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#044 - 👩‍⚕️ Dr. Monica Arroyo MD


Monica Arroyo on the incubator podcast


Hello friends!


We are very excited to welcome to the show Dr. Monica Arroyo to the podcast. She is a neonatal neurologist working in South Florida. She talks to us this week about her work as a neonatal neurologist, the art of being a consultant in the NICU and life after loss. Dr. Arroyo excels in her ability to interact with families of neonates with neurological injury, a population she follows up well after the nicu discharge. In this episode Dr. Arroyo gives us a multitude of advice that we can all take to the bedside no matter which role we hold in the care team. Enjoy!


 


Bio: Dr. Monica Arroyo is an attending Neonatal Neurologist at Joe di Maggio Children’s Hospital in Hollywood, Florida. Prior to this position she completed a Pediatric Neurology residency and subsequently a fellowship in Fetal and Neonatal Neurology at Cincinnati Children’s Hospital Medical Center in 2018 after graduating from medical school from the University of Puerto Rico. In her current position she has started a Neonatal Neurology service, fetal consultation service and a high risk clinic for NICU follow up since her arrival to the institution. Her mission is to accompany the parents in the “journey” of an unexpected neonatal brain injury. She is an advocate for optimizing continuity of care between the hospital and home and creating safe medical homes for children with complex needs. Dr. Arroyo is also interested in parent mental health and support and looking for ways to improve the NICU experience, as she herself is a NICU mother who lost her child to complications of prematurity.



 

The transcript of today's episode can be found below 👇


Daphna 0:39

Welcome


Ben 0:47

Hello, everybody, welcome back to the podcast Daphna. How's it going?


Daphna 0:51

I'm good. I'm good. I was, I was gonna say, we've been busy. But I feel like I always say we've been busy. So you know, what?


Ben 0:57

The jingle of the show is. We're busy.


Daphna 1:00

We're busy. But I am just glad that we have so many opportunities. That's what I feel about. Yeah.


Ben 1:09

I think I think I think it's fun, when we're saying we're busy is that we have tons of interesting guests. And, and we are, we are having a problem of riches where we want to bring in many, many more people on the show people with interesting ideas, personalities, and our current schedule, really has fully booked for the rest of the year. Pretty much. Yeah, I


Daphna 1:33

mean, if we, if we thought when we started this, that we'd be able to schedule out interviews, you know, nine months to a year, I mean, yeah, I still don't believe so. To do problem to have


Ben 1:46

great problem to have, and I'm gonna do, what I usually do is that if the audience has any ideas as to how they would like more content, I don't want to be, I don't want to be just pouring stuff out. And people can keep up or it messes up the rhythm. But if you guys have any ideas as to other ways that we could provide content to you that would be easy to consume, or done in a way that would fill a need, which is really what we've been trying to do, then please let us know. We're all yours. And we're working really hard to make all that stuff happen.


Daphna 2:17

So I mean, a lot of our guests came from, you know, requests, so


Ben 2:23

yeah, love it. Yeah. Yep. This is true. All right. But I'm actually very excited about about our guest today. Do you want to tell us a little bit yeah,


Daphna 2:32

I'm so excited. Um, so today we have on Dr. Monica Roya is an attending neonatal neurologist at Joe DiMaggio Children's Hospital in Hollywood, Florida. She completed a pediatric neurology residency and subsequently a fellowship in fetal and neonatal neurology at Cincinnati Children's Hospital Medical Center, after graduating from medical school from the University of Puerto Rico. In her current position, she started in neonatal neurology service, fetal consultation service and a high risk clinic for Nikki follow up since her arrival. Her mission is to accompany the parents in the journey of an unexpected neonatal brain injury. She's an advocate for optimizing continuity of care between the hospital and home and creating safe medical homes for children with complex needs. Dr. Royal is also interested in parent mental health and support and looking for ways to improve the NICU experience as she herself is a NICU mother who lost her child to complications of prematurity Monica, we are so pleased to have you on today. Thank you so much for joining us.


Monica Arroyo 3:29

Thank you guys for having me. It is really an honor and a pleasure it this is a new a new arena for me. And I think it's a great idea to be able to connect with people from multiple places and multiple specialties and, and hear about kind of us boots on the ground experiences and share knowledge. So


Daphna 3:47

every time I work with you, I'm impressed by what what you do. So I just hope that our listeners can get like just a little a little glimpse, a glimpse of you know how, what an amazing doctor you are. So I'm hopeful we can we can get there. Tell maybe you can tell it kind of in your own words, kind of what are your areas of interest specifically in the NICU.


Speaker 3 4:11

I'm a very lucky pediatric neurologist because I get to be dedicated to the NICU, which is what I love to do. So you know, the bulk of my work here is mostly having to do with neonatal brain injury. So hypoxic hypoxic ischemic encephalopathy, HIV is a big one for needle strokes, you know, seizures and, and different than my training I I'm actually involved in a lot of cases here with, you know, severe intraventricular hemorrhage and just because I'm around and I'm available. I've been involved in many of these cases. So I've gotten to learn about a new pathology that maybe I wasn't as familiar with. I know neurology typically gets involved if they're seizures or there's any other acute event in the NICU and then later on, if there's any motor concerns or epilepsy kind of surges later in life, then neurologists get involved. So I've learned how to get involved at this stage. And I actually really enjoy it. It's an opportunity to meet families in like a crisis mode, and be there in the long run and help them in the outpatient setting. So in in, that's kind of a NICU, but my work doesn't end there. I have an outpatient follow up clinic and, you know, cheering for the children as they go home. And I once they're home is probably just as important part of my work. I also do general, general pediatric neurology. So I see kids of all ages, and I see kids in other parts of the hospital, as well.


Daphna 5:47

So you're busy.


Speaker 3 5:49

Yeah, busy, I think I think I'm busy. There's not a lot of pediatric neurologists out there. So I'm very lucky to just have more time for the Nicaea, which is a great, unique thing.


Ben 6:03

It's funny to me, because having worked at multiple institutions in different states, getting neurology to be involved when it comes to ivh is always a mountain to climb, right. I mean, I remember you would call neurologists and be like, Well, what do you want from me? Like just repeat the repeat the ultrasound and and if there's a need for neurosurgical intervention, let me know, but like, the answer was usually you can give the parents the data just as well as I can. Why should I involve neurology and, and even though it's it's not very generalizable, you are on the opposite of that spectrum, where you are involved with every one of the babies that have some type of ivh. And, and again, and it's not just that you are officially consulted, like you come you sit down with the families, you go over prognosis, you go over follow up testing, you see them in the outpatient setting, and you really become a partner in their care. And my my question to you is, why would why?


Speaker 3 7:07

Yeah, why would you want to do all this extra? Unit ologists are very capable to use ivh calculator and tell the parents, you know, I think for selfish reasons. For me, I'm learning so much about the brain just being involved. I'm amazed all the time about what these children are capable of doing. And and also sometimes not pleasantly surprised about what they're not doing. So I think, you know, the picture is a picture of how the brain looks, not how it works is a true mantra for ivh particularly, it's a pretty mature brain. So still a lot of development to be done. It's like a big unknown. And I think I like I feel comfortable in the unknown. In in discussing a range of possibilities. I think, you know, if I weren't a doctor, I think I'd be a teacher. So I think this brings out that the teacher aspect of me like I like taking out my paper and drawing the ventricles and, and going over it with the family. And I think just spending a little bit extra time and hearing it from a different person, it puts in a different perspective. Also, because I'm there all the time, or most of the time, I'm a constant person for them. So just today, we were at a care conference, right? Ah, and the mom asked me, So when do I see you good? Are you gonna see my baby every day? Like? Probably not? Right? The The one thing I might see your baby every day or more often is if the baby develops seizures, which can happen with ivh. Right? I typically my approach is to kind of be peripherally involved. And then when they're kind of closer to discharge, see them again and say, you know, how's your motor exam looking? What are we going to do for fall because I have a neuro rehab clinic. So I see them in neuro rehab clinic, and then if they become more of a rehab type patient, not a lot of neurology needs and we kind of, you know, go back and forth. So I know that I have this kind of unique setup for it. And I know that I have this special interest and passion for it. So I it's unique in that way. Right? I want to do it. I think it's interesting. I can tell you when I started working here i i went into the workroom and I introduce myself and I said, you know, I will be here every day. And I think people were like, huh, like, I'm not sure if we're gonna need that's great, but I'm not sure just put your card up here, I'll call you. And then fast forward three years if I if I'm on vacation. It's like a crisis. Because I call that's true. I've put on this hat of note only, you know, neurology consultant, but parents support Yeah, outpatient follow up sounding board for the new Natalja as well what to do, when do we consider withdrawal of care? It's become it's transformed into this thing that's like, almost bigger than neurology, like I joke around and I'm like saying I mean pardoning, otologist, part palliative care, art, social work, hard PT. Meeting therapist, you know, there's a crisis I can do all of those probably, if needed.


Daphna 10:18

Yeah, I think that's what's so neat about what you have done, which your right eye is a lot more work for you. But I think it this partnership that you have with your team there and with families, I think helps everybody except I think you put in so much work. But I know that that you,


Speaker 3 10:39

I think it helps me to because I'm, I'm learning so much. And I'm getting to be involved in a lot of things that are very exciting. And, you know, I, I checked my email yesterday and I got a first steps, email from a parent, it's just all of these things that people make me a part of that maybe I wouldn't be if I hadn't met them in like the worst time, like maybe if they had met me later and the outpatient clinic, it would have been a little bit more sterile, more, you know, objective rather than, hey, you were there on the worst day. And it's like being stuck in the elevator with you. We remember you from that difficult time. And we you are part of the team, even though maybe sometimes I'm really not doing anything as outpatient. I'm just kind of chugging along and participating. But yeah, you know, you had first steps, email, I'm sure that was emailed to a close family and friends for me. So it feels good to be part of those big events, because a lot of the time, it's not pleasant, what I have to do with the bad news and things like that, but there there are some positive things like it's almost like I'm planting the seed for a relationship, and then just kind of see it come to fruition as outpatient.


Daphna 12:00

I think, you know, when we talk about anticipatory guidance for families, and giving them, you know, what they need enough prognostication that they may remain hopeful, but that we are truthful and honest, you know, it's it's hard to do, because of specifically this pathology and even some of the other pathologies, neonatal stroke, HIV, but I think you have this unique opportunity, but because you do follow them so closely inpatient, and you see their clinical course, and then you follow them outpatient, that you really have this unique perspective. And I mean, I think we're all we've all learned, you know, from you. And I think


Speaker 3 12:41

I'm learning everyday that we just don't know everything, and that's, again, the gray area. And, you know, I have learned that the parents that are at the bedside more often and more involved, can get a better outcome, no matter what the data will show, parents who are at the bedside, involved, asking questions, get a better outcome. So what I try to do, even more recently, as I keep learning this is, is whenever I'm there, just to kind of encourage them and cheer them along as you're doing little things relating to the baby singing to the baby. Asking them, you know, hey, what's the baby liking these days? Which seems like a silly question, but, but it does come to show that parents are knowing their babies are learning about their babies in a way that we can't and in a way that we know will make a difference long term in their development.


Ben 13:37

I wanted to ask you about your your path to this. I mean, I think you you have arrived in a role that you've tailored to you as a physician, and as a person, I think you are, you're the perfect person in the perfect role. But can you walk us through? How did you get to this point? Is it is it a path that involved a training in pediatrics or otherwise general neurology and how did you then go down this rabbit hole of peds? You know, and then and then this this role? It's a


Speaker 3 14:07

very long story. I'm going to try to do it short. I mean, I think growing up, you know, I'm the oldest of five kids. So I, I been involved in the lives of children, whether I wanted to or not, and I've always liked children. I think they're very honest. They're very resilient. And it's very amazing to watch how they change. I mean, I saw it with my own siblings, right? Came in with these little blankets and very pink and not doing much and then they were changing right in front of my eyes, right. So I think when I when I went to college, I wasn't really sure I had considered medicine, but I wasn't sure I wanted to really explore and take advantage of the opportunity to really see because I wanted I always was always sure I wanted a job that I liked so much that I would do for free. So I wasn't sure I did some pre med, I did some human development, some psychology. And then I actually went to graduate school. I have a master's in psychology. So little known fact about yourself. Yes. Yeah, I went to Teachers College at Columbia after Cornell University and I have I was in a program in psychology and education. So I heavily considered becoming a school psychologist. There was actually a lot of opportunity for Spanish speaking school psychologists. I sat in some sessions and I just had a gut feeling that that this is not it. This is not a that's not gonna work. That's not it. I this is not it. So I decided to, you know, go into the workforce. And I worked at University California, San Francisco for four years before I went to med school. And that's kind of where I decided, Hey, maybe I want to be a doctor. I remember I said at one time during lunch with my boss, who was a developmental psychologist, and she looked at me and she said, you'd be a great doctor. And then she really she's like, my fairy godmother, she rallied, she rallied around me to make sure it happens. So if I had physics lab, or a physics lab, come back because I was doing a lot of the clinic coordinator. So I was on the phone with parents doing the index screening, you know, a lot of the times I could tell just from the conversation, the kid clearly had autism. So it's really hard thing and and you know, and with Nana was him in the clinic, and then they were coordinate their appointments. So it was kind of doing administrative and clinical work at the same time, and in the clinic. We had psychologist, psychiatrists, child neurologist, geneticist, so I was like, That's it. That's the thing is child neurology. So I went to medical school, I went back home to put our go to med school and it was like laser focused. child neurology is child neurology, town neurology. So I applied to combine program. There's different ways that you can get to tell neurology you can do three years of peds and then finish that and then to your neurology training where you can do a combined program. So I did a combined program. So basically, we did two years of Pediatrics. 12 months of adult neurology, which, luckily, in my program is not consecutive to a month. So we split it up four months, four months, four months, we would always send each other puppy pictures and stuff when we were in the adult side. To keep us happy, because it's a very different, very different pathology. And then when I finished chelmer ology I did unit on neurology fellowship, so I speak stayed an extra year and that's not a board certifiable fellowship. It's just something some people might choose to do if they have strong research interests in neonatal neurology or just really want to focus our practice on on young babies and on the prenatal consultations for brain malformations. So for me, as an in like intern, probably my fourth rotation as an intern, I didn't even ontology. And I looked around and I saw beds and beds of critically ill children. I was like, wow, wow, what it wow, what is this, right. And you do so much as a resident, you're like going into deliveries, you're like full of blood, you are giving bad news, you're giving good news, the moms asking you how much they weighed in pounds, and you're just like, great, I have to let me take out my phone. And then you're just giving them all this information, then the mom just wants to know if the baby's out of the box today. And I'm like, Oh my god. So 50 movies that went in the bag. So it was kind of just like hectic environment that I thought was so unique and special. And you see these like really tiny, fragile humans with fragile humans at the bedside. And I feel very at home. I said, Wow, maybe I want to be an immunologist. But then I had a neurology case, as an as a piece resident, and I said this, this is the thing, this is the thing. This is this is what I'm going to do. So that's sort of kind of how how it came about. bird's eye view. I mean, there's a lot of little different stepping stones on the way and some personal things. That that,


Ben 19:25

can you talk about the fact just on what you were just describing, I mean, you spent so much time in the outpatient setting before med school and you're seeing the product of what comes out of the hospital and then you backtrack, quote, unquote, I guess you backtrack and now enter the hospital. And you start seeing the inception of what would then become the babies and children you would have followed in the outpatient setting. What is your How do you interpret and what is your impression of, ooh, this is the spectrum that I'm seeing. This is the origins of what I was seeing and how did you What was your feeling when you You were when you went through that.


Speaker 3 20:01

There is a continuum. Right? And and it is very interesting to be part of the whole thing, right. So when I was doing my outpatient clinic coordinator job, I was asking some very scripted questions. And sometimes parents would offer additional information. Oh, you know, in the ultrasound, they thought that the baby had increased nuchal translucency. And I'm like, I'm not a doctor, I'm not. I'm just googling. Googling, so and then when I was in the appointments, you would see the doctors kind of the genetics doctor and the neurologist looking at the brain picture and says, everyone's trying to put it together said, Oh, this is fun. How do we How does it all come together, I need more information to be able to play this game too. So I need to be a doctor. So I can have all these information and play this game, this amazing game of who we are as people and how we get there. And I think it's still very unknown, but it's very fascinating to be part of that whole investigator hat or trying to put everything together hat.


Daphna 21:10

I love what you just said, I'm gonna I'm gonna write that down. I'm going to keep it you said, you know, the Nikki's full of fragile. Humans with fragile humans at the bedside. And, and that's all of us, right? And myself included as the physician. But but so much. So the parents and you know, you're, you're also a mom. And you are the mom of a NICU? And also, how do you think this experience, you know, shapes what you do every day? How you interact with, with, with families and with babies? Because you really do?


Speaker 3 21:49

I'll tell you a little bit personal story, right. So I, when I was in fourth year resident, I was pregnant. And after a perfect pregnancy, I become a frazzled parent at the bedside of a 26 weaker, it happened in an instant, it happen without any warning. And all of a sudden, I was in those shoes. And my son didn't live very long, it's only 30 hours, he was very sick. At that time, I didn't understand why he was sick. I don't remember even a lot of the conversations that I had. During that time, it's a little bit of a foggy time period. But I remember very clearly certain things. I remember people's facial expressions when they were talking to me, I remember smell sights sounds, being wheeled into the NICU, like that feeling of like just helplessness, like not knowing what's going on or how you can help. So from that experience, of course, traumatic my son passed away. I try to extrapolate some of those things, from my personal experience when I'm working with family. So being mindful of my facial expressions, how I say things, and also knowing which I forget, sometimes I still, I'm not perfect human, none of us are. And even me going through that experience, I still make mistakes. I knowing that people are not hearing everything that you're saying is important to recognize because we want to be helpful, and we want to give a lot of information. But if you're not emotionally, like, there, I was even going through my own medical problem, like the first one to think about I was on oxygen. And I had my own RT, right. How are you able to an IME doctor at that time? You know, how are you able to remember, understand, ask good questions. It, it's it's pretty hard. I mean, you are in a day. So I I try to summarize and give key points at the end, and do a lot of pausing for questions. But I also know I walk away from those interactions. And no, I'm not sure. Not sure they're hurt everything. Right, which is why it's so helpful that we do a lot of these care conferences a team, because you have your bedside nurse there, right? She can go are a lot of the times the star of the show, right? They can. They're hearing everything you're saying. And then you can look back and say, hey, well, how do you think it went? Like how are the parents doing? What did they hear? What do you think it'd be helpful for them to hear again, because you're just not there. And another thing that I learned from that experience that at the time when everything happened, we didn't have a good medical explanation. My son had hydrops and we were like, Why? Right? Everything had been normal. There's no infection. Why? So? My son had an autopsy, and then unit ologists call me with the results. and my child had a CPAP. And I didn't know, it had grown really fast. We didn't see it on ultrasounds. But that explained everything. And it didn't take away the hurt, it didn't take away the grief, but having an explanation, really help with my grieving process. So I am very careful and mindful when kids have had a catastrophic outcome in the NICU to make sure we have as much of a sentinel event explanation, because it really, really helps the families move on whether the outcome is mild, moderate, severe or catastrophic. It does help accept and understand what's going on and medicine is changing. Sometimes, you might want the answer. But just to make sure we've looked everywhere that we can think of whether it's, Hey, this is a rare case, I'm going to start calling emailing colleagues at Cincinnati, where a train or chop or you know, do everything that you can to help people understand, even in the hospital, even the clinic child has a rare disorder, PubMed, who's writing about this, who is you have to go all the way and help families because they they're not doctors, but you are and you have tools that they don't have. So how do we help people get to the best place and get the most information? And you know, I'm not perfect. There's been cases that I haven't been able to help and things like that. But at the end of the day, all you can do is say, Well, I tried my hardest to get all of this stuff figured out or all of this stuff understood.


Ben 26:44

Yeah, it's almost as it's almost thank you for sharing that. But it's, it's almost as if it's what's going to allow the family to close the box and move forward as a family. Knowing that they they have an understood at least some understanding as to what happened. And and so I think it's so true. And definitely, and I unfortunately had a case not too long ago, where, yeah, it was very important to the parents to say what happened. And you could tell that this was going to be the closure that they needed to then look at the future as a family in an optimistic way and not have this ghost of the NICU. Just hunting them for future pregnancies and so on and so forth. I think that's that rings very true.


Speaker 3 27:31

And I think for you know, supporting an ontology is to see kids as outpatient or neurologists, a CTS outpatient, I can see that it's not uncommon for the outpatient appointment for parents to still have questions, even though you already went through them. I can tell you even with kids with HIV or things, they you say the words like a million times, and then you're so in a fog, you might say, what's my kids diagnosis? And you're like, we talked about it. That's why I think sometimes written materials are helpful, writing things down because it is a very foggy time and the outpatient appointment, even though you don't want to revisit the past. I think it's a worthwhile investment, just conversation to have like, let's just take a couple of minutes to talk about the NICU. This is what happened. And you do have any questions about that or now that you were home? How do you how do you process that and


Ben 28:30

I had an experience in the NICU where I had to break some terrible news to a mother of a baby with a mitochondrial disorder that was years ago. And as she walked out, she got up and walked away she was smiling. And my attending said, Just appreciate the fact that no matter how bad the news was, she did not process everything you said and she still hung up to the idea that maybe there's a chance her child is going to get better. And and that gives you the magnitude of how emotionally distracting the NICU can be and and to what you're saying that no matter how many times you have the conversation and you could be as on the nose as you want to be. It still is something that doesn't permeate until it's been repeated over and over again or until until time has done its its job. Definitely lift us up a little bit.


Daphna 29:22

No I think you brought up a really interesting point that we as humans we struggle with uncertainty and unknown and just like families want very much to have an answer. Certainly as providers we want to feel like we have an answer one for our ourselves to put the pieces together and to so we can provide them some sort of something. And but in my experience with you, I mean you really shine in those gray areas that so many people struggle with right Like how, sometimes we don't know. And we really are living in uncertainty, especially some of these trying to provide prognosis for families. And so I'm hopeful that maybe you can share some of your like tips. Because this is where I think a lot of people who maybe are not comfortable with this vague term of palliative care palliative care type communication, they'll just avoid it altogether. But I think there's a way that we can model for people how to sit with uncertainty.


Speaker 3 30:36

Right? So I think, you know, I, I've shied away from using certain terms over the years. So first of all, setting, right, I think having a conversation in private, where you can talk face to face makes a difference, particularly now in this, like pandemic, restrictions and things like that. Trying when possible not to have it at the bedside, because it's busy, and it's not private and the baby's there, and it's a lot. So I think having it in a private place, that's helpful. So the place I think, giving a little bit of a, a gentle heads up, like say, you know, hey, we're going to have a meeting in private, we have some difficulties to talk about, or, Hey, your baby's very sick, in multiple organ systems, so I think it's best to have a meeting and sit down and go over everything, as a TEAM, to answer your questions and give you information, I find it very helpful that met the family before before the meeting at least one time, just because it creates a little bit of a rapport. Particularly in these meetings, where there's multiple doctors to meet them before, even if it's briefly helps create a break a little bit of ice. If it's just me, I don't mind just meeting them for the first time. And just like being in a room with them, and say, Hey, this is this is why I am this is what I'm doing for your baby, how I'm helping your baby. And then using, being mindful about the terminology, explaining things as, as best as you can, without giving too much information. Drawing can be helpful, showing him rise or just sounds can be helpful. And then with the prognosis, kind of being cautious. Even with HIV, where we have some MRI markers that talk about for example, walking, right, instead of saying medical literature says the kids with this MRI are not going to walk, not going to talk nobody independently, right we have some of that medical information by just saying, you know, I am concerned or I am worried that the baby might not do these things, is maybe a little gentler way of putting it and also trying to be as objective as possible. So sometimes you say I'm afraid a baby's not going to eat by mouth or and say, you know, I've checked him this morning and I'm concerned, you know, to be able to eat, you have to suck, you have to swallow I'm just really concerned, it's not really normal, when I check it. So that on the MRI is really kind of helping me put this together. Or you know what this ivh prognosis just being you know, we have medical studies that show that if you have this type of blade, you are likely to have some challenges in the future. And I always like to explain to the parents that term developmental delay versus a more of a handicap. Because I think if you just say delay over and over, the impression is, you know, the train is delayed, it's gonna get here an hour later, right? The problem is, these developed, you know, these handicaps are developmental handicaps, the train might not get there, right. So explaining that there's some, some kids can have delays, meaning that they might do things later than we hope they will be doing them. And some kids might have handicaps, meaning, regardless of time and therapy and equipped medical equipment, they might still not be able to do certain things independently. And I think that that is is important to make a distinction because some people, they'll they're so stressed, they'll hear what they want to hear. So if you say, Oh, the baby's gonna have delays and there's therapy for that. Okay, we're good, right? But I think ethically, you have to explain that, you know, some cases, no matter what you do, you might not get there. And I try to leave the conversation always with a little bit of hope. Because, you know, if I'm not hopeful with them who's going to be right? And just explain that, you know, the brain can do remarkable things that baby's brains are not like nice brains are still developing and changing and are capable of forming connections. So what I need you to do is to help me enrich your child. Right. So kind of giving them a task relating to your baby singing to your baby, you're going to meet the therapy team, which are no champions in this process as well. And they'll be educating you on how to stimulate your baby. And we're going to continue to do that as an outpatient. Just kind of setting the stage that this conversation is the first of many conversations, and it's really our introduction. For us working together, not just I'm gonna give you these news, and I'll see you later. It's, hey, we're going to work together, we're going to we're going to help you we're not leaving you alone, we're gonna help you we're going to work together. And so what we're gonna do,


Daphna 35:40

yeah, it's some of the key tenants of of like palliative care is that we can both be hopeful and realistic. That was great. And then like you said, partnering with the family is so important. Remind me your son's name.


Speaker 3 35:58

So my son, his name is Thiago. So it's hard for Santiago because we didn't we were gonna name him Santiago or Yeah, we didn't know him. So we picked the shorter version, sort of as a nickname, type of thing.


Daphna 36:11

I can't help but feel like I mean, the work that I've seen you do with families is like, Thiago is legacy. I feel like you just get parents and you're able to explain it in a way that is so helpful. And, you know, I wonder how, you know, given this trauma that you that you carry with you, you know, how do you? How do you prepare for the family meeting? You know, how do you emotionally ready yourself? And you know, what can all of us do? I don't think you've need, you have to have been through a traumatic experience to be able to empathize with families. You're right. I wonder how you how you get yourself to that space?


Ben 36:56

And can I say something else? I want to say that I've worked with providers who have experienced losses themselves. And they often end up very biased on one side or the other of the spectrum. And I found to your credit, Monica, that you are so moderated. And you do you are very conscious of where you are, who you are, who you're talking to. And that is something that, again, is one of the reasons why I have you on because you're so good at that. Yeah,


Speaker 3 37:22

I think it's because there's a duality, in my experience, right. Neurologists by nature, are very kind of objective people. I view neurology as an art. Because adult neurology I think is a little bit more scientific objective. I see child neurology is a little bit of an art because we do a lot of things based on experience based on medical literature, based on what the parents wishes are, it's sort of a putting it all together. I actually am very protective of my own personal experience. I think, in my interactions with families, I can tell you in the throes of things I've only shared pay, I've been in your shoes, only like two or three times. Because I don't want that to get in the way of what I'm here to do. Like I'm here to do a job here to be objective with information. I'm here to be hopeful and realistic. And I'm here to partner with you. Okay. I understand this more than you will ever know. But I don't say that, right? I keep that in my facial expressions in my presence in my in my gentle touch, or whatever, however you want to put it, I keep it as is as the shining light. Right, but I don't express it verbally. Because I don't want it to interfere with what we're doing. Right? I don't want the parent to say, well, you know, she's been through that. And she's doing okay, so I need to, or I don't want it to be clouded my clinical judgment or my information. So it's hard to separate. But I do I do share with some parents, particularly ones that have lost children. I've shared this in funerals. Hey, I'm so sorry that you lost your baby. I want to tell you, I didn't tell you before but I've lost a child too. And it's always like, Oh, you left me speechless. I would have never imagined that you went through something like that. I say, Well, you know, I'm your pediatric neurologist and I'm a person right and but even now I'm more of a of a co parent or another mom that's lost a child. So I think and you know, it's been hard I don't have like a mentor how to do this. I've just tried to figure out this is the way that I can do this job because to be honest with you, after my son passed away, I had a lot of conversations with myself like can I really do this like is can I really do this? Am I crazy to think you know, because I had already decided that I wanted to do this, but you can always back out, you know, yeah. And walk back, you can always be ahead of neurologists. Hey, yeah, I can always be a headache and route your ADHD. Right, right. Um, how do we, I had a lot of hard conversations and I said, you know, before all of this, I had that aha moment of this is it. And maybe this is just something part of that personal that I have to, you know, integrate in this somehow make it all make sense. Like Daphna was saying, you know, to his legacy, how do I, how do I make a how do I put everything together, but still be able to do the job, right? Because at the end of the day, it is a job. I mean, it's a career for me, it's a passion, I will do this for free. I mean, if somebody called me in Jamaica tomorrow at the NeuroCare conference, I'm going to do it, and I'm not going to charge for it, because I That's how strongly you feel about, about this, this work and doing it well. And, and partnering with families, but it hasn't been easy. I just have tried to maybe take that away from the equation in the throes of things and then just maybe disclose it a little bit later. And, and I think it's been helpful in most situations that I have disclosed it. And I think that's what I'm going to choose to do from now. Because it's working, I guess,


Ben 41:28

let me ask you a question that I've heard from many, many people, and you probably are the best person to answer it is when we're dealing with babies who have unfortunate morbidities, like, like ivh, like HIV. And we do have to sit down at the bedside. There's really a fear of providing optimism and hope and you hear it in residency programs. You hear it in fellowship programs, like oh, don't don't, don't be over enthusiastic about the potential outcomes, because you don't want to give false hope. And I've always struggled with that. Because obviously, like you said, you have to be, you have to share some optimism. But how do you advise trainees and young physicians in? How do we hit this mark? Well, without giving false hope, but also not being all doom and gloom? Because I think if I were a parent, I wouldn't want a doctor that doesn't have faith that things can go well, yeah. What's your take on that?


Speaker 3 42:30

Right, and you and you read it in the, in the, in the forums, right? And online, where all this doctor said that they wouldn't do this. And they wouldn't do that and look at my child smiling. Because the thing is, parents also be their children in very different eyes. And we will, right so the successes for them, even though they're small for us are major, right. So and I think it depends on the case, if there is a case that you honestly feel, the brain is a big issue, the lungs are a big issue, the belly is a big issue. I think being doom and gloom, unfortunately, is the appropriate correct thing to do, because this is a child that's potentially going to pass away, or going to have significant morbidity and mortality. And you need parents to understand that, right? In some of these more great cases, where you know, the brain is affected how severe we don't know, it's not at the more severe and I think it's helpful to be optimistic and give a little bit of hope and know with time and therapy, and even in cases when this just the brain is severely affected, you have to be a little bit open and honest and say, I'm concerned, the child's going to be significantly handicapped. I don't and so, you know, I don't know if that means that there'll be unhappy and parents like hearing that, right. Yeah. I have patients that are severely handicapped, and are very happy. I have other patients that are severely handicapped and are not happy because either they're irritable the brain, brain abnormalities can make you very irritable. And it's that kind of irritability, that it's very hard to control and distressing, even for me as a doctor trying to help. And then there's other children that are unhappy because they keep going in and out of the hospital with a lot of medical procedures. But there is a hope, you know, when all is lost, or or you think you're going to have a handicapped child, there is a hope that they're gonna be happy in that it's a true thing that can happen, right? I mean, I have pictures of my phone or videos of kids dancing in their daycare and for us are moving around in a wheelchair in their daycare for us. We're like, well, that wouldn't be a good outcome for me. But for some parents face with death, that is a good outcome for them. And that can change over time. Because I see patients in the hospital when they're older. We've had situations where parents say chose everything in the NICU, baby As they wanted to hold on to that hope, okay. And then fast forward, they start getting sick, they start getting, like a lot of pneumonia, or sepsis episodes or bad seizures, and they come back to the hospital. And those are times that parents might choose differently, right? We wanted everything done before, because we wanted to see where we would be, hey, we have a medically fragile child, it's in our eyes suffering. And then parents might choose differently that time and choose more of a Comfort Care route at that time. So I've seen a kind of go full circle where people make different decisions over time. And there's no right or wrong way to approach it.


Ben 45:42

So what I was gonna say, So then what's your take on on the parents who are asking you the very blunt question of Is my child going to be normal? Right, that very, I would say, it's unlikely


Speaker 3 45:52

that they're normal. If you feel from the imaging, that's very unlikely, you can say, I'm concerned, they might not be. But anyway, I always go back to the spectrum, right? Could this be a child that is wheelchair bound, and nonverbal and needing assistance for feeding? That's the worst case scenario. The best case scenario, maybe it's a child that walks but can't talk or doesn't have normal language, or thinking and reasoning might not be the same as another child. So I kind of paint this spectrum. So that because you also hear these stories, like, Oh, my doctor never said that they will walk and they're walking. Yeah, but are they gonna be able to talk? Or are they going to be able to be independent? Are they gonna be able to think and reason, right? So you kind of have to get the flavor of all of the things we're worried about, in a gentle way, write down a little bit. So that way, when they walk in there, they're not like, talk to you told me they would walk in, like, Hey, doctor, they're walking. Great. What's the next? What's the next agenda item that we have to work on? And a lot of parents like that. A lot of parents asked me, so when we see you in four to six months, what would you like for him to be doing? And I say, Well, I would love for him to be sitting on its own or, and then the parents feel like, okay, that's our homework, sitting, sitting, sitting, or talking talking about you or so kind of sets the stage that this is not, you know, the first week, and I always say the first two years are critical. And I go back to, as everybody knows, babies are born and they don't do very much. And then as they're growing, they're changing, because different parts of the brain are kind of activating or polishing. These are the words that I use for parents, like, you know, different parts of the brain are waking up or activating. And that's when we will see the problems because sometimes the parents will also say, you know, the, the we're 44 weeks corrected, we're leaving the NICU. Look, doctor, perfect baby.


Daphna 47:49

Look at that baby's normal.


Speaker 3 47:51

And ethically and honest, you have to say and I say that the care conferences, and I remember or most of the time, you we might have a baby that looks very well when they leave the NICU, if they're able to feed by mouth is so the biggest problem we see. Well remember, as your brain is getting activated, as they're older. That's when we might start seeing some of these things that I'm worried about. So just to kind of, because sometimes the parents will say that the baby's moving. What do you think he's gonna be weak? The baby's moving? Late, okay.


Daphna 48:30

Yeah, no, I wonder, I wonder. Because you do see parents right in the outpatient setting, and we can't we don't have that opportunity. Most of us unless we're doing follow up care. What do you think is one of like, the most important things we can do or say, in the NICU? You know, and that may not be prognostication. But for families, you know, what do they have quite what's the question they have that they wish they had known in the NICU? Things like that?


Speaker 3 49:02

And that's a very tough question. And I think that's actually an interesting research question. If any of you guys are interested in our project, I think that's yeah, and I think that's a great project. Because we, you know, we only know what we know, we don't know, you know, we think we're doing a great job. We're think we're doing all of these wonderful things. But are we, you know, are we missing things? And the way we know is we, I try to be like, Hey, tell me what you think and what you have. And I'm even shocked. So plants are the questions because I know we discussed it, but again, it goes back to this foggy brain of only so much I can hear only so much I can take in at a time. So it's not that we didn't do our job or we didn't do our job well, or we did it poorly. It's just it's hard to simulate everything I think. I think a key point is to know that the journey doesn't end when you leave the NICU. I think if you can kind of gently remind parents, you know, we're here to make your baby to support your babies. so that the baby is able to do all the things that attend maybe supposed to do, but that the things that happen in the NICU might have a lifelong repercussion and that we need to follow your baby as they get older. And just to kind of set the stage that we're leaving the NICU, and the baby's taking a bottle, we're done. trauma, and that's what the easy way, right? Cheering writing the banner out the door by right, by just kind of cheering because it's a very, very special thing that we are there, right? We're just saying, we're very happy with how things are. We have development is kind of the next big thing we're going to be much more for. And having a team that's going to help the families with that. I think it's a big, big thing.


Ben 50:54

Let me ask you a question that, in your experience, having counseled so many families, what is your take on the importance of the Father in those sessions? I feel like the mothers are in this is so biased, what I'm talking about right now, but I don't care translates just mics. But but it's just my experience. The mothers are so dedicated that I've never seen a counseling session that happened where the mother was not present. And sometimes the father was there. Sometimes the father wasn't there. But I do feel like the father has a huge role to play. And I'm wondering, in your experiences, counseling, hundreds and 1000s of families, what is your take on the role that the father plays in those in those moments?


Speaker 3 51:37

I mean, it's a wonderful question. It's so important. The father is probably one of the more important people in the care conference, lots of the time moms are still in the wheelchair, still in their pain meds, Father, all of a sudden has mom recovering, and a child in ICU. So he is in charge of taking care of two people, right. And it's a new role, right? So I think fathers are very important in the care counseling sessions. And they should be there unless for some reason, they're not involved, which in our case, in that case, will be great to have a cousin or an aunt or some other family member there, because moms are so involved, but they're also going through their own medical stuff most of the time. And it's hard to assimilate the information. It's also very hard to be the messenger, which I'm glad that you brought this up. Because I think sometimes we tell that news to the mom thinking oh, she's the person that needs to hear it anyway. Remember, she has to tell dad, grandma, her best friend, it's just a lot for one person to have to hear that and then explain to other people. So I know in some scenarios, the father can't physically be there, or a support person can't be there. But I offer all the time. If there's a medical person in their family, do you want me to talk to grandma with your permission? Since she's a doctor in India, if this is a true case scenario? Or do you want me to talk to your auntie in Cuba who is a OBGYN and with your permission and in your presence, potentially, because it is a lot for families to have to not only get the information but to give the information. So a father is a critical or a very important part of the care counseling, if they're not available, having another person present will be best. Now with all the technology we have with videos, Zoom FaceTime. There's really no reason why someone else can't be there. This drive by bad news at the bedside when mom's there is not a good idea. In my opinion.


Ben 54:01

I appreciate you saying that. Because I mean again, and I'm talking about fathers, I'm talking about I guess, spouses in general. But I do think the poor people many, many times many times you hear a mother telling you Yeah, my my significant others working and you like alright, so like this now then, and maybe yeah, we're here. Right? But based on what you're saying, and I echo those sentiments, maybe you it should be no let's let's actually find a time where you can both be here and do this as a group rather than getting it over with which sounds so terrible.


Speaker 3 54:37

And let's get going back to like giving a little preparation, right? We're not going to tell you that your child is gaining weight and off the box. If we're setting up a meeting and we want to talk about some serious stuff, you know, we come prepared. We come with your little pen and paper and we're going to meet and we're going to have time to talk right because sometimes at the bedside we get a phone call or another child is B Being, we just need to have a little bit more private way more special time or dedicated time to talk about these very important things.


Daphna 55:09

You brought up another interesting point. So many times, you know, we've given the information to mom or if mom is sick, we've given the information to dad or the partner or again, like you said, a support person, a family member. And when you hear the the telephone chain, right, when you hear it repeated back through the second or third person, we say like, Well, they didn't get it at all. But you know, so much of it is such a burden for that person to have to share the news. Like, it's hard for us to share the news. So how can we expect family members to share the news to other family members? So I really appreciate you, you bringing that up? Yeah. And


Speaker 3 55:51

it's hard because all of us are very busy, right? But it really these phone calls that I've had with grandmas in Cuba, or in India, FaceTime, they really not been very long. And it's gone a long way. Right? So I think, you know, these are like the little acts of kindness that can really change a person's experience. And sometimes there's a there's not a lot of medically I can't do I can't go in there and fix the brain. That's how to change. But if there's a little something that I can do to help the family, again, not being afraid to wear other hats, like I'm not afraid to wear other hats. Yeah, you know, they ask a question. That's not for me, I'm not afraid to say okay, well, let me write it down and find the right person. Because we're all really a team. I think seeing the care as divided. is harmful, like, Oh, that's a question for you. manatal logist, or, you know, it is, but let me write it down. And we'll kind of let's get back together about it. Or, let me see if I can call grandma really fast now with your phone and talk to her. It's just, it doesn't take much time. And it can really make a difference in how you care for patients.


Daphna 57:04

Yeah, and I think it's multi fold. Right? We talked a lot about connectedness and how does connected this you know, with each other help, for example, mitigate burnout, but but we can connect right with our patients and with families. And I think, you know, that helps us with with our longevity. I've also found that saving the family meeting until there's a support person saves time, in the long run. Right. So if we're so cramped for time, then really, the right choice is potentially to do it one time instead of three times. You know, that's so true. Yeah. I was I was actually, you've given us a lot of perspective. And another interesting thing about you is that you've worked in so many different health care systems. And so I wonder, you know, what do you think are some of the ways we can improve? You know, life for children who are medically complex? Is it about the transition home? Is it about resources? Is it just, you know, improving our communication? Where can neonatologist kind of focus their advocacy?


Speaker 3 58:19

I think I think that for us in the trenches on the hospital, we forget how complicated it is to navigate the outpatient system. I had a family, a mom, this is a true story. And she'll probably be perfectly okay with sharing this. I had a telehealth with her after she left the NICU and like you for a long time. And I asked her, she was telling me everything, oh, something about the throat and spit up in saliva. And I'm like, okay, like, again, getting all the information, but just kind of gently bring it back. So have we seen seizures a house of medicine, right? And then I said, Well, you know, mom, a lot of this throat stuff, you have a throat specialist called the EMT. And she looked at me she's like, Dr. Royal. I don't know anyone else except you. I literally don't know why anyone is


Daphna 59:13

showing up for appointments. I don't even know why.


Speaker 3 59:17

They don't even know like this mom has limited education to like, Oh, she's not a medical person. And she was like, what are all these words? I got a letter I got I have 19 appointments. In the next few weeks. I don't even know who does want. I'm just going to show


Ben 59:33

we reviewed a paper on the journal and journal club where depending on level of education, some others could not recover that they had certain vaccines done and things like that. And then it puts into perspective exactly what you're saying. It's like well, you know, I showed up to the doctor to give me a shot and then they move on. You know, they don't they don't. There's so much


Speaker 3 59:48

so let me ask you practically are your spouse's in the medical field?


Ben 59:53

Yes, they are. Mine is.


Daphna 59:55

Mine is not mine. Okay,


Speaker 3 59:57

so Daphna, what do you think? Yeah. My husband is on a medical field. And you know, we went through this terrible medical experience and the kinds of questions that he had are very different than the kinds of questions that I had. And even no going to the pediatrician. So what they do. Okay, that's right. Which ones? I don't know. Okay. Well, and that's really, you know, they gave him a shot. So we're do I don't know. Next Next problem, right that but so that's in in this is like a low stress Well, child visit, how are we expecting people to know who the Throat specialist is? Or? Yeah, oh, I'm the end in the case. Yes, we all know what that is. But maybe they don't. And the reason that she knows who I am, is because we had so many conversations. Now, because I'm a fantastic doctor, and I'm better than everybody else is just because it can have seizures, and I was there. No, no seizures, and I was in her face a lot. So she knows who I am. Because I was in her face a lot. And she knows that I'm a senior doctor. But I had I printed it out for her. And we went one by one. And, again, not my job, right. But so I think if there's anything that we can help is this road to home, and I think even in the neurology community, we are also trying to figure out, how does that look for us to improve it? We have kids in the NICU, but we also have kids no PICU and other in other parts of the hospital or new diagnosis, seizures, like how do we make the road to home as efficient as possible? What's the best time for follow up? You know, is it a month? Is it two weeks? How do you know some parents have more questions sooner? I think it's an area of advocacy, for sure. Research for sure. I think having a very strong discharge coordinating team is essential, because some of these things can be done a little bit more efficiently in the NICU, like trying to get as many appointments as possible, done explaining, again, maybe who everybody is, I think reading material is great when it's available. Because it helps you look back instead of just oh, you know what they say again, but it is very overwhelming. So I think that even us in the medical field, taking care of these patients have no idea just to share another personal story. I for a summer I was a nanny for a child with autism, this is in between my masters and working. And he had some medications. And he's 10 years old. And I remember I had to crush them, make sure they take them. And you know, he wasn't a summer camp. So I was nervous at the camp counselor will call he misbehave or it was a problem. And he was very strict to his routine and had a lot of behavioral problems. So I can tell you that summer as a special needs mommy assistant, or mommy and many times, really opened my eyes to and soften my heart towards this problem. And in this field, and in this work, because the thing that parents do, is unimaginable. I mean, how much they do for their kids and any of their other kids, right? But how much work they have to do how many appointments, so there's anything, even if it's small, we can do to help them or take a little load off, it'd be helpful. I mean, I think places that have multidisciplinary clinics where people can see multiple people at the same time are wonderful, because you get a lot of things done and accomplished. And the teams can talk to each other. And I think those things are great, but I think there's already carrier so fragmented already. I think children's hospitals, you know, are trying to focus on building some of these clinics, complex care clinics, multidisciplinary planning, and I think those things are so valuable and so needed. And Yun otologist to be involved in some of the follow up because then you can take those things back to the bedside, right? Things that you're saying or learning or how to have the conversations go and how do we how do we improve the outcomes and the medical care?


Daphna 1:04:03

I wanted to ask one more question. And then we really we're really getting short on time. I think we could talk to you all day. Monica, I know I am a talker. You have, you know, an additional way that you help parents is, is that you're bilingual. And I wonder, you know, what are some of the most important things we can do when we have families who have language barriers, and we're just trying to really express these complicated situations in scenarios and instructions, right. So either in the acute setting or in the transition to home.


Speaker 3 1:04:42

Yeah, this is a tough situation. I'm very passionate about this problem. Actually. When I was figuring out where to work, I consider several factors. First and foremost was proximity to my family. My parents are in Puerto Rico. So I want it to be somewhere that I could drive to the airport, get on a flight and be home relatively soon. So that's like East Coast, potentially. So I also thought about hard. Where can I really be an acid because I speak Spanish, because I do feel like it makes a big difference, no matter how serious the problem is, I can tell you in the outpatient setting, kids with even minor problems that parents face will light up, when they realize that you speak Spanish, they might have asked for you, because you speak Spanish, but then you know, somebody will say this to Spanish, but they kind of speak just a little bit. And you can see their faces just light up when they realize that you speak fluently in Spanish that you're going to have a whole conversation in Spanish, sometimes even culturally can understand some of their concerns. Um, I think, you know, medical interpreters are, are really helpful and are wonderful. I feel like when, when possible, if there's a native language speaker to be involved in the medical team, that's the best. But if not using language interpreters, even if sometimes the parents would tell you, Oh, are English is good would don't believe that. Because, you know, just like we're having problems, even with the English speaking parents, right, communicating difficult things, and what they hear what they don't hear, I would not put that variable in there. I don't think it's wise to do. I've been involved in care conferences as a trainee where I was serving, and there's been medical interpreters. And I've seen the interpretation. And sometimes, you know, Spanish language in general, there's different, you know, different people have different accents and different ways of saying things. So some of the things, some of the ways can be very polite. So as I was picking your cop, I pick you care calm, and then the doctor was clearly saying your child is going to have these problems. And then the interpreter was like, well, the team is worried that maybe. And I was like, That is not the message, right? And in a critical situation like this, this wasn't a prognosis from the brain. We don't know if this was like, hardcore, we need surgery, we, you know, it can be tricky, the message can get a little misconstrued. Not willingly, right? It's just a way of saying things, we all have a different way of saying things. So I think when possible, having when it's possible, sometimes it's not possible. But when it's possible, having a native Spanish speaker, and if the parents even tell you whether English is really is good. Or if you get a sense that maybe they might need an interpreter or one interpreter, I think it's good to, or maybe one parent will say I speak English really well. Dad doesn't speak English, but I'm going to tell him, I would be mindful if, if possible to get interpreter because that's also a lot to put on a parent to listen to difficult information, translate. Translate back. No, that's not an ideal situation. Yeah,


Ben 1:08:12

this was so instructive. Thank you, Monica. We're not even close to end of time, we're past time. hours. But I feel like a lot of the stuff you've said, If I were a trainee, and I'm probably going to do that, I mean, I'm gonna have to do that just for producing the podcast. But I would save the clips and just like write down how you said to sit through and things because that's going to be so helpful.


Speaker 3 1:08:36

And, you know, to to everybody, you know, I trained at a place that is, is family centered. And I think my 20 experience has played a huge role in how I approached medicine in general. I mean, I trained at a place that we were not allowed to use a lot of medical terms in the room, we would round in the room, you will be up all night seeing bronchitis and then you would have to explain to the parents the next morning, and every room was call. What regulators is WhatsApp. So I think it really kind of trained me to be extremely mindful about medical terminology. And I had wonderful attendings and I have a lot of role models and mentors, still that, you know, taught me that sitting down in the room in the PICU, is what you do, right? is, you know, these are the sick children. These are the ones that need you. You need to you need to be their president. And I think that's kind of what I learned and I can't do it any other way,


Ben 1:09:43

not just the PICU and the NICU.


Speaker 3 1:09:45

All right. Well, yeah, you're the NICU. Of course. More importantly, because the parents are like, their little ventures but you know, you sit in the ICU and I see us


Daphna 1:09:56

Well, I think that's a you know, they're less chairs in the NICU than the PICU But I think it's taking the time to seek one out is a great last point,


Speaker 3 1:10:05

I think yeah, yeah, get a chair get more more chairs in the NICU at least that's what we're gonna spend our money on.


Daphna 1:10:14

Well, Monica, thank you so much for for sharing your your life with us and sharing Tiago with us and, uh, you, you touch a lot of families. So thank you for what you do every single day to so much.


Speaker 3 1:10:27

You're very welcome. I was really enjoyable.




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