Back On The Night Train

So after a four week reprieve, I'm back to working nights. With the new expansion spreading the patients out and our likely brief lull in patient acuity, there's a feeling of relative calm about the unit so far tonight. Our numbers right now are in the low 50's, and only 2 or 3 on ventilators. Sure a problem or two pops up here and there, but right now we're strokin' along on an even keel. I even had some time this week to catch up on some administrative tasks including catching up on resident evaluations and completing all of my medical records! I feel certain that this week will provide some excitment. Perhaps right now we're experiencing the calm before the storm!

I am currently attending a lecture geared towards teaching how to teach resident physicians. I am quite active in resident education. Teaching adults is different from teaching children. So here I am after work on a Thursday learning how to teach adults!

Tracheoesophageal Fistula

I'm caring for an interesting patient who has what's known as a tracheoesophageal fistula. This is basically a situation in which the trachea (otherwise known as the windpipe) and the esophagus (the food chute) are connected by a small passageway. It occurs in about 1 in every 4500 live born babies. My patient who is only mildly premature, started having some unexplained respiratory distress especially with feedings. It was also noted that there was difficulty passing an orogastric tube. On xray, the tube was noted to be coiled in the upper esophagus (a situation which is diagnostic of TE fistula).
Most patients with TE fistula have a short upper esophagus which ends in a blind pouch (a problem called esophageal atresia). They also have a lower segment of esophagus which connects with the trachea and the stomach. Occasionally, there will be a continuous esophagus and trachea which are connected somewhere in the middle (this is known as an "H-type" fistula).
To correct this, a surgeon enters the chest cavity and closes the connection between the trachea and the esophagus. He then attempts to connect the two ends of the esophagus. Sometimes, the two segments of esophagus are too far apart and some growth is required before esophageal connection can be done. If this is the case, then a tube is surgically inserted through the skin into the stomach (called a gastrostomy tube) as a method of feeding until the child is big enough to connect the two ends of the esophagus.
My patient had his trachea and esophagus separated surgically and was able to have his esophagus repaired during the same operation.

If You Build It, They Will Come... Eventually...

So after struggling to keep our heads above water for several months with too many babies and not enough beds, the new, improved, expanded, NICU opened. Of course, due to a lot of discharges and fewer admissions, we're at our lowest census in months! That's the way it always works, and hey! I'm not complaining. It's nice to have a bit of a break from the hustle and bustle of a unit that's filled to maximum capacity!
Moving day went smoothly with all equipment transitioning seamlessly. Of course, the massively expanded space left me wandering aimlessly at times looking for the new location of my patients. Our maximum number went from 56 to 79 with the addition of three lengthy hallways and a command center reminiscent of Mission Control. I'm now able to navigate the new terrain with some feeling familiarity especially with the reassurance of having a GPS on my cell phone. It's also nice to be getting a healthy dose of exercise during rounds!
All joking aside, the new unit is very nice and state of the art. I'm very excited about having the space and resources to take the best care of patients possible!

Long Week of Night Call.

When I was a Pediatric Resident, Neonatology Fellow, and even within the last couple of years, I've never slept well in the hospital. Oversleeping was unheard of. All of that has changed it seems. Here at the end of this long week of night call, I've managed to oversleep in the call room this morning followed by oversleeping at home this afternoon.
It's kind of a mixed blessing. On the one hand, you think, "well at least I'm getting some rest, however fitful or low quality it may be". On the other hand, you think, "Is this new found 'ability' to sleep just a function of a few more years on the old body?" I'm still sorting through my thoughts and feelings on that one.
Sleep and sleep deprivation really are fascinating topics when you really think about it. Some of the crazy dreams that I've had during this long week of night call and been able to actually recall are fit for the old Psych Textbook for sure. Oh well, I'll be outta here in the morning with some time to pay off my sleep deficit!

Weekend on Roller Skates!

Whoa! What a weekend! I worked both days as the only physician in the unit. Our NICU is still filled to capacity on most days so it made for an intense couple of days. Saturday wasn't too bad, as most everything was going according to plan, but as we all know the chances of that trend continuing for two consecutive days with 60 patients is about as close to zero as it gets.
Yes, Sunday got hairy! Two patients on opposing sides of the unit became rapidly more ill requiring frequent interventions in an attempt to stabilize. Several more patients developed less serious issues, but still required more time, more attention. As I continued to wade through it, the constant murmurings of, "The mother with the 28 weeker is dilated to 9cm... gonna deliver any time... " The voice in the back of my head, "ignore it... it's rumor... focus on what's going on right now... deal with that when it happens... " Me and the crew managed to get through it, and with the evening came a slowing of the pace, a calming of the pulse of the unit, a sort of anti-climactic winding down. And so I slowly plodded my way home to hang up my roller skates until my next weekend in the unit.

The Prenatal Consult (part III)

Picking up where I left off in this string of posts on prenatal consults. The next topic that I discuss with parents is the NICU admission. I explain that after seeing their baby briefly, the baby will be taken to the NICU. Once there, we get a weight and vital signs and start an IV. If the baby is extremely premature, then we place special IV's called umbilical catheters. The umbilical venous catheter is inserted into the umbilical vein and gives us central IV access in order to administer medications and the highest amount of IV nutrition possible. The umbilical arterial catheter is inserted into one of the umbilical arteries and allows us to monitor frequent labs and central blood pressure.


During that first hour or two, we monitor vital signs and indicators of respiratory condition very frequently. I explain to parents that sometimes even if there is no evidence of respiratory distress in the delivery room it may develop following admission. If this occurs, then we usually place an endotracheal tube and administer artificial surfactant. The baby may then require mechanical ventilation for some period of time or may be quickly extubated and placed on nasal CPAP.


I explain to the parents that the admission process usually takes about an hour. I tell them that once the baby is settled in they will be able to come and visit. Visitation in our unit for parents is virtually 24/7, though there is one hour from 6:30-7:30 am/pm that we ask them to step out in order to let the nurses do a change of shift. We also ask that they provide us with a list of people that they would like to be able to come and visit and that they stick to this list (this is to cut down on the amount of traffic in and out of the unit, a place where many immunodeficient preemies live). All visitors are required to be accompanied by one of the parents when visiting.


The next part of the consult involves a head to toe discussion of common complications and their likelihood at this particular gestational age. I'll save that for next time. Stay tuned!