Lauren Hodgson sits in a tall desk chair, swinging her legs back and forth, checking her black iPhone for a call — one that will notify her when her tiny patient is out of surgery.
Hodgson is a staff nurse in Bay 1 of the Neonatal Intensive Care Unit at the University of Iowa Children’s Hospital. Bay 1 is the most intense of the five bays in the care unit; it houses the sickest and often youngest babies.
Above Hodgson’s head, an orange light flashes, signaling a change in one baby’s charts. The 29-year-old spends her workdays analyzing and stabilizing vital signs, administering minute doses of medicine, and following an exact feeding schedule for her patients.
A few minutes later, Hodgson’s hospital-issued phone buzzes. Dressed in turquoise scrubs, she answers and spends a few minutes nodding and taking notes. She hangs up and dials another number.
She is calling the baby’s mother, letting her know the surgery went well and they are about to bring the baby back from surgery to her miniature bed in the intensive-care unit.
Hodgson gathers with the rest of the in-hospital transfer team, which can include upwards of nine people, from respirator therapists to nursing residents and a transfer bed.
While the group pushes toward the door leading to the operating room, the parents, who are lagging behind, stop just as they reach the swinging doors. The mother slides against the wall until she’s sitting on the floor, exhausted from having a baby in intensive care. The father paces back and forth in front of a long window looking down on the playground, anxious about his baby.
Despite the palpable pain in the room, Hodgson strides on.
The term neonatology refers to the care of premature babies or babies who are very sick, usually because of low birth weight, lung or heart problems, or birth defects.
A baby born before 37 weeks is considered premature — a full-term pregnancy is 39 to 40 weeks.
The survival rates of babies born at 23, 24, and 25 weeks improve considerably when a baby is brought to the Children’s Hospital; the facility is considered among the top neonatal-intensive-care providers in the country.
The Neonatology Intensive Care Unit is a Level IV ICU, which means it is ranked in the highest level of care recognized by the American Academy of Pediatrics.
Approximately 450,000 babies are considered premature each year, according to March of Dimes. Worldwide, 15 million babies are born before term.
Around 800 babies end up in the Neonatology Intensive Care Unit every year from around the state and country — and Hodgson is one of the select nurses qualified to watch over these babies for days, weeks, and sometimes even months.
Hodgson is one of the younger nurses to stand over the miniature beds. At 29, she has worked in the neonatal ICU for almost seven years and transferred to Bay 1 in 2011.
The nurses in the unit decide for the most part which patients they take every day. This system, paired with the intense and long hours they spend with babies and their families, sometimes makes forming bonds inevitable.
“I think most of us try to take back patients we know or patients we’ve had before … A lot of our sicker patients tend to have the same nurses over and over again, and then you get attached to them,” Hodgson said, tapping her Dansko clogs — a trademark for any nurse.
“But it can make it more difficult sometimes, because you have a difficult patient [and] they don’t seem to be getting any better, or the longer the babies are here, sometimes the parents get a little more worn down with the situation, too, and you can just get burned out if you keep taking the same patients over and over.”
Jonathan Klein, a UI associate professor and the medical director of the neonatal ICU, said he has seen such strong bonds form that on rare occasions, there have even been cases in which a patient who has been abandoned by parents will end up going home with a health-care professional.
“Because the babies are here for a very long time — I mean, occasionally, we’ll have a baby here even as long as a year — it’s very intense, because it’s often life and death, minute by minute, hour by hour, day by day for a very long period of time,” Klein said.
One “float” nurse, who works between the neonatal ICU and the Pediatric Intensive Care Unit, still has friendships with families whose children are now 8 years old.
“I mean, they tell you in nursing school you shouldn’t do that, but you know, sometimes it just happens,” Tracey Unverzagt said. “They get that trust, and it makes it easier for them to relax and focus on their baby … they see that you’re grieving as well, and they know that you really do care and that you’re not just here because you’re making money.”
One thing Klein sees that is different from other neonatology facilities is the role each member of the team — from nurses to fellows to nurse practitioners — plays in the babies’ care at all times.
“Now you have, rather than one mind thinking about something, you have hundreds of minds thinking about that patient,” Klein said.
Not only is this teamwork beneficial for the babies, but the nurses also find it crucial.
“We’ve had times where we’ve had [bad] runs; we’ve had a couple [really sick] babies or numerous deaths in a row, and you just feel emotionally spent,” staff nurse Mandy Karstens said. “You rely heavily on your coworkers, because they understand, and they know what you’re going through or they’re going through it, too.”
The natal ICU is an intense and exhausting place.
“I see something I’ve never seen before every day,” Hodgson said. “I think someone who’s been here 20 years would say that, too … nothing can prepare you.”
There are days or even weeks, she said, in which it seems every baby is sick or the unit is understaffed. And sometimes, she said, it can be too much.
“It’s long days, it’s difficult dealing with families, dealing with patients, dealing with doctors, there’s a lot of responsibility on us,” Hodgson said. “And when you work on any inpatient unit, really, you have patients that are really sick and demanding of your time.”
Hodgson was out of work for a few months earlier this year with an injury. On her first day back, she learned one of the babies she had taken care of in the past had become worse and another had died.
Eventually, there comes a point where the nurses must learn to separate themselves from the hardship.
“Working in this type of setting, not that you don’t ever have that emotion, most nurses are pretty empathetic, but at the same time, you have to separate yourself from here,” Hodgson said. “You have to learn how to justify things, because otherwise, it would just tear you apart.”
Loss is something the nurses in the unit have to learn to deal with right away.
For Nicole VanDeWalle, a staff nurse who has worked in the unit for 10 years, she still remembers the first baby who died during her time in Bay 1.
“I think your first is probably the one you never forget,” she said. “It was during my orientation, and it was kind of unexpected. And it’s something that you carry forever.”
Loss transcends everything, she says.
It transcends age. It transcends religious beliefs. It transcends cultures.
For Hodgson, the struggle comes when a baby doesn’t seem to get any better.
“I think it’s more difficult when you have patients who are here for a long time and are very sick for a long time, and they don’t pass away,” Hodgson said. “It gets difficult ethically, I think, to keep going, to keep doing things that seem really futile.”
A black and orange butterfly is hung outside the room of a baby who is being taken off support. But by the time the symbol is up, the natal ICU nurses are prepared — they have reached that futile stage.
“I know when babies pass away, you get really attached to them, but a lot of the babies who die here; it would be different if they were my child,” Hodgson said. “But I’m able to look at the situation and see what complications were ahead of them and what their lives probably would have been like if they had survived.
“And not that they wouldn’t have been loved and wouldn’t have been someone’s child, but I can put myself on the other side of that and say, ‘Well, if that was me lying there, would I want the life that’s ahead of me?’ ”
To make it through days like that, Hodgson said, she has had to learn to separate herself from the situation.
“I think I have to constantly remind myself with certain patients that it’s not my baby, it’s not my life, it’s not my child,” she said. “Usually, when you put it in that perspective, it’s easier to kind of take a step back and think, ‘Well, you’re the nurse, you’re here for 12 hours; the decision being made isn’t going to affect my life in the long term.’ ”
This is why Pat Davis, a staff nurse who has worked in a natal ICU setting for 25 years, said maintaining the right mindset is the most important thing.
“There was a nurse who retired, and when I first came here, she said that you have to tell the parents ‘Our job here is to save them’; everything else is done [somewhere else],” she said. “As long as you have that mindset [that] it’s not your choice, your mindset is to save them. If you can save them, you save them, if you can’t save them, you keep them alive until the parents are ready to let them go.”
Hodgson also tries to maintain this level of separation, but sometimes human nature makes it impossible to remain impartial to what is happening around her every day.
“Not that it’s not difficult,” she said. “When we have long-term patients pass away, I see families that I’ve taken care of their kid … for a long time, and I still send cards or go visit their graves and stuff on anniversaries of their death or their birthdays. So it’s not like we don’t think about them and we don’t miss them.”
But for Hodgson, and, she thinks, most nurses, everything they go through and everything they have to do to cope is worth it to save a baby’s life.
“They’re just so deserving of care,” Hodgson said. “They’re so innocent, and they’ve never done anything wrong, so you can’t help but take care of them.”
This is a feeling that hits hard and strong for the nurses who are able to stick with the work at the unit.
Hodgson said she thinks most people who work there know in the first six months that it is the right place for them.
“I don’t think anyone who works in the NICU doesn’t really want to do it,” she said. “Once a NICU nurse, always a NICU nurse. It sucks you in and keeps you here.”
Little baby Alexander teeters back and forth between the lounge chairs on the sixth floor of the Children’s Hospital. A set of large doors nearby swing open leisurely.
Alexander tries to sneak in as well but is nabbed up by his father.
A few moments later, someone else walks by. But this time, upon spotting the little visitor, the woman exclaims in joy and rushes closer.
Alexander wobbles before her, a proud 17 months — something the woman is overjoyed to see.
The last time she saw the little boy, he was behind the doors, in a bed in Bay 1 of the natal ICU. He was born 4 months early, and Alexander and his parents, Megan and Pete Stopulos spent a lot of time around the nurses in the unit.
“They were like family,” Pete Stopulos said. “These are the people we became very familiar with, and then when we came back for follow-ups, we always made sure they could see the results of their work.”
Karstens, who has been a staff nurse for 11 years, said seeing a baby years later is an indescribable feeling.
The care the nurses provide extends beyond the tubes, and diapers, and tiny baby beds — even long after the patients finally get to go home.
“Obviously, their role was to take care of our baby, but oftentimes, they were a hug or a shoulder to cry on … and helping us deal with that there isn’t always an answer or a reason,” Megan Stopulos said. “It’s kind of hard for me to put into words. They taught us how to take care of him, how to do everything for him. We’ll always be bonded to the UI and the NICU.”
“We don’t believe in a self-fulfilling prophecy that the baby’s too sick to survive, the baby’s too premature, too small to live; that’s not our philosophy,” Klein said. “The philosophy is that we expect everyone to do well and everyone to survive.”