Gilbert I. Martin

673 PROBLEM-ORIENTED PHYSICIAN NEONATAL INTENSIVE CARE PROGRESS NOTES

Care of the newborn in an intensive care setting necessitates continuous monitoring and evaluation. Changing clinical status, laboratory data, fluid balance, nutritional information, and respiratory therapy are important parts of this care. Graphic representation of this data is essential for continual care and retrospective analysis. Each discipline involved in NICU care (nurse, respiratory therapist, laboratory assistant) have devised “forms” to assist them in caring for the sick neonate. The physician needs a simple form to record clinical notes and other information to prevent communication lapses and forgotten information.We have designed a physician progress page which encompasses three separate problem-oriented records. The initial morning visit records present problems, current laboratory data, medications, pertinant physical findings, and the plan for the next few hours. A midday note on the back side of the page offers continual problem-oriented information with a therapy plan. The final note underneath the midday exam restates the problems, adds additional data, and organizes therapy. Interim visits, if necessary, are noted on regular progress notes. This method of physician problem-oriented progress notes eliminates forgotten or inaccurate information, organizes neonatal planning, and allows for a more complete summary at discharge.

674 THE ROLE OF THE PRIVATE PEDIATRICIAN IN FOLLOW-UP OF NEONATAL INTENSIVE CARE GRADUATES

Although mortality and morbidity statistics are continually improving, benefits of NICU care for the infant weighing less than 1,500 grams will be measured in long term follow-up. Compliance rates in hospital-based follow-up programs are poor due to geographic limits, financial considerations, ethnic adjustments, and poor communication. Since most births occur in the community hospital settings, and parents will gravitate to private pediatricians, it seems natural that the pediatrician be involved in the care of NICU graduates in a well-defined program. The pediatrician oftentimes has intimate knowledge of the family, its goals and attitudes. Knowledge about referral centers, financial aid, and counseling within the community point to a more direct role for the private pediatrician. An organized approach includes a program for the first and subsequent well child visits and a protocol for recording growth data, nutritional information, laboratory data, Denver Developmental Testing, psychological evaluations, auditory and visual evoked potentials, photographs, and subspecialty referrals. If the neonatologist at the tertiary center organizes this “private pediatric group”, a program can evolve which will service more physicians and patients. The pediatrician will remain interested in the total spectrum of NICU care, and will insure continuity of total care.

THE PRIVATE PEDIATRICIAN AND NEONATAL INTENSIVE CARE

Reorganisation of perinatal medicine and increasing neonatal fellowship programs have decreased the role of the general pediatrician in the care of the sick newborn. The majority of deliveries still occur in community hospitals and the transfer of infants to regional centers increases morbidity and places a burden on family visitation. The pediatrician who cares for the sick neonate has become an “endangered species”. Six pediatricians are working in a recently established “private neonatal ICU”. Ancillary services were trained and pediatric sub-specialists were added to the medical staffing. From Nov. 1972 - Nov. 1976, 835 infants were admitted to the ICU. 453 were inborn and 382 were transferred from other institutions. The neonatal mortality rate was aa fellows: 1973 - 8.5; 1974 - 7.8; 1975 - 4.0; 1976 - 5.8. The pediatricians were able to maintain full practice and staff the ICU. Community support for the unit was overwhelming and included donations, educational tours and volunteer services. This experience demonstrates that the pediatrician can continue to care for acutely ill neonates and if interested can develop and maintain neonatal intensive cere center.

Broken Umbilical Arterial Catheters

Sir .—We read with interest the letter by Choi et al in the May issue of theJournal(131:595, 1977) describing Bubble of fluid in catheter (arrow). Suture was originally tied at this position. two neonates with broken umbilical arterial catheters. We recently encountered a catheter that began to leak fluid at the point of a tightly tied suture. Oftentimes there will be leakage before the catheter completely breaks, and careful observation may prevent a serious complication. The Figure demonstrates a bubble of fluid. Originally, the suture was tied at this position.

The Ehlers-Danlos Syndrome: Report of two cases in monozygous Philippino-American twins

Abstract Two examples of the Ehlers-Danlos Syndrome are presented in monozygous Philippino-American twins from apparently unaffected parents. Both children manifested hyperelastic velvety skin, hyperextensible joints, papyraceous scars, flat feet and ectopic bone formation. Since the pattern of transmission of this disorder is so variable, and the gene so pleiotropic, one may predict that the condition will appear in every population group.