Let’s call him Joey. He came into the world way too soon and way too little, weighing less than a pound. And he came at a bad time too—right in the thick of the pandemic.
Despite the challenges of a premature birth, Joey had some things going for him—not the least of which was getting his rocky start in life at the Neonatal Intensive Care Unit on the sixth floor at John Sealy Hospital on the Galveston Campus.
That’s where he met Melissa Mudgett, who became his primary nurse.
“Our ‘chronic’ babies, the ones who are with us for a while, you get to watch them grow and see their personalities start to emerge when they’re really young and then get to a point where they're smiling and then talking and cooing,” Mudgett said. “It was special for this baby because this was all during COVID, and we were all wearing masks.
“People were saying they didn’t know how he was smiling because he couldn’t see our faces,” she said, explaining that babies often respond to what they see and who’s talking to them.
But the masks mandated during COVID meant Joey couldn’t see the faces and the smiles of the people who were with him ‘round the clock—his NICU nurses. So, his own smiles were a pleasant surprise.
“It was cool to see him learn to smile. It’s an innate thing, even though he couldn’t see our faces,” Mudgett said. “I remember it brought a lot of joy to people on the unit; everybody would come by and talk to him.
“He stands out in my mind because he reminds me that there can be joy even if, you know, everything's out to harm you or there are obstacles or the outcomes don't look great. There still can be joy in that situation.”
As for Joey, his outcome is one of the NICU’s many success stories. He celebrated his first birthday at UTMB before going home, and Mudgett still keeps in touch with Mom for photos and to check on his progress.
“I remember weighing him, putting him on the scale when I had him during the day, and was like, ‘Man, you're 20 times the size you were!” Mudgett said.
A different cloth
NICU nurses are cut from a different cloth, no doubt. Tough as nails when it comes to protecting and caring for the tiniest, most fragile of humans but tender enough to fall in love with them and have their hearts broken over and over—sometimes in tragedy but mostly, thankfully, in triumph when those little miracles go home happy, healthy and chunky.
When the babies go home, Mudgett said, she’s joyfully excited for the little patients and their families. But still…
“I'm just all-out excited for them because I know they've been waiting for this moment and the baby's gone from being 3 pounds to being 7 pounds and they’re ready to get out the door,” Mudgett said. “But there are instances where I feel bittersweet, and it's usually those babies that are what we call our chronic babies that are here for months, the ones who started with us as a really tiny baby or they started with us having conditions that needed months of therapy."
“It’s bittersweet,” she said. “because you’ve seen them grow and they smile and they talk and then you leave and you know when you come back to work, they're not going to be there and you know you’re going to miss their smile or you’re going to miss the way they talk.”
More than meets the eye
Mudgett, 28, has been a UTMB NICU nurse since graduating from nursing school more than five years ago. She knew as soon as she had a clinical in the NICU that she wanted to work with preemies. Still, it wasn’t until she was doing it that she realized the enormity of it.
“It’s a lot more than just taking care of really tiny babies,” Mudgett said, explaining that she was surprised to learn about the potential long-term effects that a premature birth can have.
“You would think that they're just born a little early and they just need to grow. But there are a lot of things that can happen when they’re earlier. Everything’s premature,” she said. “There are a lot of risk factors. There are developmental delays that are possible.
“We try to take the best care of them while they’re here to prevent complications later,” she added. “It’s definitely a group effort, and we focus on the patients and do what’s best for them and hope what we’re doing can impact their life in some way and prevent any future complications.”
Galveston has a Level 4 NICU, which means it’s certified and equipped to care for “bottle feeders who are small but healthy and just need to bulk up before they can go home” to the most critically ill babies, including those who require extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support.
It’s not hard to figure out what most NICU nurses would say are the best and worst parts of their job. The best, of course, is the babies themselves—especially when they get to leave the hospital and go home. The worst is when they don’t.
Mudgett has been ebullient until this point in the interview, but she speaks more quietly when she talks about a baby in her care who took a sudden turn for the worse and couldn’t be revived.
“I had been taking care of a baby who was with us for a while and just like that she stopped breathing. We tried everything and we couldn’t do anything to revive her,” Mudgett said. “That one was hard because I had just been taking care of her and then it happened all of a sudden.
“I feel so bad for the parents in situations like that, especially when it’s unexpected,” she said, adding that NICU nurses are there to offer comfort as much as they can when a doctor delivers bad news to parents.
Mudgett has no children of her own and believes that might make it a little easier for her when tragedy strikes because she can’t fully relate to a parent’s dread of losing a child.
It also helps that the staff is doing more debriefing sessions than they have in the past, which gives them an opportunity to talk about issues and events, both good and bad, that they encounter in their work.
“Being able to express how we're feeling, I think for me, that's kind of what helps me and then I'm able to go home and I'm OK,” she said.
Teamwork, balance—and joy
Being able to leave work at work is an important part of what it takes to handle the stress and emotions that often are part of a NICU nurse’s shift. And building trust and support within a team is what makes that possible. When you trust your team, she said, you can leave work and know that “your” babies are in good hands.
Mudgett is emphatic about the importance of teamwork in a high-functioning NICU. Knowing that there are team members ready, willing and able to lend a hand when needed helps to mitigate stress.
It also helps to keep the lines of communication open, to talk through things with each other and to treat one another with respect. Help out whenever you can, Mudgett said, because one day you’ll be depending on someone to help you.
“Most of the time the stress level is manageable, but when it is stressful, I know that I can count on my team
for support. Even if we're short staffed, we always find a way to get through.
We always get through the shift, even if it’s a tough one.”
Vacations and restorative down time also are important, Mudgett said, adding that her mother was a teacher who often had to bring work home with her.
“I knew I didn't want to do that with my career, and so what's nice about being a nurse is that I leave that stress at work,” she said. “But it can still affect your home life too, so I go on vacation or get outside or do housework or something like that just to deal with that work stress. But when I leave work, my goal is to leave it at work.”
Mudgett credits the Health System leadership’s staffing and pay incentives during COVID with helping to keep workloads manageable, as well as the subsequent hiring blitz that is still going on throughout the medical branch.
"The NICU team is a dynamic and passionate group of individuals who harness their collective strengths daily to pave the way for fragile infants to not only survive but thrive on their journeys," Franco-Fuenmayor said. "Mutual respect and constant communication forge interpersonal relationships that allow for fostering high-value, evidence-based, family-centered care in an intensive care setting."
Anyone unfamiliar with a NICU might expect it to be a sad and somber place. But from the staff’s smiles to the Dr. Seuss quotes adding a touch of whimsy to the walls, joy bubbles up around these babies, some so small and perfect it’s almost hard for an outsider to process.
In addition to precise medical care that meets each child’s specific needs, the staff advocates for breastfeeding and skin-to-skin contact for babies with both moms and dads. And there’s an annual event when volunteers come in to read to the preemies and their parents.
Mudgett enjoys when the parents visit, she said, adding that she tries to be as transparent and helpful as possible when answering their questions.
“I love it when the parents come to visit,” she said. “I try to include them in any way I can. I'm very descriptive with them when they come in and see a bunch of stuff and there are cords everywhere and they’re like, ‘What’s this machine’?
“I explain everything I can, except for things that the doctor should be talking to them about,” she said. “I try to maintain a good relationship with them so they can trust that we’re taking care of their baby and that we love their baby very much and they can trust that their baby is in good hands.”
One question the nurses get often—but can’t answer with much certainty—is, “When is my baby coming home?” That, Mudgett said, is up to the baby.
“No one can really answer that,” she said. “The baby is boss.”
What it takes
In addition to her regular work, Mudgett also is a preceptor, or trainer, for new nurses. All nurses, she said, need to be flexible and resilient but perhaps NICU nurses even more so because of the vulnerability of the very sick, very tiny babies.
“Anything can happen, anything can change in the snap of a finger."
Considering a career as a NICU nurse? Mudgett says you need a true passion for the work and that those who don’t are those who don’t last long.
“It takes a certain type of strength and a certain level of passion to be able to take care of sick babies,” she said.
Franco-Fuenmayor couldn't agree more.
"A NICU nurse is characterized by the ability to see a fragile baby, sometimes no larger than their own hand, and not be scared, but rather focused and driven to see them through their fight and eventually be the one to place them in their mother's arms as they get set to go home," she said.
New NICU nurses often can feel overwhelmed and Mudgett’s advice to them is, basically, “This too shall pass.” She also advises them to be patient—especially with themselves. They often want to get things right the first time and when they can’t, they become frustrated and beat themselves up over it.
“I tell them, ‘Be patient with yourself. Your confidence will come in time,’” Mudgett said. “We’ve all been where you are. You’ll get there. It just takes time.’”
Hope all around
Despite the emotional roller coaster that comes with being a NICU nurse, Mudgett can’t see herself doing anything else. And just like joy, hope also bubbles up in the Galveston NICU. The overarching message—for Mudgett at least? Hey,
if these babies can do it, so can I.”
“It gives me a sense of purpose, like I’m taking part in saving lives,” she said. “That’s encouraging to me. It gives me hope for the tough situations outside, like in life, because if these babies can do it, you could do it—whatever it is.”
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Top left: Coryna Williams and Melissa Mudgett
Top right: Nurse Educator Courtney DelBosque, Mudgett, Darci Bowler, Keleigh Warnke and Shawna Ocaranza, OTR
Bottom left: NICU Level 1-2 Nurse Manager Ramona Brown and Mudgett
Bottom right: DelBosque and Mudgett
Please note: The "baby" in the isolette above is a practice" mannequin.