their days and nights. Neonatologists, in common with other doctors who care for critically ill patients, generally work in a pattern in which they spend a block of time caring for patients Monday – Friday, but then are “on call” over weekends, holidays and at night. Weekends and holidays may have either the weekday doctors or other members of the group providing daytime care.
At night, there is a large variability between NICUs in how care is provided. Babies like to be born at night and they certainly need a vigilant group providing care throughout the night, every night. At Texas Children’s Hospital, we have an attending, fully trained neonatologist, who is a faculty member of Baylor College of Medicine, who works all night at the main building NICU (West Tower) and also a second one at our new Pavilion for Women. We believe that our patients at the West Tower and the Pavilion require this level of attention from our faculty.
Each morning, we begin with what is called “sign in” rounds. During this time, everyone gets together to discuss the events that occurred during the previous night. Nursing supervisors report on the number of patients and available beds or other issues. The doctors on call the night before discuss any new patients or changes and problems with existing patients. Often we’ll spend a few minutes reviewing the decisions made during the night and what the basis for them was so we can learn from each other.
After sign-in rounds we begin the daily rounding process with which families are familiar. We do this in teams. Each team consists of an attending neonatologist and then others who are providing bedside medical care. This may be a neonatal nurse practitioner or a resident in pediatrics and there may also be a neonatal fellow on the team. Rounds are designed to be multi-disciplinary. We want each baby’s bedside nurse to participate and we also benefit from routine participation in rounds from pharmacists, dietitians and others including social services to help us with the many complex care issues that arise in caring for critically ill infants.
We strongly encourage families to be present at the bedside for these rounds whenever possible. Depending on how ill some babies are, we may not be able to predict exactly what time each day we will see any individual baby. However, we can generally have an approximate idea of this and if we know a parent is waiting for us, do our very best to make sure we do rounds for those patients while the parents are there.
During rounds, parents are welcome to write down questions and to ask them, both during the rounds and afterwards. Sometimes, especially during the presentations of the events of the night before, families may not understand all of the discussion. This is expected. Families should ask, after the initial presentation, what was said and what was meant.
For example, the pediatric resident might tell me on rounds “Jane is a former ELBW baby who is up 20 g today to 1280 g and is feeding 150 mL/kg/day of FEBM. She’s had no apnea times 3 days and is on NCPAP of 8 which we plan to wean today while continuing caffeine at 7.5 mg/kg/day”. What??? This sounds like a foreign language, and is just part of what the resident will tell us on rounds in rapid fire about each baby.
What these sentences means is that Jane is a baby who was born extremely low birth weight (ELBW < 1000 g or about 2 pounds 3 ounces). She gained 20 g (2/3 of an ounce) in the last day, which is a usual amount for a baby this size, to now weigh 1280 g (about 2 pounds 13 ounces) and is being fed human milk that was “expressed” with a pump that has been fortified (fortified expressed breast milk, FEBM) to provide extra calories and minerals. She is receiving 150 milliliters (5 ounces) of milk for every kilogram of body weight (2.2 pounds), which is considered a good volume to provide enough nutrition for her to grow. She is breathing on her own, but getting some support for her small chest and ribs and to prevent her from stopping breathing using a technique called nasal continuous positive airway pressure (NCPAP or nasal CPAP) and the “pressure” applied to help her is set at 8 centimeters of water pressure.
The team is also giving her caffeine as a medicine at a dose of 7.5 mg for each kilogram of body weight to help her breathing. Thus, she is getting about 10 mg total caffeine. By comparison a cup of brewed coffee has about 200 mg of caffeine. They are beginning to think of getting her off the nasal CPAP by decreasing the “pressure” that is given in it that supports her lungs. This is called “weaning” and typically the team will discuss when they think each baby is ready for that and how they will decide if the baby has “tolerated” coming off this type of support. In this case, she’s no longer having episodes of apnea (moments when the baby stops breathing) over the last three days, leading the team to believe that they can proceed with weaning.
Wow, that was a lot conveyed by the resident in two sentences and about 20 seconds! No wonder it takes time and effort for families to understand the foreign galaxy of the NICU. So, don’t be surprised by this speaking in doctor-language during rounds. It’s part of the NICU experience. Sometimes caregivers don’t understand what a challenge all this is for families. Family members should know that “When in doubt, just ask!” Don’t ever assume that you don’t have a right to know what is being said about your baby or that your questions are dumb. My wife quilts. If I went to a meeting of quilters, I wouldn’t have the slightest idea what they were talking about. What is a “double wedding quilt” and why would you need one when only one wedding is happening?
One more thing we do is study. The literature never stops expanding and we must keep up to date by reading, going to lectures and of course, teaching others. When do we have time for this? We don’t. Hillel said it best about 2000 years ago (Ethics of our Fathers, Pirke Avot 2:5) “Do not say: When I shall have leisure I shall study, for you may never have leisure.”