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#187 - 🫀Insights in Neonatal Cardiac Care (ft Dr. Nim Goldshtrom)





Hello Friends 👋


In this week’s episode of The Incubator Podcast, hosts Ben Courchia, MD, and Daphna Yasova Barbeau, MD, dive into the complex world of neonatal care for infants with congenital heart disease. Our guest, Dr. Nim Goldshtrom, shares insights from his extensive experience in neonatology and pediatric cardiac intensive care, focusing on the multidisciplinary approach to caring for the sickest infants at Columbia University Irving Medical Center and Morgan Stanley Children’s Hospital. Dr. Goldshtrom discusses the evolution of his career, the importance of specialized training for dealing with congenital heart disease in neonates, and how modern technology like near-infrared spectroscopy (NIRS) is being used to improve patient outcomes. The conversation also touches on the challenges and opportunities presented by genetic screening and the future directions of neonatal and congenital heart disease care. Join us for an enlightening discussion that sheds light on the nuanced care required for these vulnerable patients and the ongoing advancements in the field.


Enjoy!

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In other news, we are excited to have released the agenda for the upcoming Delphi Conference! Check it out here www.delphiconference.org


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Short Bio: Dr. Goldshtrom is a neonatologist who has additional training in pediatric cardiac intensive care. He works in both the neonatal intensive care unit as well as the infant cardiac unit caring for infants with congenital heart disease. The intensive care units at Columbia University Irving Medical Center (CUIMC) and Morgan Stanley Children's Hosiptal are regional referral centers for the sickest children and infants in the tri-state area. Our teams work in a multidisciplinary fashion utilizing expertise from surgeons, pediatric subspecialists, nutritionists, pharmacists, respiratory therapists as well as social workers, psychologists and case managers, to provide comprehensive patient centered care for each child and family.


Some of the articles discussed on today’s episode of the podcast can be found here 👇


Kooi EMW, Richter AE.Clin Perinatol. 2020 Sep;47(3):449-467. doi: 10.1016/j.clp.2020.05.003. Epub 2020 May 14.PMID: 32713444 Free article. Review.

 

da Costa CS, Czosnyka M, Smielewski P, Mitra S, Stevenson GN, Austin T.J Pediatr. 2015 Jul;167(1):86-91. doi: 10.1016/j.jpeds.2015.03.041. Epub 2015 Apr 17.PMID: 25891381


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


Ben Courchia MD (00:00.642)

Hello everybody, welcome back to the Incubator podcast. We are back this Sunday with a new interview. Daphna, good morning, how are you today?

Daphna Yasova Barbeau, MD (she/her) (00:09.201)

Good morning, good morning. This interview has been on our calendar for months and months and months, so we are very, very happy to get it off the ground.

Ben Courchia MD (00:13.538)

for some time.

Ben Courchia MD (00:18.334)

That's right. That's right. We have the pleasure of having on today Dr. Nimrod Goldstrom. Nim, good morning. How's it going?

Nim Goldshtrom (00:26.853)

I'm doing great. Thank you guys for having me back. Hope you guys are enjoying sunny Florida as well.

Ben Courchia MD (00:32.851)

Oh, we are.

Daphna Yasova Barbeau, MD (she/her) (00:33.401)

We are, that was taking full advantage of.

Ben Courchia MD (00:36.702)

It's, as we're recording this, it's now pretty much December and the weather is perfect. It is sunny, just cool enough. So I really would feel really, really privileged to be in this type of environment at this time of the calendar year. But it's

Daphna Yasova Barbeau, MD (she/her) (00:52.993)

Just yesterday as I was signing out, the day nurses were coming in and they said, you know, it's cold outside. It's really all relative.

Ben Courchia MD (01:03.506)

Yeah, like 70 degrees. Yeah. Thank you for mentioning that you're coming back on the podcast for people who may have gathered. You were one of our guests for the special series we did in 2022 for NeoHeart. The coverage of the NeoHeart conference, we had so many good speakers for that series. If people have not listened to that, please go ahead. And for...

Daphna Yasova Barbeau, MD (she/her) (01:04.761)

That's right.

Nim Goldshtrom (01:06.589)

Sounds tough, sounds tough.

Ben Courchia MD (01:29.334)

The people who have not listened to that series, fine. And we'll tell you who Nim is. I have your bio right here. I'm just gonna go quickly through it. You're a neonatologist. You also have additional training in pediatric cardiac intensive care. You work both in the NICU as well as in the infant cardiac unit, caring for infants with congenital heart disease. The intensive care units at Columbia University Irving Medical Center and Morgan Stanley Children's Hospital.

are both regional centers for the sickest children and the infants in the tri-state area of New York, New Jersey and Connecticut. And your team is working on a multidisciplinary approach to utilizing expertise from multiple specialist surgeons, pediatric subspecialists, nutritionists, pharmacists, respiratory therapists and more.

as well as social workers, psychologists, and case managers to provide comprehensive patient centered care for each infant. So thank you for making the time to be to be on with us. And we're very excited to talk to you about a little bit about what your journey looks like. So I am just curious about, first of all, when you're a pediatric resident or maybe even a med student, like is this idea of PEDs so you probably know you want to work with kids, but do you have any idea you're going to go into NICU?

Or do you have a combined interest in maybe NICU and cardiac care?

Nim Goldshtrom (02:52.725)

Thank you. So first of all, thank you again for having me on the show. And to start with the question of like, did I know I wanted to do any of this? And the answer is honestly no. You know, I've listened to a lot of your guests kind of give their stories and I'm happy to get by because I think it does help people kind of gain perspective that people come in and it's like, I want to be an adult gastroenterologist doing colonoscopies for the next 30 years. And that was definitely not my case. And I had to learn like, am I proceduralist? Am I?

someone who wants to do surgeries or not surgeries. And quickly, as you funnel through, I did learn that I just like to be around children way more than adults. Not that I have anything against adults, but in a matter of care, it was just much more interesting. I honestly thought I was gonna do emergency medicine. I did like intensive care, I did like acute care. And funnily enough, as I got into like, week two of my year one pediatric residency emergency room at a fairly big children's hospital, I absolutely did not like it.

It was just not the kind of things that I thought that would be there from growing up as a child who watched ER religiously as a great show, thinking like, wow, medicine is cool. And a lot of the things that were lacking were primarily continuity, right? Like I really want to know what happens when they leave here and go into the floor of the PICU. And that while teenagers are great, they're not the kind of patient population that I wanted to care for day in and day out. And the complexity to the come with adolescent care.

Daphna Yasova Barbeau, MD (she/her) (04:08.965)

Yeah.

Nim Goldshtrom (04:20.329)

And initially, I actually didn't like NICU either, which was funny because my first rotation was bananas and you're coming in there in like a 60-bed unit of a level 3C hospital and like reading off numbers and this was, we were I think the last year of Q4 24 plus 4 hours call, right? So, I mean, I come in, you know, July 1 or July 2, day 1 late because the division chief actually tells me, it's like, no, that's fine. Just come in at like 730 a.m. I have no idea. It's like, no, you have to...

Daphna Yasova Barbeau, MD (she/her) (04:37.614)

Ehh

Nim Goldshtrom (04:49.449)

free round at like 630, 6 o'clock and do like a 28 hour call as like the start of a month of seven calls back to back. And so it didn't make any sense. Yeah. No, no. And so yeah, residency was actually in Long Island, but it wasn't a small plot. It was still a 65 bed, you know, hospital in NICU, level 3C NICU in Long Island Jewish. And so that first month was actually terrible. And I had no idea what it's going to do year two.

Ben Courchia MD (04:50.766)

Hahaha

Daphna Yasova Barbeau, MD (she/her) (04:51.439)

Oh man.

Ben Courchia MD (04:57.79)

And the unit at Columbia is a bit, it's like, you're not walking in into a 10 bed unit.

Daphna Yasova Barbeau, MD (she/her) (05:01.069)

We are big units.

Nim Goldshtrom (05:17.061)

And then, but year two comes in and you realize like, oh wow, I learned a lot of things. And then the acuity comes down and you give a responsibility. And that's really where for me, like the learning started to happen, right? Where I put it all together and I realized very quickly I did not want to do emergency medicine. And I found like a home, right? A home where like, I like the patient population, I'd like the continuity and the critical illness of it. And between that and PICU, I just enjoy much more the parental engagement, the kind of problem sets that were in the NICU.

Daphna Yasova Barbeau, MD (she/her) (05:20.837)

Yay.

Nim Goldshtrom (05:44.769)

and the delivery room management being there to resuscitate babies. It's just a different type of acute care than we do for kids. And so for me, it was an evolving process, right? And cardiac care was the same. When I got to the fellowship at Columbia, it was a lot of the same, very large hospital, very acute NICU. We did ECMO, which I saw for the first time, and all these CDHs, and some going on ECMO. And we had this unique patient population. And it was really that exposure that

got me interested in it, because I don't think if I would have seen them as much, it would have sparked as much of an interest. But seeing a whole bunch of neonatologists and cardiologists and neonatal nurses sit in one place doing the end of critical care, right? The highest level, the similar that you do to a crashing myconium aspiration with PPHN who's going on ECMO or a CDH who's like, uh-oh, I don't know if we need surgery or ECMO. And you're doing that all the time on these pre-opening post-ops. It was...

For me, 90s point, it's like, wow, I can do both these things. I can be an amyotologist, I can take care of these babies. And there are pathways, maybe not as well defined for our trainees and for our craft, but they are there. Myself and a handful of us who are multi-trained in multiple fellowships and specialties, while we're the Neural Heart Society, are trying to carve out that road for individuals who wanna be a part of it, because the data suggests that we add value to care.

from a lot of large studies and from our center. It is important for those people who are interested in the neonatal field, don't be afraid about, reach out to us, we do wanna help. Our expertise is needed when it comes to babies and the growing population of premature babies who are being born with congenital heart disease, who are trying to survive against families' hope.

Daphna Yasova Barbeau, MD (she/her) (07:29.53)

Hmm.

Ben Courchia MD (07:29.63)

Yeah. The reason I like to ask the path to neonatology is because I think very rarely do we get people who have such a dramatic experience maybe early on in life that they know they want to work with preemies. But also I think that medical studies are so long that we always need a sense of direction and we always, even if we don't commit early on, like I'm aiming for this whatever goal, but it's so nice to hear that if opportunities present themselves, if your desires change,

it's perfectly OK. You might actually find your path in that manner, where it's like, well, initially I thought I was going to do X, and then suddenly this opened up, and I ventured. And I think that's the key. I wanted to ask you, yeah.

Nim Goldshtrom (08:05.249)

And to just jump on that point, Ben, I would just say, for any trainee, right, neonatologist or people thinking out there that got outside their field or box of something of interest, my answer to them is always just do it, right? It sounds silly and cliche and the Nike, but we are entering a world, right? You guys had a lot of talks recently and wonderful people talking about the growing of databases, the growing of a lot of data and information and how do we more highly specialized care.

It will only come from bridges, right? And we as professionals need to be bridges. So if it means doing a second fellowship for a couple of years, doing a one-year training program in data analytics, or going into learning how to do palliative care, because you wanna be a neonatal palliative care doctor, this is the future for that kind of specialty care. Don't be afraid of it, expose yourself to it. That is my recommendation to all trainees, because it will get harder as you get further along in your career.

Daphna Yasova Barbeau, MD (she/her) (08:37.369)

Hmm.

Ben Courchia MD (08:37.389)

Mm-hmm.

Nim Goldshtrom (09:01.029)

and you want to start building that niche, you will never not be able to do neonatology, right? But it's very hard to do neonatology plus neuro-NICU, pulmonology NICU, palliative care NICU, right? Data intensive NICU, if you don't get that exposure and training. And if you have a curiosity about it, do it. Get yourself exposed to see if that's your future.

Ben Courchia MD (09:20.778)

Right. And so you did an additional training in pediatric cardiac intensive care. Can you tell us briefly what that looks like? This was something that was baked into your fellowship or something you did extra? And how long did it last? Yeah, can you tell us a little bit more about that?

Nim Goldshtrom (09:38.277)

Yeah, so this paradigm of additional training is pretty standard for pediatric intensive care physicians and cardiologists, right? Like the world of congenital heart disease around the country and really around the world is historically, and for lack of time, I'll save the history, there's a lot of good papers on it, just shifted and drifted into the world of pediatric intensive care, right? It came from an anesthesiology practice decades ago, right, with surgeons, anesthesiologists had to manage these patients somewhere.

they were a vast array of ages and sizes. And so the PICU made the most sense. Then they realized, well, we can't be anesthesiologist and intensivist. And so they, the craft of intensive care took over that specialty. And again, not by fault, design, or kind of trying to exclude the endotologist out of that. The endotology is a craft, which is also a young field to begin with, never really got embedded or involved in their care. And now that we're learning our discipline and our skill set is helpful, right? Is important, especially when.

body of babies is coming out also more prematurely because we're just doing such a good job of it. And so training takes on a lot of forms. My pathway that I was interested in was really I just wanted to keep doing ICU care. I wasn't so interested in being a cardiologist and doing tons of echoes at part of my time, seeing patients outpatient, working with those two divisions. And so these kind of super fellowships, these extra fourth years that are specifically

Nim Goldshtrom (11:04.717)

as training opportunities exist in tons of centers all over the country, right? There's a growing body of over 50 major children's hospitals. And the way you can do that at this point, since it's outside the ACG in the window, but still within the paradigm of giving you skills and expertise is, you know, you declare yourself as someone who's interested by reaching out to this program, using mentors and people who may be in your immediate circle to help you identify places that you would wanna go and apply almost like a job and a fellowship, right? For these kind of like extra...

extra tracked positions. And I went to Boston as a choice of both a large program, sometimes I can go too closely, that wasn't a distance from my family. And typically it's one year or maybe two years, depending on how much exposure, experience and or research you're doing at that time. And they're primarily clinically driven. You can think about it the same as a cardiology fellow who does a fourth year in echocardiography, in electrophysiology, in cath, right? They just spend months and months and months.

with a handful of academic research months doing it, just doing that craft. And that's basically what you do. You spend seven to nine months in a cardiac ICU with calls, taking care of everybody, right? And bridging within those months, other skill sets that you may not have, or you may not be strong in looking at echoes and need a month to look and read and understand echoes, or the cathlete numbers and things like that. And rounding out your skill sets to understand what it takes to take care of those children and what your other disciplines are offering and how to interpret that data.

Ben Courchia MD (12:13.131)

Yeah.

Ben Courchia MD (12:29.794)

Can you tell us a little bit more about that? Because I think that to me, pediatric cardiac intensive care feels like a very low hanging fruit for maybe our cardiology fellow colleagues or our PICU colleagues. But for neonatology, it feels a little bit more of a reach in my opinion, because you enter the cardiac intensive care and like you said, you take care of everybody. So I'm assuming there is a 15 year old with some form of cardiomyopathy. And that is really not something where, that's something that our cardiology, right.

Daphna Yasova Barbeau, MD (she/her) (12:56.578)

It sounds terrifying actually. Yeah.

Ben Courchia MD (12:58.166)

But I'm saying our pediatric cardiology colleagues see that all the time, whether in clinic, on the floors, whatever, our PICU colleagues see that in the unit. We don't. So how is that transition happening from like being a NICU fellow to then entering the space where, yeah, maybe the newborn with

Daphna Yasova Barbeau, MD (she/her) (13:10.709)

And you guys sometimes even have adults up there with congenital heart disease. Yeah.

Nim Goldshtrom (13:14.465)

Oh, for sure. Yeah, I mean, during my training, there was a 53 year old who came back in for like a reimplantation of a third defibrillator slash ACD. And again, yeah, again, it's not it's, you know, it's not my cup of tea, it's not where I would have wanted to land. And I'm lucky I don't take care of those patients anymore. I'm in a, you know, 100% baby unit where the oldest baby I have is maybe an eight month old.

Daphna Yasova Barbeau, MD (she/her) (13:23.41)

No, thank you.

Nim Goldshtrom (13:40.625)

and that's because they were really sick and they have residual lesions and they've just grown in our unit and just can't leave because their heart is dysfunctional. But you bring up a good point, right? Some trainees and people in this position who are thinking about doing this from neonatology training and fellowship might get the impression that, huh, that seems like a really big leap, right? That going from intubating 24-weekers and meconium aspiration full-term babies.

and 5 kilo LGA hyper hypoglycemic, you know, diabetic babies, is somehow a really big stretch to then think about innovating a four-year-old and a 12-year-old or putting in lines. And so I can tell you with a great degree of confidence that hill is tremendously small because if you can innovate a 500-gram baby, you can innovate a 50 kilo human being. And it's literally just exposure. If we think about what first year of neonatology fellowship looked like for us, no attending would

first-year fellow to do things on their own, right, and to climb the hill of maybe innovating once or twice or three times in residency before letting them do it alone and then doing it on high-risk babies, right? That's how we practice, right? You do sims, you do sims, and then you're on service, right? And so it's about exposure and supervision and training. And so my impression and personal belief is we are way more qualified and ready

Ben Courchia MD (14:39.822)

Mm-hmm.

Nim Goldshtrom (15:06.281)

to let's say walk into another ICU unit and start learning the skills, the practices, the medical managements for a wider variety of patient subsets, then potentially even a cardiology fellow because you can do all the things that you need to do for intensive care. As a neonatal fellow, you have run codes, you have resuscitated human beings, you have intubated people, and you have placed lines. The only thing that's different is maybe the rhythm and dynamics of doing CPR on an older child, right, in the ratio and compressions and...

and airway management, the practice of intubating someone older and with teeth and with a different sedation management where you're going to use muscle relaxant, which actually makes things 10 times easier, and the practice sets are then putting in larger lines. There is nothing difficult about these things. You are more qualified than a cardiology fellow who's not done a lot of critical care because you have the technical skills. You're just applying them to a broader patient population. And again, you're doing this not because you may want to.

Daphna Yasova Barbeau, MD (she/her) (15:57.191)

Hmm.

Nim Goldshtrom (16:02.173)

take care of all the children. And maybe you do, right? Maybe your future is, hey, I really like CSU. I like the babies and I don't mind working with adults. And so that's great. But neonatologists, neonatal fellows and trainees should absolutely not feel afraid or like they're anyway less qualified. They just have to bring up their skill sets in different domains than an intensive care, pediatric intensive care physician or a cardiologist who has to potentially pick up a lot more intensive care skills or a PICU fellow who has to just pick up a lot more cardiology skills.

Daphna Yasova Barbeau, MD (she/her) (16:08.529)

I know.

Nim Goldshtrom (16:29.741)

And obviously maybe a lot of baby skills are sort of going to have to take care of preterm babies, which I don't know if I can argue that a PICU doctor knows effectively how to innovate a 500 grammer, but you can absolutely, it's much easier going up in weight than it is to go down in weight for procedures.

Daphna Yasova Barbeau, MD (she/her) (16:32.049)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (16:38.673)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (16:45.659)

Yeah, feels that way. I love your point about this kind of growing need for the specialist neonatologist. I think it really speaks to how complex the field is really becoming. I really appreciate that you gave us this bird's eye view of your pathway. I wonder, what about people who are kind of done with training, maybe they're even mid-career and they're saying, you know, I actually love this aspect of neonatology. How do people get...

back into the pathway, I guess. Is there a place for that?

Nim Goldshtrom (17:19.453)

So it's a great point because it can't all just be, again, this is my opinion on this field that we have to wait for the next generation to go through multiple routes of training. And before I answer this question about the interested, early faculty, mid faculty who's interested in this, let me just say that my pathway is one of many available pathways. I have colleagues who have done the dual fellowship, just like Pick You or Cards Fellows, right? Three years of neonatology, two years of cardiology.

Daphna Yasova Barbeau, MD (she/her) (17:28.24)

Mm-hmm.

Nim Goldshtrom (17:46.777)

and others who have done three years of NICU and then two years of PICU, right, to just be an intensivist. There are reasons to do each. You don't have to elaborate on the reasons. They're primarily those about where you can effectively get hired and bill from, right, because of the current landscape of where babies are generally taken care of who have heart disease in hospitals. And sometimes the multi-movement of the various models, right, sometimes it's pre-op NICU, post-op PICU, then back to the NICU. Other times it's...

you know, Nick you pick you and then floor. So because of the models of care, the training that we have to go through sometimes is going to be more so than a pediatric intensive care cardiologist because of the requirements of how do you effectively bill under your training certification, right? And so it should be individualized. People who are interested should find people like myself and other colleagues around the country who exist in LA and Chicago and Texas and the East Coast to ask us these questions to help figure out and tailor what the right.

Training path could be for the things that you want. But then there are those who are interested, right? Who have a population potentially right at their disposal, right? They're a mid-level or a small to mid-level surgical center and they get all the pre-op babies and the preterm babies and they have this program where like, all right, if they're too premature, we'll leave them in the NICU to grow and you guys grow them. And then we'll talk about them as like a big surgical center. And then once they get surgery, they go to the cardiac ICU or the PICU cardiac ICU. And then depending on how they do, they're going to be able to come back to the NICU.

Daphna Yasova Barbeau, MD (she/her) (19:05.009)

Thank you.

Nim Goldshtrom (19:16.617)

The idea of advocating for your specialty is should be centered around first showing your teammates and the congenital heart program that you have gaps, right? You should, the best way to get buy-in is to say, are we doing something where the outcomes aren't at the best of the country, right? Are we not meeting the same outcomes in other places? And especially when it comes to babies, right? And so first collect data, right? See how your unit's performing. Is there a length of stay issues?

intubation issues, is there infection issues, right? And then tailor around the concept of, you know, we have nurses who can do this, we have physicians who can do this, and like, let us figure out if we as a domain can partner with you and solve this problem, right? To improve this kind of outcome, right? Maybe chronic lung disease, which I personally think is hard to define in a congenital heart population, is really bad, or there's tons of infections in the post-op neonates that you guys are having a hard time with.

and it just needs kind of more dedicated processes about preoperative handling and antimicrobial stewardship. Or maybe growth is really bad, right? That's probably the lowest hanging fruit, right? If PICUs and your combined model is really having a terrible time growing these post-op babies or having them feed appropriately, and they're all going home with NGs, that's an easily solvable problem. And then find out a way how to partner and say like, I think I can fix that. And if the individual who is interested, you will need mentorship and guidance. You'll have to have a partner.

from the heart program, a cardiologist, a surgeon, to buy in and then guidance from other places like ourselves at Columbia and other centers like Orange County and many other hospitals that have these already developed programs to help you both as an individual and as a team, get the level of training and investment to offer your program added value. And the way to do that is to then commit yourself essentially to that discipline, right? Just like you do in a fellowship, like that's all you do all the time and why you get good at it.

people who are interested are going to have to make it that thing their thing. They're going to have to make it the thing that they focus on all the time. That's where they spending their work days, off work days, research, quality improvement focus on getting better at because your other team members, cardiologists and surgeons want to see that your investment is tangible to work towards that outcome and it will require, there are ways to do it, it's just not as easy.

Nim Goldshtrom (21:35.465)

clearly defined, right? You're probably not gonna go back into a fellowship, but you do need some mentorship and support about how to bring up your knowledge in cardiology, in cardiac physiology, in post-op or physiology, so you can talk and understand what they're worried about. And then bring in the neonatal aspect to that combined model of care.

Daphna Yasova Barbeau, MD (she/her) (21:54.849)

Yeah, I think you really helped show us how somebody can integrate themselves into a model that already exists. But you guys have a really special kind of unit, which is really a neonatal cardiac ICU. So tell us what that looks like.

Nim Goldshtrom (22:14.705)

Yeah, happy to. I think it's probably less exciting in person than maybe what it sounds like on paper. But you think about what any intensive care unit is, we're lucky because we're a cohorted unit at this point and have been for five years, meaning we have a whole section of 17 beds just completely dedicated to infants with congenital heart disease.

We are part of a NICU and so we flex with our colleagues, right? If we are overloaded, then we send some of our, you know, cardiac babies to the general NICU space, right? A floor or two below us and vice versa, right? If there's, you know, ECMO candidates or severely sick CDHs that might need to go on ECMO, because we also cohort our ECMO patients on our floor, we kind of might take them there. But essentially the wonderful part is, you know, it's not different than working in any other NICU because

I get to work with and talk with people who's primarily home with neonatology, right? All my nurses are neonatal nurses first. And the nursing change over the last few years from COVID has upended that a little bit, but our core group of nurses are neonatologists first and then get cardiac training second. And our neonatal nurse practitioners are predominantly the same, right? They get trained in neonatology and practice in the general NICU with extreme prematurity and RDS.

and chronic lung disease and ophthalus seals and everything, and then gain additional training and supervision through kind of an apprenticeship in the cardiac unit and then come in to combine those skill sets. Well, fortunately, because we work with a large team, and so our model gives us a unique space, right? Where it's just neonatal beds, four neonates with radio warmers everywhere, and a team where we work with cardiology intimately and continuously. And so our model of providing care is that it's

Daphna Yasova Barbeau, MD (she/her) (24:03.697)

I don't know.

Nim Goldshtrom (24:06.321)

myself or a similarly trained cardiac neonatologist, right? And there's four of us now who are in that domain working in our unit, working side by side on every patient with a cardiologist, right? And so that's our rounding structure, right? I have a neonatal fellow who helps with the overall management and is learning about general management of the 17 patients. And there's a cardiology fellow too, right? Who helps us with cardiac aspects that we might be missing on rounds and not thinking about and how to.

think about the longitudinal care, right? Like what are we doing now that's going to affect the outpatient world and how do we think about management that is going to traverse towards outpatient life when we discharge? Helps us with attaining, interpreting, and understanding imaging at a high level, right? When we get echoes like, are we understanding it correctly? Are you as worried about the report as we are when reading it? And so we have this dual model of care, which we think sort of swell, but really integrate the endotology into the cardiac model at every level. Our physicians, our fellows, our nurses, our NPs,

We have a new name of nutritionists. Our groups rotate between our two units and they're there on rounds all the time. And I think it just speaks to the aspect that this can be done. You can, as much as you have commitment, dedication and buying from your program, it is possible. And I think our outcomes as of late from our recent publication show that we can perform this at a very high level as compared to many other centers that are producing the same data over the last decade now.

Daphna Yasova Barbeau, MD (she/her) (25:30.501)

So tell us a little bit about the culture change that was needed to allow for this to happen. I mean, I say this with some confidence that most babies with congenital heart disease, especially on the pre-operative time are cared for in the PICU. So how do we change the narrative that they can be cared for in the neonatal ICU like you guys have?

Nim Goldshtrom (25:55.045)

Yeah, I'll talk about the history as the second part. The aspect that I think will provide change is primarily data, right? And I wanna make sure that I don't press on the issue that it has to be neonatologist, right? Like we have to be the ones in there. What I think I'm trying to advocate for, and also the Neonatal Heart Society as an advocate for our craft,

is that patient populations with subspecialty problems and unique problem sets should get those subspecialists to come and work with them. I make the same reference a lot to stroke units. You're not gonna go, if you have a risk of stroke, you're not just gonna go to your local hospital. You're gonna get bused immediately to the local stroke unit where a group of experts has literally 90 minutes or less.

to figure out whether to cath you or not cath you or break open your stroke or not and figure out what your intervention is. And so neonates are not six months old, they're not two year olds, they're not five year olds with internal heart disease. And the physiology is different. And so whether it's neonatologists who come in there and bring in their craft and combine it with cardiac physiology or your current model of care just takes ownership and someone says like, hey, I'm going to be the baby specialist for a cardiac unit and just goes in and say like we

We need to change our practices a little bit. Do we have to paralyze everybody for intubation? Like we should be using TPN more aggressively versus the PICU which does not like to use TPN. And the literature says, don't use early TPN, like completely different paradigms. And so hopefully the idea is to show that there's value in these practices for self specialty populations. The way we started this practice as an institution was from my mentor and our founding program creator, Dr. Ganga Krishnamurthy.

who had the same interest and passion. And early on with kind of the growing of our program in the early 2000s, saw the opportunity where nobody else was doing it, wanted to take ownership. Did the, you know, was one of the first people to do this cardiac ICU training at Boston and other centers, came back and told the surgeon, we can do this, right? We're already doing this in the NICU. Let us prove to you that this can work, right? That babies need specialty care, that babies and premature babies, right? Better value from us.

Nim Goldshtrom (28:13.933)

And by us, I mean people with neonatal training, right? Some degree of neonatal training. And that's where, you know, our paper from last year was kind of presenting that 10 years of data, the initiation of a neonatal driven program, showing that our mortality rates are kind of, you know, in that same 10 years, between 2006 and 2017, our mortality rates are fairly low. And we see the same signal panning out that a lot of studies are coming out.

When you look at cases that do not have genetic conditions, our mortality rates, especially in premature babies, are around 10%, which is pretty good for that time span. When you look at other database studies, suggesting that this model can work, right? It can, and it's specific, right? It's not, well, this center is good because so many people take it and they have this group of doctors that does it. This is more of an explicit model, right? Here you have dual-trait people, dual-trait nurses, dual-trait MPs. That's a replicable model that you can kind of.

And if you do that, you can work towards these outcomes. You probably can get as much value out of caring for a neonate from survivability, length of stay, and morbidity in an explicit fashion. And this is more of a specific way that other places can try to replicate it if they're interested.

Ben Courchia MD (29:26.11)

One of the things that is always interesting is the trickle down effect of some of these innovative interventions that we put in place to more of the mainstream. And I'm just curious about some of the things that you've encountered in this dedicated cardiac neonatal cardiac unit that you think we can learn from in the quote unquote regular NICU. I think we were discussing off air some of the approach to monitoring.

infants, especially when it comes to near infrared spectroscopy and so on. So what are some of the things that you've been exposed to and that you've used in the infant cardiac unit that you think will provide a very useful data set of information to the general NICU field?

Nim Goldshtrom (30:15.665)

Yeah, it's a great question. And I wish there were more tools, right? I wish we could validate and find utility in many more tools. And let's say to give you the most high yield one that we use all the time is absolutely near infrared spectroscopy. And just for full disclosure, it's something I do research in for cerebral autoregulation and currently have a small grant to look specifically at cerebral autoregulation at single ventricles.

and developmental outcomes of two years, right? To see if there's an association with how the brain is adjusting post-operatively. But it's actually, we find that the somatic knee errors are the most helpful and that clinical practice change, right? Despite there being tons of evidence or published literature on muscle, abdomen, abdominal, renal knee errors, being very predictive, right? Or prospectively indicating acute failure.

that practice is now infiltrated into our general NICU, where we have CDHs and kids in conserved vasceptic shock, getting the ears placed on with our general neonatology colleagues, who are part of our collective faculty, using it routinely and frequently to look for low cardiac output states or mismatch between DO2 and VO2. And so for us, it's a very, again, we don't have a lot of data that I can quote you statistical numbers from research, but...

just from a clinical practice perspective, right, a low variability, down trending renal nears value, right, despite oxygenation numbers being the same, right? So if your SPO2 is the same and you see a very kind of like slow down trickling renal nears, which is actually you're having a higher extraction, right? You're either not delivering blood or you're not delivering oxygen, both, right, so the body's extracting a high degree is a very sensitive and specific sign from clinical experience, right?

that you are having a mismatch in cardiac output, oxygen delivery, and oxygen consumption. And for our cardiac population, the problems are usually pretty simple, right? Cardiac output is just not good. Or you're too hypotensive, and your SVR is not as you're implicated. But that sign, right? The NEAR signal, especially for the body, abdomen, muscle, muscle muscle, but renal NEARs, should have variability, right? Variability is a sign of health. And for the renal NEARs and abdominal NEARs, a lot of variability means normalcy.

Nim Goldshtrom (32:30.173)

So when you lose variability, right, when the variance drops and you've got this flat line that just keeps downturning, downturning. And the beauty is it usually gives you a couple of hours, right, kids who are rest, suddenly there's very little we can do for that. But usually a slowly decompensating child will have a reanalyze for like an hour or two or three, just moving down, right, just like a slide. And I cannot tell you how many children, right, when I see that sign and we come to the evaluation and like, yeah, there's pulses, if there's not pulses, the child could be warm shock, cold shock, like the visitality, the medical condition.

but you optimize the cardiac circuit, you give volume, you put them on the presser, you talk about sedation or intubation if they need to, and we have probably prevented a lot of arrests where five or six years ago, we were having a lot more in-unit cardiac arrests, which we just don't see anymore in our unit. We don't, we very rarely have an arresting situation where we're doing ECPR in our unit, I don't think we've had one now for two years. We haven't had a lot of significant post-op or pre-op, well pre-op, we don't have any cardiac arrests.

post-operative cardiac arrest that was kind of like missed. And I think that speaks to this kind of drift philosophy, where we've entered this tool, we've seen it and worked with it clinically, and it's added a lot of value when you understand its utility, which is it's indicating high degree of extraction and something's wrong with the circulation. And we transplanted that skillset and that practice down to our general NICU as well.

Ben Courchia MD (33:51.146)

Sorry. Yeah, I wanted to actually even clarify a little bit some of the things you are describing because you are saying how the introduction of Nears and its use in your unit has really helped you achieve better outcomes. And you've said this, and I just want to underscore it one more time just because I think it might get lost if we're not paying attention. You are not saying that Nears is the panacea of like, oh, we have this now new tool. And with this, we're able to.

to just avoid a lot of other stuff. It's a rethinking of how do we monitor these patients that includes everything that we were using in the past to monitor these patients, heart rate, blood pressure, oxygen saturation, and then adding onto that another variable, another piece of data that can then somehow elevate the overall appreciation of the patient's context, right? I mean,

This is a whole rethinking of how we monitor this patients.

Nim Goldshtrom (34:51.185)

Absolutely, and I couldn't have said it better. This is just another tool to add part of physiology that we could not see before, right? It's not a great analogy, but it's the closest analogy I can give you, which is to say that it's a surrogate for, and again, we are preferential to renal nears, and use it as a surrogate for mixed venous saturation, right? And so if that number is somewhere anywhere close to what your mixed venous hat is, and it goes down, that is a bad sign, right?

And so in isolation, we absolutely never use it and just if the renal is going or it's going down, I have to do something for the patient because it's not a perfectly sensitive tool. There are plenty of kids where the number goes down and we watch it go down and then we watch it live in the 40s, right, instead of the 60s or 70s. And we come and we do clinical evaluations, but the child's entire other hemodynamic spectrum from vital signs to urine output, to physical exam do not change. And the child is clinically unchanged.

and we just have to kind of monitor it as a reality. Like something has happened that has not clinically panned out as a change state. So it's not always a very specific tool, right, even though it has a good degree of sensitivity. And it sometimes might refer, and now I'm speculating, about other things. Maybe something has changed with the heart's function, right? Maybe the heart function has like worsened just slightly, but not enough to cause a significant decompensation, where the COD has now gone from normal state to compensated shock to uncompensated shock. So yes.

Never use it in isolation. Always put it in the clinical context. Always use it as an indicator to then go back to the baby and examine them and look at the data in whole and value whether other things are supporting this downtrend or whether it is a variation of evolving clinical state, evolving physiology, recovery from something that they were going through. Because yes, it should never, never be used in isolation.

Ben Courchia MD (36:25.058)

Mm-hmm.

Ben Courchia MD (36:39.99)

The one more question we I know you're working on this on this. You mean the work is done. You're working on the paper. Maybe by the time this episode airs, the paper will be out already. But you're looking at you had great outcomes at Choney. And and you are going to publish the 15 year review of the cardiac program where you're starting you're going to start to report some of the things you guys have identified when it comes to risk factors and and.

for morbidity and mortality. Obviously, you said you were speculating a little bit before, so I'm gonna try to tap into that one more time. But based on the data that you have currently available, without really presenting the paper, obviously, big themes that are coming out of this data review that you can share with us today.

Nim Goldshtrom (37:27.357)

Yeah, it's great. We have a lot of things that we're looking at, specifically things like our neck rates overall, and specifically because we now have this larger cohort, can we just look at our preemie population, right, and see within our preemies what makes them more at risk? That's one thing. Again, I have myself and another trainee who are looking at auto-regulation and how that could be a future feature, right, using knee errors and blood pressure to create a shift in how we think about blood pressure management.

But overall, in looking at just our practice over 15 years, we wanted to drill down who's the highest risk, premature babies, it's what we're here, it's what we're doing. And again, our sample size is reasonable and I'll wait till the whole data gets out, but our initial analysis kind of tried to look at all the stuff that everybody's looked at. What are the factors, even within preemies, that make them a higher risk for non-survival and for picking up complications and morbidities?

Ben Courchia MD (38:05.31)

Mm-hmm.

Nim Goldshtrom (38:25.789)

And we plugged in a lot of the stuff that every model uses, from gestational age and birth weight, both as a number and as a Z score, and growth status, prenatal diagnosis, and preoperative complications and postoperative complications and all the surgical values. And when we looked at this kind of an overall regression model, the signals that we came out with look a little bit different than signals reported from other database studies. And again, I'm speculating now because we haven't put this into publication one.

finishing the edits now. So it might look different by the time it's reported, but the initial signals that look to pan out are all seem to be related to physiology and the interactions with surgery. And so, you know, it's things like being ventilated and having complications, right? And so the signals like gestational age and birth weight, right, like the smaller babies, again, in our unit, are not appearing to be more at risk than the older premature babies.

SGA does not appear right now to be a signal for more risk for mortality. It does seem, at least from our data set, and again, the number of babies who we have in the non-survival group is not big, so some of this is going to be low-end phenomenon. But what we're finding is important is physiology, right, kids who are inundated beforehand, suggesting that maybe they're sicker, right, because we actually did not have any TGA's in this group, so they're not getting intubated for balloon atrial septocines.

Ben Courchia MD (39:49.902)

Mm-hmm.

Nim Goldshtrom (39:53.033)

and really post-operative complications. And even bypass, while it was apparently a signal, it's not a very strong indicator of risk for mortality. And so to me, again, a lot of this is speculation and we'll wait for the paper to come out next year, but suggests that when you put together, when you bring the right specialties and the right things that a patient needs for their care, you can potentially minimize a lot of latent things, latent factors that come with the patient.

that then you just simply expose the stuff that may be unavoidable, right? Like if you have an immature premium with really bad lungs, right? And they may be bored 26 weeks, but they're functioning like a 23-weeker, right? And their RDS is terrible. And you've intubated them and surfactant them. And they're also an AV canal, where you're going to have to grow and think about banding, right? Because they don't have a lot of PS. Then that's a sick child to begin with. That was going to be a sick child at our hospital, in Texas, in California, in India, anywhere around the world, right? But if...

Ben Courchia MD (40:48.982)

Mm-hmm.

Nim Goldshtrom (40:51.517)

if the care group, the people who come in to care for that child have the right expertise and the right training, the nurses particularly, and the bedside care team, to know what to do to not add on significant amount of care, maybe they can get away without paralysis or sedation at all. It can actually fly on CPAP once you surfactant them and gotten through RDS, where other places were like, I don't know, I'm not comfortable, their PAO2 is this. And again, we have so much experience where...

our tolerance of keeping preemie babies on CPAP of 5, 6, 7, 8, and NIMV and intubated with a mild to moderate degree of work and no lactate is high. We tolerate that all the time. And there are other places who, if you don't have that experience and subset and don't bring that to the bedside, again, not by fault or callousness or this, just because you haven't built that team that way, may gain more intubation days where other teams may not. And I think that's what...

I'm hoping once we get this data out, once our group kind of finalizes it, manifests is that the idea is to bring the skill sets and what the baby needs to the baby. And whether you want to do that with neonatologists, right, and you're a nurse or you want to take a team you have at your place and give them that added training and that added value. For the patient, we've got to get them what they need, right? A stroke, adult needs a stroke team, right? A person having a gastric emergency need a gastroenterologist and a PDF and an adult surgeon to figure out if they're having a surgical abdomen.

And babies and premature babies need people who can combine cardiology, cardiothoracic understanding physiology, and neonatology to bring that to the outside.

Daphna Yasova Barbeau, MD (she/her) (42:28.033)

I love that. And we are very much looking forward to that report. I want to, as we're nearing the end of our time together, I want to take advantage of your expertise and ask you, what are the lessons from the cardiac ICU or dealing with these babies with a complex cardiac physiology and say the interplay of prematurity? What are lessons that we can take from this world and translate them?

into what we do for all neonates, including those without congenital heart disease.

Nim Goldshtrom (43:01.713)

Yeah, it's a wonderful question. So the things I think about in application and the stuff that we talk about, even in our unit, when we review M&M or have critical physiologies happening for non-cogital heart babies is, at times, and I was part of this practice too when I was early in my career and kind of integrating, what do you do for a septic shock X32 weaker, right? Who's like,

going downhill right in front of you. And there's two or three big lessons, let's say. The first one is, I think adjunct tools like kneeers can be incredibly helpful. And so if you're even worried about a child, it's just such a low cost thing to do, to put real kneeers even on a preemie baby because there's plenty of studies and we have clinical experience and plenty of things published where, let's say the skin injury risk is trivial, especially on kids who are out of their first week of life and are not less than 1,000.

If you have a tool that can tell you potentially about DO2 and VO2 over an hour of time, it can inform you about what to do. The second thing I would say is that medications to support cardiovascular physiology, if you're worried about them, do not be afraid. Employ them, use them, you can always take them off. It's very rare. I'm going to talk about this in the context of the first three days of a transitioning premature baby, less than 1,000, less than 1,500 grams, is a very unique situation.

that has a very special management process that doesn't necessarily apply from taking all the skill sets from a cardiac unit into the first three days of transition. But let's say for the recovering ex-preemie or a late preterm child or a CDH baby, right? And any speculation, if you're putting it out at the bedside, I think cardiac output or hemodynamics or vascular tone is not good, right? And I'm worried that this child is in an uncompensated shock. Use drugs and don't be afraid of them. And...

Historically, I know we as a field love dopamine, which is great, but there is also a lot of utility in the broader spectrum of drugs, right? If you're worried that the heart is dysfunctioned for some reason, because you're in septic plus cardiogenic shock, epi is not a bad drug and neither is dobinamine, right? There's not a lot of data, and I know it's not as friendly necessarily in the scientific profile, but you're trying to resuscitate and rescue a child who, and again, as we, I'm sure you guys have seen in your unit, can be fine, right, at 5 p.m. one day.

Nim Goldshtrom (45:28.889)

and be basically peri-rest at 5 a.m., 12 hours later, because the physiology is so fragile. And so earlier recognition and earlier implementation, especially when you're sitting there and watching and you're worried that like, huh, I now have a lactate. The second you try to intensify a baby, intensify more. Again, that's just my practice. You can always take things back. And again, low dose epi.

Low dose no-renon, right, if you're thinking you have RV dysfunction and pulmonary hypertension, I personally would not worry about these medications as much ever, right, about putting them on. The benefits that they can do when your clinical assessment is your child is decompensating in front of you is trivial, right? We should not be afraid of these drugs and use them much more routinely, much more effectively. You can always stop it, right? If you're wrong, there is very little harm, again, there's no harm, from these low dose

Nim Goldshtrom (46:25.097)

Cardiogenic shock, septic shock with poor function, right, or visual dilatation, or any form of uncompensated shock from whatever the cause is, right, is to support that physiology quickly and aggressively. And we try to, and I think that's where our fellows came to, is the appreciation that these drugs, even in low doses, are not really harmful, and they can be helpful, and if you're wrong, you stop them. There's really not a lot of downside other than maybe hypertension, right, with all of

stopping the medication as well. And those are the two big lessons, right? Earlier monitoring, more aggressive use of supportive cardiovascular medications.

Ben Courchia MD (47:03.438)

Nim, my last question for you today has to do with maybe future directions. I know you and your team are very innovative. You do collaborate with Tom Hayes, who was at the Delphi Conference, who's been on... We presented his work on the show before. And so you're already using these new genetic screening tools pretty readily. Is there anything that you're looking forward to in the future as potentially one of these new...

adjunct tools, like we would have been talking about nears and other different approaches. Is there anything that gets you excited?

Nim Goldshtrom (47:41.669)

You know, yes, I think the signals in terms of what's happening with genetic diagnoses, in my opinion, will help improve our field. I don't want to just say change. And I use the word improve because I think what it does, not just for us as a team who have to make a decision about what's risky for a patient, but it potentially offers profound insight to families, right? Who before going down a road...

Ben Courchia MD (47:53.25)

Hmm.

Nim Goldshtrom (48:11.389)

that could be fraught with complications, can be offered information that might give them more clarity about decision making. And I think it's going to be an important signal because our paper last year in our first 10 years showed the same signal, right? Kids with syndromic congenital heart disease do worse than kids with isolated CHD, right? No identified syndromes. And this is now borne out in multiple studies. And some parents knowing these added risks,

may not want to take that, right? And that's a reasonable, especially when you have hard lesions to be good, like single ventricle hearts, right, hearts that are not going to go down the route of, quote unquote, complete repair or function normally. Further genetic diagnosis and better associations with larger data sets to understand where risk truly exists, right? The other thing we don't want to do is start implicating every variant of unknown significance or every disease.

as being so risky that we don't want to take chances. All for parents who want to take chances, who want to say, I don't know if I can have another child. I've worked so hard for this child and I understand the risk. That in my personal opinion, this is both informative and helpful. And the other place I'm hoping and looking for clarity and improvements are in neuroprotective and outcomes driven research. And so I got into auto regulation

Ben Courchia MD (49:17.365)

Mm-hmm.

Nim Goldshtrom (49:36.265)

I was, and you guys have individuals talking about cerebral nearers and safe booths and the kind of, you know, close but not there yet kind of data about do we target it for preemies? Is it really going to make or break the change in both mortality and functional outcomes? And again, to me, it's not surprising that just cerebral oximetry isn't the answer. They're just fixing the oxygen part of an equation.

But what auto-regulation does help us is kind of fix the second component of delivery, right, which is blood flow and stability. And the allowed adult literature is really promising, and their big debates now are we need to move into more randomized trials for adults with stroke and CPP targeting using these continuous auto-regulatory measures. Because again, from data that we do here on our populations, using those metrics to define what optimal blood pressure is.

Ben Courchia MD (50:01.619)

Mm-hmm.

Nim Goldshtrom (50:29.649)

Gestational age equals to map is way off. So I can tell you that there are kids who need a mean arterial pressure of 50 to 60 in the post-op period to quote unquote be called optimal. And a lot of this is born out in the HIE literature too, especially during cooling. Their optimal maps are somewhere in the mid-55s. And we need to move into clinical trials to figure out whether we can safely target it, prevent the untoward effects of hypertension.

Ben Courchia MD (50:45.685)

Mm-hmm.

Nim Goldshtrom (50:58.121)

supposedly hypertension in that group and can we actually modulate it to improve outcomes? Because other than the stuff that we can do inpatient like these direct interventions, I think the other major part for our care of kids is really going to be how do we bridge what we do inside to supporting the families who then leave, who degree of comfort can be very variable and can fall off really quickly. Probably the next major wave in my opinion is going to be

creating kind of a much bigger buffer and a much softer landing for parents, right? With way more support to lower the anxiety, the distress and the discomfort that we believe we have in them. When we train them how to use the NG tube and how to give them a pulse ox and how to call their doctor. And that is a perceived level of confidence that we have in them, where we have them competent in skills, but we haven't really assessed their confidence in their own stresses. And paternal stress we know affects

how these kids develop and how they grow up, and how do we get them to get way more supported and to feel, right, not just that they have the skillsets, but they have control of their situation to lower parental anxiety that is going to be probably a much more helpful bridge to further helping improve your neurological outcomes, because the kids are gonna spend 90% of their lives outside of our unit, right? And if that's where a lot of the gaps are falling through, we need to figure out how to work with pediatricians and the families and the outside resources.

to give these families a softer landing and more support as they transition out of a NICU, out of a cardiac NICU, out of CDH life, right, out of long hospital stays with various kids to make gains there.

Ben Courchia MD (52:27.106)

Mm-hmm.

Ben Courchia MD (52:37.434)

Dr. Nim Goldstrom, thank you so much for taking the time to be with us today. This was very insightful. I cannot thank you enough for sharing your experiences in such a unique environment. So that was tremendous. And I've taken a lot of notes. We will be looking out for the publication of the papers that we've mentioned and we'll share some of the papers that we discussed on this podcast on the episode page. Thanks again. This was tremendous.

Daphna Yasova Barbeau, MD (she/her) (52:52.741)

Mm-hmm.

Nim Goldshtrom (53:02.441)

Thank you for having me. I'll just make one last plug for NeoHeart. We'll be coming to New York at the end of the summer. And so those who want to be part of this organization, we are growing. We, it is, yep. End of July, registration is going to open soon. And we wanted interested parties because we'll be opening up special interest groups. We are going to be developing educational contents. And we want people who are interested in invested to help us build the content in the places where people can get specific information.

Daphna Yasova Barbeau, MD (she/her) (53:08.113)

Mm-hmm.

Ben Courchia MD (53:10.638)

It's a great time. That's a great time to be in New York.

Daphna Yasova Barbeau, MD (she/her) (53:14.085)

Ha ha ha!

Nim Goldshtrom (53:30.989)

on what to do and how to get training and how to help bring immunotology to these babies.

Ben Courchia MD (53:36.374)

Absolutely. And go listen to the NeoHeart mini series that we did a year ago with the folks at NeoHeart. You will see the quality of the people that they bring together. And it is such a well-designed conference where it toes the line very nicely. It is not like a cardiac nerd conference. As a neonatologist, you will gather, no, but that's important because as neonatologist, you may say, well, this is not for me, but it's not true. It is not true as a neonatologist.

you will get so much from this conference. And that's why I'm inviting people to go listen to these mini episodes, because when you listen to, number one, it's not only cardiac people, there are neonatologists at Neohart, which is why it's called Neohart. Then you may say, hold on, this is actually very valuable if, like, again, discussions about the PDA really at this conference involve everyone. So it is tremendous. And so I just wanted to clarify that. So thank you for putting that plug there.

Nim Goldshtrom (54:26.961)

Yes.

Daphna Yasova Barbeau, MD (she/her) (54:33.385)

For people who are interested, they can register when the registration opens at the NeoHeart website. Is that right?

Nim Goldshtrom (54:40.005)

Yeah, neonatalheartssociety.org or neoheartssociety.org. Yeah, and we'll be looking forward to seeing everyone. You're right, it's a big tent. It is absolutely for neonatologists, hemodynamics, targeted echo, POCUS, we do it all, we have training sessions. Neonatology should move just like our other critical care folks, right? There's skills, tools, techniques, and things that we can and should be bringing back to the bedside, as well as bringing neonatology to other patient populations.

Daphna Yasova Barbeau, MD (she/her) (54:44.042)

Yeah. Right. NeoHeartSociety.org. Perfect.

Ben Courchia MD (54:59.53)

Mm-hmm.

Ben Courchia MD (55:06.482)

And the good thing about this group of people, by the way, is that they are not snubs. And so if you are interested in this as a potential career direction, you may find your next mentor at this conference and you may network with people and find somebody who's going to guide you through the path that's still, some people have charted for us, but still it remains a little bit of an individual track for each and every one of us. So yeah, highly recommend your heart. Go check them out. Nim, thank you so much. Have a good rest of your day.

Nim Goldshtrom (55:34.461)

Thank you for having me. You got it too. Bye.

Daphna Yasova Barbeau, MD (she/her) (55:37.073)

Thanks, bye.

Ben Courchia MD (55:37.302)

Bye.


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