In Rochester, the Neo-Natal Intensive Care Unit at Saint Marys Hospital was building a reputation as a regional referral center. Take a step back to 1975 by reading this article from the February issue of Mayovox.
The emotional impact of the service, even by medical standards, is unusually intense. Success results in great satisfaction. On the other hand, failure brings a tremendous letdown. Every work day is accompanied by a great amount of on-the-job pressure.
These are some of the descriptions of Dr. Fredric Kleinberg, the Mayo pediatrician who is Medical Director of the Neo-Natal Intensive Care Unit at Saint Marys Hospital. Dr. Kleinberg and Saint Marys Nursing Coordinator Ane Steigerwald work with a staff of approximately 55 people—residents, nurses, and paramedics—who are involved in one of the most primary types of medical service available. One-half of the unit's normal 15-patient capacity require full-time, one-to-one nursing care 24 hours a day.
The Neo-Natal Intensive Care Unit is currently headquartered in one section of the Pediatrics wing on the second floor of Saint Marys. In a normal-sized hospital room, ten nurses and paramedical employees labor over infants in four warmers. Dr. Kleinberg moves from one tiny patient to another, asking about the infant's progress at one warmer . . . consulting with a nurse at another . . . carefully reading a chart at a third warmer.
The room is filled with constant chatter—all patient-related. Just outside the door, in the hallway, a pediatric resident discusses several cases with a member of the nursing staff. Adding to the clamor is the sound of crying babies.
Down the hall, nurses quickly move in and out of an office storeroom—selecting pre-mixed formulas, taking out needed equipment, and replacing other supplies.
The unit was started as a four-bed pilot project about two years ago by Mayo pediatric cardiologist Dr. Robert Feldt and Mayo pediatrician Dr. Lloyd E. Harris. According to Dr. Kleinberg, the pilot intensive care nursery quickly demonstrated "that a great deal more space and personnel were needed to serve the region."
The unit now serves approximately 250 patients per year, with about half born at Saint Marys and the other half transported from seven hospitals located in a 90- to 100-mile radius in southeastern Minnesota and northeastern Iowa.
'The feeling of getting a desperately sick baby through in good shape is just about the biggest high there is in medicine."
Seriously ill infants can be brought to Saint Marys from this radius in a special transporter device that is really a small box warmer with respiratory and monitoring equipment attached. The entire unit is run by a 12-volt battery.
Dr. Kleinberg says the nursery is slowly achieving regional status for the 100-mile radius, with the unit becoming a major referral center for critically ill infants.
In addition to serving the patient care needs for the region, Dr. Kleinberg, accompanied by members of Saint Marys' nursing staff, also conduct educational outreach programs for the seven hospitals which the unit now serves.
The most common problem seen, quite obviously, is prematurity. Most of the patients weigh less than 2,500 grams. The smallest survivor weighed 800 grams. The smallest patient: 500 grams.
Aside from prematurity, the biggest single diagnosis is respiratory distress syndrome. This is a problem often associated with premature babies in which the child's lungs are not well enough developed to breathe without a great deal of extraordinary effort. Other disorders seen regularly include unusual viral infections, hematological problems, chromosomal abnormalities, congenital anomalies, and "more run of the mill" pediatric problems that require hospitalization, including some babies on surgical services where the surgeon desires that the infant be kept in the Neo-Natal Intensive Care Unit.
The amount of new knowledge in pediatric intensive care is almost overwhelming. "You've got to understand that just about everything we do here can be put under the classification of a 'recent advancement,' " Dr. Kleinberg explains.
He points out one of the babies laying in a warmer breathing because of an inserted trachial tube.
"The fact that this baby is alive is a medical triumph of unbelievable proportions. That baby, five years ago, couldn't have been kept alive for more than a couple of days. But he's been here four weeks now. The fact that he is alive and in such good shape is just incredible." His voice trails off. "It's really just incredible," he repeats almost inaudibly as if talking to himself.
Pressed again to pick out major advancements in his art, Dr. Kleinberg says: "I think it would have to be continuous positive airway pressure as a means of ventilatory support in small infants with respiratory distress syndrome. Before this development maybe about half of these infants brought to us with this problem would die . . . now, we can reliably get about 75% through. Of those born right here in the hospital, we're better than 85%. This one device . . . this one system . . . has made a tremendous difference in our morbidity and mortality."
He then acknowledges the human factor. "Aside from continuous positive airway pressure, if there's one single thing, it's nurses capable of understanding the problems and effectively dealing with them.
'"About everything we do here can be put under the classification of a recent advancement."
"We give the nurses who work up here far more responsibility than most nurses are given in any other area," Dr. Kleinberg explains. "We care a great deal about what they think is happening with the patient. Very often, a nurse can tell me about problems that might be developing before they become overwhelming. A good nurse who can make those observations is worth his or her weight in gold."
Dr. Kleinberg also is supported by and relies heavily upon three pediatric residents who rotate on 24-hour schedules in the unit. "Usually, the pediatric resident on duty will be up almost all night,'' Dr. Kleinberg says. "They very rarely get any sleep. It's usually a 24-hour shift in which they're going all the time. At the end of that shift the resident is pretty well done in and desperately needs some rest, so we need a shift of three with each person getting two days of rest for every 24 hours of duty."
The emotional factor, because of the fast pace and the nature of the patient, can be devastating. The responses in a very short time can fluctuate from great satisfactions to severe disappointments.
"The feeling of getting a desperately sick baby through in good shape and returning it to a grateful mother is just about the biggest high there is in medicine. That's true for the physicians and the nurses.
"Unfortunately, after going through a great deal of work with a baby . . . after trying our very best . . . inevitably in some cases we will lose . . . we will fail. Babies will die in spite of what we do. But with the tremendous emotional investment that we all put in the work we do, the letdown can be tremendous.
"The daily pressures are really just incredible."
Nursing Coordinator Ane Steigerwald: "You realize that most of the parents have wanted this baby so badly, and then, the baby is sick. Everyone in the unit begins pulling for each individual baby and there really is a feeling of excitement that sweeps the staff when progress is made.
"We get a tremendous thrill out of seeing kids go home after they've been here for a period of time. And we can continue our involvement with the children on their followup visits and watch them grow. Then it becomes a special, long-term attachment."
"Very often a nurse can tell me about problems that might be developing before they are overwhelming. A good nurse who can make these observations is worth his or her weight in gold."
And what about death? "It's hard to accept." She pauses, searches for words, then shrugs. "You just can't put the feeling of disappointment into words.
"I cope by forcing to remind myself that we did everything that we could, and we used all the knowledge we had. I force myself to remember that we can't play God."
In five months, the Neo-Natal Intensive Care Unit will move to new quarters on the sixth floor of the hospital. More space. New equipment. Dr. Kleinberg is understandably enthusiastic and excited. Still, the focus of his thoughts about the unit and his job continues to return and center upon the people who work with him . . . their skill, their dedication, their intensity, their emotional investments.