HELP ME!! I start in the NICU...

[beaner]

I start as an intern in the NICU next month and I am terrified! Any advice?

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[oldbearprofessor]

I start as an intern in the NICU next month and I am terrified! Any advice?

The NICU is a team environment in a manner that I think is unique in medicine. You have friends in the NICU if you make them and treat them with the utmost of respect, courtesy and humility as people who know what they are doing around premies while you don't. Act superior and they'll make you pay big time.

They are:

Nurses (Bedside and nurse practioners)
Respiratory therapists
Dietitians
Pharmacists
Occupational and physical therapists
everyone else, such as radiology technicians

Be very, very nice to them and they will guide you.Try to learn as many of their names as possible as quickly as possible....

A few specifics...

1. Always ask the bedside nurse before handling, turning or otherwise disturbing a sleeping NICU baby. In fact, introduce yourself to the nurse of each of your babies each day and ask when it would be the best time to examine them.

2. Show the blood gasses to the respiratory therapists and ask what they think should be done, THEN go make the same suggestion to your senior resident, fellow, whatever - 99% of the time the RT is correct, the other 1% the gas is so bad it needs to be bumped up to the fellow or attending level to work with.

3. Ask the nearest dietitian to teach you the basics of infant formulas and TPN in the NICU. Be respectful, they know more neonatal nutrition than you'll ever know unless you do your research in neonatal nutrition as a fellow (hmmm, good idea.....).

4. Learn exactly on day 1 where to find the information you need on the nurses charts - ask them when they aren't busy where they chart the I/O, weight, VS, etc. If you're really nice, they'll help gather the info you need for rounds.

There are more, I'll let some of my colleagues add to this list...

Regards

OBP

 

[jamie]

I start as an intern in the NICU next month and I am terrified! Any advice?

In my NICU experiences, this is where I've been the most heavily supervised (always multiple people around, on call with the hospitalist, fellow, or attending). Sometimes, it's frustrating because I feel like I have the least amount of autonomy here, but, on the other hand, it's hard to screw up a baby because so many people are looking after the same babies (especially with brand new interns starting). And the deliveries are fun to attend.

Hopefully, you'll get sign-out/orientation the day before from the outgoing intern (this is expected at my program). Even before I started in the NICU this past month, I went down, and the intern who was going off-service showed me around -- the computer system, the unit, where to find things, etc. After 3 or so days, you'll get into the rhythm and feel much more comfortable.

 

[kristing]

I start as an intern in the NICU next month and I am terrified! Any advice?

I think all of the advice so far has been very good, but I must add...

first - deeeeep breath
second - realize - they KNOW you are in your first month of residency. It's ok to not be perfect.
third - remember "it's not personal." if you are this worried now, you are a conscientous person, I imagine, and in a lot of NICU's, the atmostphere can be sort of stressfull. You may get nurses not being nice to you. You may get attendings not being nice to you. (it's generally more common than other areas of peds subspecialty, I have noticed). I think if you realize that the rotation is not as much of a happy one as other peds months, you will be ok. There are exceptions to this... The residents at Christ in Chicago LOVED their NICU fellowship... But that's the only one I have ever come across...

 

[oldbearprofessor]

I think all of the advice so far has been very good, but I must add...

You may get attendings not being nice to you. (it's generally more common than other areas of peds subspecialty, I have noticed). I think if you realize that the rotation is not as much of a happy one as other peds months, you will be ok. There are exceptions to this... The residents at Christ in Chicago LOVED their NICU fellowship... But that's the only one I have ever come across...

I promise you that I am nice to interns. When they start later this month (I am rounding with them on July 1 and 2 ), should I ask them if I was nice to them and post the responses?

Regards

OBP

 

[notstudying]

Every time I rotate through the NICU the first few days feel horrid (I started there on my senior rotation last Monday-a holiday!-so this feeling is fresh in my mind!), but the learning curve is incredibly steep. Things to remember:

1. It is a completely new language. When you here the report that "This is a DOL 42 for this 32 4/7 twin B with BPD, NEC, short gut, wt today is 1565, up 5, now at total fluids of 150, receiving MJ3232A with 3% polycose..." Just remember that in just a few days, you will not only understand what that person is saying, but be able to recommend adding 1cc MCT if the weight gain isn't adequate!

2. It is a completely new system-this you will also learn soon, and as much of an idiot I felt on my first few days ("Do I HAVE any brain cells???"), most of NICU is somewhat formulaic (with apologies to OBP!)- most of the babies are preterm, and have RDS, or BPD, and the big things you worry about are sepsis, NEC, apnea of prematurity, and NEC. Many also are there to rule out sepsis, because of tachypnea or maternal infection. Each of these has its own signs, symptoms, and regimen of treatment. You will learn these fast, especially in a NICU like ours where we have 50 babies. Then you can learn about the less common (and to me, more interesting) problems such as CDH, gastroschisis/oomphalocele, CCAM, PPHN, etc.

3. It is vital to be nice to the nurses and respond to them. You will learn which ones are really on the ball, and if they don't come to you the baby is OK, and if they do they are sick. Unfortunately there are some that will miss details (like, say, a baby who hasn't peed in 12 hours), and come to you for a 1cc residual on a 30cc feed (normally not a big deal). If you are concerned about a baby, there is no substitute for checking in periodically and looking over the numbers. And double check the math from the flowsheets (like urine output in cc/kg/hr-our nurses' numbers are notoriously off!).

4. Respiratory therapists are your best friends-they are in general very knowledgable. My usual tactic is to look at the gas, propose a change, and watch their face to see whether I'm in the ballpark. Then I do what they say.

5. Don't be afraid to ask questions-everyone knows you are new and scared out of your mind!

 

[Palmetto]

I just found out yesterday that I'm starting in the NICU as well (where I will outweigh my patients by approximately 99.5 kilograms) so this thread just became a lot more relevant to me. Any recommendations on a pocket guide to toss in the bag? I've heard good things about Lange Neonatology, but thought I'd open the question up to the experts. And by experts, I mean OBP.

July 1 -
August 1 -

Thanks!

 

[oldbearprofessor]

I just found out yesterday that I'm starting in the NICU as well (where I will outweigh my patients by approximately 99.5 kilograms) so this thread just became a lot more relevant to me. Any recommendations on a pocket guide to toss in the bag? I've heard good things about Lange Neonatology, but thought I'd open the question up to the experts. And by experts, I mean OBP.

July 1 -
August 1 -

Thanks!

That book, by Trish Gomela has always been my favorite although you might also check out "Manual of Neonatal Care" by Eric Eichenwald.

My real bias however, is that interns don't need to buy any book. Why? Well, you probably won't be carrying it around with you in the NICU and when you need to look something up, the neonatal section of Up-To-Date will have almost everything you need to know. A few practical tidbits might not be there, but almost always there's a textbook hanging around an NICU to tell you things like how to measure UAC placement, etc.

To make a more general comment to all of you lurkers about to dive into the NICU soon, remember to really think about how you like or don't like the experience there. There are some residents who really hate it and that's okay as long as they do a good job - after all, I hated adolescent medicine and wasn't that fond of the ER. There are a larger group of residents who tolerate it but expect to do general pedi and don't see its relevance - for you guys the key is getting comfortable both with the normal exam (esp. things like PDA-closing murmurs) and mild respiratory distress, etc. But there are, I think, a substantial number of interns and second years who, despite themselves, really discover they like the NICU. This is helped of course by having good senior residents/fellows and perhaps faculty there.

For this group, I say, fess up to those feelings and consider neo as a career - write me, I promise I won't tell anyone such as your fellow residents who are B$#@ing about the place. Even if you don't do neo, you might find that cardiology or critical care suit you. Of course, if you're at my institution, just come talk to me directly!

Regards and good luck. Write us back August 1 and let us know if it was better or worse than you'd expected (or feared!)

OBP

 

[ekydrd]

Thanks for your input OBP. I am actually finishing up my first year of residency and just did my first NICU rotation last month. While it seems I should be more comfortable with my knowledge base I felt just like a brand new intern that first day. It was an incredible experience, and I feel now that I can probably manage a not so sick premie, and got pretty good at central sticks, LPs and intubation of something other than a plastic headed dummy, and made some nurse friends along the way. I hope that all the newbees have as good an experience as I did (it helps to have a great attending who loves to teach, great fellows and nurse practitioners who are very patient, and a super nursing staff who are willing to help you learn).

 

[RuralMedicine]

Show the blood gasses to the respiratory therapists and ask what they think should be done, THEN go make the same suggestion to your senior resident, fellow, whatever - 99% of the time the RT is correct, the other 1% the gas is so bad it needs to be bumped up to the fellow or attending level to work with.
OBP

While I would certainly emphasize that good RTs can be invaluable I'd caution any physician or medical student to take the approach of here is the information now tell me what to do with it without first thinking for yourself. (Outside of the truly life or death code situation--but if you're proposing getting the answer from the RT and then parroting it to someone else it implies that a little time delay is acceptable). I was pretty comfortable with ABGs and ventilator management before my first NICU tour as an intern (admittedly ventilation strategies in the NICU are a little different although we're now seeing variations on HFOV and jet ventilators being used more in PICU and even adult situation) so I was usually able to at least propose a reasonable interventions to the ABGs I was handed. Attendings and fellows helped me fine tune and expand my interventions and I did learn some neat tricks from the RTs along the way. I don't in any way mean to discourage you from considering the RTs colleagues or imply that they won't teach you (because if they don't you've missed out) but I'd be leary of any strategy that discourages independent thought. There will be times (not as an intern perhaps because there are others who should be involved first and then take the stand) when you should go against the RT's recommendations.

Good Luck in your NICU tour and your pediatrics residency. OBP's other suggestions seem quite useful and although the problems and patients will be different you would be wise to expect a similar cast of characters and team dynamics as you rotate through the PICU either later in your year or as an upper level.

 

[oldbearprofessor]

While I would certainly emphasize that good RTs can be invaluable I'd caution any physician or medical student to take the approach of here is the information now tell me what to do with it without first thinking for yourself. (Outside of the truly life or death code situation--but if you're proposing getting the answer from the RT and then parroting it to someone else it implies that a little time delay is acceptable). I was pretty comfortable with ABGs and ventilator management before my first NICU tour as an intern (admittedly ventilation strategies in the NICU are a little different although we're now seeing variations on HFOV and jet ventilators being used more in PICU and even adult situation) so I was usually able to at least propose a reasonable interventions to the ABGs I was handed. Attendings and fellows helped me fine tune and expand my interventions and I did learn some neat tricks from the RTs along the way. I don't in any way mean to discourage you from considering the RTs colleagues or imply that they won't teach you (because if they don't you've missed out) but I'd be leary of any strategy that discourages independent thought. There will be times (not as an intern perhaps because there are others who should be involved first and then take the stand) when you should go against the RT's recommendations.

Good Luck in your NICU tour and your pediatrics residency. OBP's other suggestions seem quite useful and although the problems and patients will be different you would be wise to expect a similar cast of characters and team dynamics as you rotate through the PICU either later in your year or as an upper level.

Okay, I confess that I was simplifying a bit on that one! My basic purpose was to remind new interns and residents that RT’s are a source of a lot of knowledge that often is vastly underutilized in an NICU. In the last 5-8 years, there has been a tremendous change in how very sick babies are ventilated and it continues to be changing. Gone is the era of looking at a gas and usually just deciding whether to change the peak pressure or the rate and what to do with the inspiratory time while changing those. Now, one has to consider target volumes, oscillators, pressure support levels and more. With the introduction of some of the newest ventilators, each breath’s hysteresis curve is displayed allowing very real-time ventilator manipulations based on the wave form. The RT’s often know as much or more about details of these ventilators than even attendings, at least at first, and for sure they know about them more than most residents in their first month of the NICU. So, a resident should first think about the gas and then consider asking for advice from an RT (or nurse) and then ask them WHY they made that suggestion. Then, the intern can make their suggestions to the senior resident, etc. I still think that the overwhelming number of times they will get good advice from the RT’s, especially once they get to know them. Like everyone in the medical care field, some are better than others.

Now then, since you asked, in looking at a blood gas in a neonate as an intern or someone starting in the NICU make sure to look carefully at the acid-base status, the pCO2 and the oxygen. We tolerate higher pCO2’s in an NICU and lower pH’s than most other places in a hospital and often lower saturations. Always look at the recent gasses if available on the same baby. A baby with a pCO2 of 65 could be a stable nasal CPAP or ventilated BPDer or could be acutely decompensating. The pattern of gasses, as well as the history are needed. The cardiologists have different ideas about what is a good pH for their babies than we do for our premies. Above all, do NOT be in a hurry to push bicarbonate on an unstable ventilated baby. Managing ventilators is, in my opinion, a tough job, especially nowadays. Not as hard as feeding babies, but still hard!

Regards

OBP

PS: All the new interns in my program will see me in the next week. Don’t forget to say hi and introduce yourselves. You can’t miss me, I look like my avatar.

 

[RuralMedicine]

Regards

OBP

I like the new avatar

 

[oldbearprofessor]

I like the new avatar

The photo's a few years old (that's one of my kids in the background with a friend holding oldbear). Unfortunately, unlike me, oldbear never seems to go grey. But you can see why my kids loved oldbear