Saturday, January 29, 2011

On Call

I am on call this weekend in North Bay.  Here's what a typical "on call" day looks like for me.

8am: arrive at the Neonatal Intensive Care Unit (NICU) to receive "handover" from Dr. Clayton who has been on call for the past two days.  Handover is a report on all the current patients given by one doctor to another.

8:30am: I speak with the NICU nurses about the babies in the NICU.  I then examine the babies and review any blood work or x-rays.  After gathering all this information, I make a plan for each baby and write a progress note as well as any orders.

Dr. Madden (in orange) with several NICU nurses who are packing in preparation for our move tomorrow!

The current NICU is extremely cramped.  The supply cart and nursing area are crammed together here.  There's really only room for 1-2 mothers to feed their babies at once, and sometimes we have 10 babies!

View from the NICU window, looking out at Lake Nipissing.

There's a baby somewhere in there...

The NICU in North Bay has 10 beds and will accept babies as young as 30 weeks gestation (term is 40 weeks).  Any babies who are younger than 30 weeks will be stabilized and transferred by air ambulance to either CHEO in Ottawa or the Hospital for Sick Children in Toronto.  These hospitals both have a neonatal transport team, consisting of a specially trained NICU nurse and respiratory therapist, who will come and pick up the baby.  If possible, any mothers presenting in preterm labor at less then 30 weeks will be transferred before delivering, since the outcome for the babies is better if they are born at a hospital which has an NICU which can care for them and don't have to be transferred.

9:30am: I leave the NICU and walk down the hall to the pediatric ward. I get a report on each of the patients from their nurse.

10-11:45am: I visit each patient.  I examine them and speak with them and their parents.  Today I had 5 patients to see.  If I think that the patient is able to be discharged then I will send them home after I see them.  I dictate a discharge summary on each patient who's discharged which gets sent to their family doctor.

Typically there are between 2 and 8 patients admitted.  Although sometimes as many as 9 or 10.  Currently pediatrics shares a ward with gynecology, however, at the new hospital, gynecology is moving into a surgical wing, so pediatrics will be alone.

Common causes for admission include bronchiolitis (a respiratory infection in babies), asthma exacerbations, jaundice requiring phototherapy, pneumonia and seizures.

11 am: My rounds on the inpatients have to be put on hold for two babies who have been brought back to have their bilirubin levels re-checked.  Often newborns are discharged home at just over 24 hrs of life and their bilirubin level may be slightly elevated and need to be repeated to ensure that phototherapy is not needed.

I examine the infants and check with the parents that their babies are breast-feeding well.  The phlebotomist comes and draws the blood and I send the babies home.  I will call each family if their infant needs to be admitted or needs to have any further checks of the bilirubin done.  I send the families home because often the result takes 2 hours to come back!

After rounding, I stop by the labor and delivery nursing station to see if there are any consults for me.  Typical consults from L&D include jaundice and any physical abnormalities which are found when a baby is born.  Today there are no consults.

I also confirm that there aren't any women who require my presence at their delivery.  A pediatrician (or resident) is required at every delivery where there is meconium (the first type of stool that a baby passes) in the amniotic fluid since this is a sign of fetal distress.  We also attend any deliveries where there is a concern about the fetal heart rate as well as all C-sections.  There is a C-section every day or two.

12:30: I drive to the pediatrician's office (less than 5 minutes away) where Dr. Madden has called in a patient who he would like me to see.  I examine the patient and then talk with the family with Dr. Madden.

2pm: I am paged by the nurses on pediatrics.  The bilirubin levels are back on this morning's babies.  I call one family back and let them know that the level is low and nothing needs to be done.  I call the second family and ask them to bring the baby back to the hospital to be admitted for phototherapy since the level is high.  The family arrives and I explain the situation and take a bit more history.  The nurses bring in the phototherapy bed and put the baby on it.  He glows blue.
This isn't my photo, but we use the same beds for phototherapy.

The phototherapy works by converting bilirubin in the skin into a water soluble form which is then excreted in the urine.  I expect that the baby should be able to go home tomorrow.  Hopefully before we move to the new hospital.

3:30pm: I go back the the NICU since the parents of one of the babies have come to visit.  I want to give them an update on their baby.  I discuss how the baby is doing and explain what to expect about how long the baby with be in the NICU for (likely until around the time of his due date).  I answer their questions and then head home.

Nursing station on the pediatric ward.
7:00pm: I receive a page from Labor and Delivery, there is a mother in labor with meconium, can I please come for the delivery.  I arrive just before the obstetrician and soon after the baby is born.  He doesn't require any resuscitation.  I write a quick note and decide on the patient's APGAR scores.

APGAR is a score given to all babies at 1, 5, and 10 minutes based on their colour, heart rate, respiratory effort, tone and irritability.  Each category gets a score out of 2, for a maximum of 10.  It helps us know if the baby had any distress at birth.

9:00pm: I'm at home when I receive a page from the NICU nurse.  The obstetrician is going to do a C-section soon.

11:15pm: Another page, this time telling me that the mother is being brought down to the operating room to start the C-section.  I head over to the hospital and get dressed for the OR (I put a gown over my clothes since you're not allowed to wear regular clothes in the OR).  The baby comes out crying and no resuscitation is needed.  We bring the baby to the NICU to be observed until the mom is awake and in her room (usually a couple of hours).

Midnight: I go home and try to get some sleep before the next call.  Thankfully I am able to sleep until 8am when I'm back at the hospital for another full day of work.

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