As a newly minted neonatal-cardiac intensivist, I was all ready to take on the world. I mean, caring for the babies with congenital heart disease (CHD), congenital diaphragmatic hernias (CDH) and all other congenital anomalies and premature birth. I was excited and ready for service. It was my 27th year of “being a student.” I had gone through the grind of medical school, residency training, fellowship training, and an additional year of cardiac critical care training. Now it was time to be a teacher. I was excited to teach some great physiology fundamentals and the nuances of cardiopulmonary interaction to our residents and fellows. I had read books, worked with great mentors, and up-to-date on the literature that was published in the field.
On my service, there was a baby with CDH with tiny lungs. When abdominal contents invade the thorax, there is competition for the heart and lungs, two major organs in the chest cavity. This competition for space from a parasitic organ makes it difficult for the heart and lungs to grow to support life. The heart is not at its most optimal functional capacity. Lungs are smaller, and pulmonary vasculature can be maldeveloped and underdeveloped. They frequently develop pulmonary hypertension (PH), which makes providing adequate oxygen and extracting CO2 a nightmare. These babies go on ECMO (extracorporeal membrane oxygenation) quite often. This is a lifesaving bridge to recovery where the heart and lungs can rest, and with medications, the pulmonary vascular resistance can be mitigated. The hernia can be safely repaired.
Back to “Joe.” (All identifying information changed.) Joe was a 4 kg baby boy with 18 percent of expected lung volume and severe PH. Mechanical ventilation and 100 percent oxygen weren’t adequate for Joe. Surgeons were called, they put in the ECMO cannulae, and our team started the medications to improve PH. We continued the collaborative efforts of saving Joe. Each morning at the surgical conference, the on-call team and the primary team gets grilled about the management, other consultants weigh-in, and we make a tentative plan. Plans aren’t always successful because the babies have their own manifesto. Unfortunately, our surgeons don’t concur.
Disclaimer: Surgeons are passionate and invested in the outcomes. I know they have the best interest of the patient. I see them trying hard to keep their emotions at bay and not succeed. They can come off as unpleasant and rude. I took their words personally. I blamed myself for the failed plan. I was devastated.
Surgery rounds day 1
Neonatologist: ECMO flow good, no clots, BP good, no anemia, sedation good, urine output adequate.
Surgeon: “The very fact that this baby still is urinating this much suggests you aren’t using the ultrafiltrate enough. You should have negative fluid balance …”
N: But the BP and the other cardiac indices are borderline, we need to be careful.
S: That’s why you have medications like epinephrine, have you ever used it?
N: You need to fill the tank before you try to empty it. The kid needs volume.
S: Please just dry the kid out.
Surgery rounds day 2
N: ECMO flow good, etc., urine output is a bit lesser today. BUN is a bit high. We are using ultrafiltration for efficient diuresis.
S: Really, don’t you know you need to fill the tank before you try to empty it. You are killing his kidneys!
N: Well, yesterday …
S: Maybe try not to damage all his organs.
Surgery rounds day 3
Neonatologist: ECMO flow good etc. Our hemoglobin is 12. We will hold off on transfusion for now as our oxygen requirement and lactates are reassuring.
S: Even the medical student knows you need more oxygen-carrying capacity in PH, I cannot believe you didn’t transfuse yet.
N: But our O2 requirements, lactates, BP are all fine.
S: I am not asking. I am telling you to do it.
This was the pattern of our interaction on every patient I took care of. I thought I was better prepared each morning, but that was never the reality. My memory biased me to prepare for the same obstacle I faced the day before. I would run the list in my head. Little did I know by preparing meticulously for the same difficult conversation, I was making myself more vulnerable to facing a new challenge or question. Because that newness caught me off-guard. Every morning I left feeling inadequate in front of a large audience. That’s when it hit me. If I wanted to be less fragile, I had to be prepared for a new disaster every day.
I came to terms with the fact that despite my best efforts, depending on the surgeon, the consultant group, it was a hit or a miss. I needed to stop trying to read their minds and come up with a defense. My priority is always the baby. I would advocate for that resilient person. The sweet baby that’s been in fight mode from the get-go. One day it is the kidney, another day the liver, despite all these adversities, Joe fought with the vigor of a seasoned warrior. His head ultrasounds were pristine. His heart functions great. I thought if this 4 kg baby can adapt to new challenges, so can I. I realized that if I prepare for something so meticulously and put all my energy into that basket, when a disaster strikes me from another direction, I freeze. If I just practice the evidence-based medicine that I can always depend on, I have data to back me up and not an individual’s opinion. Most surgeons are voracious readers; they love to teach. If I learn to listen, I might actually benefit from that conversation, and maybe I have more teachable moments.
Maybe the teachable moment was just that. Be prepared to be surprised every day, and you won’t be disappointed. Adapt, adopt, persevere, and embrace the growth mindset while practicing the humbling business of modern medicine.
The author is an anonymous physician.
Image credit: Shutterstock.com
