by Dr. Michael Narvey | Parents Corner
Neonatology is a team sport if there ever was one. It can be very confusing though to families as they go along their journey. The descriptions below are not meant to be exhaustive and if you are functioning in one of these roles and would like be to add something to your description please chime in! I thought it would be helpful to have a primer of who’s who in the NICU and what do they do exactly? Bear in mind that depending on where you are in the world the person caring for your baby may be different based on staffing models but here is a quick primer to the most common medical staffing positions in Canada. In Neonatology we also tend to like using abbreviations a lot so where there is a common one used I have indicated that in parentheses next to the name.
Attending Neonatologist (NEO)
This is a doctor who has done special training in newborn intensive care. Like me, they will have gone through a residency first in Pediatrics and then done anywhere from 2-3 years of extra training specific to the care of sick newborns. The Neonatologist is commonly seen leading morning rounds and will be the one typically asked to speak with parents when there is something important to share. We may not always be seen front and centre but when not on rounds we are in continual communication with the other “front line medical staff” and stay on top of what is happening with all the babies on the clinical service. You will typically see us in the hospital during day time hours but for the sickest of patients we will come in from home when on call to provide expert guidance on care. Many Neonatologists will have been certified by a national organization such as the Royal College of Physicians and Surgeons of Canada. Not all will however as there are other pathways to taking on this role.
House Medical Officer (HMO)
HMOs are members of the team will have also done a Pediatrics residency. They will have done a Neoatology fellowship as well. These individuals typically will do a mixture of day and night call. You will get to know them over time as they are on the front line and will be seen day and night in the units.
A fellow has done a Pediatric residency and is now doing specialized training in NICU. In their first year they do an abundance of clinical work as they try and learn the core knowledge of the specialty and obtain expertise in all the common procedures needed in the field. As they move into their second and optional third year they take on additional responsibilities and typically will do a “junior attending” role on a few occasions. in this capacity they act as the Neonatologist and run the NICU. The Neonatologist who is on with them continues to be appraised of the patients in the unit but will not be always on rounds during these weeks. This graduated responsibility is part of the development of the Neonatal fellow.
Residents are training to become a Pediatrician. They do a mandatory number of rotations in NICU which varies depending on the province you are in. As residents they are learning and in many cases will not yet have mastered all the procedural skills in the profession such as intubation and putting in umbilical catheters but they are on their way to obtaining those skills. These are people though who have comprehensive training in all areas of Pediatrics and will be familiar with the ability of the wards to care for your infant if they are transferred potentially to a hospital ward.
Clinical Assistant (CA)
CAs as they are also know will typically not have had a full Pediatrics Residency but in most cases have come VERY close. They function in a capacity very similar to the HMO. Do not be fooled by the lack of a complete residency in the eyes of the local College of Physicians and Surgeons. Many of these individuals are exceptional and would be impossible to distinguish in performance from an HMO.
Nurse Practitioner (NP)
NPs or Neonatal (NNPs) are nurses who have gone through a very advanced program and function as part of the medical team. If you reside in Alberta, NNPs have been the dominant form of housestaff support in Neonatal units for many years. They are meticulous care providers who by virtue of their nursing background have a very holistic approach to care of infants. Their plans always factor in impacts on nursing and in many respects their care is similar to that provided by their MD counterparts. NNPs are capable of performing all the procedural skills as their MD counterparts and it has been a real pleasure to work with them over the years both in Alberta and Manitoba.
Nurse managers are responsible for the day to day operations of the NICU. They are also the person to which all of the nurses working in the NICU report. If you have concerns about your experience in the NICU they will eventually filter there way through to this person and sometimes the medical lead for Neonatology. This person can also be of great help sometimes when you don’t feel like you are getting the answers you need as they have a great birds eye view of the unit and are well versed in policies and accepted practices.
This position is many respects is the nursing equivalent of the Neonatologist. The Charge nurse will co-lead with the Neonatologist on rounds and is involved in bed management as well. The person in this position is aware of all events that occured overnight and often serves as an advocate for the night staff who may have expressed concerns overnight that need to be dealt with on days.
If you are in the NICU as you read this already you will be very familiar with this position. The bedside nurse is who you will have the most contact with. This person provides direct nursing care to your infant and is often the person you will speak most to during your day. They also wil one day help transition you to home but in the meantime you will bond with many of those you come across. With the sheer amount of time you will be exposed to each other you won’t be able to help bonding.
Registered Respiratory Therapist (RRT)
RRTs as they are known provide a great deal of support to our babies who are having difficulties with breathing. The RRT is the person who will be called when a baby is in need of CPAP or a ventilator and is also the one who takes blood for analysis to check oxygen and carbon dioxide levels amoung other things. They are experts in the airway and breathing and will often be the one seen providing breaths with a bag and mask at the head of the bed if your baby needs support getting in each breath, They also possess the skill to intubate babies so much like the residents, fellows and HMOs you may hear that if your baby needed a breathing tube they were the ones to place it.
Occupational therapist (OT)
These inividuals can perform many tasks but one of the things that has really developed into a strong role is the assessment of feeding. Many ex-preterm infants have challenges after the initial period when they were quite ill, establishing full oral feedings. Many OTs have developed exceptional skills at assessing infant sucking and swallowing. They may recommend pacing strategies to help your baby achieve full oral feedings faster than they would have otherwise.
PTs as they are often called specialize in assessing infant tone and posture. They are very helpful when it comes to helping your infant with their musculoskeletal system. They may provide devices or recommend stretching exercises to help with their limb positioning or muscle tone. Some babies can develop what are called contractures where a limb is quite flexed and they will provide recommendations to help lessen these.
You will already know what a pharmacist is but when it comes to the NICU they provide a very important role. Unlike the adult world where dosing is pretty standard for drugs, in babies the dose is typically measured out per kg of body weight. Moreover, as many studies are not done yet in babies in order to determine proper dosing, the pharmacist helps us determine what drug and at what dose is best to maximize benefit and reduce risk to your infant. Almost all drugs have side effects and by keeping track of the drugs your baby is on they remain vigilant to look for drug interactions and advise us if any are likely.
Registered Dietician (RD)
You would think that nutrition should be an easy thing to manage. Give a baby milk and they will grow. Unfortunately, while this approach works for most babies as they are born term, the preterm infant provides a lot of challenges. Considerations of calories, fat, carbohydrates and protein need to be considered and adjustments made over time. The RDs keep a very close eye on your infant and help advise us about adjustments needed in order to optimize growth and achieve the right balance for weight, length and head circumference. These people are meticulous in their monitoring of nutritional intake and the addition of them to our team has meant more babies going home with the right proportions!
NICU can be a stressful time for anyone. After you come to find the expected outcome of pregnancy has not gone as planned there is no doubt that you will experience stress. You may have other children that you are worried about or have been displaced from your home and traveling long distances to visit. In addition to the bedside nurse the social workers are here to talk to you and to help you access programs and resources that may be of help to you.
In our unit we have a person who experienced the journey through NICU firsthand. Having had a preterm baby in the NICU they are very much in tune with the needs of parents. This person may organize information sessions for families or parent groups. The veteran parent and the veteran parent volunteers that she coordinates provide direct one-on-one support to families. They also are responsible for arranging baby cuddlers as mentioned below to help ensure that your baby is not deprived of that important contact time when you can’t be there. The nurses of course help with this as much as they can but with multiple babies to care for having a dedicated person to help coordinate this.
A recent addition to the team are baby cuddlers who have volunteered their time to be with your baby when you can’t be. Parents often worry about who will be with their baby while they are gone. This service which also includes reading to the infants helps to reduce the isolation many babies would otherwise experience in particular when families are needed back home and need to take a few days to be with their family. There may be a coordinator in the unit as we have for this program who will also help families by providing information sessions and opportunities to get together and share experiences and let you know that you are not alone.
Spiritual Health Services recognizes and celebrates diversity. WE provide care to all whether you identify as spiritual, atheist, religious or agnostic. We are available to journey with you and support the values and belief that are important to you. Spiritual Health Practitioners are professional members of the health care team, specifically trained to provide support for your emotional and spiritual well being especially during times of difficulty and crisis. We also arrange for ceremonies, smudge, sacraments and rituals.
Starting in January 2020 Dr. Narvey has added a Parents Corner on his webpage. The goal of this new section here is to help parents understand in plain language the journey of their baby through the NICU .