Blog-post: Stepping Up Week

Author: Dr Liam Mahoney, Senior Neonatal Trainee, Severn Deanery

It’s Sunday evening, the night before stepping up on the NICU.

Oh my days what am I doing?!

Thoughts were pacing through my mind-

Can I really do this?

Do I know enough Neonatology?

What if a patient gets worse?

What about all the other stuff that goes with being a consultant?

A wee time ago during my Educational Supervisor meeting it was suggested that I try and organise a week of acting up on the Neonatal Unit in ITU. Whilst a scary prospect, the idea of coming out of my “comfort zone” and pushing myself was very tempting. First hurdle- the practical/governance aspects. Find a Consultant willing to do this. One of the consultants kindly offered me to act up in her week which was great (she was amazing as a supervisor). You also need to have your START assessment for the Hospital to officially sign off you acting up. Even though COVID has stopped START you can still do a week acting up but your Supervisor will still be the official Consultant.

Now I have been wondering how to write this up, without waffling to much. I thought that instead of writing about each day I thought I would summarise some of my most important take home messages about the challenges/difference/opportunities of acting up as a Consultant.

Clinical stuff

In terms of different pathologies and presentations, St. Michael’s has a plethora of really interesting and varied cases. This was the part of acting up that I was most worried about- Would I know how to manage hydrops well? When should I bail out and intubate a term baby on CPAP with a rising FiO2 -now or wait longer?  My first reaction was that I needed to make sure I knew the latest research for all of the conditions. However, NICU cases have a habit of not exactly following the textbook and there are multiple different “right” ways of managing any particular sick patient. As the week went on, I did begin to feel more comfortable with the clinical decisions I had to make. But this wasn’t the main take home message for me.

I used to think that as the Consultant you have to be this all knowing entity and that everyone looks to you. However, in the week of acting up I learnt its just as important to be ok with not knowing the answer but knowing where to find answers with extremely challenging cases. Two minds are better than one and this week I learnt how important it was to use your colleagues and bounce ideas of each other. By doing this you not only benefit from others experience (and learn something) but I also felt a little burden was offloaded when talking through a case. I also learnt a secret in that the Consultants do this a lot!

Managing the unit stuff

Conserving bandwidth

This was the part of the job I learnt the most about, but strangely was the part of the week I was least worried about. I WAS WRONG. I now feel quite lucky to have done a week of acting up and have some (albeit little) experience in this aspect of the job. I think when you are given your CCT they must implant a second brain- you really need it. Brain 1 to think about the clinical stuff and  brain 2 to manage the governance/safety/risk issues that come up on the unit.

St. Michael’s is a very busy unit and patient flow is key- you need to ensure you have that bed for the unexpected HIE cooled baby. It became apparent important the safety brief was. I began to make mental notes during safety brief of patients that could be transferred out of ITU so that potential beds could be made. This was a very pressing issue during the week and was compounded further by acute issues coming up on the ward round e.g. a neurosurgical emergency in DGH or the transfer of a patient for contrast etc. This made knowing the nursing and medical staffing levels/skill mix so important so the right people could peel off to deal with the issue. I found it hard to keep the ward round flowing when this would occur.

Olive, 1996

Phew! Just writing down all of extra stuff you needed to think about outside the ward round is making me dizzy. However during the week I soon realised again, as Olive said in her 1996 Dance hit, “You’re not alone”. I always knew the Nurse in Charge was amazing, but I didn’t realise how amazing they were. So many of the issues were resolved with Nurses it really eases the burden on the whole medical team. I was constantly talking to the nurse in charge throughout the day and I was staggered at the amount of stuff they have to deal with. I felt they were almost playing a filter/gatekeeping role for the unit and medical team- so many of the problems are fixed by them before you even know about them. Their skill in doing this is something to behold really.

I feel like a broken record here but I feel like I need to emphasise the point- I don’t think I anticipated the amount of non-clinical things I would have to deal with. As a registrar you know that you have ITU to look after and many of the managerial aspects of the unit are being looked after by the powers that be. I learnt that during the acting up week that sometimes I needed to walk away and allow the team manage the clinical work and make a very conscious effort to ensure that I was available for people/to deal with other issues that arise. The situations that come up (e.g. admission of a baby with potential COVID that has just meant HDU is down two nurses) are unpredictable, tricky, need time and careful problem solving. This means that you inevitably some things you may not get to or (and this is a lesson for me as I think I’m a people pleaser by nature) you need to learn to, and be ok with, saying no. This makes delegating key. I think as Neonatologists we like doing things- procedures is one of the reasons I love this job. But again appropriately leaving tasks to different members of the team (e.g. leaving the intubation of a preterm baby)  helps to give you the headspace to deal with everything else.

Looking after yourself stuff

Make sure you eat! This is obvious but medics as breed (I feel) often may forget to do this. Being designated the “Consultant” you need to be available in multiple capacities and there is not a lot of time for yourself. Make sure you eat and drink when you can. I get HANGRY so this a must.

There Are LOTS of Meetings- Set alarms for these so you are not late and also set a 15 minute warning (pre-alarm) is useful.

Switching off! This is something that I am poor at. However, you need to do it if you are going to get through a service week. During the week I began to make sure that I did the home workouts, even dabbled in a spot of meditation and made sure I spent time with my family.

Celebrating the wins– I found myself at the end of the week thinking about the babies who became unwell rather than the ones that got better. Again, I think Medics might be pre-programmed to be a self-deprecating bunch on people, but at the end of the week it was important to highlight those wins with the team, “remember the no. of babies that extubated during the week”.

Final bit of waffle

I am so pleased to have been given the opportunity to do this. If you are thinking about doing it then just do it; you will get so much from acting up.  It made me realise how different the Consultant role is to anything else I have done in medicine. It was daunting, there are certainly lots of things I need to work on (great for old e-portfolio PDP). I hope to do another period of time acting up before my CCT certainly. Overall it made me rather excited for the new role I hope to undertake in the not so distant future.

I want to say thank you to the nurses and doctors team on that week for being generally an awesome bunch of people to have the privilege to work with. I want to use this final bit to thank Beth for allowing me to steal her ITU week and for being a really supportive mentor during that week!

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