Fellows in training are expected to remain in direct, active and close contact with patient care in order to become an authority in the subject. It is expected that the fellow will handle many problem cases. The fellow will have the opportunity to practice neonatology at a high standard, manage problem cases that cannot be handled outside an academic framework and have the opportunity to apply new techniques at the advancing edge of neonatal-perinatal medicine. HMC has an active transport service that is operated by nurse clinicians with neonatal fellows participating in the transport of critically ill neonates who require a more advanced level of expertise.
Day-to-day patient care of NICU patients assigned to the Pediatric Residents is, in part, supervised by the fellow in neonatal-perinatal medicine. The fellow on-service is called to attend and supervise the resuscitation deliveries, participate in the teaching of medical students and house staff and may help with difficult transports. During the course of the 3 year training program, the fellow will participate in at least 12 months of full time clinical work as the fellow on-service. Each fellow will rotate on the night and weekend call schedule, together with the senior pediatric residents and neonatal nurse practitioners.
The fellowship training program consists of 3 years. Trainees spend 4 months of each year on clinical service in the NICU. One month is allocated to vacation and the remainder of the year is applied to research. The evening on-call and weekend on-call schedule is spread evenly throughout the year. The fellow is on after-hours call between 5 and 6 nights a month. Call is on site in-house. The call is spread evenly throughout the year. Weekend days are regarded as after hour calls and are included in the 5 to 6 days a month. When fellows are on NICU service they do not take call for both weekend days. This insures the fellows have a monthly average of 1 day in 7 away from program duties. Trainees not on clinical service will attend follow-up clinic, Journal Club, ‘Executive Rounds' (rounds with the neonatologists), Perinatal Conferences and Staff Meetings. Each of the 3 years is similarly structured in terms of the time allocated to research and clinical duties. The program allows for flexibility in scheduling to meet individual demands.
There are approximately 1200 deliveries per year at PSHMC with a high-risk perinatal service serving the high-risk community of the surrounding hospitals as well as high-risk referral patients. The prenatal care of the fetus includes a full range of services such as maternal transport, fetal diagnostics, fetal therapy, prevention of prematurity and a multispecialty interdisciplinary team to manage the high-risk pregnancy with active involvement of the neonatology team.
Currently, the newborn intensive care unit (NICU) has a capacity of 28 patients. Medical care in the NICU is provided by residents, neonatal nurse practitioners, as well as the fellows and attending physicians. The fellow is responsible for teaching routine procedures to the residents. The fellow is in turn supervised by the attending neonatologist. There are five attending neonatologists. During NICU service, the fellow has an opportunity to learn and teach the care of critically ill neonates, neonatal resuscitation and procedures like endotracheal intubation, central venous and arterial line placement, umbilical vessel cannulation, neonatal ventilation, including high frequency ventilation.
PSHMC offers a full range of pediatric subspecialties, and the Section of Newborn Medicine offers state of the art technology in a Level IV NICU, and a comprehensive newborn follow-up program. Working at a university-based hospital, the faculty has access to current treatment protocols and shares information with other leading medical centers around the world. Our neonatal-perinatal specialists attend international and national meetings where they present and share information. The staff has experience in high frequency oscillatory ventilation, ECMO, inhaled nitric oxide therapy and pulmonary function testing used to help determine appropriate ventilator settings. More than 150 infants are ventilated annually. A training course in ECMO is held annually.
The fellows are supervised by a neonatologist who makes rounds each morning. The fellow, residents, nurse practitioner, and neonatal attending see each patient together every morning. Rounds last from 2-3 hours each morning 7 days a week (i.e. total of 14-21 hours a week for morning rounds). The attending leads discussion during the first training year, and as the fellow gains experience they assume more of a leadership role during rounds. Teaching is done at the bedside and emphasis is placed on physical examination and the interpretation of physical signs. The pathophysiology of the sick neonate is discussed in reference to the patient. The differential diagnosis and management plans are also discussed at the bedside. When necessary, subspecialist consultation is included. This occurs frequently with Cardiology, Endocrinology and Nephrology At 1:15p.m. Monday through Friday, the NICU team is supervised in the interpretation of radiographs by Pediatric Radiologists at a regular conference. At 4 p.m. each weekday afternoon sign-out rounds occur at the bedside. These last about 1 ½ hours (5-7 ½ hours per week). Trainees are supervised by the attending on-call for the night together with the attending on clinical service. When a patient is admitted, the trainee documents the history and examination. The neonatologist also examines the patient and the differential diagnosis and management plan is discussed.
At neonatal follow-up clinic, the fellows see patients that they discharged during their clinical months in the NICU (inpatients). Patients are seen at 6 weeks post discharge from the NICU, then at 6 months and 1 year of corrected age. The patients are also seen with a physical therapist who assesses motor development and tone. A neonatal attending is present at each clinic so that patients can be discussed. Frequently the attending will see the patient with the trainee, especially during the early months of training until the trainee is comfortable performing the follow-up assessment. The fellow dictates a letter to the primary physician after every visit. The letter is approved and countersigned by a neonatologist.