Kimberly Hillyer, DNP, NNP-BC

Introduction 

Thank you for joining us on today’s broadcast. I’m Dr. Kimberly Hillyer, a Nurse Practitioner and the Media Correspondent for Neonatology Today. This segment features Dr. Benjamin Rattray. Dr. Rattray is the author of “When All Becomes New,” a compilation of his experiences and reflections over years of doing what we all do every day in the world of neonatology. 

Dr. Hillyer: Thank you for joining us on today’s segment of Neonatology Today Media; I’m here today with Dr. Benjamin Rattray. Thank you for joining us today, Ben. How are you doing? 

Dr. Rattray: I’m great. Thanks so much for having me. 

Dr. Hillyer: Thank you so much. You wrote a book that was very inspiring to me because it’s an area that I’m working in. It’s a story of not just you but individual families and the babies that you come in contact with throughout your career. Can you tell me a little bit about your journey to becoming a Neonatologist? 

Dr. Rattray: Yeah, so the story really starts for me in college when I started as a Psychology major. I was actually a Psychology and English major. I took an abnormal psychology class and really got interested in Medicine and the sort of physiology behind everything. Funny enough, it’s funny how these things come full circle because my mom was actually a district nurse in New Zealand and, before that, a midwife in England. So, I had some exposure to Medicine through her as a kid. Sometimes that exposure kind of scares you a little bit, but it also, I think, fascinated me and intrigued me. Looking back now, I think that that was probably a big part of it. Every once in a while, when I had a day off school, and she was working, I was able to go around with her. She drove to each patient’s house to see them and check up on them. I don’t think it happened very often, but it definitely made a big impact on me. That started my interest in Medicine. I always loved kids, was excited to look into Pediatrics, and was also really interested in neurosurgery for a while. I thought that was going to be my residency path, but [I] ended up choosing Pediatrics. Then going through the different rotations, I really fell in love with Pediatric intensive care, neonatology and then ended up in neonatology. 

Dr. Hillyer: Now, your book is, like I said, your life story. In a sense, because it goes from your introduction into Medicine in the world of neonatology, being a Fellow, and then going on to becoming an Attending. Can you tell me why you felt that it was very important to see the growth and progression of you as a Physician through these stories? 

Dr. Rattray: There are those two elements of the book. One: each chapter is a different patient story, but it also really follows my arc of training. Sort of that young idealistic way that we kind of come at things. Then, sort of reckoning with some of the difficulties as some babies don’t make it, and we do have some really difficult outcomes. Also, a faith struggle as I’m kind of going through all of this. So, it seemed like the logical thing to do as I was laying out the chapters was to do it chronologically as I’m moving through my training, as I’m maturing in my journey. 

Dr. Hillyer: What did you feel was the biggest difference as you were putting these stories together as you moved from, let’s say, the fellowship to becoming an Attending? 

Dr. Rattray: One of the biggest things, and I’m not sure, to be honest, that this part of it comes through as much in the book, but one of the things I think for most people when you’re in training, certainly myself you’re really so focused on the Medicine. You’re just trying to get your medical care to be right. You’re trying to get the right diagnosis and the right medications. You’re learning your skills, putting in umbilical lines, doing intubations. That’s really, I think it is where the focus is, and I think it should be. I mean, that’s such an important part of this step, but I think as time has gone on, I’m probably more focused on the families. The relationship that I have with the families, I hope that comes through in the book, but I don’t know that I necessarily spelled that out exactly. 

Dr. Hillyer: I think through some of the stories, you could definitely tell it is. I remember one of the stories you were standing behind, kind of an outside observer. Watching this family as they mourned the loss of the child, I think you really were able to show that in those moments. 

So, you have some ups, and you have some downs. As you said, it is a roller coaster in the NICU. Can you tell me about one of the ups that you’ve found helps really get you through some of the lows of the NICU? 

Dr. Rattray: Yeah, so one of the ups. There’s a story about a baby girl called Faith. She was born really early, about 24 weeks, and like a lot of 24-weekers, had a really rough NICU course. Her parents were amazing; they were like the light of the unit. They would come in and hug everybody, really upbeat, really encouraging. It was like, you felt like we should be trying to encourage them, not the other way around. They were just amazing parents, but they certainly had some really difficult times. 

I was there in the delivery room when she gave birth, and then I actually got to be there on the day that she went home. She did great. She’s just like this beautiful girl now. In the book, I talk about that. Actually, I was at my daughter’s preschool graduation, and Faith was there too. She just happened to go to the same school, so it’s one of those really great stories that you go through a lot together, but the outcome is really great. 

Dr. Hillyer: I know for me, that was definitely one of the stories that I enjoyed because you’re right; you need to have some of those very positive heartfelt moments that remind you once again of the positive aspects of why you do some of these things. Now we are also experiencing very low, lows. Can you tell me about one of yours and how you were able to adjust and move forward? 

Dr. Rattray: Yeah, one of the other stories is called “The Sniper’s Son,” and the reason for that is because the father was a sniper in the army. I met him several weeks into his son’s NICU stay. I had met the mother and kind of formed a relationship with her by talking with her each day. Then one day, the dad came in, and we kind of struck up a conversation. He was in army fatigues, and he kind of ended up telling me what he did; I just remember thinking at the time how we were in such different worlds. But his son was doing pretty well, until all of a sudden, he got sick with necrotizing enterocolitis; it just happened so fast. It happened, it really started overnight. I came in the next morning and saw the x-ray. I just couldn’t believe it; it was awful. I did anesthesia for the case, and the surgeon opened him up, and essentially it was just black necrotic bowel, all the way through. 

So, we had to make that really difficult decision with the parents to withdraw support. When we did that, the father showed up. He was with the mother, and a lot of the men from his unit showed up in their full military dress uniform and stood with the mom and the dad. They supported them. It was really difficult because I was still in training, and it was just that feeling of total helplessness. There was just nothing that we could do, I mean, we could keep his son alive for a little bit longer if we had needed to, but we couldn’t ultimately save him. He had no bowel and was too small for an intestinal transplant. There just wasn’t anything that we could do. It was really difficult. 

I remember we talked about the case at the M&M conference that next week, and it really struck me how we talked about the medical part of it. How quickly did we start an anti-fungal? Which antibiotic did we use? We looked at those initial films, and we dug through the whole case, which was appropriate. It is the right thing to do, but I just remember thinking about how we didn’t talk at all about any of the other parts, kind of that interpersonal part of the case. Nobody in M&M really knew that this guy’s regimen had come in and stood there with him. 

I just remember walking outside. At the end of the day, in the North Carolina sunshine, it was still summer, and walking back to the car, trying to take it all in. I definitely remember that one. 

Dr. Hillyer: Now, I know that that is definitely one of the hardest parts of our job, for sure. As you’re trying to come up with words to comfort the family during these most difficult times in their lives. have you found anything you feel based on your Faith or your belief that helps you to find that connection with the families? 

Dr. Rattray: I think one of the things is getting back to that early training. I think that what I thought at the start was that I needed to have that distance, that emotional distance from the parents. I needed to be so professional that the only thing that I was communicating was the medical information. So, what I think I’ve found is there’s more power in just sitting there and being quiet and not even saying anything. I think there’s more power in that than trying to say a lot of words. I think that, to be honest, there really isn’t anything that we can say that really makes it better; perhaps other than just saying, I’m so sorry that this is happening to you. Sometimes I’ll give the mom a hug, depending on if that seems appropriate. I think the biggest thing is to just show how much we care. I think if a tear slips out, it’s okay. I think that as long as the family knows that we truly care, certainly, I think anything else can come across as trite. It’s interesting because I do take comfort in believing that God makes all new for these babies. At the same time, it’s not something that I would say out loud to the parents because I don’t think that there’s comfort in that. Certainly not at the time, maybe at some point in the future. It’s not something I feel can really be expressed, certainly not at that moment. 

Dr. Hillyer: Absolutely. As we are seeing more and more premature babies, extremely immature, extremely low birth weight babies, I feel we have this opportunity more so. Maybe it’s just me, where you have these extremely long courses. Sometimes you think you’re out of the woods, then something like NEC happens. Then you’re having to readjust and re-connect with the family. Sometimes you have to go through these moments with them, but you’re not doing it alone as just the physician provider. You have this whole team that you’re working with. 

You were just speaking about the M&M conference and talked about the technical aspect. How can we, as a full team in the NICU, deal better with these kinds of situations? Do we just let palliative care be a part of it? How do we incorporate that into our field? How do you suggest that we work as a team together? 

Dr. Rattray: Yeah, I mean, I think part of it is exactly what you said, we work as a team together. This is really something that always is a team activity. You just can’t stress that enough in terms of the bedside nurse, the nurse practitioner, respiratory therapists, and all the people that are involved in the care of the baby. I do think that we definitely should incorporate palliative care. That’s something that we do at our hospital because for some babies like you were referring to that are born so early. It is a trial of life, and we often do get to a place where palliative care is the right thing for a baby. Having the resources and the best setup to guide parents through that, I think, is really the best thing to do. 

Dr. Hillyer: Now, as you were telling these stories, it’s not just your story, but it’s someone else’s story, families. Were there any concerns that you had when bringing these stories to life for the reader? 

Dr. Rattray: Yeah, so there are huge concerns when doing this. Part of it is that I feel like I’m just tasked with the hugest responsibility to get it right because I’m remembering babies’ lives. I’m remembering families. So, that’s perhaps the biggest weight that I felt. I really felt compelled to tell their stories too. Sort of both feelings compelled to tell the stories and really wanting it to truly portray what happened the right way. 

The other part of it, of course, is privacy and protecting family privacy, so I changed a lot of details to make sure that I was providing that level of privacy for families. There’s one family that actually asked when I ended up interviewing the mom to get a little bit more of a story from her perspective. She wanted me to keep her babies’ names the same and keep the story the same. So, there’s one chapter where I actually didn’t change anything, and that was based on her request. 

Then there’s a reunion chapter where I use the baby’s name again because the mother asked me to, but everything else, I’ve changed things. The essential part of the story is exactly the same, but enough has changed so that you can’t tell which baby it was. 

Dr. Hillyer: As we go through this book, we’re seeing your growth, as you said, but what kind of growth or direction do you think this book can help others? 

Dr. Rattray: Well, my hope is that it helps us with the connection. I’ve had a lot of nurses read the book who says, I didn’t know that you felt this way; we feel this way too. I think that speaks to the way that we practice. You know, we can have a pretty rough day, and at the end of the day, everybody goes home. We talk during the day about medical care, and here are the orders that are changing; here’s the plan of care. Asking the bedside nurse, what they think about certain things, but we’re really not talking about the emotional part of these situations at all. I think partly a book can really help bridge that gap. I mean, I think we should be talking to each other as well, but I think sometimes you can express things in a book that you can’t always say, and sometimes you know, especially for me, it takes me a long time to figure out what I’m feeling and thinking. A book allows me to do that. 

Dr. Hillyer: So, with this book coming out, you’ve said nurses come to you and reflect on some of the stories that you told. Seeing themselves in it. Has it changed your practice and your interaction today? 

Dr. Rattray: I think it’s changed; in that, I feel even more comfortable with parents in terms of trying to interact with them where they are. Just trying to be more personable. Certainly, doing all the right medical things, but also being just more human, more down to earth. That’s the goal. Just more connection with the parents and also with all of us in the NICU, the staff. 

Dr. Hillyer: As I remember reading through some of the different stories, some of the different chapters. Things like the Sniper story that was extremely powerful to me. Was there a story that didn’t quite make the cut of the book? That you really felt was also powerful and may have changed the direction in which you viewed things. 

Dr. Rattray: Yeah, so the interesting thing is there are actually chapters that didn’t make it into the book. The hard part, I think about a book like this, is that you end up with some cases that just aren’t that dramatic. You have a baby who’s maybe delivered early and has a really significant course from a parental standpoint, but it’s just not something that you can write down in a way that’s compelling. Or really, sometimes the stories just don’t go anywhere. So, I definitely had some chapters like that that I really wanted to make work because I had a strong interaction with the parents. I really cared about the babies and wanted to tell their stories, but every time I rewrote the chapter, it just didn’t go anywhere. I don’t know that it really changed the book, necessarily. 

Then there’s another story that I wish I could have put in, which was actually the backstory for the baby that I saw at the reunion. He actually had hydrops, but it happened so far in the past. Probably when I was so sleep-deprived as a Fellow. I just could not make it come alive on the page, so I ended up putting him into the reunions chapter. The thing that’s really interesting about that, though, is I realized that’s actually where he belongs in my story because, as significant as his story was in the NICU. He’s more significant in a way to me now out of the NICU because his mom has texted me pictures and sent me photos as he’s grown up, and getting to see him like grow up has just been amazing. So, he’s really significant to me more in that reunion way. It’s not to say that he wasn’t significant in the NICU because he was, and I remembered. I remember that time really vividly; I just couldn’t make it come alive the way I could once he was out of the NICU. 

Dr. Hillyer: That’s understandable, and I really think that, like you said, that reunion part is very powerful. Also, it’s one of those factors that keep us moving forward and driving forward. Were there any times during your fellowship or as an Attending where you felt that one of these stories, whether one that’s made it in the book or one that wasn’t able to make it in the book, really had you re-evaluate the direction in which you were going as a physician? 

Dr. Rattray: That’s a great question. I mean, I think I’ve always been pretty steadfast in my direction; I don’t think that I’ve ever really hit that place where I thought, you know, I’m going to throw in the towel. I’m not doing this anymore. I certainly have had times where I’ve really had self-doubt and really worried. 

In one of the stories, we have twins, and one of the babies ends up having sepsis and dies. The other one, because of the other twin getting sick, alerted us. We did a CBC and early screening for infection, and it was flagged as high risk. We got a blood culture, started antibiotics, and sure enough, the other baby was also getting bacteremic and getting septic. That was a really difficult time, where I wondered have we started the right antibiotics on the sibling who died. Was there more that we could have done? As it turns out, we did start the right antibiotics, and we did everything we could. It definitely was a stressful time and really made me wonder if we’d made the right choices. 

Dr. Hillyer: Now that stress, the continued questioning of whether or not you ordered the right antibiotics, ordered the right labs. It doesn’t just stop as soon as you walk out of the Neonatal Intensive Care Unit. How do you deal with that going home? 

Dr. Rattray: So, you’re right about that. You just bring it right home; I mean, I try and have that decompression time as I’m driving in the car, but the truth is you bring it home. I think I even wrote in that story; I was periodically going to my laptop and logging into the electronic health record just to see how the baby was doing. What the blood culture was, seeing what the sensitivities were. So yeah, I mean, I think the main thing is to try and stay grounded as much as possible. I really try and be in the moment with the kids, be in the moment when I’m at home. Really focus on those things, and sometimes I do a better job than other times. Even the administrative part of work can get the better of me sometimes. I’m checking my cell phone and checking my work emails at nine o’clock at night. I think, why am I doing this right now? This email can wait until tomorrow. I think there’s that weird mix of administrative and leadership responsibilities and clinical responsibilities that sometimes it’s really hard to walk away from. 

Dr. Hillyer: Absolutely, and I can understand that this has been something that you’ve just started to realize, especially during the pandemic, where we’ve really had to put a mirror in front of us. Being in the healthcare field, learning how to decompress. To step away, to find that healing for yourself. Was this something that you’ve been working on throughout your progression? Or is this something that during this pandemic really has made you, kind of, focus on? 

Dr. Rattray: I think both. I think I go through these cycles where I’m not very good at my work-life balance, and things feel really out of kilter. Then I’ll set some guard rails. I’ll say that there’s no more logging in at night, no more checking my email past six or seven at night. I put those guard rails in. But then something will come up, and I’ll end up kind of falling back into it a little bit. So, I think to keep recalibrating. I think the pandemic definitely puts the pressure on us to draw those boundaries in a way because, you know, it’s been such an intense time. Even for us in neonatology, I mean, I can’t imagine, for our colleagues in Adult Intensive Care. I think certainly we really have to remember kind of who we are as people and do things that help us to decompress. 

Dr. Hillyer: Absolutely, and as we’ve now gone through this pandemic. We’re also going through a time where politics is once again becoming a factor. Especially in the neonatal world, it may become a factor as our legal system looks at Roe vs. Wade. Do you have any kind of thought process as far as how you think this may affect us in the neonatal world? 

Dr. Rattray: That’s a great question. One of the interesting things is this morning, I was just listening to a podcast that was really focusing on the nuance of everything. Right now, as you’re alluding to, everything is so incredibly polarized, and the reality is there’s so much more nuance to everything than I think the politicians at least can really allow for. I think, more than anything, if we can care for and love the people around us, my opinion is that that’s what we’re called to do. It’s interesting to wonder how these changes might affect us. Certainly, something that I’ve been thinking about, and it’s tough to say right now. It’s so difficult to predict how things will be in the future. I think, especially in healthcare, I think we’re called to serve the people around us. So, I think that that’s where our focus should be. 

Dr. Hillyer: I know that in our neonatal world, there is this balance with ethics. Especially when it comes to the extremely low birth weight infants between the bounds of 24, 23, to 22 weeks, is there a point in time where you think healthcare and Medicine won’t be able to push anymore? That it will cause a direct conflict with what’s going on with the rest of our society? 

Dr. Rattray: It’s a great question because it feels like it always changes. If you talk to people that are older than us, for example, they’ll say, “Wow, I remember when 28 weeks was just the earliest that we could save a baby.” Yet, here we are; we’re wrestling right now, in our center, with 22 weeks trying to decide how ethical it is for us, given our outcomes, to really push that boundary. I think a lot of centers around us we’re really struggling with that. It certainly feels right now like 20 weeks. I just can’t imagine going lower than 22 weeks without a massive change in technology; in the way that we practice. That would be a completely different paradigm. So, it’s interesting because you wonder if anyone ever looking back on this interview in 10 years or 20 years could potentially be so different at that point. 

Dr. Hillyer: You’re right. Technology changes consistently, and Medicine keeps pushing the boundaries. It’s been amazing to see that neonatology is still considered a very young part of Medicine. 

Dr. Rattray: Yeah, but kind of like you’re pointing out, though, at what point are we doing families a disservice. If you get to that point where the outcomes are so poor, then we’re really doing a disservice. On the other hand, though, this is the tension. There’s always so much tension here because we want to help families; we want to save babies. Some babies have really wonderful outcomes like we were talking about baby Faith, who was born so early and had such an amazing outcome. Then you don’t want to pull these kinds of kids. Sometimes you can pull an outlier case and then base your whole practice on that; that doesn’t seem like the right thing to do either. So, there’s a very real tension. As it happened to me last week, it happened at two o’clock in the morning very, very quickly with a baby who was approaching 23 weeks. I had five minutes to talk to mom; dad was out of state. You know, five minutes, two o’clock in the morning to make these really big decisions. So yeah, these things are never, never easy. 

Dr. Hillyer: Now, these decisions aren’t just NICU to parent, but we also bring in our OB colleagues. They’re also struggling during this time with maternal death rates. Is there a way that we are able to collaborate with them? Dealing with the holistic care of a family when there may be issues with maternal mortality and morbidity and then the neonatal side of mortality and morbidities. 

Dr. Rattray: Right. Yeah, I mean, I think that’s the most important thing is having that collaboration. Sometimes everything happens so quickly that it’s hard to have a good conversation, but it’s the ideal case when we can. I had a case where I was working closely with Maternal- Fetal Medicine and the OB over the course of two weeks. We had a baby that was actually too growth-restricted for us to be able to intubate if they delivered. That was a case where even though the chance of intrauterine demise was fairly high since it was essentially 100 if they delivered. We just tracked everything really closely, but that was a good situation where we had really good collaboration, and we had a great outcome. I think that’s the key because you’re pointing out that we’re not just balancing the baby. We’re balancing the mom as well and the mom’s health. So, we really have to keep everything in mind and hopefully have really good discussions. 

Dr. Hillyer: As we talked earlier also about the technological advances that we’ve seen, we also see advances when it comes to the human genome. How do you see that play an effect on our medical management and care? 

Dr. Rattray: That’s a great question and one that I don’t think I can answer right now. Certainly, it looks like there is technology for isolated diseases to modify. Once again, it seems like there’s so many ethical questions that come up both for the obstetricians and for us. Because you can certainly see situations where you know, modifying something to get rid of a lethal disease could be very beneficial or a disease that’s a lifelong impairing disease. You could certainly see the benefit there, but then it’s also easy to quickly see how that can become a very dangerous situation. Where you’re no longer just modifying single diseases, but you’re modifying all sorts of things and really tailoring, which could be a very big problem. 

Dr. Hillyer: One of the things that you talked about was what you hoped your colleagues would get out of this book. What if a parent was to read your book? What would you hope that they would get out of it? 

Dr. Rattray: It’s interesting because I have; I’ve told a number of parents do not read the book because I’m afraid that it might cause some sort of PTSD for them. Or, at least if you read it, please wait until you’re out of the NICU. I mean, that’s definitely important, but I’ve actually had a number of parents who have read it and have given me feedback. A lot of them actually just said it really helped them to know how much the medical community cares about their babies because they can see we’re thinking about their babies as we’re driving home, we’re thinking about their babies at home. We really, really care. We’re not just punching the clock from eight to five. This is our life, and we really care, and so I think it really helps them to know that. I’ve actually had really good feedback from parents, but in terms of the target audience, I wouldn’t say that that’s really my target audience. It’s been surprising. I thought, talking about target audiences; I thought that maybe then the nurses wouldn’t be that interested in the book because it’s kind of like reading about what you do at work all day. It’s like, maybe you just want to come home and watch a legal thing or something totally removed from work, but they have been my biggest supporters. So, there’s sort of surprises, I think, along the way about who wants to read the book, I should say. 

Dr. Hillyer: Well, it definitely hit home for me, and I enjoyed reading it. As a nurse, I could definitely see your thoughts as far as what it’s like for the parents to read it and why you might not want to have them read it. But also, for those parents that do read it, letting them get that sense that we do care, even after, like you said, we’re not just punching the clock. If you were to write another book, what do you think that book would be a reflection of? 

Dr. Rattray: I think I’m done with the NICU stories for now. It’s hard to imagine writing another book because I feel like it would just be too similar. I think my writing at the moment is more articles talking about reflection, talking about drawing near, and observing. I’d like to try my hand at a novel, and I’ve got a rough draft. I’m not sure if it’s going to go anywhere. It’s all up in the air right now. 

Dr. Hillyer: Well, you were able to put together some really compelling stories, some heart-wrenching stories. So whatever direction you choose to go for your next book. I’m sure it is going to be just fascinating. Is there any other work that you’re doing out there that you would like us and my audience to know about? 

Dr. Rattray: I think the biggest thing right now is I’m mainly involved in local leadership in our NICU. I do have a website, which is my name benjaminrattray.com. Where I’m putting some blog posts and also some links to media, definitely, each blog takes me a very, very long time to put up on the website. It’s just, I’m a very kind of slow writer. Some people I know can put out a blog a week or a blog a day, and it turns out that’s not me. But I do have some blog posts up there, so that’s where I can be found online. 

Dr. Hillyer: I look forward to going to that website and checking out some of those blogs. I don’t write a lot, I talked to someone, and they said within their first day, they just wrote pages and pages, and I was just amazed. 

Dr. Rattray: Oh, I know that is not me. I mean, Hemingway said, “writing is easy. You just sit there and bleed.” That is me; it’s like I could spend an entire morning changing two words around and then put them back the way they were. Or, like, one sentence could take me an hour. So, it’s a pretty slow, sometimes painful process, but it’s also very rewarding when I feel like I’ve been able to express some of the things that I’ve been thinking and feeling. 

Dr. Hillyer: Well, I think this book really did grasp some of those things that you were feeling as you processed and went through your journey into neonatology. I hope that you continue to find that balance. That work-life balance and find the pleasure in writing your next book, and then I look forward to seeing the blogs and anything else. 

Dr. Rattray: Thank you. I appreciate that. 

Dr. Hillyer: I want to thank you for joining us on today’s segment of Neonatology Today with Dr. Benjamin Rattray. 

Thank you for joining us. 

Dr. Rattray: Thanks so much for having me.