Stethoscopes and Poop

There are few places that can make an intern feel as inept as can the neonatal intensive care unit (NICU).   The medical care required by premature and very ill infants is unlike anything in the rest of pediatrics.  But before new residents can even begin to build a knowledge base, they must chisel through layer upon layer of the foreignness that envelops the place.  As the interns who rotated in the NICU before me repeatedly intoned, it’s just different over there.

A special language is spoken in the NICU, one awash with acronyms – GIR, HMF, PPHN – whose meanings are not easily intuited.  There is a distinct – and distinctly unique – format for presentations during rounds.  Add to these challenges the fact that the NICU is located in a separate hospital from the rest of the pediatric services, with a separate electronic medical record system, and it becomes clear why new interns find it so intimidating. Not to mention the fact that the babies there make our usual patients look like giants.

As I progressed through my first days in the NICU, I felt increasingly unmoored, drifting ever farther from the competence I craved.  It seemed that there was no time to learn, only to do, yet each task highlighted my ineptitude more than the last.  I asked question after question of the senior residents, the fellows, the attending physician, the nurses and nurse practitioners – anyone, which is to say, everyone, who had more experience than I did.

The best and worst parts were the deliveries.  The pediatrics team was called to the labor room or operating room each time a baby was being born that might need some extra support or resuscitation.  We were called for premature babies, twins, and triplets; for babies who had already passed meconium (the baby’s first stool) and so were at risk of breathing it into their lungs; for babies born to mothers who showed signs infection during labor.  Interns took turns responding to these calls, and were accompanied early on by a more senior member of the team.  Once we had demonstrated proficiency with the required skills, we responded on our own.

It was exhilarating and terrifying: the initial scramble to find the right room, never knowing just how far along the delivery would be by the time you arrived; the frantic gloving – or, for the OR, scrubbing – while checking the infant warmer to be sure that all the right equipment was available and properly functioning; the mental checklist, running on repeat, of just what equipment to use when.  And, of course, the ever-present possibility of being handed a baby that refused to breathe on its own.

As with everything else NICU-related, I asked questions.  I double-checked the indications for giving oxygen and for intubating to suction out meconium.  I even discussed Apgar scores – just how pink had the baby been at that first minute of life? – before committing them to the medical record.

But it was tiring, pestering people with so many questions.  I felt irritating, was even irritating myself.  And so, for anything that wasn’t directly related to patient care, I shied away from querying and began to make educated guesses.

I had begun to feel the first tinges of proficiency when I was called to the delivery room, accompanied by a nurse practitioner seasoned in deliveries.  We arrived just as the baby was about to, and rushed to check our equipment.  I grabbed the stethoscope dangling from above the warming lights and set it down on the table where we would soon place the infant.  I had seen others lay the instrument with its diaphragm on the table and the ear pieces hanging off, but this seemed arbitrary, more of a style thing, and so I laid it my own way, with the ear pieces curled up next to the diaphragm, right next to where the baby would soon lay.

The nurse brought the baby to the warming table and I dried him vigorously.  As she wrangled a hat onto his tiny head, I used a bulb syringe to suction the secretions from his nose and mouth.  He began to cry and, as many babies do, to poop.  Black, sticky meconium poured onto the table, oozing over everything in its path.  The nurse practitioner rescued the stethoscope just in time.  “That’s why we lay it like this,” she said, grinning as she straightened it to lay in the normal fashion, with the earpieces safely out of the meconium’s reach.

And so I went back to asking questions, not only in the NICU but also in every unit where I work.  I ask questions about medicine, about how things are run, and about whether there are better ways to do things than I have already found.  It’s exhausting.  But it helps me to keep learning.

And it also helps to keep the poop out of my ears.

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