Neonatal ICU: Thrown into the Rose

Today, I want this to be beautiful for you. It is intense and trying and miraculous and interesting for me, but for you it is intended straight for your heart (especially since I was planning on studying, but decided writing was more important for my mental health right now and honestly, the only place to which I can turn, really). I do begin with some frank explanations though -you will need them to be able to feel what I feel and hopefully, just know from feeling (oh, how very unscientific a statement that is!).

Honestly, I was quite apprehensive about pediatrics -after 4 half-days in family medicine about 8 months ago, I had decided that I particularly disliked dealing with sick children in a healthcare setting, with all their crying and squirming, etc. But so, I started my pediatrics rotation with two weeks in the Neonatal Intensive Care Unit (NICU) -this is week 2. And goodness, it is heart wrenching... though not only in the way you think.

This is the hardcore, stereotyped stuff of medical school: the typical making Rounds on all the patients every morning and evening, the "pimping" as they call it (i.e. getting constantly put on the spot with a zillion questions to which you mostly do not know the answer, often guess the answer and sometimes, miraculously and from God-knows-where, very certainly and quite confidently know both the answer and the answer behind the answer... of course, this gets better as you go along, so basically, we are all totally and utterly stupid the first few days and by the end we learn so very, very much that we can actually say that... well, we're still relatively pretty ignorant...), and of course the very intense call schedule.

For all the non-medical people (most of you), let me clarify what this "on-call" jargon is all about and how it works, because depending on who you are in the medical food-chain, call entails different things. In the NICU (as in some other specialties as well), med students and residents on-call keep a pager on them while they actually stay in the hospital for the duration of the shift. For med students, because of accreditation standards of the 21st century and the university trying to meet them, this means call until 11 pm on weekdays, but 24 hr call on weekends when you can get the post-call day "off", without the hospital actually giving you a real extra day off... oh those exploitive geniuses! Don't misunderstand me, I'm not complaining because I know how much worse it used to be, but it still could be better... like who wants someone cutting them open when they haven't slept in 24 hours, I ask you?

So what exactly happens when you're on call in the NICU? If you're not being paged for the caseroom (i.e. labour and delivery, who generally call if there's going to be a risky delivery, in terms of premature deliveries, fetal distress, other complications, etc... so they call up NICU, we run in there and prepare to resuscitate the neonate, sometimes just assess a healthy infant, decide whether the baby needs to be admitted to the NICU for observation / investigations / treatment, etc...), then you're rounding on the 20+ infants in the NICU, making sure to follow-up on labs / blood-work / microbiology, stabilizing babies on different forms of supportive ventilation, antibiotics, nutrition protocols, inserting or removing IV lines, etc... and there are bjillion monitors all beeping, all the time for various reasons.

In just little over 1 week, I have seen a few deliveries, assisted / tried to stay out of the way for a few resuscitations, examined a bunch of healthy and sick newborns, learned to juggle keeping up to date on labs and examining and writing up patients and trying to establish a good rapport with the nurses and administrators and my supervisors and colleagues all at the same time, have had 3 calls in 7 days (including one 24-hr call), assisted with 3 circumcisions and prepared and delivered a presentation. I have dealt with desperate parents, sometimes annoying parents who are really just scared to death about whether or not their baby will survive the great physical effort of living, overjoyed mothers, and even a mother who has been to Hell and back after delivering twins prematurely, losing one of them after a short while and now lives for every breath, test and feed of her remaining darling.

I have been deprived of sleep and rest and sometimes, of meals. I have become addicted to matcha green tea soy lattes at Second Cup. I have sneaked scrubs away from the surgery nurses who guard over blues (blues, greens = synonym for scrubs) like crows over cheese (Aesop anyone?)... I have felt privileged and grateful, angry and ashamedly, momentarily hateful. There has been joy and energy, and dragging lethargy. Sometimes, all of these, simultaneously (or at least variable from moment to moment). I have been thrilled with the vibrating of my pager, and also wanted to beat the pager to a pulp at 4:45 am.

Such is the emotional life of a medical student. We are veritably thrown into the rose -the spiral of fragrant petals, blood red, silky soft in its heart, and perilous anywhere else around it. It is beautiful and delicate and ethereal, blossoming and then drooping, perking up with a little nourishment, before wilting again and requiring the extremes of protection in order to survive the harsh weather. I nearly forget whether I am in the rose or whether I am the rose or whether the rose is me. But I know that I am thrown.

Today though, is the reason that I write to you. I assisted with the re-intubation of one of my patients, one of my babies in the NICU. The doctor was having a hard time getting the tube into the infant's tiny orifices (teeny, tiny nostrils and a mouth into which I could barely fit my pinky) -the goal of all this, of course, being to allow for proper and easier ventilation for respiration (ahem, sorry... the more jargon we learn, the harder it is to avoid using it... basically, breathing). Anyway, so doctor and respiratory therapist are failing miserably (before eventually succeeding, many an oxygen desaturation, bagging and suctioning episode later) at intubating this 600-gram baby, in the first few tries (hey, it's a complicated business for anyone, I can assure you!).

And what is my job? To hold baby down. This tiny little thing squirming and crying with its teeny-tiny limbs and tiny little rib cage moving up and down and baby abdomen twisting from side to side, writhing in distress. So I gently hold her limbs down and out of the way of the people who are trying to save her life, really. But I also profer my finger for her to hold onto in her delicate, miniscule hand. And she squeezes hard with all her might through the whole ordeal. I am there to hold her hand. That is all I can do for her right now. She is so small but in all her anguish, there is surprising strength in that grasp, and she squeezes till her fingers and toes are ghostly pale. Her oxygen saturation plummets down and then comes back up with every attempt to intubate and she cries and writhes and squeezes my finger. I tap her feet to help stimulate her and also to reassure her that here I am, baby, I am still here, I am right here, here. It is torture to watch this little thing fight for her life, struggling relentlessly with every effort. And the tears well up, threatening to spring from my eyes... twice. And I hold it together -of course I do, that's my job and my function here. And I pray and I pray and I do what I'm told, and I help suction and I hold baby's hand. And also I love her because everything we do in medicine is so vitally important, but love heals too and she needs my love in all that frenzy. So I just stand there and hold her hand and love her like she was a part of my soul. And then she is stable. She does not die in my arms as in the morbid image that flashed in my mind earlier that morning when I was on the metro. She is alive and more stable than she was before the intubation.

That's the rose. That's where I flew for a few eternal moments in a long and difficult day for many a baby in the NICU. It's true that you should not get too emotionally attached in some ways, but there is so much more to learn and to be gained and to be given if you do allow your heart to be opened. If you choose to go there, it is worth all the pieces of your soul and every breath of your life.