Join medical resident Siobhan Deshauer, MD, for a shift in the NICU with Nikki, a nurse practitioner. Learn about what’s involved in caring for premature babies.
Following is a rough transcript (note that errors are possible):
Siobhan Deshauer, MD: Hey, guys! I’m Siobhan, a 5th-year medical resident, and today I’m bringing you to the largest neonatal ICU in Canada. We’ll be shadowing a nurse practitioner as she cares for the tiniest, sickest babies in the hospital. I have got to admit I’m actually a bit nervous. In this NICU, they care for babies who are delivered as early as 22 weeks. That’s tiny, and it’s so far out of my comfort zone as an adult doctor.
Nikki: Welcome to the NICU. We’re thrilled to have you here.
Deshauer: This is Nikki. She started out working as a nurse in the NICU and then went on to complete her Master’s in nursing to expand her skills and become a nurse practitioner. Now, she can order tests, prescribe medications, and even do advanced procedures like intubation and chest tubes.
Nikki’s day starts by receiving handover about any issues that came up overnight. As a nurse practitioner, she cares for about six patients per day, similar to a resident doctor. Now, it’s time to head into the unit.
Nikki: You might wonder why some of our babies are covered in this kind of fashion, and that’s just because we really want to mimic what it might feel like in mom’s belly still. In there, they’re nicely tucked in a warm isolette with humidity in a dark, quiet environment, just like they would be if they were still in mom’s belly.
Deshauer: Now, it’s time for a special time called handling when all the medical care for the baby is clustered together. This includes physical exams, vital signs, blood work, x-rays, and newborn care like diaper changes and mouth care. The goal is to only disturb the baby a few times per day because when they are sleeping their brains are actually developing. I just love seeing how parents get involved in the care and get to spend some extra time with their baby.
While Nikki is going to be caring for many babies today, we are going to be focusing on one particular family: baby Kalani and her mom, Paola. For the first 5 and a half months, Paola had a normal healthy pregnancy. Then, without any warning, she went into labor shockingly early, at 23 weeks and 5 days.
Paola: I just really separated myself. I’m like, “Okay, this isn’t me. This isn’t what’s happening to me right now. This is what’s happening to my body, and this is what’s happening to my baby right now, so we need to … this is what’s going to happen.”
Williams: We often talk about survival because that’s the first thing that parents are thinking about going into labor at 23 weeks. “What are the chances our baby will survive?” For a baby like Kalani, her parents would have probably been told her chances of survival are somewhere around 50% to 60%.
In our survivors, so babies that do survive at 23 weeks, there is a higher risk of some developmental delays. We talk about things like learning difficulties in school. There is a higher risk of autism or ADHD [attention-deficit/hyperactivity disorder]. We might also talk about things like cerebral palsy. We’ll also screen for vision and hearing difficulties.
Deshauer: Then another surprise, her baby was in a breech position, which meant Paola needed a C-section — also not part of her plan. Paola didn’t get a chance to see her baby, hold her, or even hear the reassuring sound of her cry. At such a premature age, babies can’t breathe on their own yet. As soon as the baby was delivered, she was rushed off to be stabilized and intubated.
Unlike adults, babies are often intubated through their nose, and then the breathing tube is pushed down into their trachea so that the baby’s lungs can finally fill with air. Then, they put in a central line, basically a big IV, to take blood work and give medications. But rather than putting a central line in the neck like we do for adults, they put it into the baby’s umbilical cord, which has a big artery and vein.
Paola: I went to recovery and then they brought her down the isolette beside me. They like let me see her …
Paola: … and put my hand in. They let me see her and then they said, “Okay. We need to go.” Then, they brought her to NICU. Then, I went to postpartum and I went to breastfeed her later that night. But everything was very, very [quick].
Deshauer: At birth, Kalani weighed only 580 grams [about 1.3 lbs]. That’s six times smaller than the average full-term baby. It must have been so tough to be then separated from your newborn.
Paola: Oh, that was the worst part — not a second to process it. There was nothing I could have done to prepare for it, so it was a lot.
Deshauer: The first 72 hours after the birth of an extremely premature baby is critically important. This is the highest risk for brain injuries, often bleeding in the brain. The protocol is to minimize any disturbances during this time, which meant Paola couldn’t even hold her baby.
After making it through this initial critical period of time with minimal disturbances, she went through lots of tests, including an ultrasound of her head that showed no bleeding in her brain. What a relief! This was the beginning of a long journey as the medical team anticipates the needs of a growing baby that would normally still be inside their mother.
To help her lungs mature, she received IV steroids. Because of her immature bone marrow, Kalani received multiple blood transfusions. To stimulate her brain to breathe, she was given caffeine citrate. To improve her growth, extra nutrients were added to the milk. Every day Paola was there by Kalani’s side, experiencing good days and the terrifying ones.
One thing that really stuck with me is that you said that nobody gets it.
Deshauer: That people don’t get it. What is it that you find people don’t really get?
Paola: Ever since … I mean, even when I had her, everyone was sending me nice messages. “Congratulations!” “This is so amazing.” Like, “I’m so happy for you.” I just felt like this is not a congratulations-worth situation. I think people don’t understand like the magnitude of what a 23-weeker looks like and what that even means. That I think people just think that she is sitting in an incubator and growing, peacefully growing in an incubator, and she is just there being warm.
But that’s just far from what happens. Until you walk in here and you see really what goes on, you can’t get it. You won’t get it. I think it’s like a very like lonely experience.
Deshauer: How have you been able to cope with this? I mean, most new mothers, it’s a huge adjustment and there is a lot of people who struggle. That’s not even including all of this that’s going on in NICU. How are you managing?
Paola: Honestly, the nurses. I know it sounds like so like, “Oh, you’re just, ‘Oh the nurses,'” but, no. The majority of the time I spend here is because everyone here understands what I am going through and knows my baby so well, and enjoys the milestones with me. They understand these little things about how exciting they are.
Deshauer: With each week that goes by, Kalani grows stronger and Paola becomes more and more involved in her care.
Paola: This week, or the past 2 weeks, she is becoming a baby.
Paola: She is becoming an actual baby that I can interact with and like I know what she wants now. I know what’s going to calm her down and I know the way she likes to be positioned. I know what she needs.
Deshauer: This experience has given Paola a unique insight into human life.
Paola: I have such a greater appreciation for our bodies and like in general. If you can carry a baby to term, I am like, “You’re a miracle.” I even sometimes lay in bed at night and I’m like I’m breathing, just like that. I’m just breathing. That’s like … it blows my mind because she … who knows? Like will she be able to do that on her own without some assistance? Who knows?
Deshauer: Well, we’ve got every finger and toe crossed for her.
What a strong incredible woman she is. Oh my gosh. It’s actually a lot to take in, especially as a young woman myself, imagining things going so differently than you planned, living with so much uncertainty and having your life just change in an instant.
I mean, I’ve got to be honest. It makes childbirth sound really scary, and yet I see this incredible bond that Kalani and Paola have together. It’s so special and how she celebrates all the things that she has achieved already in life. I just hope that they can get some certainty and get some answers about why Kalani is still intubated.
The biggest issue that baby Kalani is still facing is her airway. Because now that she is 36 weeks old, it’s more unusual for a baby, even a premature baby, to still need to be intubated. The question is, why? The medical team is still trying to figure that out.
It’s likely a combination of things. Maybe her airways are still a bit small and when she’s breathing they are partially collapsing, in addition to a condition called bronchopulmonary dysplasia. Bronchopulmonary dysplasia is a chronic lung disease that develops in newborns after some kind of damage to their immature lungs. This can be from the pressure of a ventilator or even exposure to high levels of oxygen. Luckily, most infants recover within their first few years of life and that’s what we are really hoping for Kalani.
Now, it’s time for rounds, where the entire medical team discusses Kalani’s case. This includes the neonatologist, Dr. Williams, nurse practitioners like Nikki, a respiratory therapist, dietitian, and bedside nurse. Plus, they encourage parents like Paola to be present for rounds so that they are involved in the care decisions.
Female: Her oxygen was 28 to 30 most of the nights. We did have to go up to 46 with the handle, but have been slowly leaning back. Still swinging quite a bit, but no bradys. Feeds are …
Deshauer: Just as the team was about to move on to the next patient, Kalani’s oxygen saturations dropped into the 70s. Quickly, the team mobilizes around her bedside. Her bedside nurse places her hand on Kalani’s belly to feel her respiratory rate and the respiratory therapist suctions her breathing tube.
We all watched the monitor, and a few seconds later breathed a sigh of relief as her oxygen levels returned to normal. The tube had gotten blocked by some secretions, which have now been cleared, so crisis averted. You can see how things change so quickly, and that’s why there is a bedside nurse watching these babies closely day and night.
Finally, rounds are over. Kalani is sleeping happily and Nikki finally has a chance to sit down and start her documentation. Paperwork is one of those things you just can’t escape in any field of medicine.
I just can’t get over how small and fragile these little babies are compared to the adults that I treat.
Nikki: One of my most favorite part about the job is the family and integration portion of things. We also really love to personalize every single baby’s bed spot. We do this by making crafts and name banners. The staff and the parents work together for this.
You can imagine that being born at 23 weeks you’ll have 4 or 5 months, sometimes more, in the hospital and it’s so important to make it really feel like home. When they are finally ready to go home, a lot of times we make these little memory boxes for them to remind them of their time here. That would include things like a little tiny diaper, the little tiny blood pressure cap from when they were first here, and comparisons of their first handprints and their last handprints to see their growth.
I actually hold on to some of the handprints and footprints of my most memorable patients as well. These are actually the hands and footprints of some really important patients to me. These are the footprints of my primary patient who was here for 451 days in the NICU. These are the hands and footprints of my first loss, the first baby that ever passed on my shift. Whenever I am having a really tough day on the unit, I just look down to my badge and remind myself that this is why we do what we do.
Deshauer: Nikki, I have noticed these big red things everywhere we go. What are they?
Nikki: These are our Weevacs. They are used for our code reds and code greens. If we ever need to evacuate, the babies go into the different pockets inside the stretchers and multiple people can carry them out. It opens up like this and babies go in these little pockets, and then we’ll have multiple people carry them out.
Deshauer: Wow. Oh, my goodness, that’s so creative.
What an incredible day. I have learned so much and experienced a completely different part of medicine. I really owe it all to Nikki, to Paola, and, of course, to baby Kalani, and the entire NICU team for making it possible.
If you want to see more videos like this, then be sure to subscribe and that way I’ll see you in the next video. Bye for now.
Siobhan Deshauer, MD, is an internal medicine resident in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.