As a consultant neonatologist at the Coombe Women and Infants’ University Hospital, I specialise in newborn medicine. My job involves caring for premature and sick newborn babies in the neonatal unit, many of whom need specialist intensive care.
I’m predominantly based in the Coombe but I also have a substantial commitment at Our Lady’s Children’s Hospital, Crumlin, where I have a clinic every week. In a year I’m rostered to do about 15-17 weeks in total “on-service”. That means that I’m the consultant for all admissions for newborn medicine from Monday to the following Monday: I do about five weeks in Crumlin and about 12 weeks in the Coombe.
Premature babies
The biggest group we treat in the Coombe are premature babies. In both hospitals we take babies below 28 weeks’ gestation and are able to take babies with birthweights as low as 500g or even 400g.
The babies who go to Crumlin are a different population. They have complications or problems such as abdominal-wall defects or congenital malformations.
Babies deemed to have a surgical problem that’s going to need immediate treatment shortly after birth all have to be delivered in Dublin, because the cardiac centre is in Crumlin and the surgical centres are in Crumlin and Temple Street. We get a huge number of babies with cardiac problems delivered at the Coombe.
There could be a perception that we get involved only after the baby is born, but in fact that’s not the case. We work as part of what’s called perinatal medicine, which is ourselves [the neonatology team] and obstetrics providing care before, during and after birth.
We have several meetings a week with obstetrics, at which we would discuss what they would see on scans. The emphasis is on trying to give families the best information. Antenatal diagnosis and foetal medicine have improved greatly in this country in the past 10 years and, increasingly, part of our job is doing antenatal consultations with parents.
If a baby is diagnosed with a major problem [before birth], the parents meet the paediatricians and us because the baby will be delivered in our hospital and we talk to them about what we will be doing, as well as about the child’s overall condition. That has improved things for parents in that there are fewer surprises.
The slightly negative side of that is that if you are told your baby has a major problem at 30 weeks’ [gestation], you have eight to 10 weeks of that to get through. But psychologists and studies have shown that knowing there’s a major problem is better psychologically than having something just sprung on you.
The timetables at Crumlin and the Coombe are basically very similar: we have handover and do a round of the intensive care units and wards in the morning and we do a teaching session or have a multidisciplinary meeting at the start of practically every morning.
The way we do it at the Coombe is that we do four nights on-call the week we are on-service, as well as being on during the day. One person carries the can really for the week, with support from their colleagues.
In Crumlin, we are on for the full seven 24-hour periods, including being on-call for seven nights. A lot of things such as meeting parents would tend to be after we’ve done the formal round because we have to provide care first. At night, Crumlin is probably a little less busy than the Coombe because paediatric intensive care provides some of the first-line management.
At the Coombe, Monday mornings of an “on-service” week begin at 8am with an intensive care handover with the on-call registrar, followed by a teaching session or neonatology department meeting. At 10am there are the grand rounds of the units and wards, and our team sees every baby who has been born in the hospital. In the afternoon there are ICU procedures, and other events such as planned delivery of premature babies.
There is some teaching of some kind every morning. That’s often the best way to do it because you get both the people who are finishing a shift and the people who are coming on for the day.
We do a lot of scenario training with a mannequin baby. On Tuesday afternoons there’s a dedicated medical developmental follow-up clinic; this is important to see if babies are developing and gaining weight properly. Then there are evening rounds and I’m on call from home every Tuesday night until 9am the next day. Then there is a multidisciplinary meeting with nursing and obstetrics to discuss case outcomes and to plan future delivery of complex cases, followed by ICU rounds and procedures, an outpatients clinic and antenatal consultations with parents.
I might also have a bereavement meeting with parents of infants who have died. I usually schedule those for the weeks when I’m not on-service, unless families have particular needs. They could take 90 minutes to two hours, and I don’t want to rush people and say, “I’m sorry, I’ve got to go now.” I can’t do that.
As well as rounds, on Thursday mornings there is a teaching session in Crumlin for the Royal College of Surgeons. I stay at Crumlin for an afternoon clinic, after which I prepare letters and reports, phone parents and do a follow-up round.
On Friday mornings in the Coombe we have a journal review where we teach our junior staff to critically analyse an article, followed by rounds and meeting parents. Later there is a weekend handover of problem cases with obstetric colleagues, followed by procedures in the ICU.
The job in Crumlin does not occur in isolation. As a neonatologist you may have conducted the consult prenatally, and you have a very close relationship with the family over several months in Crumlin. Families want to know there’s a doctor responsible for that child’s care . . . every week I’m there, I check what’s been happening since I was last on.
Training
I trained in Ireland and then in Duke University in North Carolina, where I did a neonatal fellowship. I came back in 1997 and took up my post in the Coombe. I was actually originally thinking of doing general practice . . . but I started off as a newborn medicine senior house officer at the Rotunda, and I loved it.
I liked working with kids and I particularly liked newborn medicine and intensive care. I like providing critical care and getting patients better.
While it is demanding, the fact that we’re part of a team with other medical and nursing colleagues means we can sustain what are very busy hours.
I would say I’d see between 200 and 400 babies a month.
I think if we were single practitioners, we probably couldn’t do it. We’d burn out. We need our time on, when it’s intense, but we also need downtime, where we are doing more correspondence, reports, paperwork and teaching.
I think probably what’s most rewarding about the job is seeing a baby go home who has been very sick initially.
The second-best bit is seeing people later on.
If I’m in Crumlin, people come up and introduce their child and say, “Do you remember so and so? He is now five years old.” That is probably one of the better feel-good moments.
The most challenging parts of my job are cases for which you are trying to provide care, but the overall outlook is not very good and you know it.
