Princeternship stories: Vivian Yao ’17, Maria Fareri Children’s Hospital

This post was written by Vivian Yao after her Princeternship. 

I met Dr. Shah for the first time in the lobby of the Maria Fareri Children’s Hospital in Westchester County, New York, and Day 1 officially started with “Grand Rounds.” These weekly lectures are held by academic departments on subjects related to their specific medical specialty. The presentation focused on how hospital care can be strengthened through improved national standards and better communication within the often disparate divisions in the medical system. For the remainder of my Princeternship, the idea of effective communication resonated.

Yao 2From 9:00 a.m. to noon, I shadowed neonatologists in the neonatal intensive care unit (NICU), where premature and ill newborn infants are treated. I followed a different neonatologist and the department’s pediatric residents and neonatal fellows as they conducted their “daily rounds,” where they analyzed the infant’s measurements and prescribe his/her medications and procedures for the day. Measurements include everything from vitamin intake amount to number of stools collected to head size. It was interesting to see how some of these measurements were interpreted. For example, abnormal breathing could be a normal variation of a premature baby’s physiology just as easily as it could herald respiratory problems. I was surprised to see how calmly and efficiently “rounds” took place. The team discussed each baby in detail, chatted with the baby’s nurses on further progress information, made their final decisions, and moved on.

At noon, I stepped out of the NICU to attend “Journal Club,” a lecture where neonatal fellows present in-depth analyses of a specific scientific journal article. The neonatal faculty then discusses the strengths and weaknesses of the study, and their thoughts on the subject. Dr. Shah was the mentor of the fellow who presented on the topic of “Head Cooling Effects on Ischemic Encephalopathy.” Afterward, I returned to the team as they finished rounds. Rounds were prolonged because of the snowstorm, as the team had to catch up on two day’s worth of clinical progress rather than just one. For adults, an extra day may not require so much extra time, but for fragile babies, their level of illness can change dramatically, and so the information for the past 48 hours was crucial in making informed decisions for their future treatment. Day 1 wrapped up with a small lesson on head cooling given by Dr. Shah to the residents and me because there was a new baby admitted who required the treatment. This is somewhat rare as only ten to fifteen of these cases present themselves in the NICU each year.

An interesting detail I noted on Day 1 were the phototherapy lights that shone on some of the babies’ “omnibeds,” or specialized cribs where the babies were housed. These lights cause chemical rearrangement in the isomeric structure of bilirubin molecules, and I was pleasantly surprised that something I learned in organic chemistry truly does matter.

Day 2 started at 8:00 a.m. when I went with some residents to check on the patients and catch up with the overnight nurses on the babies’ progress. Then from 9:00 a.m. to noon, I again attended routine rounds. I was most taken aback by the feelings I developed for the babies over the course of just one day. Though having just encountered them the day before, I already felt emotionally attached as I waited to hear the outcome of the neonatologist’s decisions: Does the baby need another IV inserted? Does he have to undergo surgery?

Throughout the day, I was able to observe both caesarean sections and natural births. These are obviously critical moments in a newborn’s development, but what was interesting to me was, again, how calmly the entire procedure happened. The obstetrician and her team was never shaken, even during one situation when the baby was at risk of having his oxygen supply severed. In addition to the doctor’s team, the NICU team was also present. The small room was crowded but worked like a finely tuned machine in which everyone knew their roles even when something completely unexpected happened.

From noon to 1:00 p.m., I attended a small conference with Dr. Shah as we had lunch. This was the second day in a row that Dr. Shah had worked during his lunch break, and I wondered to myself whether doctors ever took a real break. During the monthly “Joint Practice” conference, representatives from various hospital departments attended to improve issues related to the optimal function of the NICU. Topics ranging from insurance approvals to Ebola outbreak warnings were discussed. Again, I was witnessing the communication that exists within a successful unit. Another example included the pharmacist reviewing medications that recently became limited and what prescriptions and treatments could serve as replacements until the original medications became readily available again.

On Day 2, Dr. Shah also spoke to me about mortality rates in this particular NICU. I learned that mortality when defined as an actual death of a patient is relatively low at the unit, and that neonatologists across the country are more concerned with a term called “intact survival.” Intact survival refers to whether the baby is able to leave the unit without bleeding in the brain, eye disease, severe lung problems or intestinal disease. Of course, these factors are only minimized with optimal care and equipment, all of which come at a significant price. For example, total parenteral nutrition bags (plastic, liquid filled bags that include specially prescribed amounts of vitamins, lipids, sugar and electrolyes) cost $800 a bag. Each baby in this 60-bed NICU will go through roughly one bag a day until ready to tolerate feedings.

On Day 3, these issues were put into perspective as Dr. Shah and I hit the road to yet another commitment. Dr. Shah is a prominent member of the American Academy of Pediatrics. A large part of his role in the Academy is to represent the AAP in meetings with various state and federal representatives to discuss and inform these lawmakers of AAP’s policy proposals and provide insight into how federal legislation impacts child health care on Long Island. Dr. Shah does this because he feels a strong need to fulfill his civic duty toward his community and the children he cares for. He stresses how this drive was fostered during his time at Princeton and how much the volunteer work he does benefits him as much as it does the children for whom he advocates.

On this particular trip, Dr. Shah presented on various issues, including the current hot topic of whether immunizations should be mandated for preschool attendance and a bill that he authored mandating that insurance companies cover the costs of donor breast milk to high-risk premature newborns. On Day 3, I was able to witness firsthand how a doctor’s day (and oftentimes night) job translated into health advocacy. Dr. Shah’s research and clinical experience over the years has exposed him to hundreds of medical cases, which he clearly draws from during his meetings with policymakers. Most are not experts in pediatrics and naturally ask questions covering an entire spectrum, and Dr. Shah, in my opinion, was able to approach their curiosity from appropriate angles. I definitely saw how difficult it must be to be able to do this, given that each person we met with had different personalities and different ideologies.

While we were en route, Dr. Shah updated me the status of the babies whose cases I followed during the first two days of my Princeternship. He was on call the night before, sleeping overnight at the bedside of a particularly critically-ill baby who had undergone a bronchoscopy the night before. As a result he slept only 2 hours. It was amazing how close I felt to these patients and how well I felt like I knew them. Just knowing how I felt on Day 3 made me wonder how heavy a doctor’s heart feels for each of his patients, those who he cares for throughout their lifetimes.

Overall, my Princeternship with Dr. Shetal Shah was more productive than I could have asked for, and I now have a much clearer understanding and insight into a doctor’s “day-to-day,” which truthfully is not routine at all. A day’s schedule may include: mentoring, progressing with individual research, advocacy, NICU rounds, emergency deliveries, meeting with residents and fellows, and the list goes on. I was able to see the many stages of becoming a neonatal physician and was able to shadow various specialists – young physicians in their residencies and fellowships, senior fellows, neonatologists, pharmacists, dieticians, pulmonologists and surgeons. I would recommend this experience to students on the pre-health track. It was eye opening to see how much these professionals work and how little they sleep. After this experience, I have even more respect for neonatal physicians and may even consider going into the field someday.