My Old Nemesis, The NICU: Part III

“Hi. I’m the new very, very late intern. Where should I be?”

I just didn’t want to get yelled at. I knew I could make it through the day if the attendings and NPs were just politely irritated with me, but if I got outright YELLED at I’d definitely start crying -, and if there’s one thing I’ve learned neonatologists have in common with surgeons, it’s absolutely zero tolerance for clinician breakdowns.

So that was going to be my order of priorities:

  • #1, Absolutely no crying, and
  • #2 demonstrate that, on the plus side, I’ve already had the month of hell that is NICU as an MS-4 and I at least know the relevant math and fancy acronyms and therefore am not too much of a burden and perhaps might even (hope to god) be useful.

It was go-time.

I had thrown on my scrubs while calling the chief resident (who, upon learning that I was not in fact actually dead, seemed just as disappointed as I was about it. Can’t blame him for that one: there’s probably a set protocol for dead interns. It must be less clear how to manage the dumb oversleeping ones.)

After almost locking the door behind me, I suddenly realized what I needed, and took 20 seconds to run back into the house just to grab a pair of thick, horn-rimmed glasses.

No, I don’t need glasses. I never wear them.

But if there’s one thing I learned from TV it’s this: Nobody yells at the girl with thick glasses. They just vastly over-estimate her IQ and general reliability.

Yes, it’s dumb, but that kind of over-estimation was just what I needed to pin my hopes on in order to not just succumb to my innate desire to write off the entire month and possibly also drive off a cliff.

The difference between

The difference between “Aw, poor girl – that’s a rough start to the rotation” vs “Irresponsible and needs YELLING.”

It might sound dishonest, but I was honest where it counted: when the unit secretary pointed me toward the neonatologists, I walked up and told them straight-up “Hi, I’m Action Potential, I have no excuse. I slept through my alarm. I know it’s inexcusable. What should I get started with?”

Apparently the answer was an ABG, a central line, and pre-rounding on 4 patients in the 30 minutes I had before rounds.

BUT! No yelling!

… Yay?

So, had I been allowed to do ABGs and central lines in medical school, we would be back in the territory of things I could conceivably do.

But I wasn’t.

So we weren’t.

neverbeaherolucy

On the bright side: I prerounded on everyone and managed to come up with plans that made some clinical sense and just generally didn’t suck.

On the shadier side: ABGs and central lines on infants weighing less than a kilo… whose parents trust you because you are wearing a long white coat and introduce yourself as a doctor before torturing their tiny, innocent baby in the name of “practice”…

The NICU and I just don’t get along.

I am beginning to think we never will.

My old nemesis, the NICU: Part II

So we’ve established that my NICU Sub-internship as an M4 left me with nothing but the strong, permanently ingrained sense that “this hell had damned well better be worth it”.

And it sort of was, in that I came to the NICU rotation as an intern already knowing all the lingo and TPN calculations. Which is half the battle! On top of that, I spent the weekend reviewing all the popular pimp questions, making flashcards, and preparing myself for battle.

I was ready. I was going to show those goddamned former residents that this former-M4 was, in fact, perfectly capable of being a NICU superstar and permanently erasing the bad memories of my NICU experience. That horrible M4 month of pain was going to be worth it even if I had to kill myself in the process.

All I had to do to shine, essentially, was show up.

So I carefully went through my 2 page set of alarms and selected the ones for 4:45, 4:50, 5:00 and 5:30…..

… PM.

fucks up consistently

Yes, I set my alarms 12 hours late.

So I awoke Monday morning, bleary and well-rested, to a strange sound.

It was like my alarm but my phone wasn’t making noise? I tried to hit my phone a few times but it didn’t stop. The noise was coming from OUTSIDE MY PHONE.

So I sleep-walked towards the horrible noise and found myself standing in front of my hung-up white-coat, picking up my pager out of the pocket.

Pro tip: If you find yourself waking up in the process of  staring at your pager, it never says anything good.

nicu

holy shit

what is this jeez no text

To be fair, that’s a bit of dramatic license. The page actually said “Just heard from the NICU that you are not there. Please call [chief cell phone] immediately.”

… but it doesn’t change the fact that my immediate reaction was “Shit, I’m not dead.”

if i could breathe i would vomit

yelling into pillow aaaaaaagh

My old nemesis, the NICU: A flashback (Part I)

Some of you might remember the many subdued, nuanced posts I made in 2013 about how my NICU sub-internship made me want to quit medicine, quit life, become a hobo who hops trains for a living and never have to calculate a TFL or realize I forgot to write down a UOP or adjust 42 meds for the brand-new weight of +5 grams ever again so help me god.

fucks up consistently

But more likely none of you remember these NICU sub-I posts because, in looking back to link to them, I realize I must have deleted them all in a fit of self-awareness.

Regardless, it was in 2013 – and lucky for you I lack that same sense of self-aware professionalism 2 years later- so LET ME GIVE YOU A RECAP:

  1. My first day, I was given a “feeder and grower” baby who was supposed to be my simple exercise in NICU mathematics (calculating intake per kilo, counting apneas / bradys / destats, etc.)
  2. My first day, said baby had an eye exam and promptly decided to stop breathing, stop pumping blood, and just generally feign death. Which is apparently a thing that NICU babies like to do.
  3. My first day I was essentially somewhat convinced, for at least the duration of the code blue, that I had murdered the baby.
  4. Probably by failing to properly calculate the fluids/kg/hr.
  5. My second day, I had to present the above to a new attending (who apparently didn’t hear about the code on sign-out? What?) while the mother was in the room (What?)
  6. It was my first NICU patient presentation.
  7. It went poorly.
  8. The senior resident noticed and took me quietly by the hand afterwards to ask me what the hell I was thinking in trying to give a narrative account of what happened as opposed to just going by systems.
  9. You could tell he was disappointed because he literally walked with me for about 20 minutes just trying to find a place quiet enough to loudly voice his disapproval. That made it so much worse.
  10. It’s a little like when a delivery note describes a baby as “stunned”. I was ‘stunned’. I was out of my element. There was no placenta. There was only an angry senior resident speaking words I did not understand.
  11. I cried.
  12. a lot.

The rotation had a few ups on its way to a largely permanently downhill slide, but largely the only redeeming factor it had for me was that goddamnit, I did it. I left that rotation with a well-earned sense of THIS MAY HAVE SUCKED, BUT WHEN I AM ON NICU AS AN INTERN I WILL BE THE BEST NICU INTERN EVER.

i will take what is mine with fire and blood

The worst thing about my NICU sub-I, as a 4th year med student, was that you couldn’t overcome inadequate knowledge with superhuman effort: I tried showing up to pre-round 2 hours earlier, and I learned the hard way that it just meant that all of my calculations would be 2 hours behind everyone else’s. 

When you think about it, that’s just supremely unfair.

(“Uh, sorry, med student? you said the urine output was 3.2? It was actually 2.9. Try doing your math again” “Oh, but I calculated from 5am-5am…” “Well, don’t do that. It’s 7-7am. Because reasons.”)

infuriated silently

But again with the optimism: Most peds interns have no NICU experience when they start- but I had a full month! A bloody, torturous, terrible month as a sub-intern! I know what TPN is and what the abbreviations mean! I know that “trialing CPAP” means trialing off CPAP. I know that grunting is auto-PEEP, and I know how to ask insightful questions when the RT explains HFOV, which will never make any damned sense to anyone, sorry.

(it works by magic.)

the more you know

Anyway.

I started NICU again on Monday: but this time, instead of being the scared sub-I who cries when the intern berates me for reporting 4 bradycardias in 24 hours instead of 5 (“I’m sorry, this makes a difference in your management HOW?”) (<– is a thing I should have said) I will instead BE THAT INTERN.

i'm free 1

Also I don’t have a senior resident.

should i have

Also this may be the worst month of my life.

what have i become eh what are you gonna do

Last month of general peds as an intern

This is beautiful.

I can answer almost all RN questions in satisfying ways that include a confident explanation of the relevant physiology and discharge criteria.

On D/C day my scripts are signed, my follow-up appointments are made – and when attendings ask questions I get to answer “Yes, I thought so too, so I already called X and scheduled Y as an outpatient” and see said attending nod happily in approval as they make a little tick mark on their sign-out sheet.

Sign-out is quick and painless.

I finally understand that when we talk about ‘correction’ insulin it refers to sliding scale orders and not, in fact, carb correction. This is because the medical world is a goddamn madhouse.

This misnomer is still as dumb as ever, but no longer bothers me to the point where it keeps me up at night.

I emailed my new intern ‘buddy’, who is still currently an M4 and has matched here. She will take my place in July and I will get to finally work legit 80 hour weeks (and not the fake 80 hour weeks I’m currently working where seniors and chiefs keep asking me “WHY ARE YOU STILL HERE” and I have to duck behind a chair and respond “I’M A FIGMENT OF YOUR IMAGINATION finishing up my work. I’m not DOCUMENTING it. Shoo. I’m imaginary“)

My new intern buddy doesn’t know what she’s in for.

She’ll have fun though, I think.

I mean – I have, so far.

It’s been a good year.

Newborn Nursery

… is the closest medicine will ever get to an assembly line.

Sure, I have a certain appreciation for how evidence-based newborn medicine is: The NRP algorithm (the process we go through with neonatal resuscitation) is rock-solid. The science is satisfyingly pure physiology. There is no Past Medical History. If the baby so much as blinks at you funny, you simply send it to the NICU for a rule-out sepsis work-up.

And the answer to 99% of new parent questions is “Ah, that’s perfectly normal newborn behavior. Your baby’s body is just trying to figure out how to adapt from being in a dark swimming pool to being in the outside world.”

… literally, that’s pretty much the stock answer I use for almost any parent question.

Sure, I like to change it up a bit sometimes – for newborn congestion I’ll say that it’s the baby’s mucous membranes that are getting used to air instead of water… for erythema toxicarum I’ll say it’s the skin cells… occasionally I’ll have to talk about in utero positioning or birth trauma, sure, but… largely, everyone’s simple.

In fact, I’m getting this weird phenomenon where I really enjoy nurses stopping me in the hall to ask me questions. There’s no dread! No sinking stomach feeling! No problem I cannot solve with stock answers!

No matter what the RN asks, the answers are always so clear! It’s so different from general peds! It’s either

  • “Oh, really? Let me take a look and then we’ll notify NICU.”
  • or “That much weight loss? I’ll go talk to Lactation.”
  • or “OK, I’ll put in the order for bili lights.”

And newborn exams are beautiful. Sure, sometimes, when the census is full, I wish I could just line up all the babies in the hallway and do a slow-mo run down the hallway high-fiving all their anterior fontanelles (“Soft and flat! Soft and flat! EVERYBODY’S SOFT AND FLAT! And I’m done with pre-rounds.”)  to improve my efficiency, but usually I’m okay with going to their rooms individually.

I guess the biggest problem is that newborns are essentially just fat irritable potatoes.

I really miss being able to make faces at babies old enough to laugh or mimic my dumb expressions.

I think I even miss the babies who are old enough to shoot me skeptical looks.

Mostly I just miss babies who are real, live, people.

ONE TICKET BACK TO GENERAL PEDIATRICS PLEASE.

(One more week…)

Peds Urgent Care

“My baby has a cough. Does he have ebola?”

No.

“My son got this lump on his neck right with his cold, do you think it’s cancer?”

No.

“Lovely presentation. Do you want to do any work-up?”

No.

“What about a CBC, CRP, LDH, LFTs, Monospot, and CXR?”

No.

“Okay, we’re going to get them.”

Okay.

“Do you think this kid needs to be admitted?”

No.

“We’re going to admit him.”

Ok.

“It’s a soft call, but it’s a Friday, and I have 32 years of experience. This is where experience tells you if a child will get worse before he gets better.”

Ok.

“Uh, thanks for calling me – most interns don’t remember to call the floor senior before a new admit – but I’m confused… Why are you admitting a totally stable kid?”

Because it’s a Friday. And my preceptor is citing his experience. So, you know.

“Okay. Does your preceptor have any idea of what we’re admitting him for?”

Well, either the lump in his neck will turn out to be a deep neck infection that will cause him acute respiratory distress and send him to the PICU, or it will not. So watch out for that.

“Thank you.”

Anytime.

“My baby is here for his well-child check.”

Your baby is blue.

“He is here for his well-child check. How many shots will he be receiving today?”

He will be receiving resuscitation. Incidentally, why is your baby blue?

“I will need a note for work. Saying that I was here for his well-child check.”

We are calling a code.

“May I have a note now?”

You may not.

 

I just – when were we supposed to learn how to wrangle babies? WHEN?

I feel like I generally actually do a really great job with kids –  but somehow seniors only see me at my worst moments.

Case in point: This morning I was on pulmonology consults, seeing a baby in the PICU. Baby was lying face down and I wanted to listen to her heart, so I gently turned baby face up….

… and oh my god, guys – this is not a thing you should do in the PICU. She immediately thrashed all 4 of her tiny limbs and got herself enmeshed in ALL OF HER WIRES which between the 12 lead EKG, the IVF, the pulse ox, and good god I don’t know what else – this baby was slowly strangulating every extremity and neck on her body.

Basically, my physical exam was only good enough to verify that she did, indeed, have only 4 extremities enmeshed in cords, and 1 neck that was flirting with her EKG leads.

So I sat her up and quickly started the process of untangling every wire which she seemed dead-set on ending her tiny life with (as she HOWLED) and the PICU senior actually came in the room cause the baby was crying so hard.

The PICU senior looked at me.

“Hi,” I said helpfully.

“Ah, good… okay… glad pulm is here,” he said. “Um.”.

“Yes?”

“So… the baby’s only 9 months old. Please don’t sit her up like that. She’ll fall and bang her head on the side of the crib.”

Apparently I had done such a good job untangling all her wires, right in the nick of time, that it now looked like I had just sat her up for the physical exam just, you know, for funsies.

“Right,” I said, clearly expressing this complicated concept “Yeah. No, you’re right. Sorry.”

I laid her back down. She glared at the world at large.

“Cool,” said the senior. He left the room slowly, backwards.

The baby waited patiently for him to leave. Then she immediately flipped onto her stomach and enmeshed every extremity and neck on her body in wires again.

10 minutes later, I ripped off my contact/droplet precautions and met the primary team in the hall.

“Um,” I said to the nurse, with all the brilliant dexterity of the best of interns. “So… I think I untangled her wires. But she’s kind of thrashing around and maybe you want to check? I’m not sure? She’s really upset.”

The attending stared at me. I had probably interrupted him.

“Cause I don’t want to undo all your hard work or anything,” I helpfully added.

The senior was pretending to be extremely interested in the nurses milling about across the hall.

The nurse sighed. “Okay,” she said.

“Great….” I said, walking backwards.

“Great.”

Bronchiolasthma Is Upsetting

Half of our attendings believe that there is an Asthma plan and there is a Bronchiolitis plan – and by mixing the two you might as well be burning incense and chanting ritual Latin over the soon-to-be dead-of-malpractice baby, you non-EBM heathen, you.

… Honestly, their clear-cut attitude greatly appeals to my Evidence-Based soul.

But the other half of our attendings will not take kindly to your clear-cut plan. They’ll just ask you where you got those 10 slabs of stone engraved by God with the Official Universal Rules On Exactly Where The Airway Inflammation Resides In This Particular “Bronchiolitic”.

Who are you to say that a trial of albuterol is pointless just because it’s bronchiolitis? they ask. Are you 100% sure it won’t help?

… and they probably have a point too. Right? I mean.. it makes sense that all inflammation is a continuum and could happen in multiple locations, so why not trial albuterol?

But I’m sick and tired of admitting kids for respiratory distress just to get mocked for my inability to Adhere To Established AAP Guidelines (if the attending falls in Camp 1) or Understand That Airway Inflammation Is A Continuum (if they turn out to adhere to Camp 2).

I didn’t get into medicine just to stake my supposedly scientific plan solely on the attending-of-the-hour’s personal ideology when not even Nelson can explain this shit to me.

but why i need to know why

The Respiratory Therapists are no help, either. My favorite RT once told me:

“It’s not so much a matter of where the inflammation is – what you’ve got to remember is that kids don’t even have bronchiolar smooth muscle until 2 years of age, so even if they ARE asthmatic, albuterol won’t help. That’s why some people say there’s no point to the albuterol trial.”

Which sounded like the solution to all my problems until I actually looked it up. (Spoiler alert: not true).

everything was making sense and now it doesnt

So I bit the bullet and took a pediatric pulmonary elective. Because the Pulmonologists should know, right? THEY SHOULD HAVE THE ANSWERS.

And my very first case of “This is definitely, 100% verifiable on formal PFT and albuterol testing, clear-cut URI-triggered asthma”… what does the Pediatric Pulmonologist diagnos it as?

Bronchitis.

BRONCHITIS.

MOTHER-EFFING FULL-ON ADULT BRONCHITIS because fuck you, that’s why.

igiveup

I hereby rescind all my respect for the respiratory tract. May god have mercy on its stupid, alveoli-filled soul.

This shouldn’t be so hard. Air goes in, air goes out – unless it’s blocked by inflammation, which should be able to be attacked by obvious anti-inflammatory measures, unless it can’t be because of, I don’t know, reasons no one will ever tell me.

Screw you, lungs.

opening wine confidence

Family Centered Rounds Are Bad

Normal Rounds:

Attending: So GI recommends a neuro consult, huh? Do you want to get one?

Me: Well, the patient actually has neuro outpatient follow-up scheduled in two weeks and no acute issues. The relevant genetic labs were drawn yesterday and will likely be pending for at least a week. And after speaking to the GI fellow, I believe he recommended we consult neuro as a way of tacitly implying that he thinks the GI consult was dumb.

Attending: Neuro wouldn’t want an MRI or anything? Nothing we could do inpatient?

Me: Well, a head ultrasound was normal, all he has are diffuse LMN signs without any focal abnormalities on exam – and dysmorphism alone isn’t an indication for a head MRI, especially with pending genetic labs… so…. honestly, definitely not.

Attending: Well, at least curbside neuro – if they agree, the family can go home today.

Family-Centered Rounds:

Me: So, sounds like we’ve gotten all the worrying symptoms under control! Do you feel comfortable going home, or would you prefer to stay another night?

Mother: No, I feel great! So relieved about the new medication. My ride should be here this afternoon!

Attending: Actually, GI floated the idea that we should get Neuro involved – they might want an MRI or something! We could get that done inpatient for you. What do you think?

Me: …!!

Mom: … well, I don’t know… would it help? Do you recommend it?

Me: erm.

Attending: Well, it couldn’t hurt! Here’s how the MRI would go: he likely wouldn’t have to be sedated, cause he’s so small, and I bet we could get you on the schedule for today!

Mom: Well… okay then!

Me: :(

Status-post Family-Centered Rounds:

Neuro Fellow: Okay, so the kid has no acute issues and outpatient neuro follow-up already scheduled. What are you guys consulting us for?

Me: …. the question of whether a head MRI would be indicated.

Neuro Fellow: …

Me: Today. Stat.

Neuro Fellow: Without any focal abnormalities or UMN signs? Really? You’re consulting us for a head MRI for diffuse hypotonia?

… Hey, wait a minute – aren’t you supposed to be in our program in 2 years?

Me: …. that’s… that’s another intern. I’m someone else entirely. Please forget my name immediately, thanks.

My Suprachiasmatic nucleus is SO MAD at me right now

Assessment: 27 yo intern p/w erratic sleep schedule s/p rapid night-day scheduling shift, at risk for impending circadian failure. Post-sched-chng Day #1.

Plan:

  • NPO for AM rounds d.t. professionalism
  • Post-rounds may PO caffeine ad lib, goal volume 200 mL QD
  • Rapid caffeine taper 4 hours prior to end of shift
  • Will not monitor I&Os; could not care less frankly
  • C/s Taylor Swift for reccs on afternoon dance break
  • Dispo: neverrr