So far, this has been, hands down, the most amazing rotation of my medical school career. I have amazingly wonderful patients and families, just as inspiring 'teachers' in the NICU NNP's and neonatologists, and patient and encouraging nurses who care infinitely about the welfare of their patients.
Many of the NNP's with whom I am working this month have been working here, in the NICU, for more than 20 years, some more than 30 years. They have seen neonatology grow through infancy into the well-respected and research-backed pediatric subspecialty that it is today. It is a rapidly evolving field, as it has been since it's establishment. The advent of several key therapeutics, such as artificial surfactant, has spun the practice of neonatology from one of many poor outcomes to miraculous rescues of the most fragile lives to challenging the ethics of saving the earliest of babies.
One thing I have witnessed in my two weeks on this rotation is the involvement in the March of Dimes organization with every family whose child is admitted. I have long respected this organization and am anxious to contribute to it on a professional level, but I am also certain that the role they play in the lives of families present and future is monumental to parents struggling to understand the why, how, and what of their respective situations. I am grateful that my future specialty has such and organization with whom to partner.
The most precious twin baby girls were my first patients of the month. As of earlier this week, they have both graduated to the "Continuing Care Nursery," where they can continue to practice eating, growing and prove that they remember to breath as they should. I am no longer responsible for their medical care, but with their parents' blessing I have asked if I can stop by for the occasional visit to check in on them. Their parents are beautiful people and, I'm certain, are going to do fabulously with these adorable little girls.
They will always hold a special place in my heart, as I told their parents, as my first ever neonatology patients. For someone who has been longing for the day when I can enter the field of neonatology officially, recalling the course of these sweet babies will be a memory I call on when the day is not going as well or when I need a reminder of why I chose this field. It also has served as a perfect motivation to me to in this, my last year, of medical school. With graduation now just 182 days away (almost exactly 6 month!), it would be easy to coast in, finish up my interviews, submit my Match lists and wait for June to arrive. Instead, the needs of these little babies has my brain churning with ideas for ways to get involved with the specialty even before I know where I'll be entering pediatric residency in the fall. If something that weighs a mere 2 pounds has the grit to beat their odds, you can bet that I'm going to work as hard as they are at giving them every chance to succeed. I think I have my work cut out for me!
Saturday, December 3, 2011
Thursday, November 24, 2011
Neonatal hyperbilirubinemia
Having just started a new rotation in the NICU at Maine Medical Center in Portland, Maine, I've already come upon the question of phototherapy several times with unsatisfactory conclusions. To manage the hyperbilirubinemia plaguing my two charges, twin ex-32 week (ADORABLE!) baby girls, I've done several interweb searches, consulted the all-knowing Harriet Lane Handbook, and conducted an Up-To-Date search with little, if any, helpful guidelines pertaining to these kids.
The problem is, most bilirubin curves are for 35 week infants and up. And most guidelines regarding preemies offer suggestions for the first 7 days of life, but not beyond. So the current therapy is a hybrid of the two guidelines mixed in with a Tablespoon of experience from the unit's neonatologist du jour. This is a frustrating situation to say the least, not only because some extra thought is required to determine 'to light or not to light', but also because it's not entirely clear if the therapy we're using is really the best treatment for these little girls.
In light of all the other advances neonatology has made in the last decade-plus, it's realistic to think that some studies will begin to pop up soon with more evidence-based data and guidelines for babies like these who fall between current recommendations. In the meantime, here are the current guidelines for preemies and full-term infants when it comes to phototherapy treatments for neonatal jaundice:
And for premature infants:
Begin phototherapy in infants less than 35 weeks GA and who are less than seven days of age :
GA <28 weeks - TB >5 mg/dL (86 µmol/L)
GA 28 to 29 weeks - TB 6 to 8 mg/dL (103 to 137 µmol/L)
GA 30 to 31 weeks - TB 8 to 10 mg/dL (137 to 171 µmol/L)
GA 32 to 33 weeks - TB 10 to 12 mg/dL (171 to 205 µmol/L)
GA >34 weeks - TB 12 to 14 mg/dL (205 to 239 µmol/L)
The problem is, most bilirubin curves are for 35 week infants and up. And most guidelines regarding preemies offer suggestions for the first 7 days of life, but not beyond. So the current therapy is a hybrid of the two guidelines mixed in with a Tablespoon of experience from the unit's neonatologist du jour. This is a frustrating situation to say the least, not only because some extra thought is required to determine 'to light or not to light', but also because it's not entirely clear if the therapy we're using is really the best treatment for these little girls.
In light of all the other advances neonatology has made in the last decade-plus, it's realistic to think that some studies will begin to pop up soon with more evidence-based data and guidelines for babies like these who fall between current recommendations. In the meantime, here are the current guidelines for preemies and full-term infants when it comes to phototherapy treatments for neonatal jaundice:
For infants >35 weeks, guidelines for initiating phototherapy:
- For infants at low risk (≥38 weeks gestation and without risk factors), phototherapy is started at the following TB values.
- 24 hours of age: >12 mg/dL (205 micromol/L)
- 48 hours of age: >15 mg/dL (257 micromol/L)
- 72 hours of age: >18 mg/dL (308 micromol/L)
Infants in this category who have TB levels 2 to 3 mg/dL (34 to 51 micromol/L) below the recommended levels may be treated with fiberoptic or conventional phototherapy at home.
- For infants at medium risk (≥38 weeks gestation with risk factors or 35 to 37 6/7 weeks gestation without risk factors), phototherapy is started at the following TB values.
- 24 hours of age: >10 mg/dL (171 micromol/L)
- 48 hours of age: >13 mg/dL (222 micromol/L)
- 72 hours of age: >15 mg/dL (257 micromol/L)
The threshold for intervention may be lowered for infants closer to 35 weeks and raised for those closer to 37 6/7 weeks.
- For infants at high risk (35 to 37 6/7 weeks gestation with risk factors), phototherapy is initiated at the following TB values.
- 24 hours of age: >8 mg/dL (137 micromol/L)
- 48 hours of age: >11 mg/dL (188 micromol/L)
- 72 hours of age: >13.5 mg/dL (231 micromol/L)
And for premature infants:
Begin phototherapy in infants less than 35 weeks GA and who are less than seven days of age :
Another useful tool for determining the same, available online and as a mobile app, is BiliTool. Using the baby's date of birth, date and time of blood sample and total bilirubin level, a risk stratification (ie, "low risk," "moderate risk," etc) is assigned to guide in determining need for phototherapy. These guidelines however are only intended for infants >35 weeks gestational age as premature infants have been determined to need more aggressive phototherapy protocols.
Wednesday, October 19, 2011
The notepad used by the Pediatric Cardiology nurses
For those days when you've just had to be thankful for the little things!
Onward toward the Match!
Tomorrow wraps up the final day of my Pediatric Cardiology rotation at the University of Tennessee at Chattanooga Pediatric Residency Program. It's been a great month, filled with murmurs and echos, interview invites, and 2 completed interviews. These interviews took place at UT Chattanooga and the Cleveland Clinic (Ohio).
I started this year with the frustration of having my first two rotations in Pediatric Hematology and Oncology and General In-Patient Pediatrics cancelled and having to lunge at a rotation back at my "home base," the Asheville VA Hospital, for an adult ICU rotation. Despite what seemed like a rough start to the year, during that month in the ICU I learned about pulmonary critical care, received a generous recommendation letter from my ICU attending, passed my USMLE exam, and got a rotation set up with Asheville Children's Medical Center, practice of long-time family friend Dr. Bill Bryan and his colleagues Dr. Sam Kohn, Dr. Colby Grant and Dr. Bridgette Fogleman. Having had a full year lapse since my last pediatric rotation, I was a bit apprehensive about starting this rotation, but all of these docs took me under their wing and taught me how to fly. I learned and saw so much during this month, and on top of that, had an absolute blast doing it! They have wonderful personalities with more than enough knowledge and enthusiasm for teaching than I could have ever asked for. To make things even better, their office staff was simply amazing, both with the fluidity with which they kept the practice moving smoothly and with their welcoming attitudes, taking me in as if I belonged there. I am absolutely grateful to each and every one of them for all they taught me in those four weeks.
This month my Pediatric Cardiology rotation has been similarly educational. Working with "Dr Nisha", Dr Johnson and Dr Hays for the past 4 weeks has given me a solid insight into the world of congenital heart defects and the impact they have on the lives of patients and their families. I feel much more comfortable with recognizing an innocent/benign murmur than I did 4 weeks ago, and I have a deeper appreciation both for the altered lifestyles of the bearers of these defects and the upkeep that is required on the part of the physicians in maintaining the cardiovascular function of their patients and in constantly searching for new ways to treat these patients to maximize their lifespan and ability to participate in their own lives.
Tomorrow, or perhaps Friday, I leave for Denver, Colorado. There I will be spending a month with the University of Colorado at Denver Pediatric Residency program at Denver General for a Pediatric Sub-Internship. This is my chance to show off what I have learned over the past 3 years, but more importantly, what it is like to work with me and what an asset I would be to this program. I interview with them during my second week there and am hoping to make a better-than-good impression to have a chance at being ranked by them during the Match process. I have five additional interviews scheduled in the next 3 months and I anticipate scheduling at least as many more, but I know that whether or not Denver is the best program for me, I am going to have a great month and try to learn as much as possible. It'll also be a great chance to brush up on my Spanish and begin incorporating some medical Spanish into my basic conversational Spanish background, which I know will be an asset no matter where I end up.
Tengo que prepararme para el examen de manana, asi que le deseo una buena noche!
I started this year with the frustration of having my first two rotations in Pediatric Hematology and Oncology and General In-Patient Pediatrics cancelled and having to lunge at a rotation back at my "home base," the Asheville VA Hospital, for an adult ICU rotation. Despite what seemed like a rough start to the year, during that month in the ICU I learned about pulmonary critical care, received a generous recommendation letter from my ICU attending, passed my USMLE exam, and got a rotation set up with Asheville Children's Medical Center, practice of long-time family friend Dr. Bill Bryan and his colleagues Dr. Sam Kohn, Dr. Colby Grant and Dr. Bridgette Fogleman. Having had a full year lapse since my last pediatric rotation, I was a bit apprehensive about starting this rotation, but all of these docs took me under their wing and taught me how to fly. I learned and saw so much during this month, and on top of that, had an absolute blast doing it! They have wonderful personalities with more than enough knowledge and enthusiasm for teaching than I could have ever asked for. To make things even better, their office staff was simply amazing, both with the fluidity with which they kept the practice moving smoothly and with their welcoming attitudes, taking me in as if I belonged there. I am absolutely grateful to each and every one of them for all they taught me in those four weeks.
This month my Pediatric Cardiology rotation has been similarly educational. Working with "Dr Nisha", Dr Johnson and Dr Hays for the past 4 weeks has given me a solid insight into the world of congenital heart defects and the impact they have on the lives of patients and their families. I feel much more comfortable with recognizing an innocent/benign murmur than I did 4 weeks ago, and I have a deeper appreciation both for the altered lifestyles of the bearers of these defects and the upkeep that is required on the part of the physicians in maintaining the cardiovascular function of their patients and in constantly searching for new ways to treat these patients to maximize their lifespan and ability to participate in their own lives.
Tomorrow, or perhaps Friday, I leave for Denver, Colorado. There I will be spending a month with the University of Colorado at Denver Pediatric Residency program at Denver General for a Pediatric Sub-Internship. This is my chance to show off what I have learned over the past 3 years, but more importantly, what it is like to work with me and what an asset I would be to this program. I interview with them during my second week there and am hoping to make a better-than-good impression to have a chance at being ranked by them during the Match process. I have five additional interviews scheduled in the next 3 months and I anticipate scheduling at least as many more, but I know that whether or not Denver is the best program for me, I am going to have a great month and try to learn as much as possible. It'll also be a great chance to brush up on my Spanish and begin incorporating some medical Spanish into my basic conversational Spanish background, which I know will be an asset no matter where I end up.
Tengo que prepararme para el examen de manana, asi que le deseo una buena noche!
Wednesday, August 24, 2011
New Chapters, Old Chapters
Hello friends!
If you've found your way to this blog, chances are you, like me, are interested in the medical specialty of pediatrics. I am a fourth year medical student at Via College of Osteopathic Medicine in Blacksburg, VA. I have intended on entering the specialty of neonatology since before I began medical school, and it has stuck! Neonatology is a fascinating field that is rapidly evolving with miracles occurring every day. Whether you are a pre-medical undergrad, a medical student interested in pediatrics, or a pediatric resident, I hope you find this blog and the information contained within useful. Happy studying...but don't forget about recess!
Subscribe to:
Posts (Atom)