A day in the NICU: Rituals of communication and care

by Tom Ulrich on April 12, 2012

It was 7 in the morning, and the lights were still low in the neonatal intensive care unit (NICU). The babies were stirring, and it was time for the handoff, the first of the day’s rituals.

Walking from crib to crib, the tired-looking doctors from the previous night’s shift were bringing the daytime team up to speed on each child, summarizing from handwritten notes a dozen-plus variables about each baby into a single picture: This is how ill, or well, the child before you is at the moment.

I cover research in Boston Children’s Hospital’s Division of Newborn Medicine, which runs the NICU. I spend more time in laboratories than in clinics. To better understand the questions that the doctors and nurses I work with are trying to answer, I wanted to see what they see every day as they care for some of our littlest patients.

The division’s Donna Brezinski, MD, kindly offered to let me tag along with her for a day “on service,” giving me a chance to take part in the rituals of communication and care, like the handoff, that underlie the NICU’s work.

I learned that some of these children had been in the NICU for months, others for hours. At one end of the spectrum was the little girl recovering from her second surgery for esophageal atresia (the first, performed elsewhere, had not gone well; her parents brought her here to repair the repair); she had been here for eight months. At the other was the baby boy, not even a day old, rushed here the night before; his parents hadn’t even had a chance to give him a name yet.

“We’re a referral unit,” Brezinski told me, “and we literally have patients sent from all over the globe for their care. It’s a place where rarity is common, meaning that it is not unusual to have patients with very rare conditions transferred here.”

Quick on the heels of the handoff ritual was that of the daily care plan. In a scene reminiscent of a courtroom examination, each nurse testified before the doctors about how each of her babies was feeling and what the day held for them.

Then the ritual—as old as medicine itself—of the physical exam. One by one, Brezinski visited each baby under her care. Gently listening to lungs and hearts. Checking dressings and monitors. Looking at skin and eyes. Soothing each child as she finished her exam: “I hate to walk away from a crying baby,” she said.

Around her, the unit buzzed with quiet activity. Parents—often looking tired in a way that sleep could not fix—trickled in and out, visiting babies they could not yet bring home. EEG and ultrasound technicians came and went. Doctors from specialties like neurology, surgery, cardiology, radiology and anesthesia—all tailored here to children’s unique medical needs, and available as the need arises—arrived to discuss their respective specialties’ roles in each baby’s care.

“It’s a place where rarity is common, it’s not unusual to have patients with very rare conditions transferred here.”

All through it, the unit’s nurses went about their work with quiet efficiency, making each baby as comfortable as possible while paying attention to medications, diapers and lines. “I have found the nurses here to be among the most dedicated in terms of pursuing professional advancement in order to effectively deliver care,” said Brezinski, reflecting on her NICU experiences in light of her past work as a community physician. “They are interested in both asking the questions and helping find the answers.”

Though full of ritual activity, no day in the NICU could be called straightforward: As Brezinski noted, “There really is no workflow here, just work.” Today there were two family meetings, one anticipated, one not. There were phone calls and consults. One little boy, his eyes alert and smile wide over the ventilator tube connected to his throat, was leaving the next day for a hospital closer to home in New York; someone needed to arrange his transportation.

And then, suddenly, it was 4 PM. Time to repeat the morning’s handoff ritual, but in reverse. Now the one looking tired, Brezinski walked from crib to crib with her night shift relief—the unit’s medical director, Anne Hansen, MD—using her own handwritten notes to pass on each child’s story for the day.

I pulled on my coat, wondering to myself where the last nine hours had gone. But I was the only one leaving. Her shift over, Brezinski retreated to her office. She still had work to do: enter her notes, work on her grants (the lifeblood of every doctor at an academic medical center), check on her research projects. And prepare to repeat the rituals tomorrow.

 

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