Neonatal clinical experience is acquired during NICU/IICU rotations (primarily supervisory role), neonatal transports, and multiple neonatal and subspecialty conferences. The fellow supervises and orientates two to four PL-1/PL-2 residents (pediatric, obstetric, family practice, and emergency room) or medical students (fourth year). He conducts daily work/teaching/x-ray rounds with the attending neonatologist and is responsible for delineating diagnostic work-up, ventilator support, nutritional support and management of all infants in the NICU/IICU (27 patients). The fellows are initially instructed on all neonatal procedures by the neonatologists. Afterwards, the fellow teaches and supervises residents and medical students. There are extensive neonatal procedures performed daily.
The fellow also coordinates subspecialty consultations and provides additional contact with referring pediatricians, obstetricians and perinatologists. The fellow attends all high-risk and many problem deliveries in addition to many routine cesarean sections. The fellow teaches and supervises the resuscitation team (resident, neonatal nurse, neonatal nurse practitioners, respiratory therapist) in the delivery room. The fellow also supervises the neonatal transport team (resident, neonatal nurse, neonatal nurse practitioners, respiratory therapist) which provides teaching, clinical care and communication experiences. The fellow writes up neonatal transport admissions and inborn admissions while on-call. The fellow works with the neonatal attending answering consultations from the normal nursery while on call, or when on the Continuing Care Nursery rotation, and communicates with the referring physician. The fellow discusses high-risk pregnancies with the obstetric residents and perinatologist on a daily basis especially during on-call hours. The fellow helps the residents communicate discharge plans to the discharge team and initiates transfer of neonates to community hospitals. The fellow provides recent literature on problem cases for residents. The fellow takes in-house night call every 6-7 nights with a PL-1 / PL-2/Nurse Practitioner.
The fellow gives at least one lecture to the residents and/or medical students each month. The fellow also has rotations in the Continuing Care Nursery (primarily direct patient care) with a supervising attending neonatologist. The fellow provides direct patient care by examining and determines diagnostic work-up and management of 16 growing premature infants per day. In addition, the fellow initially responds to all neonatal consultations from the normal nursery. The fellow communicates discharge plans with the discharge team and referring physician. The fellow discusses neonatal diagnoses, plans and follow-up with families and dictates transfer/discharge summaries. The fellow covers the delivery area for resuscitation (for approximately two-three hours) while the NICU team makes work/attending rounds. The fellow works with the neonatal social worker on problem cases providing experience of the social implications that chronic disease has on families.
The fellow rotates at Boston Children's Hospital (New England Regional Center for Cardiac Surgery) for at least one month to provide more extensive cardiology and cardiac surgery experience. The fellow is exposed to a larger volume of EKG's, ECHO's, catheterizations, and new cardiac surgical techniques with pre and postoperative care. This complements the ECHOs (neonatal and fetal), EKGs, cardiac lectures, and PDA ligations performed at Memorial Health Care. An ECMO rotation (2-4 weeks) can be arranged at Boston Children's or Mass General Hospital, if desired by the fellow (optional).
An additional elective is a one month laboratory rotation which takes place at both UMMS and MHC. The month is divided into four one-week rotations. One week is spent under the supervision of Dr. Catherine Nowak on the genetics service at UMMS. The fellow has the opportunity to observe genetic laboratory techniques, see congenital anomalies or deformations, and participate in prenatal and postnatal genetic counseling. The second week is in pediatric pulmonology under the supervision of Drs. Robert Zwerdling, and Brian O'Sullivan at UMMS. The fellow participates in the pulmonology clinics (7 per week) and observes the long-term outcome of infants with BPD, congenital lung disease, home oxygen or ventilation, reactive airway disease, and cystic fibrosis. He will learn oxygen monitoring and weaning techniques, pulmonary function evaluation, and management of medical problems related to chronic disease. He will observe the stress of chronic disease and patients. The third week is spent at UMass MHC under the supervision of Lawrence Owens, Chief Neonatal Respiratory Therapist. Ventilation (conventional , HFOV, SIMV, and CPAP), oxygen monitoring (O2 saturation, TcO2 monitoring), CO2 monitoring (TcO2 monitor and end tidal CO2) and pulmonary function testing is stressed. Knowledge and setup of the equipment, its physiology, and potential side effects/inaccuracies will also be stressed. The fourth week is spent at UMass MHC observing the FLM and PG testing, cranial, abdominal, and renal U/S and CT scans and reviewing U/S videos, EEGs, and BAER testing.
Follow-up of NICU graduates is an important part of the fellowship training. There is a full-time developmentalist (Alice Miller, Occupational Therapist) in the NICU. All high-risk neonates are evaluated prior to discharge and are seen again at 6, 12, 18, 24 and 36 months at the UMMS/Fallon Developmental Clinic. Extensive Brazelton exams, developmental screens and audiovisual testing (BAER) are routinely performed. A multidisciplinary conference follows the clinic for thorough case discussions. The neonatal fellow attends the developmental clinic one-half day/week during the non NICU rotation months (approximately 10-12 months) during the second two years. The fellow also attends the quarterly developmental conference attended by developmentalists and their fellows, neonatologists, neonatal nursing, neonatal nurse practitioners, pediatric residents, and medical students. Two to four cases beyond the one to one and one-half year follow-up are presented and discussed. The developmentalist and early intervention teams are also a part of the weekly discharge conference. The fellow also has a clinic area at UMass Memorial Health Care in which research or interesting patients may be followed.
The neonatal fellow attends and becomes certified as a neonatal resuscitation regional trainer. The fellow participates in local and regional resuscitation programs.